Harmony River Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to report an allegation of sexual abuse to the state agency (SA) for 2 of 3 residents (R4, R5) reviewed for reporting of alleged violations when R1 displayed sexual behaviors towards R4 and R5. Findings include: R1 R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. R1's care plan dated 4/13/26, identified limited physical mobility and indicated he required assistance from one staff for transfers and ambulate. The care plan revised on 3/17/26 indicated a history of requiring one-to-one staff supervision due to sexual advancements toward others. Interventions included:…

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, interview and document review the facility failed to develop and implement resident specific approaches to behavior for 1 of 3 residents (R1) diagnosed with dementia who displayed negative behaviors affecting himself and other residents in the facility. Findings include: R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. R1's care plan: Revised on 3/17/26, identified an alteration in mood or behavioral expression due to Alzheimer's and dementia. Targeted behaviors included exit seeking, wandering into other residents' rooms, sexual behaviors toward staff, delusions and hallucinations. Revised on 3/1/26, see…

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 interview and document review the facility failed to ensure pharmacy recommendations were addressed to include a clinical rationale for declined recommendations and failed to identify and address medications as a contributing factor for falls for 1 of 3 residents (R1) reviewed who sustained multiple falls following the implementation of hospice prescribed medications. Findings include: R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. R1 received scheduled and as needed medication to relieve pain as well as non-medication interventions. R1 denied having, pain or hurting, during the assessment period. R1's care plan…

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 interview and document review, the facility failed to report allegations of abuse to the state agency, immediately, but not later than 2 hours after the allegation is made, for one of three residents (R1) reviewed. R1 reported he was abused in his room multiple times during the night.Findings include: Minimum Data Set (MDS) dated [DATE] indicated R1 was admitted to the facility for treatment of osteoarthritis of the right knee. R1's relevant diagnoses included chronic pain, mild intellectual disability, anxiety, unspecified psychosis, and developmental disorders. R1 required substantial to maximal assistance with repositioning in bed. R1 used a wheelchair to ambulate. R1's Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had mild cognitive impairment. R1's care plan indicated he had a history of behavioral disturbances. R1's care plan indicated R1 experienced delusions and paranoid about people in his room intending to harm him. R1's care plan indicated R1 was at risk for…

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 interview and document review, the facility failed to conduct a formal investigation into the allegations of physical and sexual abuse for one of three residents reviewed (R1) for abuse.Findings include: Minimum Data Set (MDS) dated [DATE] indicated R1 was admitted to the facility for treatment of osteoarthritis of the right knee. R1's relevant diagnoses included chronic pain, mild intellectual disability, anxiety, unspecified psychosis, and developmental disorders. R1 required substantial to maximal assistance with repositioning in bed. R1 used a wheelchair to ambulate. R1's Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating he had mild cognitive impairment. R1's care plan indicated he had a history of behavioral disturbances. R1's care plan indicated R1 experienced delusions and paranoid about people in his room intending to harm him. R1's care plan indicated R1 was at risk for abuse and had a history of making allegations against staff. R1's care plan indicated staff were 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 interview and document review, the facility failed to create a comprehensive care plan for a resident with a history of respiratory conditions for 1 of 1 residents (R102) reviewed for care plans. Findings include: R102's Medicare 5-day Minimum Data Set (MDS) dated [DATE], indicated R102 cognitive impairment could not be decided. Diagnoses included pneumonia and respiratory failure. R102's comprehensive care plan undated, lacked a patient specific care plan or interventions related to R102's history of pneumonia and respiratory failure. During an interview on 2/20/25 at 1:16 p.m., registered nurse (RN)-B stated the care plan was updated either when there was a change in the resident's condition or when a new MDS assessment performed. RN-B reviewed R102's MDS and 5-day care plan. She acknowledged the respiratory conditions listed in the MDS but were not found on the care plan. RN-B stated the care plan should have been updated with a respiratory care plan, goals, and interventions when the MDS was updated…

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, interview and document review facility failed to provide activities of daily living (ADL) assistance for 1 of 1 resident (R38) who required assistance with eating. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R38's diagnoses included progressive neurological conditions, seizure disorder/epilepsy, bipolar disorder and other drug induced secondary parkinsonism. MDS did not indicate R38 exhibited any behaviors. R38's care plan dated 12/16/23, identified R.8 required assistance of 1 for eating due to extensive tremors. During observation on 2/18/25, at 5:19 p.m., R38 was seated at dining room table with two other residents. Staff served the other two residents their plates, who started eating, R38 sat there watching the other residents eat. At 5:25 p.m., R38 continued watching other two resident eat. At 5:28 p.m., staff brought R38's plate to table and…

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, interview and document review, the facility failed to follow provider orders for a resident on mild thickened liquids for 1 of 2 residents (R102) reviewed for diet changes. Findings include: R102's Medicare 5-day Minimum Data Set (MDS) dated [DATE], indicated R102 cognitive impairment could not be decided. Diagnoses included pneumonia and respiratory failure. R102's Order Summary Report dated 1/16/25 indicated R102 had an active diet order for level 6 soft and bite sized texture with mild thick consistency liquids. R102's care plan revised on 12/29/24, indicated R102 had a nutritional problem and diet was to be served as ordered. R102's therapy interdepartmental team (IDT) communication dated 2/3/25, indicated nursing and dietary was notified by speech therapy (ST) R102 was on mild thick liquids. Facility care sheets undated, indicated R102 was suppose to have mild thickened liquids. On 2/19/25 at 2:47 p.m., R102 was observed with a plastic glass half full of non-thickened water that was…

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, interview and document review, the facility failed to ensure medication carts were properly secured for 4 of 8 medication carts observed. Findings Include: On 1/8/24, at 8:50 a.m. during medication observation trained medication aide (TMA)-A stepped away from medication cart, entered nursing office out of view of medication (med) cart with lock button observed to be in extended position. TMA-A returned to cart, continued with medication administration When interviewed on 1/8/24, at 9:03 a.m. TMA-A stated when lock button in extended position the medication cart was unlocked. TMA-A demonstrated entering code into touchpad on top surface of cart locked med cart by pulling lock button into cart. TMA-A then re-entered code demonstarting lock button extended out from cart then opening drawer demonstrating med cart was unlocked. On 1/8/24, at 9:04 a.m. observed TMA-A step away from med cart with lock button extended out. TMA-A went into nurse office dropped blood pressure machine into office,…

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 interview and document review, the facility failed to ensure 3 of the 5 residents (R16, R63, R89) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R16's face sheet, dated 1/9/2024, indicated she was [AGE] years old. The immunization record, dated 1/5/2024, indicated she received 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.