Harmar Place Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Harmar Place Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Mar 3, 2025

  Based on closed medical record review, review of emergency responder record, hospital record review, facility policy and procedure review and interview, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #26. The facility failed to ensure changes in the resident's medical condition were timely identified and comprehensive and individualized interventions were implemented for Resident #26 when the resident was assessed to have a decline in health including tachycardia, shortness of breath, fatigue, and weakness. […]

• Actual harm, isolatedF684May 16, 2025

  Based on closed medical record review, policy review, and interview, the facility failed to timely report and provide adequate, necessary and timely care for Resident #72 following a fall during a staff assisted transfer resulting in a delay of treatment for newly diagnosed compression vertebra fractures. This affected one resident (#72) of three residents reviewed for accidents. The census was 71. Actual Harm occurred on 05/06/25 at approximately 9:00 A.M. when Certified Nurse Assistant (CNA) #34 failed to notify the licensed nurse that Resident #72 sustained a fall during a staff assisted transfer resulting in a delay in treatment. […]

• Actual harm, isolatedF689May 16, 2025

  Based on observation, medical record review, policy review, and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure fall interventions were implemented for Resident #28 and to ensure Resident #72 and Resident #75 were provided adequate assistance with transfers. This affected three residents (#28, #72, and #75) of three residents reviewed for accidents. The census was 71. Actual Harm occurred on 05/06/25 at approximately 9:00 A.M. […]

• Actual harm, isolatedF692Mar 3, 2025

  Based on observation, record review, policy review and interview the facility failed to ensure residents were properly assessed, monitored, and provided adequate nutrition to prevent weight loss. This affected three residents (#5, #7, and #69) of five residents reviewed for nutrition. Actual harm occurred on 01/29/25 when Resident #5, who required staff set-up assistance with meals was assessed to sustain a 12.1 pound severe weight loss (in approximately 30 days) as a result of the facility's failure to revise and/or implement comprehensive and individualized care plan interventions to address changes in the resident's nutritional status (decrease in oral intake) and impaired wound healing (of a Stage III pressure ulcer). […]

• Actual harm, isolatedF686Jul 31, 2023

  Based on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to prevent the development of pressure ulcers and failed to provide the necessary treatment and services to promote healing. Actual harm occurred to Resident #12, who had impaired mobility and required staff assistance for activities of daily living, on 06/02/23 when the resident's in-house pressure ulcer deteriorated to a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. […]