Gundersen Harmony Care Center

In the surveyor’s words

From the most serious findings on record at Gundersen Harmony Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 11, 2023

  Based on observation, interview and record review the facility failed to ensure resident-to-resident sexual abuse were identified timely, and implement appropriate actions to prevent ongoing abuse for 1 of 1 resident (R1) who had severe cognitive impairment and unable to give consent. This deficient practice resulted in an immediate jeopardy (IJ) for R1, a reasonable person would have experienced severe psychosocial harm-dehumanization, and humiliation as a result of the sexual abuse. The IJ began on 5/13/23, when the facility failed to implement protection measures after staff observed R2 inappropriately touching R1's perineal area (in-between legs) which subsequently resulted in R2 continued inappropriately touching of R1. […]

• No harm, potential for more than minimal, widespreadF880May 26, 2021

  Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was used during cares of a catheter for 1 of 1 residents (R14) who was on transmission-based precautions. Findings include: During an observation on 5/25/21, at 10:05 a.m., registered nurse (RN-A) identified R14's catheter was found to be leaking. RN-A informed RN-B and both RN's entered R14's room washed hands and donned gloves to assess catheter. RN-B clamped the catheter, unhooked and cut tubing to avoid the tube kinking again. RN-B used a alcohol pad to wipe the tip of tubing and connected to catheter. […]

• No harm, potential for more than minimal, isolatedF689Apr 10, 2025

  Based on observation, interview, and record review, the facility failed to comprehensively reassess, implement appropriate person-centered interventions and analyze falls to help prevent future falls and potential injury for 2 of 2 residents (R22, R7). In addition, the facility failed to assess for proper use of a heating pad for 1 of 1 residents (R28) reviewed for accidents. Findings include: R22's Minimum Data Set (MDS) assessment dated [DATE] indicated no cognitive impairment. R22's function status showed she requires a walker for mobility, substantial assistance for toileting, partial assistance for dressing, and is dependent on facility staff to put on or take off footwear. R22's bladder status showed occasional incontinence. […]

• No harm, potential for more than minimal, isolatedF578Feb 29, 2024

  Based on interview and document review, the facility failed to ensure resident current wishes for resuscitation status were accurately documented in the medical record in a timely manner for 1 of 16 (R184) resident reviewed for advanced directives. Findings include: R184's Provider Orders for Scope of Treatment (POST) indicated Do not attempt resuscitation/DNR dated by the medical provider on [DATE] at 12:16 p.m. R184's electronic medical record (EMR) review on [DATE] at 5:36 p.m., lacked indication of code status in the identification banner. R184's Progress notes indicate R184 admitted to the facility on [DATE] at 11:15 without resident representation present. At 4:51 p.m., Social Worker (SW)-A attempted to reach R184's power of attorney Family member (FM)-A. […]

• No harm, potential for more than minimal, isolatedF609Oct 11, 2023

  Based on interview and document review, the facility failed to ensure the State Agency (SA) were notified within 2 hours of staff witnessing three allegations of resident-to-resident sexual abuse for 1 of 1 residents (R1) when R2 inappropriately placed his hands in between R1's legs. Findings include: A Facility Reported Incident (FRI) submitted to the State Agency on 10/11/23 at 8:08 p.m., alleged resident to resident sexual abuse when staff witnessed R2 wheeled self over to R1 and stated to her, Do you want me to touch you, as R2 placed his hand in R1's inner leg/peri area, staff intervened and told R2 not to do that and removed R1 from the area. Another male resident [R4] stated to R2, I'm glad you got caught. R2 told [R4], Fuck you. The incident occurred on 5/13/23, at 4:30 p.m. […]