Harmony Hall Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Harmony Hall Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 25, 2023

  Based on record review and staff and physician interviews, the facility failed to provide incontinence care safely to a dependent resident for 1 of 1 residents reviewed for falls. Resident #307 fell out of bed during incontinence care provided by Nursing Assistant (NA) #1 resulting in an upper lip laceration which required to 7 sutures, a laceration to the left side of the head that required 12 staples and a small laceration to the 2nd digit on the left foot. Findings included: Resident #307 was admitted to the facility on [DATE] with medical diagnosis which included in part: stroke with hemiparesis, vascular dementia, contractures of left wrist and hand and right hand, aphasia, and epilepsy. […]

• Actual harm, isolatedF760Aug 25, 2023

  Based on observations, record review, staff, Regional Pharmacy Manager, and Physician interviews the facility failed to: 1) administer 25 doses of a controlled substance hypnotic medication (Ambien) as prescribed for the treatment of insomnia resulting in decreased sleep, restlessness, and anxiety (Resident #84, and Resident #6); 2) administer 4 doses of a controlled substance antianxiety medication (Temazepam) as prescribed for the treatment of insomnia resulting in decreased sleep and fear of withdrawal (Resident #31); 3) ensure the correct dose of a controlled substance medication (Dronabinol) was administered as prescribed for an appetite stimulant (Resident#256); and 4) ensure the correct dose of antianxiety medication was administered in accordance with the physician's order… […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2023

  Based on observations, record review, and staff interviews the facility failed to a) ensure expired beverages were discarded and not available for use, b) ensure that frozen foods were sealed when stored to prevent freezer burn, c) ensure that foods were labeled, dated, stored, and left to thaw in a safe manner to prevent the potential for food borne illness. These practices had the potential to affect residents in the facility. Findings included. During the initial tour of the kitchen on [DATE] at 10:45 AM the following was observed: a. The walk-in refrigerator was observed with a crate of approximately 50 milk cartons, each with an expiration date of [DATE]. b. The walk-in freezer was observed with an opened box of fried chicken patties. […]

• No harm, potential for more than minimal, patternF602Aug 25, 2023

  Based on observations, record review, staff, Regional Pharmacy Services Manager, and Physician interviews the facility failed to protect a resident's right to be free from misappropriation of a resident's controlled hypnotic medication (Ambien) which was prescribed by the physician for insomnia. This resulted in 78 missing doses of Ambien for 2 of 2 residents (Resident #84, Resident #6) reviewed for misappropriation of medications. Findings included. 1a.) Resident #84 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Insomnia. A physicians order dated 03/06/23 for Resident #84 revealed an order for Ambien 10 milligram (mg) tablets. Administer one tablet by mouth at bedtime for Insomnia. […]

• No harm, potential for more than minimal, patternF756Aug 25, 2023

  Based on record review, staff, physician, and Regional Pharmacy Services Manager interviews the facility failed to address drug irregularities noted by the Consultant Pharmacist on six consecutive monthly Medication Regimen Reviews for an antipsychotic medication prescribed by the physician for 1 of 5 residents (Resident #10) reviewed for unnecessary medications. Findings included: Resident #10 was admitted to the facility on [DATE] with medical diagnoses which included in part: dementia wiht behaviors and major depression with psychoses. […]