Inspection Report Summary
The most recent inspection on October 16, 2025, found no deficiencies, confirming correction of previously cited issues. Earlier inspections showed a pattern of deficiencies primarily related to inadequate housekeeping and maintenance, insufficient staffing levels, failure to provide appropriate activities in the Alzheimer's/dementia unit, and lapses in incident reporting. Several complaint investigations were substantiated, often citing these same themes, while most complaints were unsubstantiated or corrected upon follow-up. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record indicates improvement over time, with recent follow-up inspections verifying correction of prior deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
31.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
251% worse than West Virginia average
West Virginia average: 9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
104 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Census: 104
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
Second follow-up to Complaint #38048 conducted from 2025-10-06 to 2025-10-16 to verify correction of previously identified deficiencies.
Complaint Details
Complaint #38048; the deficiency was corrected.
Findings
The deficiency related to the complaint was corrected as of the follow-up inspection.
Report Facts
Census: 73
Census: 31
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
Investigation of Complaint #40128 conducted from 2025-10-06 to 2025-10-16 to determine the validity of the complaint.
Complaint Details
Complaint #40128 was investigated from 2025-10-06 to 2025-10-16 and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 3
Date: Sep 10, 2025
Visit Reason
Investigation of Complaint #39996 regarding the Alzheimer's/dementia special care unit's activities program and overall care.
Complaint Details
Complaint #39996 was investigated from 2025-09-02 to 2025-09-10. The complaint was unsubstantiated, but unrelated deficiencies were cited.
Findings
The complaint was unsubstantiated, but unrelated deficiencies were cited including failure to provide appropriate activities in the Alzheimer's/dementia special care unit, lack of a qualified Activities Director, and inadequate housekeeping and maintenance in the adolescent consumers' residence.
Deficiencies (3)
Failed to ensure the Alzheimer's/dementia special care unit provided activities appropriate to the needs of the individual residents and structured the residents' routine seven days per week.
Failed to employ an Activities Director meeting all regulatory requirements for the position.
Failed to ensure adequate housekeeping and maintenance required to carry out its services, including presence of personal belongings behind furniture, carpet damage, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Census: 69
Census: 29
Sample Size: 3
Completion Date: Nov 10, 2025
Completion Date: Nov 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Coordinator #2 | Memory Care Coordinator | Interviewed regarding activities calendar and staffing |
| Corporate Liaison #0 | Corporate Liaison | Interviewed regarding Activities Director vacancy and hiring plans |
Inspection Report
Follow-Up
Census: 98
Deficiencies: 0
Date: Sep 2, 2025
Visit Reason
Follow-up to Complaint #38414 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #38414 was the basis for the follow-up visit; the citation was corrected.
Findings
The citation related to the complaint was corrected as of the follow-up inspection.
Report Facts
Census: 69
Census: 29
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Aug 11, 2025
Visit Reason
Investigation of Complaint #39715 regarding the assisted living and memory care units at Harmony at Southridge.
Complaint Details
Complaint #39715 was investigated and substantiated; however, no deficiencies were cited.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Report Facts
Census: 72
Census: 30
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
Revisit to Complaint #37661 to verify correction of previously cited deficiency.
Complaint Details
Complaint #37661 was investigated and the deficiency was corrected by the time of the revisit inspection.
Findings
The deficiency related to the complaint was corrected as of the revisit inspection conducted on 07/22/2025.
Report Facts
Census: 66
Census: 26
Inspection Report
Follow-Up
Census: 94
Deficiencies: 2
Date: Jul 9, 2025
Visit Reason
First follow-up to Complaint #38048 conducted from 07/07/25 to 07/09/25 to verify correction of previously cited deficiencies.
Complaint Details
Follow-up to Complaint #38048. Census at time of follow-up: Assisted Living- 67, Memory Care- 27. One deficiency was re-cited.
Findings
The licensee failed to ensure the residence was free of insects, with observations of tiny black flying insects and bed bugs in Room 230. Additionally, inadequate housekeeping and maintenance issues were noted, including personal belongings behind furniture, carpet damage, and missing bathroom fixtures.
Deficiencies (2)
Failed to keep the residence free of insects, including presence of tiny black flying insects and bed bugs.
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, and missing bathroom fixtures.
Report Facts
Census: 67
Census: 27
Deficiencies re-cited: 1
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
Investigation of complaint #39101 conducted from 07/07/25 to 07/09/25 at Harmony at Southridge, an assisted living and memory care facility.
Complaint Details
Complaint #39101 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 67
Census: 27
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
Revisit to Complaint #37505 conducted from 07/07/25 to 07/09/25 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #37505 was investigated and the deficiency was found to be corrected upon revisit.
Findings
The deficiency cited in the prior complaint investigation was corrected as of the revisit inspection.
Report Facts
Census: 67
Census: 27
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: May 29, 2025
Visit Reason
Investigation of Complaint #38555 regarding the assisted living and memory care units at Harmony at Southridge.
Complaint Details
Complaint #38555 was investigated from 05/27/25 to 05/29/25. The complaint was found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 66
Census: 26
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Date: May 27, 2025
Visit Reason
Investigation of Complaint #38414 regarding failure to report a major incident involving a resident with injury.
Complaint Details
Complaint #38414 was substantiated. The deficiency involved failure to report a major incident concerning Resident #1, who was found with injury on 03/29/25 and sent to the hospital on 03/30/25. The incident was not reported as required.
Findings
The Licensee failed to report a major incident involving a resident found with a large knot, bruising, and swelling to the right eye to the Office of Health Facility Licensure and Certification within the required timeframe. The complaint was substantiated and a deficiency was cited.
Deficiencies (1)
Failure to report major incidents to the Office of Health Facility Licensure and Certification no later than the next business day.
Report Facts
Census: 66
Census: 26
Sample Size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding the failure to report the major incident |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 7, 2025
Visit Reason
Follow-up inspection conducted to verify correction of deficiencies cited in Complaint #37381.
Complaint Details
Follow-up to Complaint #37381. The deficiencies were corrected.
Findings
The deficiencies identified in the previous complaint investigation were corrected as of the follow-up visit on 05/07/2025.
Report Facts
Complaint number: 37381
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
Investigation of Complaint #37521 regarding the assisted living and memory care units at Harmony at Southridge.
Complaint Details
Complaint #37521 was investigated from 04/07/25 to 04/17/25. The complaint was substantiated, and no deficiencies were cited.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Report Facts
Census: 62
Census: 29
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as an investigation of Complaint #37661, which started on 04/07/25 and ended on 04/17/25, to assess allegations related to insufficient staffing and delayed response to call pendants at the assisted living and memory care residence.
Complaint Details
Investigation of Complaint #37661 from 04/07/25 to 04/17/25. The complaint was substantiated and a deficiency was cited.
Findings
The facility failed to ensure sufficient staffing levels to provide residents with all required care and services, resulting in delayed responses to call pendants and late meal deliveries. Observations and interviews confirmed residents experienced wait times exceeding one hour for assistance and meals. The complaint was substantiated and deficiencies were cited related to staffing and timely response.
Deficiencies (1)
Failed to ensure sufficient staffing levels to provide residents with all required care and services, including timely response to call pendants.
Report Facts
Census: 62
Census: 29
Call pendant response time: 76
Call pendant response time: 57
Call pendant response time: 126
Call pendant response time: 106
Call pendant response time: 124
Late lunch delivery: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee M | Executive Director | Stated new walkie talkies had been ordered and staff would receive re-training on timely call light answering |
| Interim Executive Director | Acknowledged staffing shortages and plans for hiring fair and new walkie talkies |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Date: Apr 17, 2025
Visit Reason
Investigation of Complaint #38048 regarding facility conditions and compliance with health and safety regulations.
Complaint Details
Complaint #38048 was substantiated. The investigation started on 2025-04-07 and ended on 2025-04-17. Census during investigation was Assisted Living-62, Memory Care-29.
Findings
The complaint was substantiated with deficiencies cited including failure to keep the residence free of insects, inadequate housekeeping and maintenance, and failure to provide disaster and emergency preparedness plans at all staff stations with staff knowledge of their location.
Deficiencies (3)
Licensee failed to ensure the residence was free of insects; insects found in Resident #15's kitchen and bathroom.
Licensee failed to provide adequate housekeeping and maintenance; issues included personal belongings behind dresser, carpet damage, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Licensee failed to provide a copy of the disaster and emergency preparedness plan at all staff stations and ensure staff knew the location of the plan.
Report Facts
Resident census: 62
Resident census: 29
Resident identifier: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Employee | Interviewed regarding insect issue and pest control | |
| Licensed Practical Nurse (LPN) #7 | Interviewed about knowledge of emergency preparedness plan location | |
| Licensed Practical Nurse (LPN) #16 | Interviewed about knowledge of emergency preparedness plan location | |
| Management (M) #11 | Interviewed regarding corrections for emergency preparedness plan deficiencies |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
Investigation of Complaint #37505 regarding infection control practices at the facility.
Complaint Details
Complaint #37505 was investigated from 04/07/25 to 04/17/25. The complaint was unsubstantiated, but an unrelated deficiency was cited.
Findings
The licensee failed to ensure staff followed appropriate infection control practices, specifically an employee licking fingers to separate lunch menus before distributing them to residents. The complaint was unsubstantiated, but an unrelated deficiency was cited.
Deficiencies (1)
Staff failed to follow appropriate infection control practices when working with residents, including licking fingers to separate papers given to residents.
Report Facts
Census: 62
Census: 29
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 3
Date: Mar 6, 2025
Visit Reason
Investigation of Complaint #37381 conducted from 03/02/25 to 03/06/25 at Harmony at Southridge, an assisted living and memory care facility.
Complaint Details
Complaint #37381 was investigated from 03/02/25 to 03/06/25. The complaint was substantiated with deficiencies cited related to notification failures, medication administration neglect, and physical facility maintenance issues.
Findings
The complaint was substantiated with multiple deficiencies cited including failure to notify a resident's physician of a significant change in condition, missed medication doses for several residents, and inadequate maintenance and housekeeping resulting in physical environment issues such as a faulty door threshold and damaged carpets.
Deficiencies (3)
Failure to promptly notify resident's physician or licensed health care professional of a significant change in condition for Resident #58.
Failure to ensure residents were free from neglect related to missed vital medications for Residents #6, #48, and #55.
Failure to keep the interior and exterior of the residence clean and in good repair, including a faulty threshold causing difficulty opening and closing a resident's door.
Report Facts
Resident census: 72
Resident census: 29
Missed insulin doses: 13
Missed medication dates: 8
Missed medication dates: 11
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
Investigation of Complaint #36725 regarding the assisted living and memory care units at Harmony at Southridge.
Complaint Details
Complaint #36725 was investigated from 2025-02-11 to 2025-02-12. The complaint was found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 73
Census: 34
Inspection Report
Annual Inspection
Census: 73
Capacity: 34
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was an Environmental-Annual survey conducted to evaluate the facility's compliance with emergency preparedness and safety regulations.
Findings
The facility failed to maintain a comprehensive emergency preparedness program, specifically lacking a current emergency transportation policy. The facility census was 73 with 34 memory care residents. The emergency transportation policy and contract were expired but were updated and renewed during the plan of correction.
Deficiencies (1)
The facility failed to have a current emergency transportation policy and contract, which was only valid for one year.
Report Facts
Deficiencies cited: 1
Sprinkler count: 13
Permit number: 202514318
Employees mentioned
| Name | Title | Context |
|---|---|---|
| B. Palmer | Fire Marshall | Fire Marshall report referenced in the inspection |
| Executive Director | Executive Director | Named in plan of correction for emergency transportation policy update |
| Maintenance Manager | Maintenance Manager | Named in plan of correction for emergency transportation policy update |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The inspection was an environmental annual survey conducted to assess compliance with health and safety regulations at Harmony at Southridge.
Findings
The survey included a full sample size inspection with 44 deficiencies cited. The facility's fire marshal and health department reports were also referenced.
Report Facts
Deficiencies cited: 44
Sprinkler count: 13
Sample size: 100
Census: 73
Memory Care Census: 34
Inspection Report
Follow-Up
Census: 107
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
Follow-up visit to verify correction of deficiencies cited in Complaint #35124.
Complaint Details
Complaint #35124 was investigated and the citations were corrected.
Findings
The citations related to the complaint were corrected as of the follow-up inspection.
Report Facts
Census: 73
Census: 34
Inspection Report
Follow-Up
Census: 6
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
Follow-up to Complaint #34792 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #34792 was the basis for the follow-up visit; the deficiency was corrected.
Findings
The deficiency related to safety and supervision was corrected as of the follow-up visit on 12/12/2024.
Deficiencies (1)
The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including lack of awake-night supervision on weekends and unsecured outside doors.
Report Facts
Center Census: 6
Sample Size: 3
Inspection Report
Follow-Up
Census: 6
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
Follow-up to Complaint #34795 to verify correction of previously identified deficiencies.
Complaint Details
Complaint #34795 was investigated and deficiencies were found; this follow-up confirms the deficiencies were corrected.
Findings
The deficiencies identified in the prior complaint investigation were corrected as of the follow-up visit on 12/12/2024.
Report Facts
Center Census: 6
Inspection Report
Follow-Up
Census: 6
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
Follow-up to Complaint #34610 to verify correction of previously identified deficiencies.
Complaint Details
Follow-up to Complaint #34610; the deficiency was corrected.
Findings
The deficiency related to safety and supervision was corrected as of the follow-up visit on 12/12/2024.
Deficiencies (1)
The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including lack of alarms on outside doors and insufficient awake staff on weekend nights.
Report Facts
Center census: 6
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The visit was conducted as an investigation of Complaint #34792 regarding the functionality of the emergency call system in the Memory Care unit.
Complaint Details
Investigation of Complaint #34792 from 11/05/24 to 11/07/24. The complaint was substantiated and a deficiency was cited.
Findings
The investigation found that the emergency call system in the Memory Care unit was not functioning properly on the day of the survey, as there was no audio or visual alert when the call cord was pulled. The complaint was substantiated and a deficiency was cited. The facility planned corrective actions including ordering additional handheld radios for staff use.
Deficiencies (1)
Failed to provide maintenance to the interior of the facility to provide a safe environment, specifically the emergency call system in the Memory Care unit was not functioning properly.
Report Facts
Census: 61
Census: 36
Additional radios ordered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Named in relation to the call system deficiency and corrective actions |
| Memory Care Director | Memory Care (MC) Director | Observed and reported the call system failure during the inspection |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 3
Date: Nov 7, 2024
Visit Reason
Investigation of Complaint #34795 conducted from 11/05/24 to 11/07/24 at Harmony at Southridge, an assisted living and memory care facility.
Complaint Details
Complaint #34795 was investigated from 11/05/24 to 11/07/24 and was substantiated. Unrelated deficiencies were also cited.
Findings
The complaint was substantiated. Deficiencies were found related to incomplete resident records missing physician contact information and social security numbers, as well as inadequate housekeeping and maintenance issues including damaged carpets, missing bathroom fixtures, and unclean sinks.
Deficiencies (3)
Resident records missing addresses and phone numbers for physicians for three residents (20, 29, 72).
Resident record missing social security number for one resident (74).
Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Resident census: 61
Resident census: 36
Residents with deficient records: 3
Residents with deficient records: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in relation to findings and plan of correction |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 4
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint #35124 from 11/05/24 to 11/07/24 at Harmony at Southridge, an assisted living and memory care facility.
Complaint Details
Investigation of Complaint #35124 from 11/05/24 to 11/07/24. The complaint was substantiated, and deficiencies were cited.
Findings
The complaint was substantiated with deficiencies cited related to failure to report major incidents timely, failure to notify the registered nurse immediately upon resident admission with nursing care needs, and failure to perform and document nursing assessments within 24 hours of admission. Additional findings included inadequate housekeeping and maintenance issues.
Deficiencies (4)
The licensee failed to report major incidents to the Office of Health Facility Licensure and Certification within the required timeframe for three residents.
The licensee failed to ensure the Registered Nurse was notified immediately when a resident with nursing care needs was admitted.
The licensee failed to ensure the Registered Nurse performed and documented a nursing assessment within 24 hours following admission of a resident with nursing care needs.
The facility failed to ensure adequate housekeeping and maintenance required to carry out its services, including issues such as carpet damage, missing bathroom fixtures, and unclean sinks.
Report Facts
Census: 61
Census: 36
Residents with unreported major incidents: 3
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Discussed findings related to major incident reporting and nursing care |
| Health Care Director | Health Care Director | Discussed findings related to major incident reporting and nursing care |
| Registered Nurse | Registered Nurse | Responsible for nursing assessments and notification |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Date: Oct 16, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint #34610 regarding the lack of a functioning call system audible to staff.
Complaint Details
Investigation of Complaint #34610 on 10/16/24. The complaint was substantiated and a deficiency was cited.
Findings
The facility failed to ensure residents had access to a functioning call system audible to staff, affecting all residents. The complaint was substantiated and a deficiency was cited. The Administrator and Healthcare Director confirmed the issue and implemented interim measures while awaiting replacement parts.
Deficiencies (1)
The residence did not have a functioning call system audible to staff, potentially affecting all residents.
Report Facts
Census: 102
Census: 66
Census: 36
Wellness check frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed the call system issue and ordered a new transmitter | |
| Healthcare Director | Confirmed the call system issue and increased wellness checks | |
| Maintenance Director | Determined new transmitter incompatibility and installed new transmitter with IT assistance |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Sep 23, 2024
Visit Reason
Investigation of Complaint #33700 regarding the assisted living and memory care facility.
Complaint Details
Complaint #33700 was investigated from 2024-09-17 to 2024-09-23. The complaint was found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 68
Census: 35
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
Investigation of Complaint #33199 regarding the assisted living and memory care units at Harmony at Southridge.
Complaint Details
Complaint #33199 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 56
Census: 36
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
Investigation of Complaint #33190 regarding the assisted living and memory care units at Harmony at Southridge.
Complaint Details
Complaint #33190 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 56
Census: 36
Inspection Report
Follow-Up
Census: 92
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
This visit was the first follow-up to Complaint #32492 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #32492 was investigated and the citations were cleared as of the follow-up visit on 08/06/2024.
Findings
The citations related to the complaint were cleared during this follow-up visit.
Report Facts
Census: 92
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
Investigation of Complaint #32496 regarding the assisted living and memory care units at the facility.
Complaint Details
Complaint #32496 was investigated from 06/03/24 to 06/05/24. The complaint was found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census: 64
Census: 34
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Date: Jun 5, 2024
Visit Reason
Investigation of Complaint #32492 conducted from 06/03/24 to 06/05/24 regarding concerns about major incident reporting and resident record security.
Complaint Details
Complaint #32492 was investigated from 06/03/24 to 06/05/24. The complaint was unsubstantiated, but deficiencies were cited related to major incident reporting and record security.
Findings
The licensee failed to notify the Office of Health Facility Licensure and Certification of a major incident involving an unwitnessed fall of Resident #53. Additionally, the licensee failed to ensure residents' medical records were secured, as an unattended and unlocked computer displaying resident information was observed. The complaint was unsubstantiated but deficiencies were cited.
Deficiencies (2)
Failure to report a major incident to the Office of Health Facility Licensure and Certification in a timely manner.
Failure to retain residents' medical records in a secure area, exposing confidential information on an unattended and unlocked computer.
Report Facts
Resident census: 64
Resident census: 34
Total census: 98
Inspection Report
Follow-Up
Census: 98
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
Second follow-up to Complaint #30590 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #30590 was the basis for this follow-up visit; the citation was cleared.
Findings
The citation related to the complaint was cleared during this follow-up visit.
Report Facts
Census: 64
Census: 34
Inspection Report
Follow-Up
Census: 98
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
Second follow-up visit to verify correction of deficiencies identified in the annual survey.
Findings
The deficiencies identified in the previous annual survey were corrected as of the follow-up visit.
Report Facts
Census: 64
Census: 34
Inspection Report
Follow-Up
Census: 104
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
First follow-up to Complaint #30853 conducted from 04/23/24 to 04/25/24 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #30853 was the basis for this follow-up inspection. The citations from the complaint were cleared.
Findings
The citations related to the complaint were cleared during this follow-up visit. The census included 68 residents in Assisted Living and 36 in Memory Care.
Report Facts
Census: 68
Census: 36
Inspection Report
Follow-Up
Census: 104
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
Second follow-up to Complaint #30592 conducted from 04/23/24 to 04/25/24 to verify correction of previous deficiencies.
Complaint Details
Complaint #30592 was the basis for the follow-up visit; the citations were cleared.
Findings
The citations related to the complaint were cleared during this follow-up inspection.
Report Facts
Census: 68
Census: 36
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
Investigation of Complaint #32376 conducted from 04/23/24 to 04/25/24 at Harmony at Southridge, an assisted living and memory care facility.
Complaint Details
Complaint #32376 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Report Facts
Census Memory Care: 36
Census Assisted Living: 68
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
First revisit to complaint #30854 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #30854 was investigated and the citations were cleared upon this revisit.
Findings
The citations related to the complaint were cleared during this revisit inspection.
Report Facts
Census - Assisted Living: 63
Census - Memory Care: 32
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Date: Apr 17, 2024
Visit Reason
The inspection was a first follow-up to Complaint #30590 to assess compliance with staffing requirements and facility conditions.
Complaint Details
First follow-up to Complaint #30590. One deficiency was re-cited related to staffing requirements.
Findings
The facility failed to meet staffing requirements by not having the required number of direct care staff on the day shift for residents with two or more care needs. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.
Deficiencies (2)
Failed to ensure the residence had one direct care staff on the day shift for each 10 residents with two or more care needs.
Failed to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and dirty sink.
Report Facts
Residents with 2 or more care needs: 31
Direct care staff required for day shift: 4
Census: 63
Census: 32
Direct care staff on day shift: 3
Direct care staff on day shift: 2
Direct care staff on day shift: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Named in relation to staffing deficiency and plan of correction |
| Healthcare Director | Healthcare Director (HCD) | Named in relation to staffing deficiency and plan of correction |
| Memory Care Director | Memory Care Director (HSD) | Named in relation to staffing deficiency and plan of correction |
Inspection Report
Follow-Up
Census: 95
Deficiencies: 2
Date: Apr 17, 2024
Visit Reason
First follow-up to annual survey conducted to verify correction of previously cited deficiencies related to nursing documentation and medication administration timeliness.
Findings
Two deficiencies were re-cited involving incomplete RN visit documentation signatures and delayed medication administration for three residents. The facility implemented new RN log forms and revised medication pass scheduling to address these issues.
Deficiencies (2)
Registered Nurse failed to maintain documentation for each visit with a complete signature.
Residents did not receive medications in a timely manner according to current standards of practice.
Report Facts
Census: 63
Census: 32
Deficiencies re-cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in medication administration delay findings and plan of correction |
| Healthcare Director | Healthcare Director | Named in medication administration delay findings and plan of correction |
| Memory Care Director | Memory Care Director | Named in medication administration delay findings and plan of correction |
| Employee #65 | Approved Medication Assistive Personnel (AMAP) | Interviewed regarding medication pass delays due to computer issues |
| Director of Nursing | Director of Nursing | Interviewed regarding medication pass delays |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 3
Date: Mar 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to maintain accurate records of residents' shower schedules and concerns about personal hygiene and housekeeping.
Complaint Details
Investigation of Complaint #30854 from 03/18/24 to 03/20/24. The complaint was substantiated and deficiencies were cited.
Findings
The facility failed to maintain accurate shower documentation for multiple residents and did not adequately address personal hygiene and grooming needs, including nail care. Additionally, housekeeping and maintenance deficiencies were observed, such as damaged carpet, missing bathroom fixtures, and unclean areas.
Deficiencies (3)
Failure to maintain accurate records related to residents' shower schedules for three residents.
Failure to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sink.
Failure to ensure one resident was not neglected regarding personal hygiene and grooming, including unkempt hair and long toenails.
Report Facts
Census: 61
Census: 32
Number of residents with shower record deficiencies: 3
Number of residents observed for neglect: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding shower documentation deficiencies and personal hygiene issues | |
| Executive Director | Interviewed regarding Memory Care Director hiring and resident care issues | |
| Memory Care Director | Recently hired to address Memory Care Unit resident assessments and care |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
Investigation of Complaint #30737 regarding the assisted living and memory care units at Harmony at Southridge.
Complaint Details
Complaint #30737 was investigated and substantiated; however, no deficiencies were cited.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation conducted from 03/18/24 to 03/20/24.
Report Facts
Census: 61
Census: 32
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 3
Date: Mar 20, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint #30853 regarding staffing and medication administration issues on the Memory Care Unit.
Complaint Details
Complaint #30853 was substantiated. The complaint involved insufficient staffing and delayed medication administration on the Memory Care Unit.
Findings
The facility failed to provide sufficient direct care staff to ensure timely medication administration for residents on the Memory Care Unit, affecting all 32 residents. Additionally, inadequate housekeeping and maintenance issues were observed in the adolescent consumer residence.
Deficiencies (3)
Failed to provide sufficient staff to ensure timely medication administration on the Memory Care Unit.
Failed to provide adequate housekeeping and maintenance in the residence, including damaged carpet, missing bathroom fixtures, and unclean sink.
Failed to provide staffing at no less than 2.25 hours of direct care personnel time per resident per day on the Memory Care Unit.
Report Facts
Resident census: 61
Resident census: 32
Medications delayed: 8
Medications delayed: 8
Medications delayed: 10
Medications delayed: 5
Direct care staff: 2
Dates with insufficient staffing: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Discussed staffing inadequacies and inability to reconcile adequate coverage for medication pass | |
| Approved Medication Assistive Personnel | AMAP | Reported call-in and delay in medication pass on 03/19/24 |
Inspection Report
Follow-Up
Census: 93
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
First follow-up to Complaint #30592 to verify correction of previously cited deficiencies related to resident roster accuracy and facility compliance.
Complaint Details
This visit was a first follow-up to Complaint #30592. The deficiency related to inaccurate resident records was re-cited.
Findings
The facility failed to maintain accurate resident records as the Resident Roster did not match the Resident Registry, with discrepancies noted on multiple review dates. The deficiency was re-cited. Plans of correction included staff training and improved monitoring of resident records.
Deficiencies (1)
Licensee failed to maintain accurate records and reports as required when the Resident Roster did not match the Resident Registry.
Report Facts
Census: 61
Census: 32
Discrepancies in resident records: 15
Discrepancies in resident records: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged discrepancies in resident records and conducted in-service training | |
| Director of Nursing | Interviewed regarding resident record discrepancies | |
| Healthcare Director | Participated in in-service training on resident roster and registry completion | |
| Harmony Square/Memory Care Director | Participated in in-service training on resident roster and registry completion |
Inspection Report
Follow-Up
Census: 93
Deficiencies: 1
Date: Mar 18, 2024
Visit Reason
First follow-up to Complaint #30587 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #30587 was the reason for the initial visit; deficiency was corrected upon follow-up.
Findings
The deficiency related to the complaint was corrected as of the follow-up survey date.
Deficiencies (1)
Deficiency related to Complaint #30587 was corrected.
Report Facts
Census - Assisted Living: 61
Census - Memory Care: 32
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 21
Date: Feb 8, 2024
Visit Reason
Annual survey conducted to assess compliance with state regulations for assisted living and memory care units.
Findings
The facility was found deficient in multiple areas including medication administration timeliness, incomplete nursing assessments and care plans, inadequate staff training and supervision, improper food storage, maintenance issues, and incomplete documentation of resident care and employee records.
Deficiencies (21)
Failed to offer monthly educational and family support group meetings for the Memory Care unit.
Failed to ensure adequate housekeeping and maintenance required to carry out its services, including damaged carpet, missing towel bars, and dirty sinks.
Failed to ensure prior to admission each resident and/or their legal representative was provided with a copy of the disclosure statement and that a signed copy was kept in the record.
Failed to ensure at least one employee per shift was responsible for activities programming on the Memory Care unit.
Failed to ensure outdated or discontinued drugs listed in controlled substance schedules were destroyed in the presence of a pharmacist and registered nurse.
Failed to notify the Secretary in writing within 10 days of any permanent change in the consulting or supervising registered professional nurse and failed to obtain an extension allowing operation without a RN for more than 30 days.
Failed to ensure service plans reflected residents' current needs, including diabetes management and assistance with showers.
Failed to ensure the Registered Nurse was notified immediately when a resident with nursing care needs was admitted or readmitted and when a nursing care need was identified.
Failed to store food in a safe and sanitary manner; expired or undated food items and improper storage of opened containers and cleaning chemicals.
Failed to ensure resident care was provided by appropriately licensed health care professionals; AMAPs administered Ozempic injections outside their scope of practice.
Failed to maintain accurate records and reports, including incomplete transfer/discharge forms and improper documentation of AMAP quarterly reviews and competencies.
Failed to offer Grade A vitamin D milk daily with meals on the Memory Care unit.
Failed to maintain a confidential personnel record for all employees, including contracted staff.
Failed to ensure all residents had a written, signed, and dated health assessment completed by a licensed health care professional within required timeframes.
Failed to complete and maintain a record of refrigerator temperatures to ensure medications were stored within recommended ranges.
Failed to ensure residents received all necessary care and services in a timely manner; multiple residents received medications after the required time frame.
Failed to ensure a record was kept of all medications given to each resident indicating each dose administered.
Failed to ensure a nursing assessment was performed and documented within 24 hours of admission and updated at significant changes for residents with nursing needs.
Failed to maintain the residence in a safe and accident-free manner; main door to Memory Care unit did not latch properly creating a safety hazard.
Failed to ensure no resident was abused, exploited, neglected, mistreated, or restrained improperly; residents did not receive medications timely and one resident lacked timely catheter orders.
Failed to ensure a Registered Nurse saw residents weekly for those with nursing care needs and documented progress notes reflecting resident status and changes.
Report Facts
Residents with late medication administration: 24
Residents with nursing care needs lacking weekly RN visits: 2
Residents reviewed for medication administration: 25
Residents with incomplete nursing assessments: 2
Residents with incomplete service plans: 3
Residents with incomplete medication records: 1
Employees with incomplete personnel files: 1
Residents with medications administered late: 25
Residents with medications due at 8:00 AM: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shayla Clark | AMAP Registered Nurse | Actively managing the AMAP program, supervising staff, reviewing orders, and providing education. |
| JT Hunter | Certified Dementia Practitioner | Scheduled to lead monthly Memory Care Family Support Group starting April 2, 2024. |
| Al Fulks | Express Care Pharmacist | Contacted to schedule medication destruction with RN. |
| Shayla Clark | Registered Nurse | Scheduled to be present in community for AMAP supervision and clinical staff training. |
| Emily Jarvis | Sent email regarding administration of Ozempic pens by licensed healthcare professionals. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
Investigation of Complaint #30584 regarding facility operations and resident care.
Complaint Details
Complaint #30584 was investigated from 01/29/24 to 02/01/24. The complaint was substantiated, and no deficiencies were cited.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Report Facts
Census AL: 69
Census ALZ: 36
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 3
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint #30587 from 01/29/24 to 02/01/24 to assess compliance with medication administration and facility safety standards.
Complaint Details
Investigation of Complaint #30587 from 01/29/24 to 02/01/24. The complaint was unsubstantiated, but a deficiency was cited related to medication administration records.
Findings
The facility failed to maintain complete medication administration records for three residents and had deficiencies in housekeeping and maintenance, including unsafe door alarms and physical environment issues. The complaint was unsubstantiated but deficiencies were cited.
Deficiencies (3)
Failed to maintain a complete medication administration record (MAR) for three residents, including missing signatures and incomplete information.
The adolescent girls' bedrooms had outside doors without alarms, and staff were not awake on weekend nights to monitor safety.
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, torn chair, missing towel bars and toilet paper holders, and dirty sink.
Report Facts
Resident identifiers affected: 3
Census: 105
Complaint census: 69
Complaint census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #117 | Interviewed regarding Resident #47's medication administration records. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Date: Feb 1, 2024
Visit Reason
Investigation of Complaint #30592 conducted from 01/29/24 to 02/01/24 to assess compliance with regulatory requirements related to resident records and facility environment.
Complaint Details
Complaint #30592 was investigated from 01/29/24 to 02/01/24 with a census of 69 assisted living and 36 memory care residents. The complaint was unsubstantiated, and one unrelated deficiency was cited.
Findings
The licensee failed to maintain accurate resident records, with discrepancies found between the registry and roster, including residents listed as discharged without documentation and residents listed who had not moved in. The complaint was unsubstantiated, and one unrelated deficiency was cited. Additionally, observations noted inadequate housekeeping and maintenance issues in the adolescent residence.
Deficiencies (2)
Licensee failed to maintain accurate records and reports; registry and roster did not match with discharged residents lacking discharge documentation and residents listed who had not moved in.
Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage, missing bathroom fixtures, and dirty sink.
Report Facts
Census: 105
Census: 69
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed on 01/29/24 regarding resident record discrepancies | |
| Operations Supervisor | Conducted tour of adolescent residence on 2/11/04 | |
| Treatment Coordinator | Accompanied tour of adolescent residence on 2/11/04 |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 4
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint #30590 from 01/30/24 to 02/01/24 to assess compliance with staffing and housekeeping regulations.
Complaint Details
Investigation of Complaint #30590 from 01/30/24 to 02/01/24. The complaint was substantiated, and deficiencies were cited.
Findings
The facility was found deficient in staffing requirements across day, evening, and night shifts, failing to meet required staff-to-resident ratios based on residents' care needs. Additionally, housekeeping and maintenance issues were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.
Deficiencies (4)
Failed to have the appropriate number of direct care staff on the day shift, affecting 47 residents with two or more care needs.
Failed to have the appropriate number of direct care staff on the night shift, affecting all residents in the facility.
Failed to have the correct number of direct care staff on the evening shift, affecting all residents in the facility.
Failed to ensure adequate housekeeping and maintenance, including iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Facility census: 105
Residents with two or more care needs: 47
Direct care staff on 01/14/24 day shift: 3
Direct care staff on 01/15/24 day shift: 4
Direct care staff on 01/15/24 night shift: 2
Direct care staff on 01/14/24 evening shift: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loretta Thompson | Program Director | Met with Executive Director and Healthcare Director to schedule recruitment event for CNA class graduates |
| Health Care Director | Licensed Practical Nurse | Interviewed and unaware of incorrect staffing on day, evening, and night shifts |
| Executive Director | Teamed with Healthcare Director to review staffing regulations and develop plans for correction |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 4
Date: Jan 31, 2024
Visit Reason
Annual environmental inspection conducted to assess the facility's maintenance, housekeeping, and safety conditions.
Findings
The facility failed to maintain a safe, sanitary, and accident-free living environment, with issues including dust accumulation, black substance growth on ceiling tiles, soiled kitchen floors, and overflowing trash cans. The findings were verified by staff and acknowledged at exit interview.
Deficiencies (4)
Air return in the kitchen dish washing area loaded with dust.
Black substance growing from ceiling tiles to floor and across wall behind kitchen counter.
Floors of the kitchen along walls and around equipment visibly soiled.
Uncovered trash can overflowing by the walk-in freezers.
Report Facts
Deficiencies cited: 1
Facility census: 105
Inspection Report
Plan of Correction
Census: 6
Deficiencies: 2
Date: Jan 18, 2024
Visit Reason
The document is a plan of correction submitted in response to a behavioral health survey conducted from February 9-11, 2004, addressing deficiencies related to the safety and appropriateness of the environment for adolescent consumers.
Findings
The survey found that the facility did not provide a safe environment for adolescent consumers, specifically noting that some outside doors lacked alarms or locks and that staff were not awake on weekend nights to monitor consumers. The citation was later cleared based on credible evidence accepted on 01/18/24 in lieu of an onsite visit.
Deficiencies (2)
The adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers.
An outside door in the TV room does not lock.
Report Facts
Center census: 6
Sample size: 3
Inspection Report
Follow-Up
Census: 6
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
Follow-up to Complaint #26895 to verify correction of previous deficiencies.
Complaint Details
Complaint #26895 was investigated and found to be cleared based on credible evidence without an onsite revisit.
Findings
Credible evidence was accepted in lieu of an onsite revisit, and all citations were cleared.
Report Facts
Complaint number: 26895
Center census: 6
Inspection Report
Follow-Up
Census: 6
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
Follow-up to special focus survey to verify correction of previous deficiencies.
Findings
Credible evidence was accepted in lieu of an onsite revisit and citations were cleared.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
The inspection was conducted in response to a complaint identified as Complaint ID 28689, with the visit occurring on July 13, 2023.
Complaint Details
Complaint ID 28689 was investigated from 9:00 AM to 1:30 PM on 07/13/23. The complaint was substantiated but no new deficiencies were found.
Findings
The complaint investigation was substantiated but resulted in no new deficiencies being identified during the inspection.
Report Facts
Census: 109
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
This was the first revisit to the annual survey to verify compliance and clear citations.
Findings
The revisit to the annual survey found that citations were cleared. The census at the time was 84 assisted living residents and 25 Alzheimer's residents.
Report Facts
Census: 109
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 4
Date: Mar 15, 2023
Visit Reason
Revisit to complaint investigation survey conducted from 03/13/23 to 03/15/23 at Harmony at Southridge ALR/ALZ to assess compliance with staffing, resident death reporting, and record-keeping requirements.
Complaint Details
The visit was a complaint investigation triggered by concerns about staffing levels, resident death reporting, and record accuracy. The complaint was substantiated based on documentation review and staff interviews.
Findings
The facility failed to maintain adequate staffing levels in the Alzheimer's/Dementia unit, failed to immediately notify the resident's physician of a resident death, and failed to maintain accurate resident rosters. Additionally, housekeeping and maintenance deficiencies were noted in an adolescent behavioral health unit (historical reference).
Deficiencies (4)
Failed to provide staffing at no less than an average of 2.25 hours of direct care personnel time per resident per day in the Alzheimer's/Dementia unit.
Failed to immediately report the suspected death of a resident to the resident's physician.
Failed to maintain accurate resident rosters for Assisted Living and Memory Care units.
Inadequate housekeeping and maintenance in adolescent behavioral health residence including personal belongings left out, carpet damage, missing bathroom fixtures, and unclean sink.
Report Facts
Resident census: 58
Resident census: 30
Direct care staff hours per resident per day: 2
Number of direct care staff per shift: 5
Number of medication passes: 3
Number of residents requiring assistance: 28
Number of residents with inappropriate behaviors: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director #27 | Executive Director | Interviewed regarding staffing levels and resident rosters; acknowledged citation |
| Director of Nursing #63 | Director of Nursing / Healthcare Director | Interviewed regarding incomplete death information form |
| Memory Care Director #31 | Memory Care Director | Interviewed regarding resident death notification and record-keeping |
| Anonymous Employee #01 | Interviewed about medication passes and staffing | |
| Anonymous Employee #02 | Interviewed about staffing and AMAP duties |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
Revisit to Complaint Investigation #27665 conducted from 03/13/23 to 03/15/23 to verify correction of previously identified deficiencies.
Complaint Details
Complaint Investigation #27665 was revisited; deficiencies were corrected and no new deficiencies were identified.
Findings
No new deficiencies were found during the revisit, and previously cited deficiencies were corrected or cleared.
Report Facts
Census: 58
Census: 30
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: Mar 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#27956) regarding medication administration and facility conditions.
Complaint Details
Complaint Investigation #27956 was substantiated. The complaint involved medication administration issues for Resident CR #59 and facility safety and maintenance concerns. The investigation period was from 03/13/23 to 03/15/23.
Findings
The investigation found that the facility failed to ensure a prescription or order for medication for one resident, resulting in medication unavailability and subsequent administration of an enema. Additionally, the facility had housekeeping and maintenance deficiencies including damaged carpet, missing bathroom fixtures, and unclean sinks.
Deficiencies (3)
Failed to ensure a prescription or written/verbal order for medication for one resident, resulting in medication unavailability.
Inadequate housekeeping and maintenance including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks.
Unsafe environment due to unlocked outside doors and lack of awake staff on weekend nights.
Report Facts
Resident census: 58
Resident census: 30
Sample size: 3
Medication dosage: 145
Dates medication unavailable: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director #63 | Healthcare Director | Interviewed regarding medication procurement failures |
Inspection Report
Routine
Census: 88
Deficiencies: 3
Date: Mar 15, 2023
Visit Reason
The inspection was conducted as a routine Special Focus survey to assess compliance with care planning, medication administration, housekeeping, and maintenance standards at Harmony at Southridge Assisted Living and Memory Care facility.
Findings
The survey found deficiencies in care plans not reflecting residents' current needs related to nail care, inaccurate medication administration records resulting in missed eye drop treatments for a resident, and inadequate housekeeping and maintenance issues including damaged carpets, missing bathroom fixtures, and unclean sinks.
Deficiencies (3)
Care plans did not include nail care or specify who was responsible for monitoring and reporting nail care needs for two residents.
Medications were not accurately reflected on the medication administration record for one resident, resulting in missed administration of prescribed eye drops for several months.
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing towel bars and toilet paper holders, and dirty sinks.
Report Facts
Resident census: 88
Residents with deficient care plans: 2
Resident records reviewed: 14
Date of survey: Mar 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #15 | Licensed Practical Nurse | Unaware of medication omission and uncertain about nail care notifications |
| Director of Nursing | Interviewed about care plan deficiencies and medication order clarifications | |
| Executive Director | Interviewed regarding efforts to obtain podiatry care and medication issues |
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 9
Date: Jan 12, 2023
Visit Reason
Annual survey conducted to assess compliance with state regulations for assisted living and memory care residents.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly care plan reviews, inadequate housekeeping and maintenance, incomplete resident registries, insufficient documentation of post-accident monitoring, medication administration issues including lack of proper certification and training for AMAP staff, incomplete tuberculosis testing procedures, incomplete transfer/discharge documentation, failure to conduct weekly nursing assessments for residents with nursing needs, and failure to weigh residents monthly as required.
Deficiencies (9)
Failed to ensure five out of five memory care resident records were evaluated and revised quarterly as indicated by changing needs.
Failed to provide adequate housekeeping and maintenance; observed personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bars and toilet paper holders, and dirty sink.
Failed to maintain a register of all residents in order by admission dates; three residents omitted.
Failed to document resident condition at least every 8 hours post-accident or illness for four residents.
Failed to ensure medications and treatments were administered as required; ten employees lacked documentation of high school diploma/GED or CPR certification; AMAPs administered insulin via insulin pens without approved policy or training.
Failed to provide appropriate tuberculosis testing per CDC guidelines for four employees; second TB test administered too soon.
Failed to ensure transfer/discharge documentation included all required information for one resident.
Failed to ensure six out of ten residents with nursing care needs were seen weekly by RN and documented accordingly.
Failed to weigh one resident upon admission and monthly thereafter; weights not recorded for three months.
Report Facts
Memory Care Residents: 28
Assisted Living Residents: 56
Deficiencies related to medication administration: 10
Residents with missing weekly nursing documentation: 6
Residents with missing quarterly care plan reviews: 5
Residents with missing transfer documentation: 1
Residents missing monthly weights: 1
Residents omitted from registry: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Director #47 | Memory Care Director | Interviewed regarding missing quarterly service plans and social assessments. |
| Executive Director #26 | Executive Director | Interviewed regarding transfer documentation and AMAP insulin administration policy. |
| Healthcare Director #57 | Healthcare Director | Interviewed regarding weekly nursing documentation, resident weights, and TB testing procedures. |
| Employee #31 | Personnel file missing high school diploma/GED and CPR certification. | |
| Employee #37 | Personnel file missing high school diploma/GED and CPR certification. | |
| Employee #44 | Personnel file missing high school diploma/GED and CPR certification; transcript provided at exit. | |
| Employee #21 | Personnel file missing CPR certification. | |
| Employee #40 | Personnel file missing CPR certification. | |
| Employee #14 | AMAP employee with missing documentation. | |
| Employee #19 | AMAP employee with missing documentation. | |
| Employee #42 | Personnel file missing proper TB testing timing. | |
| Employee #46 | Personnel file missing proper TB testing timing. | |
| Employee #55 | AMAP employee with missing documentation. |
Inspection Report
Follow-Up
Census: 6
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
Follow-up to Complaint #26870 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #26870 was investigated and the citation was cleared during the annual survey on 01/12/2023.
Findings
The citation related to the complaint was cleared at the time of the annual survey conducted on 01/12/2023.
Report Facts
Center Census: 6
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 2
Date: Jan 3, 2023
Visit Reason
The inspection was an annual environmental survey conducted to assess compliance with health, safety, housekeeping, laundry, and emergency preparedness regulations at the facility.
Findings
The facility was found deficient in proper laundry storage practices, lacking procedures for severe winter weather in the emergency preparedness plan, and housekeeping and maintenance issues including damaged carpets and missing bathroom fixtures. Corrective actions and plans of correction were provided for these deficiencies.
Deficiencies (2)
Failed to ensure that soiled and clean laundry were stored separately and appropriately, with soiled laundry carried in uncovered containers.
The disaster and emergency preparedness plan lacked procedures for severe winter weather and missing residents.
Report Facts
Census: 75
Sample size: 100
Tags cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #21 | Resident Assistant | Interviewed regarding laundry storage deficiency |
| Maintenance Director | Verified laundry storage findings | |
| Administrator | Acknowledged findings during exit interview | |
| Executive Director | Responsible for corrective actions and policy completion |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 1
Date: Jan 3, 2023
Visit Reason
The inspection was an annual environmental survey conducted to assess compliance with health and safety regulations at the facility.
Findings
The survey identified concerns related to tags 0440 and 0496, but all deficiencies were corrected by the first revisit on 03/06/2023.
Deficiencies (1)
Tags cited: 0440, 0496
Report Facts
Census: 75
Sample size: 100
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 3
Date: Dec 7, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to document notification of significant changes in a resident's condition and inadequate documentation related to resident transfers and discharges.
Complaint Details
Complaint #27665 was investigated on 12/07/22 and found unsubstantiated with related citations regarding documentation failures.
Findings
The facility failed to document notification to the resident's responsible party and physician upon transfer to a hospital, did not maintain current documentation of resident health status and changes, and failed to prepare a summary to accompany residents upon transfer or discharge. Additionally, housekeeping and maintenance deficiencies were noted but not related to this facility.
Deficiencies (3)
Failed to document notification to resident's responsible party and physician upon transfer to hospital.
Failed to keep current documentation regarding resident's health status, changes, and staff responses.
Failed to prepare a summary to accompany resident upon transfer or discharge including medical history, functional needs, physician's orders, advanced directives, allergies, and progress notes.
Report Facts
Census: 75
Sample Size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Interviewed regarding documentation failures; identified as #61. | |
| Harmony Square Director/Licensed Practical Nurse | Interviewed regarding documentation failures; identified as #50. |
Inspection Report
Re-Inspection
Census: 75
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
Revisit inspection conducted to verify correction of previously cited deficiencies at Harmony at Southridge assisted living and memory care facility.
Findings
The revisit inspection found that all previously cited deficiencies were cleared. The census at the time was 46 assisted living residents and 29 memory care residents.
Report Facts
Census: 46
Census: 29
Inspection Report
Follow-Up
Census: 39
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
Follow-up to complaint #26634 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #26634 triggered the follow-up inspection.
Findings
The inspection cleared all previously cited tags, indicating that the facility met compliance requirements at the time of the follow-up visit.
Report Facts
Census: 39
Inspection Report
Follow-Up
Census: 60
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
Follow-up to complaint #26600 to verify correction of previous deficiencies.
Complaint Details
Complaint #26600 was the basis for this follow-up visit. The citation related to the complaint was cleared.
Findings
The inspection found that one citation from the previous complaint was cleared and no new citations were identified during this visit.
Report Facts
Census Memory Care: 23
Census Assisted Living: 37
Citations cleared: 1
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
The inspection was conducted in response to Complaint #26492 on August 24, 2022, to investigate the allegations related to the assisted living and memory care facility.
Complaint Details
Complaint #26492 was investigated on 08/24/22 from 8:00 a.m. to 4:30 p.m. Citations related to the complaint were cleared.
Findings
The inspection found that citations related to the complaint were cleared during the visit. The census included 37 residents, with 23 in memory care.
Report Facts
Census: 37
Memory Care Census: 23
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
Investigation of Complaint #27069 conducted from 08/01/22 to 08/04/22.
Complaint Details
Investigation of Complaint #27069 resulted in two allegations being unsubstantiated with no deficiencies found.
Findings
Two allegations were investigated and found to be unsubstantiated. No deficiencies were identified during the investigation.
Report Facts
Census: 61
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Aug 4, 2022
Visit Reason
The inspection was a complaint survey conducted from August 1 to August 4, 2022, to investigate staffing and care concerns at Harmony at Southridge Assisted Living and Memory Care units.
Complaint Details
Complaint survey number 26895 conducted from 08/01/22 to 08/04/22. Census at time of survey was 35 Assisted Living and 26 Memory Care residents.
Findings
The facility failed to provide adequate staffing levels on the Alzheimer's/dementia special care unit and evening shifts, not meeting the required direct care hours per resident. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.
Deficiencies (3)
Failed to provide staffing on the Alzheimer's/dementia special care unit at an average of 2.25 hours of direct care personnel time per resident per day, with census greater than five residents requiring minimum two direct care personnel present.
Failed to ensure adequate housekeeping and maintenance, including personal belongings behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Failed to have a number of qualified employees on the evening shift to provide required care and services, with only one resident assistant for 35 residents.
Report Facts
Resident census: 35
Memory Care census: 26
Direct care hours per resident: 1.91
Required direct care hours per resident: 2.25
Residents requiring minimum two direct care needs: 20
Staffing shortfall hours: 14.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding staffing shortages and corrective actions | |
| Director of Nursing | Director of Nursing | Stated she covered Memory Care Unit as needed and confirmed aides completed and documented shifts |
| Memory Care Coordinator | Memory Care Coordinator | Worked on floor but had no documentation due to salary status |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: Aug 4, 2022
Visit Reason
Investigation of Complaint #26870 regarding the adequacy of functional needs assessments and service plans for residents.
Complaint Details
Investigation of Complaint #26870 was substantiated. The investigation occurred from 08/01/22 to 08/04/22. Census at the time was 35 Assisted Living and 26 Memory Care residents.
Findings
The licensee failed to ensure that two of nine residents had functional needs assessments and service plans reflecting their current conditions. The complaint was substantiated. Census included 35 Assisted Living and 26 Memory Care residents.
Deficiencies (1)
Failed to ensure two of nine residents had functional needs assessments and service plans that reflected their current condition.
Report Facts
Resident census: 35
Resident census: 26
Residents reviewed: 9
Residents with deficient assessments: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #37 reported on resident mobility status during interview | ||
| Employee #45 confirmed resident mobility status during interview |
Inspection Report
Follow-Up
Census: 60
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
Follow-up to complaint survey #26394 to verify correction of previously cited deficiencies.
Complaint Details
Complaint #26394 triggered the survey; deficiencies were found and have now been corrected.
Findings
Both deficiencies identified in the prior complaint survey have been corrected as of the follow-up visit.
Report Facts
Census: 60
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 5, 2022
Visit Reason
Follow-up survey was conducted on 05/05/2022 to review the corrections on tag 450 from a prior complaint-related inspection.
Complaint Details
Survey type was Complaint Re-Visit; the follow-up was to verify correction of previously cited deficiency on tag 450.
Findings
The deficiency cited under tag 450 has been corrected as of 05/05/2022 according to the follow-up survey.
Deficiencies (1)
Deficiency on tag 450 reviewed and found corrected.
Report Facts
Tags cited: 450
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Apr 14, 2022
Visit Reason
Complaint survey conducted from 04/13/22 to 04/14/22 to investigate concerns related to resident care, medication administration, and housekeeping.
Complaint Details
Complaint ID 26634 triggered the survey. The complaint investigation found substantiated issues with medication administration and care planning.
Findings
The facility failed to update functional needs assessments and service plans after residents experienced falls, failed to ensure accurate medication orders and administration, and did not maintain adequate housekeeping and maintenance standards. Multiple medication shortages and unclear physician orders were documented, and housekeeping deficiencies such as damaged carpet and missing bathroom fixtures were observed.
Deficiencies (3)
Failed to ensure functional needs assessments and service plans reflected residents' current needs after significant changes such as falls.
Failed to ensure no resident was neglected; unclear and blurred physician orders led to possible incorrect medication dosing and multiple medication shortages without proper documentation or follow-up.
Failed to maintain adequate housekeeping and maintenance; observed personal belongings behind furniture, carpet damage, missing towel bars and toilet paper holders, and dirty sinks.
Report Facts
Facility census: 51
Residents with falls and no updated assessments: 3
Medication administration record entries noting unavailable medications: 20
Carpet replacement deadline: 2004
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Director #126 | Memory Care Director | Interviewed regarding missing service plans and assessments for residents #8 and #21 |
| Director of Nursing #107 | Director of Nursing | Mentioned as possibly having service plans awaiting review; was out on sick leave during survey |
| Healthcare Director | Responsible for providing education on clarifying orders and ensuring accurate documentation on MAR | |
| Administrator | Administrator | Interviewed regarding admission orders and pharmacy communication |
Inspection Report
Follow-Up
Census: 51
Deficiencies: 8
Date: Apr 13, 2022
Visit Reason
Follow-up to annual survey conducted from 04/11/22 to 04/13/22 at Harmony at Southridge, an assisted living and memory care facility.
Findings
The facility was found deficient in multiple areas including failure to provide required annual staff training, inadequate housekeeping and maintenance, incomplete and inconsistent behavioral medication monitoring, inaccurate resident assessments and care plans, incomplete medication storage and disposition policies, lack of documented employee training on special care needs, incomplete annual health assessments, and inaccurate medication administration records.
Deficiencies (8)
Failed to provide minimum eight hours of documented annual training to all staff on required topics.
Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean sink.
Failed to ensure daily monitoring for side effects or adverse reactions for resident receiving psychotropic medications.
Functional needs assessments and service plans did not reflect current resident needs or were not updated after significant changes.
Resident admission agreement lacked information on secure storage and disposition of Schedule II medications.
Failed to provide and maintain records of training on special care needs for new employees prior to unsupervised work.
Failed to ensure annual health assessments were completed, signed, and dated by a licensed healthcare professional.
Medication administration records were inaccurate with discrepancies between MAR and Controlled Drug Record sheets.
Report Facts
Census: 30
Census: 21
Number of employees lacking training: 8
Number of residents with care plan discrepancies: 3
Number of residents requiring special care: 4
Number of employees lacking special care training: 8
Number of residents with incomplete annual health assessment: 1
Number of residents with medication administration record discrepancies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #68 | Named in deficiency for lack of annual training on facility philosophy | |
| Employee #82 | Named in deficiency for lack of annual training on facility philosophy | |
| Assistant Executive Director #60 | Assistant Executive Director | Interviewed regarding annual training deficiencies |
| Executive Director #117 | Executive Director | Interviewed regarding behavioral medication monitoring and medication record discrepancies |
| Director of Nursing #107 | Director of Nursing | Interviewed regarding lack of special care training for new employees |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Mar 30, 2022
Visit Reason
The inspection was conducted as a complaint investigation to assess the facility's compliance with health and safety regulations, specifically regarding maintenance and housekeeping.
Complaint Details
Complaint investigation conducted on 03/30/2022; complaint was substantiated.
Findings
The facility failed to maintain a safe and sanitary environment, including unprotected bottom door gaps allowing vermin/weather entry and various housekeeping deficiencies such as damaged carpet, bleach spots, and missing bathroom fixtures. These findings were substantiated during the inspection.
Deficiencies (2)
Doors leading to the outdoor courtyard have unprotected bottom door gaps allowing vermin and/or weather to enter the facility.
Miscellaneous small personal belongings behind dresser, iron burn and bleach spots on carpet, chair with tears, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Census: 38
Tags cited: 450
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: Mar 17, 2022
Visit Reason
The inspection was conducted as a complaint survey (#26362) from March 14 to March 17, 2022, to investigate concerns at Harmony at Southridge, an assisted living and memory care facility.
Complaint Details
Complaint Survey #26362 conducted from 03/14/22 to 03/17/22.
Findings
The report documents the complaint survey visit with a census of 25 assisted living and 18 memory care residents. Specific deficiencies or findings are not detailed in the provided page.
Report Facts
Census: 25
Census: 18
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Mar 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to inaccuracies in medication administration records and controlled drug records, specifically concerning narcotics documentation and administration.
Complaint Details
Complaint Number: 26600. The complaint involved inaccurate medication records and narcotics administration after resident transfer. The Executive Director was unaware of the issues until the investigation.
Findings
The facility failed to maintain accurate medication administration records, including narcotics being signed for after a resident had left the facility. Additionally, there were issues with housekeeping and maintenance, such as damaged carpets, missing bathroom fixtures, and unclean sinks.
Deficiencies (3)
Failure to maintain accurate records and reports, including incomplete documentation of PRN narcotic administration and narcotics signed for after resident transfer.
Failure to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks.
Unsafe environment due to lack of alarm on outside doors and inadequate awake-night supervision on weekends.
Report Facts
Census: 25
Census: 18
Hours billed: 11.25
Hours worked (documented): 16
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Mar 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations of staff neglect and failure to report abuse involving Resident #17 at Harmony at Southridge assisted living and memory care facility.
Complaint Details
The complaint involved Resident #17 who reported a staff member being 'mean' to her. The facility did not complete an investigation nor report the incident to appropriate agencies. The assistant administrator was aware of the issue but could not locate documentation of investigation or reporting. Employee #26 was identified as the staff member involved and was no longer assigned to care for Resident #17.
Findings
The licensee and staff failed to immediately report suspected neglect and abuse as required by state code. An investigation into allegations that a staff member was rude and neglectful to Resident #17 was not completed, and appropriate agencies were not notified. Additionally, the facility failed to maintain adequate housekeeping and maintenance standards.
Deficiencies (3)
Failure to report neglect, abuse, or emergency situations immediately as required by W. Va. Code §9-6-9.
Failure to ensure all allegations involving abuse, exploitation, or neglect are immediately and thoroughly documented and investigated.
Failure to maintain adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, torn chair, missing bathroom fixtures, and dirty sink.
Report Facts
Census: 25
Census: 18
Complaint Survey Duration (days): 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #26 | Staff member alleged to have been rude to Resident #17 and no longer assigned to care for her | |
| Assistant Administrator | Assistant Administrator | Interviewed regarding complaint and lack of investigation |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Date: Mar 17, 2022
Visit Reason
Complaint survey conducted from 03/14/22 to 03/17/22 to investigate allegations related to staffing, housekeeping, maintenance, hygiene, and provision of supplies at Harmony at Southridge.
Complaint Details
Complaint ID 26492 initiated survey due to concerns about staffing, hygiene, housekeeping, and maintenance at the facility. Census at time was 25 Assisted Living and 18 Memory Care residents.
Findings
The facility failed to provide adequate staffing on the Memory Care Unit, proper housekeeping and maintenance resulting in unsanitary conditions, and failed to provide liquid soap in resident bathrooms. Additionally, a resident was found with poor hygiene due to lack of staff assistance. Multiple deficiencies were cited related to staffing, housekeeping, hygiene, and physical facilities.
Deficiencies (5)
Failed to provide minimum staffing of two direct care personnel for Memory Care Unit with 18 residents; several night shifts had only one staff.
Failed to ensure adequate housekeeping and maintenance; observed personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bars and toilet paper holders, and dirty sink.
Failed to provide liquid soap in toilet and bathing facilities; residents responsible for their own soap.
Resident #10 dependent on staff had long fingernails with debris, indicating failure to provide necessary hygiene care.
Resident #17's bathroom was unsanitary with feces splashed on commode and strong urine smell; maintenance issues with vanity light bulbs.
Report Facts
Resident census: 25
Resident census: 18
Number of night shifts with insufficient staff: 3
Resident identifiers: 18
Inspection Report
Census: 23
Deficiencies: 3
Date: Mar 2, 2022
Visit Reason
The inspection was conducted to assess environmental conditions and compliance with health and safety regulations at Harmony at Southridge.
Findings
The facility had deficiencies noted during the November 29, 2021 survey, with some deficiencies corrected by the January 27, 2022 follow-up survey, while others remained uncorrected.
Deficiencies (3)
Deficiencies noted during the November 29, 2021 environmental survey.
Deficiency 0445 noted and not corrected as of January 27, 2022.
Deficiency 0450 noted during the November 29, 2021 survey.
Report Facts
Facility census: 23
Deficiency code: 445
Deficiency code: 450
Inspection Report
Re-Inspection
Census: 15
Deficiencies: 1
Date: Jan 27, 2022
Visit Reason
The visit was a re-inspection to verify correction of previous deficiencies related to disaster and emergency preparedness plan documentation and rehearsal.
Findings
The facility failed to document and rehearse the disaster and emergency preparedness plan annually as required. A disaster emergency preparedness response event was held on 01/07/22 but documentation was not completed at the time of the re-visit survey on 01/27/22.
Deficiencies (1)
Failure to document and rehearse the disaster and emergency preparedness plan annually, including verification of participation by each employee and a critique of the rehearsal.
Report Facts
Facility census: 15
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings regarding failure to document and rehearse emergency preparedness plan | |
| Healthcare Director | Acknowledged findings at exit interview | |
| Executive Director | Acknowledged findings at exit interview |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 17
Date: Dec 9, 2021
Visit Reason
Annual survey of Harmony at Southridge assisted living and memory care facility to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including staff training, housekeeping and maintenance, resident assessments and care plans, medication administration, staffing levels, resident rights postings, and documentation related to resident deaths and admissions.
Deficiencies (17)
Failure to ensure staff completed required Alzheimer's disease and dementia training prior to unsupervised care.
Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean areas.
Failure to maintain accurate resident registry with admission dates.
Failure to complete daily monitoring for side effects of psychotropic medications.
Activities program not directed by qualified professional with required experience and training.
Failure to maintain a register of all residents with required admission and discharge information.
Failure to maintain documentation of destruction of controlled substances in presence of pharmacist and nurse.
Failure to ensure personnel records contained required tuberculosis screening documentation.
Failure to complete individualized care plans within 21 days of admission reflecting resident needs.
Failure to complete quarterly medication reviews for Approved Medication Assistive Personnel and review MARs monthly.
Failure to post house rules and resident rights information in a conspicuous place accessible to residents.
Failure to document release of resident belongings and funds to estate administrator or executor upon death.
Failure to record date, time, and circumstances of resident deaths including release of body.
Failure to provide and document required orientation and training for new employees and agency staff prior to unsupervised work.
Failure to provide and maintain policies and procedures available for review by employees, residents, and the public.
Failure to weigh residents monthly and document weights; failure to report unplanned weight changes to physician.
Failure to have at least one awake staff per story while residents are sleeping as required.
Report Facts
Facility census: 38
Staff training hours required: 30
Staff training hours required: 8
Number of days with single staff on night shift: 7
Number of residents affected by medication monitoring deficiency: 1
Number of residents with missing registry admission dates: 10
Number of residents missing from registry log: 3
Number of employees missing tuberculosis screening: 8
Number of employees missing annual training: 2
Number of days narcotic reconciliation not done: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kara Risk | Life Enrichment Director | Did not meet experience and training requirements at time of survey |
| Employee #54 | Missing Alzheimer's training and tuberculosis screening documentation | |
| Employee #59 | Healthcare Director | Missing Alzheimer's training |
| Employee #62 | Missing Alzheimer's training and tuberculosis screening documentation | |
| Employee #68 | Missing annual training and tuberculosis screening documentation; missing quarterly medication review | |
| Employee #72 | Missing annual training and tuberculosis screening documentation | |
| Employee #83 | Missing tuberculosis screening documentation | |
| Employee #93 | Missing tuberculosis screening documentation | |
| Employee #102 | Missing tuberculosis screening documentation | |
| Employee #68 | Approved Medication Assistive Personnel | Missing quarterly medication review |
Inspection Report
Routine
Census: 15
Deficiencies: 3
Date: Nov 29, 2021
Visit Reason
The inspection was conducted as a routine environmental survey to assess compliance with physical environment, housekeeping, maintenance, and emergency preparedness requirements.
Findings
The facility was found deficient in ensuring proper signage and staff training for keypad exit locks, inadequate housekeeping and maintenance including carpet damage and missing bathroom fixtures, and failure to document annual disaster and emergency preparedness rehearsals.
Deficiencies (3)
Key pads used to lock and unlock exits did not have directions for operation posted on the outside of the doors, and staff training documentation was lacking.
Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage (iron burns and bleach spots), torn chair, missing towel bar and toilet paper holder, and dirty sink.
Failure to document and rehearse the disaster and emergency preparedness plan annually, including verification of staff participation and critique of the rehearsal.
Report Facts
Facility census: 15
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified findings related to keypad locks and emergency preparedness documentation | |
| Healthcare Director | Acknowledged findings at exit interview |
Inspection Report
Re-Inspection
Census: 14
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The visit was an initial survey first revisit to assess compliance and verify correction of previous deficiencies.
Findings
The report indicates that citations have cleared as of the revisit on 02/24/21, with a census of 7 assisted living and 7 memory care residents.
Report Facts
Census: 14
Inspection Report
Routine
Census: 6
Deficiencies: 4
Date: Jan 7, 2021
Visit Reason
The inspection was a routine initial survey of the assisted living facility to assess compliance with state regulations including activities program qualifications, housekeeping and maintenance, medication administration records, and resident health assessments.
Findings
The facility failed to ensure the activities director had completed required state-approved training, maintain accurate medication administration records for a resident, and ensure adequate housekeeping and maintenance. Additionally, three of four residents lacked properly documented health assessments including tuberculosis screening.
Deficiencies (4)
Activities director had not completed the state-approved training course for Activity Director.
Licensee and registered nurse failed to maintain accurate medication administration records; Resident #40's physician orders did not correlate with the Medication Administration Record.
Facility failed to ensure adequate housekeeping and maintenance; observations included personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Three of four residents lacked a written, signed, and dated health assessment by a physician or licensed health care professional, including tuberculosis screening.
Report Facts
Census: 6
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Activities Director | Named in deficiency for not having completed state-approved training |
| Employee #30 | Administered medications to Resident #40 and involved in medication record discrepancy | |
| Health Care Director #4 | Health Care Director | Involved in clarifying physician orders and resident interviews |
Inspection Report
Routine
Census: 6
Deficiencies: 0
Date: Jan 7, 2021
Visit Reason
The inspection was conducted as an infection control survey for the Alzheimer's unit and assisted living at Harmony at Southridge.
Findings
No deficiencies or citations were found during the infection control survey conducted on 01/08/21. The census was 3 residents in the Alzheimer's unit and 3 in assisted living.
Report Facts
Census: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Smith | Executive Director | Named as present during exit interview |
| Kim Taylor | Director of Nursing | Named as present during exit interview |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
The inspection was an annual environmental survey conducted to assess the facility's compliance with health and safety regulations.
Findings
The survey found no deficiencies during the annual environmental inspection conducted on January 5, 2021.
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