Harmony Manor Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Harmony Manor Skilled Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF604May 11, 2021

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure residents were not restrained for 23 of 33 residents (Resident #2, #5, #6, #7, #8, #9, #10, #11, #13, #15, #17, #18, #19, #20, #21, #22, #23, #26, #27, #28, #29, #31, and #34). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/03/21 at 2:30 PM, Resident #2 was in bed with a half bed rail up on the right side of the bed, the left side of the bed was against the wall, the bed was in low position, and fall mats were on the floor beside the bed. On 05/05/21 at 3:00 PM, Resident #2's bed had a half bed rail up on the right side of the bed and the left side of the bed was against the wall. […]

• No harm, potential for more than minimal, widespreadF837May 11, 2021

  Based on interview and document review the facility failed to ensure a Governing Body was providing management and oversight of the facility. On 05/10/21 at 4:05 PM, the Director of Nursing (DON) verbalized the governing body for the skilled nursing facility (SNF) was the hospital Board of Trustees and the Board of Trustees met monthly. The Hospital Board of Trustees Bylaws, Rules, and Regulations, Article II line a., dated 06/30/20, documented the board was authorized through NRS Chapter 450. The document lacked evidence the Hospital Board of Trustees were the designated Governing Body of the SNF or were responsible to provide management or oversight of the SNF. […]

• No harm, potential for more than minimal, widespreadF843May 11, 2021

  Based on interview and document review the facility failed to provide a written Transfer Agreement with a hospital. Findings include: On 05/11/21 at 11:56 AM, the Director of Nursing (DON) confirmed the skilled nursing facility (SNF), and the hospital were two different entities with two separate licenses. The DON verbalized the SNF did not have a transfer agreement with a hospital. The DON explained despite contacting the hospital's administration no transfer agreements for the SNF could be provided. The facility Patient Transfer Agreement, dated 10/01/11, and 02/26/21 and Inter-Facility Patient Transfer Agreement, dated 04/15/1990 and 05/01/12, documented transfer agreements between the local Hospital and other hospitals.

• No harm, potential for more than minimal, widespreadF867May 11, 2021

  Based on observation, interview, record review and document review, the facility Quality Assessment and Assurance (QAA) committee failed to identify the use of restraints resulting in substandard quality of care (See F Tag 0604) and the pattern use of side rails (See F Tag 0700.) Findings include: On 05/11/21 at 10:34 AM, the Director of Nursing (DON) and the Infection Preventionist and Staff Training Coordinator (IP/STC) explained the QAA committee met quarterly. On 05/11/21 at 10:51 AM, the DON and IP/STC verbalized the use of restraints and side rails were not monitored in QAA committee meetings. The facility was cited for pattern use of side rails during the 12/13/18 recertification survey. […]

• No harm, potential for more than minimal, widespreadF562Jan 29, 2021

  Based on interview and observation, the facility delayed entry of State surveyors into the Long Term Care facility, preventing the access to 37 of 37 residents for twenty minutes. Findings include: On 01/20/21 at 12:30 PM, three State surveyors arrived and attempted entry into the Long Term Care facility by ringing a doorbell. The doors were locked. A Registered Nurse (RN) greeted the State surveyors and left to get instruction on how to allow entry. The RN returned to the entry door where surveyors remained outside of the unit. […]