Harmony House Nursing and Rehabilitation Center, I

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF604Oct 1, 2025

  Based on record review, observations, and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for 1 (#13) of 1 (#13) resident reviewed for restraints. The facility failed to ensure Resident #13's pre-restraint assessment was completed and a written consent was obtained prior to the use of lap tray. Findings:Review of the facility's undated policy for Restraints: Physical revealed in part:Policy:A physical restraint is defined as any manual method or mechanical, physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to… […]

• No harm, potential for more than minimal, patternF812Oct 1, 2025

  Based on observation, record review, and interview, the facility failed to store, prepare, and distribute and serve foods in a sanitary manner by: 1. Failing to clean the dry food storage room.2. Storing a styrofoam cup inside a bin of sugar.This had the potential to affect 85 residents served meals on 09/29/2025 according to S1 Administrator. Findings:Review of the facility's undated Cleaning Schedule policy provided by S1 Administrator on 10/01/2025 revealed:Daily cleaning schedule: 8. Food Storage - dust mop, wet mop, and dust shelves, check food arrangements, put up new deliveries as needed. Observation of the kitchen on 09/29/2025 at 8:00 a.m. […]

• No harm, potential for more than minimal, patternF656Aug 2, 2023

  Based on record review and interviews the facility failed to ensure a resident's plan of care was implemented for 1 (#1) of 5 (#1, #5, #6, #53, #109) residents who were reviewed for unnecessary medications. The facility failed to ensure resident #1's insulin was given as ordered by a physician. Findings: Review of the facility's Insulin Guidelines policy revealed the following; 1. Insulin is administered following doctors orders with an insulin syringe. Review of resident #1's medical record revealed an admitted [DATE] with a diagnosis of but not limited to Type 2 Diabetes Mellitus and long term use of insulin. Review of resident #1's July 2023 Physicians Orders revealed an order for Novolin N 100 units/ml (millimeter) vial, inject 30 units subcutaneously every morning. […]

• No harm, potential for more than minimal, patternF678Aug 2, 2023

  Based on record reviews and interviews, the facility failed to ensure a resident's medical record reflected the resident's advance directive choices for 1 (#109) of 29 sampled residents. The facility failed to ensure each of Resident #109's code status documentation was in agreement. Findings: Review of Code Blue-Licensed Nursing Staff document provided by S3 DON (Director of Nursing), who reported the document was used for staff training revealed: This procedure is to be followed when any resident is found unresponsive, no breathing or no normal breathing (gasping). . 3. Licensed Nursing Staff to establish code status: Review the resident's medical record, this is the most reliable way to know the resident's code status. […]

• No harm, potential for more than minimal, patternF690Aug 2, 2023

  Based on record review and interview the facility failed to ensure a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections for 1 (#73) of 2 (#54, #73) residents reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #73's indwelling catheter was changed as ordered. Findings: Review of Resident #73's medical record revealed Resident #73 had an admitted [DATE], with a readmission on 06/22/2023, and had diagnoses that included, in part, benign prostatic hyperplasia with lower urinary tract symptoms, other obstructive and reflux uropathy, other retention of urine, unspecified kidney failure, type 2 diabetes mellitus, atherosclerotic heart disease, vascular dementia, and essential… […]