Harmony Village of Warren

In the surveyor’s words

From the most serious findings on record at Harmony Village of Warren, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 17, 2025

  This citation has two deficient practice statements. Deficient practice number one. This citation pertains to Intake MI00059836. Based on observation, interview, and record review, the facility failed to protect one resident from physical abuse from staff (R800) out of three reviewed for abuse, this deficient practice resulted in an Immediate Jeopardy (IJ) and the likelihood for serious physical and /or psychosocial harm, injury, impairment, or death. Findings include: R800 A review of Facility Reported Incident (FRI) noted the following, On April 3, 2025, Abuse coordinator made aware of an abuse allegation by DON [Director of Nursing] .around 10AM. [DON] stated, while rounding the A-wing unit, [R800] stated [they] was slapped by [their] midnight nurse. […]

• Immediate jeopardy, isolatedF689Jan 19, 2024

  This citation pertains to Intakes: MI00139923, MI00139924, MI00138212. Based on observation, interview, and record review, the facility failed to ensure the safety and prevent an elopement for one resident (R905) who has a legal guardian, and is incapable of making safe decisions. R905 eloped from the facility which is located on a busy four lane intersection on 7/25/2023 between 12:00pm and12:30pm without the facility staff being aware of the resident's whereabouts for approximately one hour. R905 was allowed to exit the facility by a visitor between 12:00-12:30pm on 7/25/23. R905 exited through the front door which requires a code to enter/exit. […]

• Actual harm, isolatedF684Dec 21, 2022

  This citation has three deficient practices. Deficient Practice Statement number 1. Based on observation, interview, and record review, the facility failed to appropriately assess and recognize skin alterations for one resident (R28) of four reviewed for quality of care, resulting in the development of untreated wounds, acute osteomyelitis, and toe amputation. Findings include: A review of R28's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on [DATE] and most recently readmitted from the hospital on 11/18/22. […]

• Actual harm, isolatedF686Sep 8, 2022

  This citation pertains to intake MI 425. Based on interview and record review, the facility failed to provide care consistent with professional standards of practice to treat existing pressure ulcers by 1) failing to initiate wound care treatments timely, 2) failing to complete wound care per orders, and 3) failing to follow up on a noted skin concern, affecting one sampled resident (R906) of five reviewed, resulting in the delayed and extended healing of wounds and infection, pain, and the potential for additional skin complications. Findings include: A review of R906's medical record indicated that the resident was initially admitted into the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812May 7, 2025

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 05/05/25 between 7:15 AM-7:45 AM, during an initial tour of the kitchen, the following items were observed: In the walk-in cooler, there was a large piece of cardboard on the floor underneath the rack holding the milk crates. The surface of the cardboard was covered with a spotty, black mold-like substance. […]