Inspection Reports for Harmony House Memory Care

The visit included a complaint investigation triggered by incidents involving resident elopement and failure to send a resident for hospital evaluation after assaulting a roommate.

The facility failed to ensure windows in the Special Care Unit (SCU) were operable and restricted to a six-inch opening to prevent elopement, resulting in a resident eloping. Additionally, the facility failed to send a resident to the hospital for evaluation after an assault on a roommate and failed to immediately notify law enforcement when a resident eloped and was missing.

The visit included complaint investigations related to medication administration errors and failure to administer prescribed medications.

The facility failed to administer medications as ordered for multiple residents, including crushing extended-release tablets that should not be crushed, and failure to administer prescribed laxatives. Medication aides were not properly trained or following medication administration protocols, and medication audits did not detect these issues.

Complaint investigation initiated by Iredell County Department of Social Services on 07/12/24.

The facility failed to implement physician's orders for compression stockings for one resident, failed to clarify medication orders for seizure medication resulting in administration errors, failed to administer medications as ordered for two residents, failed to maintain accurate medication administration records, and failed to ensure a Special Care Coordinator was on duty as required.

Complaint investigation was initiated by the Iredell County Department of Social Services on 05/02/24 related to resident elopement and physical aggression incidents.

The facility failed to provide adequate supervision resulting in a resident eloping and being hospitalized, failed to ensure referral and follow-up for acute health care needs, failed to provide required snacks, failed to provide an activities program, failed to administer medications as ordered, failed to maintain accurate medication administration records, failed to maintain accurate controlled substance records, failed to notify DSS of accidents requiring emergency medical evaluation, failed to maintain adequate staffing levels in the special care unit, and failed to ensure a Special Care Unit Coordinator was on duty as required.

Complaint investigations were initiated by the Iredell County Department of Social Services. The complaint was substantiated by findings that Resident #5 did not receive ordered medications fluconazole and Macrobid as prescribed.

The facility failed to ensure physician orders were implemented for Resident #5, who had orders for medications to treat bacterial and fungal infections that were not administered as ordered. Interviews and record reviews confirmed the orders were not received by the pharmacy or implemented by the facility staff.

The facility still has deficiencies that were not corrected, including lack of emergency lighting at exit gates equipped with locking systems and absence of handrails on an exit ramp from Hall B.

Complaint investigation was initiated by the Iredell County Department of Social Services on 08/17/23 regarding Resident #3's elopement from the facility.

The facility failed to provide adequate supervision for Resident #3, who had dementia and a history of wandering and exit-seeking behaviors, resulting in the resident eloping from the Special Care Unit and being found 45 minutes later on facility property. Additionally, the facility failed to immediately notify law enforcement after the resident was missing, delaying the response.

Complaint investigations were initiated by the Iredell County Department of Social Services on 06/15/23 and included issues related to medication aide training, diabetic care training, admission documentation, health care referrals and follow-up, and resident safety related to roommate conflicts.

The facility failed to ensure medication aides completed required training, failed to have admission FL2 documentation for a resident, failed to ensure referrals and follow-up for residents' health care needs, and failed to respond to a resident's reasonable request to change rooms which resulted in a resident assault causing serious injury and death. Additionally, the facility failed to ensure special care unit staff completed required orientation and training.

Complaint investigation initiated by Iredell County Department of Social Services on 01/12/23, followed by a survey conducted 01/31/23 - 02/02/23.

The facility failed to ensure medication aides completed required training, including 5-hour medication aide training and diabetic care training. Medication administration errors were identified for 3 of 7 sampled residents, including incorrect insulin dosing, incorrect eye medication administration, and missed medication administration. The facility also failed to maintain accurate electronic Medication Administration Records (eMAR) for 2 of 5 sampled residents, with missing documentation of finger stick blood sugars and medication administration.

Complaint investigation included allegations of physical abuse by Staff A who allegedly slapped the hand and arm of Resident #2. The facility failed to report this to the Health Care Personnel Registry within 24 hours and did not send Staff A home until after the investigation was completed.

The facility was found deficient in multiple areas including tuberculosis testing, annual medical examinations, health care referral and follow-up, licensed health professional support evaluations, nutrition and food service, medication administration, resident rights, health care personnel registry reporting, incident reporting, and special care unit resident profiles. Several residents' records were incomplete or missing required documentation, medication administration errors were observed, and controlled substance counts did not match records.

The visit included a complaint investigation triggered by concerns about medication administration and infection control during a COVID-19 outbreak.

The facility failed to ensure medication administration records were complete and accurate for 2 of 3 sampled residents related to medications for anxiety and sleep. Additionally, the facility failed to maintain accurate controlled substance records and failed to follow infection prevention and control guidelines during a COVID-19 outbreak, resulting in multiple resident infections, hospitalizations, and one death.

The facility failed to protect food from contamination by maintaining clean food storage areas, as evidenced by mold in the refrigerator and unlabeled employee food. Additionally, the facility failed to administer medications as ordered by a licensed prescribing practitioner for 2 of 4 residents, including medications for anxiety and combative behavior.

The facility failed to meet several physical plant and safety requirements including improper operation and training related to special locking arrangements on doors, unsafe storage of portable medical oxygen cylinders, lack of regular fire drill rehearsals on all shifts, corridor doors not closing and latching properly, compromised fire separation between basement and main floor, and missing documentation for monthly inspections of the range hood fire suppression system.

The survey found deficiencies related to the use of unrated foam to seal holes in the ceiling of the room where the furnace was previously located, compromising the required one-hour fire rated walls and ceilings.

The facility failed to correct several deficiencies including unpermitted and non-compliant furnace installation, lack of proper fire safety rehearsals with fire alarm activation, malfunctioning emergency lights, and compromised one-hour fire rated walls and ceilings with unsealed penetrations.

The facility was found to have multiple deficiencies including unpermitted renovation work with building code violations, lack of current sanitation and fire safety inspection reports, inadequate housekeeping and maintenance hazards, failure to conduct required fire safety rehearsals properly, malfunctioning emergency lighting, fire doors not closing or latching properly, compromised fire-rated walls and ceilings, non-functioning exhaust ventilation, and a non-working electric call system in some bedrooms.

Complaint was initiated by Iredell County DSS on August 17, 2016, leading to a complaint investigation combined with the annual survey.

The facility failed to ensure that one of three medication aides (Staff D) successfully completed the medication competency examination within 60 days of hire. Observations showed Staff D administered medications accurately and followed proper infection control procedures, but documentation of passing the competency exam was missing.

The facility was found to have multiple deficiencies including non-compliant corridor doors that do not meet fire-resistive construction standards, lack of current fire and building safety inspection reports, fire alarm system inspection overdue since 2013, obstructed exit paths, inadequate fire safety rehearsal documentation, and multiple fire safety and building equipment issues such as doors not latching properly, compromised fire-rated walls and ceilings, and improper ice machine drain line installation.

The facility was found deficient for failing to ensure a criminal background check was completed for one staff member, failing to serve residents milk at least twice daily as required, and failing to obtain proper verification for a positive drug screening of a staff member. The facility provided plans of correction for these deficiencies.