Inspection Reports for Harmony Court Rehab and Nursing

6969 Glenmeadow Ln, Cincinnati, OH 45237, OH, 45237

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 13.2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

187% worse than Ohio average
Ohio average: 4.6 deficiencies/year

Deficiencies per year

20 15 10 5 0
2018
2020
2023
2024
2025

Census

Latest occupancy rate 107 residents

Based on a October 2025 inspection.

Census over time

91 98 105 112 119 Dec 2018 Jul 2023 Jan 2024 Dec 2024 Oct 2025

Inspection Report

Complaint Investigation
Census: 107 Deficiencies: 4 Date: Oct 30, 2025

Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration errors and related compliance issues at the facility.

Complaint Details
The deficiencies represent non-compliance investigated under Complaint Number 2591479.
Findings
The facility failed to ensure medications were administered as prescribed, resulting in medication errors affecting one resident. Additionally, the facility failed to ensure proper medication storage and infection control practices during medication administration.

Deficiencies (4)
Failed to ensure medications were given as prescribed, including incorrect dosage and medication form for Resident #15.
Failed to ensure medication error rates were below 5%, with an 11.11% error rate observed.
Failed to ensure proper storage of medication; medication cart was left unlocked and unattended.
Failed to implement proper infection prevention and control measures during medication administration, including handling medication with ungloved hands and contamination risk.
Report Facts
Medication error rate: 11.11 Facility census: 107 Medication errors: 3 Medication opportunities observed: 27

Employees mentioned
NameTitleContext
Registered Nurse #100Named in multiple medication administration and storage deficiencies

Inspection Report

Complaint Investigation
Census: 112 Deficiencies: 2 Date: May 14, 2025

Visit Reason
The inspection was conducted to investigate complaints regarding verbal abuse by staff towards a resident and failure to prevent resident elopements.

Complaint Details
The verbal abuse complaint was substantiated involving LPN #500 towards Resident #104, resulting in termination and reporting to the Ohio Board of Nursing. The elopement complaint involved Resident #45 exiting an alarmed door unnoticed by staff due to low alarm volume and lack of supervision; staff were unaware of the resident's elopement risk.
Findings
The facility was found to have substantiated verbal abuse by a Licensed Practical Nurse towards a resident and failed to prevent elopement of another resident from a secured unit due to inadequate supervision and insufficiently loud door alarms.

Deficiencies (2)
Failed to ensure residents were free from verbal abuse by staff, affecting one resident.
Failed to prevent resident elopements, affecting one resident.
Report Facts
Residents reviewed for abuse: 3 Residents reviewed for elopements: 3 Facility census: 112

Employees mentioned
NameTitleContext
LPN #500Licensed Practical NurseNamed in verbal abuse finding towards Resident #104; terminated and reported to Ohio Board of Nursing.
CNA #151Certified Nursing AssistantConfirmed not hearing door alarm and unawareness of Resident #45's elopement risk.
LPN #241Licensed Practical NurseNot working on Resident #45's unit during elopement; notified aides after police called.
AdministratorConfirmed investigation and substantiation of verbal abuse and elopement incidents.
Assistant Director of Nursing (ADON) #357Assistant Director of NursingConfirmed investigation and substantiation of verbal abuse and elopement incidents.
Maintenance Director (MD) #385Maintenance DirectorConfirmed knowledge of elopement incident and no request to increase alarm volume.

Inspection Report

Routine
Census: 107 Deficiencies: 1 Date: Dec 31, 2024

Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically focusing on staff adherence to enhanced barrier precautions (EBP) for residents with indwelling medical devices and wounds.

Findings
The facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to providing care to residents on enhanced barrier precautions. Observations and interviews confirmed that staff did not wear gowns during high-contact care activities for two residents, potentially exposing residents to multi-drug resistant organisms.

Deficiencies (1)
Failure to ensure staff donned appropriate PPE prior to provision of care for residents on enhanced barrier precautions.
Report Facts
Residents affected: 2 Residents reviewed: 3 Facility census: 107

Employees mentioned
NameTitleContext
Certified Nursing Assistant (CNA) #33Did not don gown prior to providing incontinence care for Resident #13
Licensed Practical Nurse (LPN) #32Did not don gown prior to providing wound care for Resident #11

Inspection Report

Complaint Investigation
Census: 110 Deficiencies: 2 Date: Oct 30, 2024

Visit Reason
The inspection was conducted due to complaints regarding misappropriation of resident medications, specifically allegations involving a nurse misappropriating narcotic medication.

Complaint Details
This deficiency represents noncompliance investigated under Complaint Number OH00159179 and Complaint Number OH00158434.
Findings
The facility failed to timely report allegations of misappropriation to the Ohio Department of Health and did not conduct a thorough investigation or protect residents during the investigation. The alleged perpetrator nurse was allowed to work for two days after concerns were raised before suspension and termination. The investigation focused only on one nurse and did not include other staff.

Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to conduct a thorough investigation of misappropriation of resident medications and failed to protect residents during the investigation.
Report Facts
Residents reviewed for misappropriation: 12 Facility census: 110

Employees mentioned
NameTitleContext
RN #175Registered NurseAlleged perpetrator of medication misappropriation, terminated
LPN #225Licensed Practical NurseSent photograph of suspicious medication record
Director of NursingDirector of NursingReceived initial report, delayed reporting and investigation
AdministratorAdministratorNotified of concerns and confirmed reporting and termination actions

Inspection Report

Complaint Investigation
Census: 102 Deficiencies: 2 Date: Jan 30, 2024

Visit Reason
The inspection was conducted as a complaint investigation related to noncompliance issues including malfunctioning toilets and unsafe water temperatures in resident bathrooms.

Complaint Details
This deficiency represents non-compliance investigated under Complaint Numbers OH00150152 (toilet issues) and OH00150387 (water temperature issues). The toilet issue was a continued noncompliance from a prior survey dated 12/26/23.
Findings
The facility failed to ensure residents' toilets were functioning properly, affecting two residents, and failed to maintain safe water temperatures in residents' rooms, affecting two other residents. Both issues posed potential harm and represented continued noncompliance.

Deficiencies (2)
Residents' toilets were out of order and bathroom floors were covered with water and debris, affecting Residents #58 and #63.
Water temperatures in residents' rooms exceeded safe limits, with temperatures of 127°F and 122°F recorded, affecting Residents #35 and #38.
Report Facts
Facility census: 102 Water temperature: 127 Water temperature: 122

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN) #163Confirmed Resident #63 and #58 bathroom conditions and toilet malfunctions
State Tested Nursing Assistant (STNA) #296Confirmed Resident #63 and #58 bathroom conditions and toilet malfunctions
Maintenance Director (MD) #210Confirmed toilets were clogged and water temperatures exceeded safe limits

Inspection Report

Complaint Investigation
Census: 108 Deficiencies: 4 Date: Dec 26, 2023

Visit Reason
The inspection was conducted as a complaint investigation related to allegations of neglect, injury of unknown origin, misappropriation of resident property, and failure to maintain working call light systems.

Complaint Details
The complaint investigation was triggered by allegations of neglect, injury of unknown origin, misappropriation of resident property, and failure to maintain working call light systems. The investigation found substantiated neglect related to Resident #87's untreated painful and discolored hand, failure to notify family and physician, and failure to provide timely medical care. The facility also failed to report and investigate allegations of abuse and misappropriation for Residents #69 and #87.
Findings
The facility failed to ensure residents' call lights were functional, failed to notify family and physicians of changes in condition, failed to provide timely pain management and medical assessment for a resident with a discolored and painful hand, and failed to report and investigate allegations of abuse, neglect, and misappropriation of resident property. Immediate Jeopardy was identified related to neglect of Resident #87 but was removed after corrective actions. The facility also failed to document medication administration accurately.

Deficiencies (4)
Facility failed to ensure residents' call lights were functional and accessible, affecting residents #38, #60, and #69.
Facility failed to notify Resident #87's family and physician of a significant change in condition and failed to provide timely pain management and medical assessment, resulting in Immediate Jeopardy.
Facility failed to report and investigate allegations of misappropriation of Resident #69's money and injury of unknown origin for Resident #87.
Facility failed to accurately document administration of pain medication for Resident #87.
Report Facts
Facility census: 108 Residents reviewed for call lights: 35 Residents affected by call light deficiency: 3 Residents affected by neglect: 1 Residents affected by misappropriation: 1 Amount of money allegedly stolen: 6500 Dates of alleged theft: 12

Employees mentioned
NameTitleContext
LPN #120Licensed Practical NurseReported Resident #87's hand discoloration and pain, called hospice
Hospice Nurse #171Hospice NurseEvaluated Resident #87's hand, communicated with hospice physician and facility
Primary Care Physician #600Primary Care PhysicianUnaware of Resident #87's hand bruising and condition
AdministratorFacility AdministratorNotified of Immediate Jeopardy, verified lack of reporting and investigation
Director of Nursing (DON)Director of NursingImplemented corrective actions, educated staff, and monitored compliance
LPN #93Licensed Practical NurseVerified call light issues and observations of environmental deficiencies
Maintenance Director #147Maintenance DirectorVerified call light system malfunctions
Business Office Manager (BOM) #138Business Office ManagerReported awareness of alleged misappropriation and communication with APS and Ombudsman
Hospice Physician #172Hospice PhysicianOrdered pain medications and X-ray for Resident #87, ordered hospital transfer

Inspection Report

Routine
Census: 108 Deficiencies: 20 Date: Dec 26, 2023

Visit Reason
Routine inspection of Harmony Court Rehab and Nursing to assess compliance with regulatory requirements including resident care, safety, medication administration, infection control, and facility environment.

Complaint Details
The immediate jeopardy was related to neglect of Resident #87 who had a discolored and painful left hand that was not assessed or treated timely, resulting in dry gangrene and hospitalization. The facility failed to notify the resident's family and physician, failed to provide pain medication timely, and failed to follow up on hospice orders. The deficiency was investigated under Complaint Number OH00148957.
Findings
The facility had multiple deficiencies including failure to ensure residents were served meals in approved containers, inadequate privacy and call light accessibility, inaccurate advanced directives documentation, failure to notify family and physician of resident injury, lack of Skilled Nursing Facility Advance Beneficiary Notices, environmental concerns including mold and water damage, neglect resulting in immediate jeopardy for a resident with untreated hand injury, improper use of restraints, failure to report and investigate abuse and misappropriation allegations, inaccurate resident assessments and care plans, inadequate assistance with activities of daily living, failure to provide safe respiratory and catheter care, medication errors, failure to post nurse staffing data, and failure to maintain clean kitchen and equipment.

Deficiencies (20)
Residents were served meals in disposable Styrofoam food boxes instead of approved containers.
Residents' privacy was compromised due to damaged curtains and call lights being out of reach.
Inaccurate documentation of resident's code status in medical record.
Failure to notify resident's family and physician of injury and change in condition, resulting in immediate jeopardy.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage to residents cut from skilled services.
Environmental deficiencies including mold, water damage, and unpainted wall patches in resident rooms.
Use of physical restraints without proper orders and monitoring.
Failure to timely report suspected abuse, neglect, or theft and failure to investigate allegations.
Failure to ensure accurate resident assessments and care plans reflecting current status and risks.
Failure to provide routine nail care and grooming assistance.
Failure to ensure fall interventions and call light accessibility for residents at risk of falls.
Failure to provide working call light systems in resident rooms and bathrooms.
Failure to provide routine dental care for residents.
Failure to follow approved menus and document food substitutions properly.
Failure to maintain kitchen and equipment in clean and sanitary condition and improper food storage.
Failure to provide safe and appropriate respiratory care including dated and clean oxygen tubing and proper tracheostomy care.
Failure to provide timely pain management interventions and accurate documentation of pain medication administration.
Failure to provide regular performance evaluations and required in-service training for nurse aides.
Failure to post daily nurse staffing data as required.
Failure to ensure safe condition of kitchen hood with flaking metal pieces.
Report Facts
Facility census: 108 Medication error rate: 7.4 Residents affected by call light issues: 3 Residents affected by nail care deficiency: 3 Residents affected by feeding tube deficiency: 1 Residents affected by respiratory care deficiency: 2 Residents affected by medication errors: 2 STNAs without annual evaluation: 2 STNA without required in-service training: 1 Residents affected by fall intervention deficiency: 2 Residents affected by restraint use deficiency: 1 Residents affected by abuse reporting deficiency: 2 Residents affected by assessment and care plan deficiencies: 3 Residents affected by menu substitution deficiency: 101 Residents affected by kitchen sanitation deficiency: 101 Residents affected by infection control deficiencies: 108

Employees mentioned
NameTitleContext
Licensed Practical Nurse #120Licensed Practical NurseNamed in pain management and neglect findings related to Resident #87
Hospice Nurse #171Hospice NurseNamed in pain management and neglect findings related to Resident #87
Licensed Practical Nurse #93Licensed Practical NurseNamed in call light and pain management findings
Licensed Practical Nurse #127Licensed Practical NurseNamed in call light and pain management findings
Licensed Practical Nurse #118Licensed Practical NurseNamed in pain management and neglect findings related to Resident #87
Licensed Practical Nurse #92Licensed Practical NurseNamed in pain management and neglect findings related to Resident #87
Licensed Practical Nurse #107Licensed Practical NurseNamed in medication administration and infection control findings
Licensed Practical Nurse Unit Manager #148Licensed Practical Nurse Unit ManagerNamed in infection control and pain management findings
Dietary Supervisor #80Dietary SupervisorNamed in food service and kitchen sanitation findings
Registered Dietician #58Registered DieticianNamed in food service and menu substitution findings
Director of NursingDirector of NursingNamed in multiple findings including pain management, infection control, call light issues, and abuse reporting
Human Resource #90Human ResourceNamed in personnel file and training findings
Maintenance Director #147Maintenance DirectorNamed in call light and infection control findings
Clinical Director #16Clinical DirectorNamed in infection control and medication administration findings
Medical Director #201Medical DirectorNamed in psychotropic medication and pain management findings
Psychiatric Physician #203Psychiatric PhysicianNamed in psychotropic medication findings
Psychiatric Physician #204Psychiatric PhysicianNamed in psychotropic medication findings
State Tested Nurse Aide #24State Tested Nurse AideNamed in personnel file and training findings
State Tested Nurse Aide #15State Tested Nurse AideNamed in tuberculosis screening findings

Inspection Report

Complaint Investigation
Census: 103 Deficiencies: 1 Date: Jul 24, 2023

Visit Reason
The inspection was conducted as a complaint investigation related to non-compliance in medication administration and care for Resident #110, specifically regarding blood glucose monitoring and insulin administration.

Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144575.
Findings
The facility failed to provide timely and appropriate care for Resident #110 in assessing blood glucose levels and administering insulin as ordered. The resident refused medications and blood glucose checks at noon, and staff did not attempt to check or administer insulin at that time due to being overwhelmed.

Deficiencies (1)
Failed to ensure a resident was provided with quality and timely care related to assessing blood glucose levels and administering insulin based on those levels.
Report Facts
Facility census: 103 Units of Humalog insulin: 5 Date of admission: Jun 15, 2023 Date of discharge: Jul 8, 2023

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN) #105Interviewed regarding Resident #110's medication refusal and failure to administer insulin at 12:00 P.M.

Inspection Report

Routine
Census: 97 Deficiencies: 13 Date: Feb 27, 2020

Visit Reason
The inspection was conducted as a routine survey of Harmony Court Rehab and Nursing facility to assess compliance with regulatory requirements related to resident care, activities, medication management, safety, and infection control.

Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination in food choices, failure to provide timely Medicaid/Medicare notices, inadequate transfer/discharge notifications, incomplete implementation of care plans for activities, inadequate discharge planning, insufficient assistance with activities of daily living, failure to provide adequate activities to meet resident needs, unsafe water temperatures, failure to discard expired medications, incomplete wound treatment documentation, improper infection control practices, and environmental maintenance issues.

Deficiencies (13)
Failed to ensure residents were enabled and encouraged to make choices on what they preferred to eat at mealtimes.
Failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) letter 48 hours prior to discharge from Medicare Part A Services.
Failed to provide timely notification to residents and representatives before transfer or discharge including appeal rights.
Failed to implement each resident's plan of care related to activity needs and preferences.
Failed to develop and implement a discharge plan to meet residents' goals and needs.
Failed to provide care and assistance to perform activities of daily living for residents unable to do so.
Failed to provide an ongoing activity program to meet each resident's individual needs and preferences.
Failed to maintain water temperatures in resident areas at a safe and comfortable level, with temperatures up to 139 F noted.
Failed to discard expired medications and glucometer control solution.
Failed to ensure documentation of wound treatments was completed in resident records.
Failed to implement infection prevention and control program including proper cleaning of sputum and glucometers, and failure to implement Legionella policy.
Failed to provide a safe, clean, functional, and comfortable environment including broken dressers, inoperable call light, and foul odors.
Failed to attempt gradual dose reductions and ensure correct dosing of psychotropic medications.
Report Facts
Facility census: 97 Residents affected: 1 Residents affected: 1 Residents affected: 4 Residents affected: 3 Residents affected: 2 Residents affected: 5 Residents affected: 6 Residents affected: 11 Expired naloxone vials: 8 Residents affected: 1 Dates with missing wound treatment documentation: 10 Residents affected: 1 Residents affected: 4 Residents affected: 25 Residents affected: 3

Employees mentioned
NameTitleContext
LPN #43State Tested Nursing AssistantInterviewed about resident feeding and refusal to eat
Dietician #97DieticianInterviewed about resident nutritional supplements and diet changes
STNA #67State Tested Nursing AssistantDelivered lunch tray to resident
Social Services Director #131Social Services DirectorInterviewed about failure to provide 48 hour notice for Medicare Part A discharge
RN #175Director of Clinical Operations, Registered NurseInterviewed about transfer notification deficiencies and shower schedule
LPN #48Licensed Practical NurseInterviewed about activity participation and shower schedule
STNA #128State Tested Nursing AssistantInterviewed about resident activity participation
STNA #32State Tested Nursing AssistantInterviewed about resident grooming and hygiene
STNA #176State Tested Nursing AssistantInterviewed about resident grooming and hygiene
RN #7Registered NurseInterviewed about wound treatment documentation and resident hygiene
LPN #49Licensed Practical NurseInterviewed about glucometer cleaning and blood sugar monitoring
Director of Clinical Operations #175Director of Clinical OperationsInterviewed about infection control and glucometer cleaning
MD #26Maintenance DirectorInterviewed about water temperature issues and maintenance requests
MA #37Maintenance AideInterviewed about maintenance requests and environmental concerns
AdministratorAdministratorInterviewed about maintenance issues and water temperature monitoring

Inspection Report

Routine
Census: 110 Deficiencies: 17 Date: Dec 19, 2018

Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, safety, care planning, medication administration, infection control, and facility environment.

Findings
The facility was found deficient in multiple areas including failure to ensure residents had access to their funds on weekends, unsanitary and damaged call light devices, failure to prevent resident to resident abuse, improper use of physical restraints without physician orders, failure to notify residents and representatives of hospital transfers in writing, incomplete Minimum Data Set (MDS) assessments, inaccurate and incomplete care plans, failure to provide discharge summaries, inadequate blood sugar monitoring for diabetic residents, medication administration errors, unsafe food storage and handling, inadequate infection control practices including Legionella monitoring and tuberculosis screening, malfunctioning call light systems, and failure to provide adequate supervision of residents who smoke.

Deficiencies (17)
Facility failed to ensure residents had access to their funds from their resident trust fund on weekends.
Facility failed to maintain resident call light devices in sanitary condition and good repair.
Facility failed to ensure a resident was free from resident to resident abuse.
Facility failed to ensure residents were assessed for physical restraints and had physician orders for restraints.
Facility failed to implement abuse policy to ensure resident was free from resident to resident abuse.
Facility failed to provide timely written notification to residents, representatives, and ombudsman of hospital transfers.
Facility failed to complete discharge Minimum Data Set (MDS) assessment for a resident discharged to hospital.
Facility failed to develop and implement complete care plans that meet residents' needs with measurable timetables and actions.
Facility failed to provide necessary information to resident and receiving healthcare provider at time of planned discharge.
Facility failed to routinely monitor blood sugar levels for a resident on insulin with history of uncontrolled levels.
Facility failed to ensure Tuberculin Protein Derivative Diluted Aplisol (mantoux solution) was dated and not expired.
Facility failed to ensure residents' call lights were functioning properly to allow them to call for staff assistance.
Facility failed to procure food from approved sources and maintain food, beverages, and equipment to prevent contamination and spoilage.
Facility failed to have appropriate Legionella monitoring, tuberculosis control plan implementation, and infection control in laundry areas.
Facility failed to ensure adequate supervision of residents who smoke and failed to complete quarterly smoking assessments.
Facility failed to ensure nurse aides received at least 12 hours of in-services per year.
Facility failed to ensure resident falls were investigated to determine cause and update care plans to keep resident safe.
Report Facts
Residents' funds managed: 89 Resident census: 110 Residents affected by call light deficiency: 2 Residents affected by abuse deficiency: 1 Residents affected by restraint deficiency: 1 Residents affected by hospital notification deficiency: 4 Residents affected by discharge MDS deficiency: 1 Residents affected by care plan deficiency: 3 Residents affected by discharge summary deficiency: 1 Residents affected by blood sugar monitoring deficiency: 1 Residents affected by medication error: 1 Residents affected by food service deficiency: 6 Residents affected by infection control deficiency: 110 Residents affected by smoking supervision deficiency: 8 Residents affected by smoking policy deficiency: 15 Residents affected by nurse aide training deficiency: 2 Resident falls: 8

Employees mentioned
NameTitleContext
STNA #15State Tested Nursing AssistantVerified call light condition and assisted resident with call light
Maintenance Director #129Maintenance DirectorVerified call light cord was frayed with exposed wires
Regional Business Office Manager #150Regional Business Office ManagerInterviewed about resident funds management
Activities Supervisor #81Activities SupervisorInterviewed about resident funds management
Activity Aide #8Activity AideInterviewed about petty cash
AdministratorAdministratorInterviewed about resident funds access and abuse incidents
STNA #93State Tested Nurse AideWitnessed resident altercation and smoking supervision
LPN #400Licensed Practical NurseWitnessed resident altercation
STNA #9State Tested Nurse AideWitnessed resident altercation
DONDirector of NursingVerified restraint use, care plan accuracy, blood sugar monitoring, and hospital notification
RN #124Registered NurseReported no routine blood sugar level draws
MD #200Medical DoctorReported resident's blood sugars were uncontrollable and insulin order missed
Dietary Supervisor #22Dietary SupervisorVerified food storage and smoking policy issues
Dietician #59DieticianVerified resident NPO status
Human Resources #74Human ResourcesVerified tuberculosis testing and nurse aide in-service deficiencies
Housekeeping Aide #91Housekeeping AideDescribed laundry process and clean/dirty laundry handling
Housekeeping Director #131Housekeeping DirectorVerified clean linen transport through dirty area
Director of Clinical Operations #300Director of Clinical OperationsReported no policy on call light functioning
STNA #17State Tested Nurse AideVerified resident smoking materials in room
STNA #54State Tested Nurse AideVerified smoke room door holes

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