Harmony Pointe Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686May 9, 2023

  Based on record review and interviews, the facility failed to ensure one (#92) of three residents reviewed for pressure injuries out of 29 sample residents remained free from worsening of a pressure injury. Resident #92, was admitted on [DATE] for short term rehabilitation with a goal to return home. The resident was admitted to the facility without any skin conditions. The resident had a fall on 4/5/23 in which he sustained a right hip fracture. In addition, the resident had a subsequent fall on 4/20/23 in which he refractured his right hip around the periprosthetic (structure in close relation to an implant), a distal femur fracture (fractures of the thigh bone that occur just above the knee joint) and nondisplaced left superior pubic fracture (a break in one of the bones that make up… […]

• Actual harm, isolatedF689May 9, 2023

  Based on observation, record review and interviews, the facility failed to ensure one (#92) of six residents reviewed for accidents out of 29 sample residents remained as free from accident hazards as possible. Resident #92, was initially admitted for short term rehabilitation on 2/28/23 with a goal to return home. He was identified as a high fall risk and as a high elopement risk upon admission. The resident had numerous predisposing factors which included: dementia, confusion and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from: eloping on one occasion and falling seven times within a period of two months. The resident sustained major injuries from two out of seven falls which led to hospitalization . […]

• Actual harm, isolatedF689Feb 7, 2022

  Based on record review and interviews, the facility failed to ensure four (#66, #70, #29 and #50) of six residents reviewed for accidents out of 35 sample residents remained as free from accident hazards as possible. Resident #66, who was identified as a high fall risk, had numerous predisposing factors which included dementia, confusion, unsafe sleeping habits, and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from falling on multiple occasions. Due to the facility's failures, the resident sustained an acute distal ulna fracture to her left wrist subsequent to a fall on 1/18/22 requiring hospital treatment for trauma to the left wrist and pain. […]

• Actual harm, isolatedF600Mar 3, 2021

  Based on interviews and record review, the facility failed to ensure two (#1 and #4) of three residents reviewed out of 11 sample residents were kept free from abuse. The facility failed to ensure Resident #5 was kept free from resident-to-resident abuse by Resident #4. Resident #4 who had a known history of verbal aggression toward others was not provided the necessary tools and behavioral interventions when she expressed she was unhappy with her roommate (Resident #5) on multiple occasions over a six month period of time. Furthermore, the facility failed to determine the root cause of Resident #4 frustration with Resident #5 and provide intervention to prevent a potentially abusive incident from occurring. […]

• No harm, potential for more than minimal, patternF567Sep 26, 2024

  Based on observations and interviews the facility failed to ensure that residents personal funds accounts were managed adequately for the facility and accessible to the residents. Specifically, the facility failed to ensure residents were able to access their personal funds accounts on the weekend. Findings include: I. Resident interviews Resident #27 was interviewed on 9/23/24 at 11:48 a.m. Resident #27 said she could only access her personal funds account when the lady in the front office was in the facility. Resident #27 said she could not get money from her personal funds account on the weekends. Resident #16 was interviewed on 9/26/24 at 11:32 a.m. Resident #16 said residents could not get money from their personal funds account on the weekends. […]