Harmony Healthcare & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Harmony Healthcare & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 18, 2022

  Based on observation, interview and record review, 1. Facility failed to ensure that one resident (R1) with known diagnosis of seizures, psych disorders; use of anticoagulants and history of scissors puncturing him in the past is free of accident hazards such as grooming scissors, stainless steel blades and other hazards; 2. Facility failed to assess if R1 is appropriate to use grooming scissors independently; 3. Facility failed to provide assistance and supervision to a resident who requires assistance for personal hygiene and grooming. As a result of the facility's failures, on 9/18/2022, R1, was found with bleeding in the right lower abdominal area with a pair of scissors embedded in R1's abdominal wall. […]

• Actual harm, isolatedF684Feb 23, 2026

  Based on observation, interview and record review the facility failed to ensure that one resident (R3) received the necessary treatment and care for R3 to maintain the highest level of functioning. Failed to identify and treat symptoms of altered cardiovascular status in a patient with CHF, hypertension and stage 3 kidney disease. This failure resulted in R3 having a weight gain of 53.4 pounds, 48% weight gain in 6 months. This failure affected one resident (R3) out of two residents reviewed for death. This failure resulted in R3's hospitalization with a diagnosis of acute decompensated heart failure and diuresing 15 pounds of fluid. […]

• Actual harm, isolatedF689Jan 29, 2023

  Based upon observation, interview and record review the facility failed to provide supervision to (R2, R4) and failed to implement appropriate fall prevention interventions for three of four residents (R2, R3, R4) reviewed for falls. These failures resulted in R2 sustaining (1/5/23) fall with facial injury and (acute) right tibia & fibula fractures. Findings include: R2's diagnoses include Alzheimer's disease, repeated falls. (8/17/22) fracture of shaft of left fibula and (9/8/22) fracture of shaft of right tibia. R2 was transferred to the hospital (1/11/23) and did not return to the facility. R2's (11/23/22) BIMS (Brief Interview Mental Status) determined a score of 5 (severe impairment). […]

• Actual harm, isolatedF684Jul 1, 2022

  Based on interview and record review, the facility failed to monitor and assess a change in condition for one resident (R1) reviewed for change of condition. This failure resulted in R1 going into septic shock requiring hospitalization and critical care. Findings include: R1's medical record (Face Sheet, Progress Notes) documents is a [AGE] year-old, admitted to the facility on [DATE] following L3-L4 decompression arthrodesis, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set, 02/24/2022) documents R1's Cognitive Skills for Daily Decision Making as independent-decisions consistent/reasonable. R1 requires extensive assistance with transfer and toilet use. Skin/Wound Note (02/17/2022) documents in part: 1. […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2022

  Based on observations, interviews and records review, the facility failed to follow their policy on sanitation and food safety by failing to date open food items with open date and use by date. This failure has the potential to affect 151 residents who are on an oral diet. Findings include: On [DATE] at 9:53 am, in the kitchen freezer, surveyor and V4 (Dietary Manger) observed the following open food items with no opened by date and no use by date: Carrots in a plastic bag, noted bag on the bottom shelf on top of a box. No open or use by date. Chocolate vanilla/strawberry ice-cream, No open on date or use by date. Chicken legs in a knotted plastic bag, placed in a tin pan. The chicken legs were observed to have a lot of ice inside the plastic bag. […]