Harmony River Living Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 7, 2026

  Based on observation, interview, and document review, the facility failed to provide care consistent with a resident's needs and care plan to eliminate/reduce the risk of an accident during cares in bed for 1 of 3 residents (R111). This resulted in actual harm to R111 when staff repositioned R111 on her side with one staff member instead of two staff members per care plan, causing R111 to roll out of the bed to the floor. As a result, R111 was admitted to the hospital on [DATE] for a fracture of the right femur and a closed fracture of the left hip. R111 had surgery on 12/6/25 on the right femur and surgery on 12/11/25 on the left hip femur. […]

• Actual harm, isolatedF760Oct 15, 2025

  Based on interview and document review, the facility failed to ensure medications were administered according to physician orders for 1 of 3 residents (R1) reviewed for significant medication errors. This failure resulted in actual harm when R1 did not receive twelve doses of a medication for treatment of congestive heart failure and subsequently required a two-day hospitalization. The facility implemented appropriate corrective action prior to the onsite investigation; therefore, the deficiency is being cited at past non-compliance. […]

• No harm, potential for more than minimal, widespreadF761Jan 9, 2024

  Based on observation, interview and document review, the facility failed to ensure medication carts were properly secured for 4 of 8 medication carts observed. Findings Include: On 1/8/24, at 8:50 a.m. during medication observation trained medication aide (TMA)-A stepped away from medication cart, entered nursing office out of view of medication (med) cart with lock button observed to be in extended position. TMA-A returned to cart, continued with medication administration When interviewed on 1/8/24, at 9:03 a.m. TMA-A stated when lock button in extended position the medication cart was unlocked. TMA-A demonstrated entering code into touchpad on top surface of cart locked med cart by pulling lock button into cart. […]

• No harm, potential for more than minimal, isolatedF609Jun 10, 2026

  Based on interview and document review the facility failed to report an allegation of sexual abuse to the state agency (SA) for 2 of 3 residents (R4, R5) reviewed for reporting of alleged violations when R1 displayed sexual behaviors towards R4 and R5. Findings include: R1 R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. […]

• No harm, potential for more than minimal, isolatedF744Jun 10, 2026

  Based on observation, interview and document review the facility failed to develop and implement resident specific approaches to behavior for 1 of 3 residents (R1) diagnosed with dementia who displayed negative behaviors affecting himself and other residents in the facility. Findings include: R1's admission Record printed 6/11/26, indicated he was admitted to the facility 2/10/26. Diagnoses included Alzheimer's disease, dementia and psychosis. R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed verbal behaviors toward others one-to-three days during the assessment period. The MDS indicted R1 transferred independently and ambulated with supervision. […]