Harmony Davenport

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, family representative and staff interviews, the facility failed to treat each resident with dignity and respect when a staff member made a resident condition statement in the presence of a family member for 1 of 9 resident records reviewed (Resident #7). The facility reported a census of 64 residents.Findings include:Review of the electronic health record (HER) revealed Resident #7's admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis, chronic respiratory failure with oxygen dependence, adult failure to thrive, peripheral vascular disease, diabetes and dementia, and hospice services in place. A Nursing Care Plan problem initiated 6/25/25, included a Focus area to address Resident has complaints of pain described as chronic > (greater than) 3 months, related to osteoarthritis, peripheral vascular disease and wounds. Interventions directed staff to, in part: a. Administer pain medication per physician orders, initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, the facility failed to ensure a resident with a history of poly substance overuse smoked safety when under the influence for 1 of 1 (Resident #1) residents reviewed for smoking safety. The facility reported a census of 70 residents. Findings include: Review of the Minimum Data Set (MDS) assessment tool dated 4/10/25 revealed Resident #1 admitted to the facility on [DATE]. A score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicated intact cognition. The MDS list of diagnoses included anxiety, asthma and respiratory failure. Review of the document Smoking Program assessed the following areas to determine if a resident is an unsafe smoker of cigarettes. Per the instructions the assessor to evaluate or observe the resident in the following areas. Any check will make the resident unsafe smoker using a cigarette: a. Unable to comprehend facility-smoking policy? b. Smokes in unauthorized areas? c. Careless with smoking materials?…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (for October 1st to December 31, 2024) review, facility staffing assignments review and staff interview, the facility failed to submit accurate agency staffing data for the PBJ Staffing Data Report. The facility reported a census of 66 residents. Findings include: The PBJ reported for the first fiscal year (FY) 2025, triggered for Excessively Low Weekend Staffing. The Daily Nursing Staffing Schedule for 9/2024, showed a consistent number of staff from the week and the weekends. The Daily Nursing Staffing Schedule for 10/2024, showed a consistent number of staff from the week and the weekends. The Daily Nursing Staffing Schedule for 12/2024, showed a consistent number of staff from the week and the weekends. Review of the Audit for PBJ 10/2024 through 12/31/2024, revealed 20 agency staff not submitted to the BPJ. On 3/19/25 at 3:43 PM, the Administrator reported the data submission for the PBJ and staffing reports were completed by the corporate office. On 03/20/2025 at 8:45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to label and date opened food items in the refrigerator, freezer and dry storage areas in an effort to prevent foodborne illness. The facility reported a census of 66 residents. Findings Include: During the initial kitchen tour with Staff G, [NAME] on 3/16/25 at 10:10 AM, observations included: a. In the cooler, apple sauce, cheese, cabbage, and ranch dressing observed open. No label present or open date indicated. b. In the ice freezer, breadsticks, biscuits and slider rolls observed open. No label present or open date indicated. c. In the 3-door freezer, waffle fries and breaded fish fillets observed open. No label present or open date indicated. d. In the 2-door freezer, two packages of vegetables observed open. No label present or open date indicated. e. In the dry storage room, a box of fruit flavored cereal and bag of toasted flake cereal observed open. No label or open date indicated. When queried about storage of opened food items, Staff G stated food items that had been opened should have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review and staff interviews, the facility failed to ensure urinary catheter bags and tubing placed off the floor to minimize the risk of urinary tract infections for 2 of 4 residents reviewed (Resident #37 and Resident #121) with indwelling catheters. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 for Resident #37, which indicated intact cognition. The MDS listed diagnoses included: neurogenic bladder (lose of control of bladder function due to nerve damage) and urinary tract infection. The MDS assessed Resident #37 dependent on staff for all activities of daily living with the exception of eating. The MDS indicated the resident had an indwelling urinary catheter. Review of the Care Plan, Date Initiated: 5/8/24 revealed a Focus area to address Resident requires the use of a indwelling catheter related to neurogenic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to utilize proper infection control methods during the change of a resident's colostomy bag/wafer (Resident #2) for one of one residents reviewed with a colostomy and during wound care for one of three residents reviewed for wound care (Resident #37) and failed to initiate and follow precautions for one of four residents reviewed for Enhanced Barrier Precautions (Resident #121). The facility reported a census of 66 residents. 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed a diagnosis of paraplegia identified a colostomy. The Brief Interview for Mental Status (BIMS) score was 15 that suggested an intact cognition. The Care Plan for Resident #2 directed staff to utilize Enhanced Barrier Precautions (EBP) by wearing a gown and gloves while performing high-contact care activities such as colostomy care due to colonized multidrug-resistant organism (MDRO). A Physician Order, dated 1/19/25 for Resident #2 revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, maintenance record review, resident and staff interviews the facility failed to provide dignified care to residents when the water temperature unpredictably changed from a comfortable temperature to a cold temperature for 6 of 6 resident reviewed for dignity. The facility reported a census of 66 residents. Findings include: During interview on 11/19/24 at 2:40 p.m., the facility Administrator stated she became aware shower water temperatures were not hot enough on 11/12/24 when a resident informed her of the concern. She contacted a local plumbing company at that time for service. The Administrator stated the plumbing company was on site the same day, and identified the 2nd floor central shower required a new cartridge. She stated the plumbing company returned on 11/15/24 and replaced the cartridge. On 11/20/24, the State Agency took water temperatures from the identified location with the following results: a. At 9:57 a.m., the 2nd floor central shower measured at 107.8 Fahrenheit (F). b. At 10:59 a.m., the 1st floor central shower measured at 109.7 F. c. At…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, maintenance record review, and resident and staff interviews the facility failed to maintain essential equipment in acceptable operating condition to maintain water temperatures in resident showers between 110 degrees Fahrenheit (F) and 120 degrees F as required. The facility reported a census of 66 residents. Findings include: During interview on 11/19/24 at 2:40 p.m., the Administrator stated on 11/12/24 a resident informed her the shower water temperatures were not hot enough on 11/12/24. She stated she contacted local plumbing company A at that time for service. She stated the repair company was on site the same day. The plumber identified the central shower on the 2nd floor required a new cartridge. The cartridge was replaced on 11/15/24. The Administrator stated maintenance staff monitored water temperatures. She stated the facility had 1 boiler and 2 water heaters in use. During an interview on 11/20/24 at 11:34 a.m., Staff F, Licensed Practical Nurse (LPN) stated the facility had warm water today so they were able to do a few showers. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews, the facility failed to follow physician orders for wound care and positioning for 1 of 3 resident records reviewed for wound care (Resident #2). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 9/20/24, revealed Resident #2 diagnoses listed included osteomyelitis (infection of the bone) of the vertebra, sacral and sacrococcygeal region, hypertension (high blood pressure), peripheral vascular disease (restricted blood flow), paraplegia (paralysis of the lower body), and hemiplegia (paralysis of one side of the body). Resident #2's Brief Interview for Mental Status score of 15 out of 15 indicated intact cognition. The MDS assessed the resident dependent on staff to roll left and right, and for a chair/bed-to-chair transfer. The MDS indicated the resident at risk for developing pressure ulcers. The MDS identified Resident #2 with two Stage 4 pressure ulcers. A review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, resident and staff interviews the facility failed to treat residents with dignity and respect, in full regard of the resident's stated needs and right to refuse a shower, for 1 of 8 resident's reviewed (Resident #5). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) Assessment tool, dated 7/23/24, revealed Resident #5 scored 13 out of 15 points possible on the Brief Interview for Mental Status (BIMS) Cognitive assessment, indicating intact cognition. Diagnoses listed on the MDS included: adult failure to thrive, anxiety, depression, and contractures in left hand, and feet. The resident required substantial/maximal staff assistance for personal hygiene, bathing and dressing the upper body, completely dependent on staff for dressing the lower body, toileting/hygiene, and unable to stand or ambulate. The MDS indicated the residents speech is clear, usually understood by others and usually understands others. A review of the Care Plan, dated 7/17/24, revealed a Focus Area to address Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review the facility pharmacy failed to deliver medications ordered to the facility in a timely fashion for 4 out of 4 residents reviewed, (Resident #22, #30, #47, and #70). The facility reported a census of 70 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 included diagnoses of stroke, and hypercholesterolemia. The Medication Administration Record (MAR) for Resident #47 dated 4/25/24, lacked documentation of administration for the medication, ticagrelor (help prevent blood clot). The MAR directed to see Nurses Notes. The Medication Administration Nurses Note for Resident #47 dated 4/25/2024 at 11:03 PM reflected ticagrelor 90 mg unavailable. 2. The MDS for Resident #70 dated 4/27/24 reflected his admission date as 4/27/24. The MDS dated [DATE], listed diagnoses of coronary artery disease (CAD), high blood pressure, Alzheimer's disease, and psychotic disorder and post traumatic stress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and staff interview the facility failed to maintain a sanitary kitchen, ensure the disinfectant solution was within proper test range, label food appropriately for storage, wear hair restraints appropriately and dispose of expired food items. The facility identified a census of 70 residents. Findings include: 1. The initial tour of the kitchen on 5/20/24 at 10:10 AM revealed the following: a. The Vulcan stove backsplash and sides by griddle were 50% covered with black/brown residue, both handles to oven doors with sticky residue, doors on outside with scattered areas of brown and white residue. b. The floor to all areas of kitchen with debris. c. The Hoshizaki ice machine with dispenser. Housing units with white debris noted along seams. d. The [NAME] dishwasher with debris noted along seams of outer doors. e. At 10:18 AM, the Dietary Director filled a bucket with water and sanitizer and put test strip in it and it read zero. The Dietary Director had run chemical directly from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to obtain a physician order to obtain Lorazepam from the facility's Med Bank for one of six residents reviewed, (Resident #30). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #30 with a BIMS (Brief Interview for Mental Status) score of 15, intact cognitive status and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Peripheral Vascular Disease, Anxiety Disorder and Chronic Obstructive Pulmonary Disease. The MDS also identified Resident #30 required only set up or clean up assistance with most activities of daily living. In an interview on 5/20/24 at 11:08 AM, Resident #30 reported he had trouble getting his Lorazepam. When he had trouble breathing, he got anxious. When he no longer received hospice services, the nurses told him he could not get the Lorazepam until he saw the doctor tomorrow. He reported he was afraid to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to follow the care plan and transfer the resident with the use of the stand lift for one of one resident reviewed, (Resident #55). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #55 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Mellitus, Multiple Sclerosis and Depression. The MDS also identified Resident #55 was totally dependent on staff for all transfers. On 3/21/24, the Care Plan identified Resident #55 required assistance with ADL's (Activities of Daily Living) related to immobility, Multiple Sclerosis with impaired range of motion and directed staff to transfer with the stand lift. A review of the Progress Notes dated 3/29/24 at 3:32 PM had documentation of the following: Was informed by staff that resident had fallen and was on the floor. Upon entering the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview the facility failed to date feeding tube equipment, flush for patency with the correct water amount, and confirm correct settings on a feeding tube pump in order to follow physician orders for 1 of 1 resident reviewed, (Resident #4). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #4 identified the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive impairment. The MDS reported diagnoses including: sarcoidosis of the lung (lung cancer), paraplegia (inability to voluntarily move lower parts of the body), and pneumonia. The Care Plan updated 2/2/24 documented the resident's risk for altered nutritional status related to his inability to eat or drink by mouth, and a PEG tube (feeding tube directly into the stomach) due to dysphagia (difficulty swallowing). It instructed staff to provide nutrition through the PEG tube. The Physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, staff interviews and facility policy review, the facility failed to follow accepted practices for enteral (feeding tube formula bags) feeding supplies, and to follow a Physician's Order to continue clopidogrel (Plavix, the brand name of the medication. The medication purpose is to keep platelets from sticking together) for 1 of 3 residents in the sample (Resident #1). The facility reported a census of 66 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 2/14/24, listed diagnosis for Resident #1 included hemiplegia (one sided paralysis) following a stroke affecting the right dominant side, dysphagia (difficulty swallowing), and aphasia (difficulty with communication). The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating severely impaired cognition. A review of Hospital Discharge Records, dated 2/7/24, indicated during the hospitalization Resident #1 had a Foley catheter inserted, and developed hematuria (blood in urine). During the hospitalization, a consulting Urologist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review the facility failed to notify the Resident Representative/Emergency Contact of a hospital transfer for 1 of 3 residents reviewed for transfers out of the facility (Resident #3). The facility reported a census of 72 residents. Findings Include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident discharged to the hospital on 1/17/24. A readmission MDS dated [DATE] documented the resident re-admitted back to the facility The Care Plan initiated 4/5/23 documented Resident #3 with altered cardiovascular status, heart disease, congested heart failure and history of cerebral vascular accident (stroke). The Notice of Transfer Report to the Ombudsman for January 2024 identified resident #3 transferred for hospitalization on 1/17/2024. The Progress Note dated 1/17/24 at 5:49 PM, documented Resident #3's family notified via phone call by Staff A, Licensed Practical Nurse (LPN), regarding the transfer to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and Dietician Job Description review, the facility failed to ensure Registered Dietician (RD) involvement for consultation, education, Care Plan updates for nutritional interventions to address protein needs and nutritional deficits for promotion of chronic wound healing of 1 of 3 residents reviewed (Resident #1). In addition, the Dietician lacked participation of expectations in Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 72. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for resident #1 included diagnoses of paraplegia and malnutrition. The MDS revealed 3 pressure ulcers and coded for protein and/or calorie malnutrition, risk for malnutrition. A Brief Interview for Mental Status (BIMS) Assessment scored 15 out of 15 indicating no cognitive impairment. Review of Resident #1's Care Plan revealed the following Focus Areas: a. A Focus Area initiated on 1/14/24 encourage good…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews and facility policy review, the facility failed to provide services that met professional standards regarding medication administration, weight documentation, catheter care documentation and wound treatment completion for 4 of 12 residents observed (Residents #2, #6, #15, and #16). The facility reported a census of 53 residents Finding Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 points. The MDS also identified Resident #2 with the following diagnoses: Type 2 diabetes mellitus with diabetic neuropathy, heart failure and hypertension (high blood pressure). The MDS documented Resident #2 required extensive staff assistance with most activities of daily living. On 7/3/23, the Care Plan identified Resident #2 with the problem of cardiovascular dysfunction related to hypertension and failed to include the Physician Orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.