Harmony House Memory Care

The facility failed to ensure the call light system was operating correctly to ensure resident calls were received and responded to in a timely manner. Specifically, in 10 of 19 resident rooms requiring evacuation assistance, the call lights failed to illuminate when activated, and the system failed to produce sound or send signals to the medication room.

The facility failed to ensure the call light system was operating as designed to ensure residents' calls were received and responded to in a timely manner. In 10 of 19 resident rooms, the call lights did not illuminate when activated, and the system failed to produce a sound or send a signal to the medication room. Additionally, some residents lacked alternative signaling devices, such as hand bells, as required for those unable to evacuate without assistance.

The facility failed to ensure that one of three sampled staff members had no findings listed on the North Carolina Health Care Personnel Registry (HCPR). There was no documentation that an HCPR check was completed prior to the staff member's hire date.

The facility failed to maintain documentation of a signed consent for a criminal background check in a staff member's personnel file. Specifically, for Staff B, there was no evidence that consent for the required background check was obtained prior to employment.

The facility failed to provide necessary personal care to residents according to their care plans. Observations and reviews showed that two of six sampled residents required staff assistance with fingernail and toenail care that was not provided.

The facility failed to ensure that one of three sampled staff members had no substantiated findings on the North Carolina Health Care Personnel Registry (HCPR) prior to hire. Specifically, there was no documentation that an HCPR check was completed for a personal care aide hired on 11/12/25.

The facility failed to maintain documentation of consent for a criminal background check for one of three sampled staff members. The personnel record for a personal care aide hired on 11/12/25 lacked the required signed consent form.

The facility failed to meet specific requirements regarding the physical environment of resident bedrooms. The regulation outlines standards for bedroom size, occupancy limits, ventilation, and window safety to ensure resident safety and comfort.

The facility failed to ensure that windows in the Special Care Unit were operational and maintained to allow for a six-inch opening. Following recent elopement incidents, the Administrator instructed maintenance to screw all 37 resident windows shut using metal L-shaped brackets, preventing the required ventilation and access.

The facility failed to administer medications in accordance with physician orders. Specifically, a medication aide crushed an extended-release metoprolol succinate tablet, which should not be crushed, and failed to properly administer ordered medications for blood pressure, potassium, ammonia, and constipation for several residents.

The facility failed to administer medications as ordered for several residents, specifically involving a failure to follow instructions regarding extended-release medications. An observation revealed a medication aide attempting to crush a metoprolol succinate ER tablet, which is a medication that must not be crushed or chewed. Additionally, the facility failed to ensure that medication orders for lowering ammonia and constipation were properly administered for sampled residents.