Harmony Gardens

In the surveyor’s words

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

• Immediate jeopardy, patternF880Aug 30, 2021

  Based on observation, interview and document review, the facility failed to conduct risk assessment of residents for significant exposure to two COVID+ staff who worked after knowledge of COVID+ status and quarantine residents as appropriate. They also did not implement source control masking of all staff and residents in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guideline for COVID-19. Additionally, the facility lacked policies and procedures reflective of current CDC requirements. This had the potential to affect 26 residents in the facility that were exposed to COVID-19. […]

• Immediate jeopardy, isolatedF689Oct 20, 2021

  Based on interview and document review, the facility failed to prevent an elopement and provide safety for 1 of 2 residents (R1) identified at risk for elopement. R1 successfully eloped from the building, undetected, and was found by citizens about 0.2 miles away. This deficient practice resulted in immediate jeopardy (IJ) for R1. The Immediate Jeopardy (IJ) began at 6:45 p.m. on 10/8/21, when R1 attempted to elope through the front door of the facility. R1 was redirected to her room and assisted into bed at which time the attending nurse left to assist another resident. At 7:00 p.m. the door alarms sounded to alert staff one of the doors accessing the exterior of the building had been opened. […]

• Actual harm, isolatedF689Sep 19, 2024

  Based on observation, interview and document review the facility failed to ensure care planned interventions were followed during transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to use a transfer belt. This resulted in actual harm for R1 who fell during a staff assisted transfer and sustained a subarachnoid hemorrhage. The deficient practice was corrected prior to the start of the survey therefore, was issued at past noncompliance. Findings include: R1's Resident Face Sheet indicated R 1 was readmitted to the facility on [DATE]. The face sheet identified diagnosis that included vascular dementia, cerebral infarction with left sided weakness, anemia and heart failure. […]

• Actual harm, isolatedF686Feb 3, 2023

  Based on observation, interview, and document review, the facility failed to implement timely interventions to promote healing and reduce the risk of complications for a newly developed unstageable pressure ulcer for 1 of 2 residents (R22) reviewed for pressure ulcers. This resulted in actual harm for R22 whose right buttocks wound worsened. Findings include: Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead or devitalized tissue that is hard or soft in texture; usually… […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2026

  Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled, dated, and not expired. This had the potential to affect all 61 residents who received food from the facility kitchen. Findings include:On 3/25/26 at 10:40 a.m., director of food and nutrition (DFN) provided a tour of the facility kitchen. In the walk-in refrigerator there was a container of beets labeled with an opened date of 2/23. Multiple white patches of a substance were observed on the top surface of the beets. DFN confirmed and stated the substance was mold. DNF further stated the beets had been opened longer than seven days and should have been discarded. […]