Harmony at Greensboro

The facility failed to ensure all assisted living residents were served water at each meal in addition to other beverages. Specifically, during lunch on 04/15/25, 26 of 40 residents were not served water, and during breakfast on 04/16/25, 13 of 14 residents were not served water. Staff and management were unaware that water must be served with every meal and believed it was optional.

The facility failed to ensure water was served to each resident at each meal in addition to other beverages. Observations and interviews revealed that for many residents, water was not provided unless specifically requested, and the facility's daily menus did not include water as a standard meal service item.

The facility failed to ensure health care follow-up was completed for a resident regarding an order to fax weekly blood pressure and heart rate results to their primary care provider. While vital signs were recorded daily, there were no fax confirmations documenting that the required weekly reports were successfully sent to the physician.

The facility failed to ensure health care follow-up was completed for a resident regarding an order to fax weekly blood pressure and heart rate results to their primary care provider. While vital signs were being recorded daily, there was no documentation to confirm that the required weekly faxes were actually sent to the physician.

The facility failed to maintain the building in a safe condition, specifically regarding security for residents in the secured assisted living unit. Nine windows and two courtyard gates accessible to cognitively impaired residents were found unlocked. This lack of security previously allowed an intruder to enter the facility through a ground-level bedroom window.

The facility failed to maintain the building in a safe condition because nine windows in the secured assisted living unit and two courtyard gates were not properly locked. Despite new protocols implemented after an intruder entered through a window on January 15, 2024, subsequent inspections found multiple windows could still be opened several inches despite the latches being in the locked position.

The facility failed to ensure timely primary care physician notification and follow-up for a resident whose indwelling Foley catheter had been accidentally removed. This failure resulted in a delay in catheter reinsertion, contributing to the resident developing severe sepsis and a UTI.

The facility failed to ensure timely primary care physician notification for a resident with an indwelling Foley catheter that had been accidentally removed. This failure to coordinate follow-up care contributed to the resident developing severe sepsis and a UTI.