Harmony Park Ridge

In the surveyor’s words

From the most serious findings on record at Harmony Park Ridge, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 23, 2026

  Based on interview and record review, the facility failed to ensure necessary services and treatment were provided to prevent the development and/or worsening of pressure injuries for one (R2) of three residents reviewed for pressure ulcers. This failure resulted in R2 developing a Stage 3 pressure ulcer to the left buttock and a Stage 4 pressure ulcer to the right buttock while residing in the facility.Findings:R2 was a [AGE] year-old resident. admission nursing note dated 02/05/2025 documented incontinence and slight redness to the sacral area. A skin assessment completed the same date indicated pressure ulcers to the right and left buttocks.On 04/20/2025 at 1:45 PM, V4 (R2's family member) stated R2 had two black holes on their buttocks while they lived in this facility. […]

• Actual harm, isolatedF689Jun 11, 2025

  Based on interview, and record review the facility failed to ensure resident safety by failure to provide 2 persons assist when transferring resident using a mechanical lift. This affected one resident (R1) of three residents reviewed for falls. This failure resulted in resident (R1) falling from mechanical lift and sustaining a left displaced femoral neck fracture. Findings include: R1 was admitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of base of neck of left femur, unspecified osteoarthritis, encounter for other specified surgical aftercare, hypothyroidism, hemiplegia, unspecified affecting left nondominant side, unspecified dementia, unspecified severity without behavioral disturbance, difficulty in walking, unspecified fall, subsequent… […]

• Actual harm, isolatedF600Apr 6, 2025

  Based on interview and record review, the facility failed to protect a resident from allegedly being roughly handled, threatened, punched, and intimidated by an agency staff person; failed to assess resident of any injuries; and failed to train staff on screening, abuse prevention and investigation. This failure affected 1 (R1) of 3 residents reviewed for abuse from the sample of 3 and resulted in R1 abruptly ending her rehabilitation to discharge home due to the resident feeling unsafe and distressed for fear of agency staff's return. Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. […]

• Actual harm, isolatedF692Mar 14, 2025

  Based on observation, interviews, and a review of records, the facility failed to follow its weight monitoring policy to prevent or reduce the risk of residents experiencing unplanned significant weight loss. This failure affected three of ten residents (R17, R28, and R61) who were reviewed for weight monitoring and weight loss as part of a sample of 40 residents. As a result, R17 experienced an unplanned weight loss of 6.15% over a 30-day period, R28 experienced a 15.3% weight loss over six months, and R61 experienced an 11.2% weight loss during a six-month period. Findings include: 1) On 3/11/25 at 10:15 AM, R17 was observed to be on a pureed diet with nectar thick liquids. R17 was observed attempting to self-feed breakfast. R17 was observed to have only consumed 20% of breakfast. […]

• Actual harm, isolatedF689Dec 26, 2024

  Based on interview and record review, facility staff V3 (Certified nursing assistant, CNA) failed to report a fall to the nurse for one resident (R2). This failure resulted in R2 being transferred back into bed with no nurse assessment for over 10 hours. R2 was transferred to the hospital for a left ear laceration requiring eleven sutures and broken ribs for one of three residents reviewed for falls. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Covid 19, urinary tract infection, Parkinson's and overactive bladder. […]