Harmony House Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF609Aug 6, 2025

  Based on observations, record review, resident, and staff interviews, the facility failed to report an allegation of abuse to the Administrator, as well as the State Survey Agency within the mandated timeframe (2 hours). This resulted in a failure to protect a resident from further harm. Resident #51 reported he told staff about a staff member who grabbed his arms, hurt him, and resulted in multiple dark purple bruises to forearms. The facility's failure to report an allegation of abuse prevented an investigation into the incident, as a result, the harm continued to occur. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident.The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/25 at 4:15 PM. […]

• Immediate jeopardy, isolatedF610Aug 6, 2025

  Based on observations, record review, resident, and staff interviews, the facility failed to conduct a thorough investigation of an allegation of abuse, resulting in failure to protect a resident from further harm. Resident #51 reported he told staff about a staff member who grabbed his arms, hurt him, and resulted in multiple dark purple bruises to forearms. The facility's failure to investigate the allegation of abuse resulted in further harm to occur. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident.The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/25 at 4:15 PM. […]

• Actual harm, isolatedF692Mar 25, 2026

  Based staff interview, clinical record review, and facility policy review, the facility failed to maintain a resident's nutritional status for 1 of 5 residents reviewed (Resident #4). As evidenced by a significant, unexplained weight loss from 130 pounds on 1/05/26 to 119.5 pounds on 3/25/26. The facility failed to consistently follow the Care Plan intervention to notify the physician and dietitian of significant weight change. Furthermore, the facility did not follow its own policy for Notification for Change in Condition by failing to consult with the resident's physician and notify the Dietitian of a significant change in status (weight loss) and the significant alteration of treatment (reduction of enteral feedings from five times to two times per day) without a documented physician's… […]

• Actual harm, isolatedF550Jan 24, 2024

  Based on observations, interviews, and record review the facility failed to ensure communication devices were utilized for 2 out of 3 residents reviewed (Resident #1 and Resident #2). Resident #1 had a communication device that used a button he controlled with his head to select words and phrases on a computer. The communication device could be used when it was not on his wheelchair(w/c). The nursing staff were not educated on how to use the communication device nor did they know they could use the communication device, therefore Resident #1 was communicating with the staff by answering yes or no questions only, limiting his ability to communicate his wants and needs to his full potential. Resident #2 had a picture board with pictures of items that she would/could frequently request. […]

• Actual harm, isolatedF689Oct 6, 2022

  Based on observation, clinical record review, interviews, and facility policy review the facility failed to ensure one (1) of five (5) residents received adequate supervision to protect against hazards in the environment, (Resident #5). Resident interview, record review and staff interviews revealed Resident #5 required assistance of two staff with a mechanical stand lift for transfer. On 8/15/22, one nursing staff person assisted Resident #5 to transfer without a gait belt. The resident lost balance and fell to the floor, required transfer to the local emergency room (ER) where determined resident had sustained a lower left leg fracture. […]