Harmony Pointe Care Center

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Egress Deficiencies

Install proper backup exit lighting.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Services Deficiencies

Have an externally vented heating system.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Egress Deficiencies

Have exits that are accessible at all times.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.31. Corridor 3 fire doors missing latch.. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain firewalls in accordance with NFPA 101, 8.3.1.2. 1. Scab patches in the dry storage2. Fire stopping is needed in the ou.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Delayed egress door panic hardw.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7.1. Hallway 2 exit sign is pointing in .. Based on observation and staff interviews, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70.1. Open junction box in memory careNFPA 101 9.1.2 Electrical Systems. Electrical wiring .. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. Oxygen storage door missing signage 2. Hall.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1... Based on observations and records review, it was determined that the facility did not have Fire Alarm out of service guidance in accordance with NFPA 101. 1. Missing time frame of when the sprinklers are down for 4 or more hours. 2... Based on observations and records review, it was determined that the facility did not have Sprinkler System out-of-service guidance in accordance with NFPA 101 and NFPA 251. Missing time frame of when the sprinklers are do.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Paperwork is missing 2nd and 3rd shift for first quarter, no paperwork for 4th quarter.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The f.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by:1. Extension cord around suppress.. Through observation during the survey, it was determined that the facility failed to meet the rubbish chutes, incinerators, and laundry chute requirements in accordance with NFPA 101, This was evidenced by:1. No inspection r..

A recertification survey with complaint #CO37358 was completed on 9/23/24 to 9/26/24. Seventeen deficiencies wer.. An Emergency Preparedness survey was conducted from 9/23/24 to 9/26/24. No deficiencies were cited. Based on interviews, record review and observations the facility failed to ensure residents consistently received food.. Based on observations and interviews the facility failed to ensure that residents personal funds accounts were manag.. Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored a.. Based on observations and interviews, the facility failed to ensure residents' personal privacy for one (#13) of one res.. Based on observations and interviews, the facility failed to ensure the services provided or arranged by the facility m.. Based on observations and interviews, the facility failed to maintain an infection prevention and control program des.. Based on observations, record review and interviews, the facility failed to ensure activities designed to support resid.. Based on observations, record review and interviews, the facility failed to ensure that a resident who displayed or w.. Based on observations, record review and interviews, the facility failed to ensure the residents environment remaine.. Based on observations, record review and interviews, the facility failed to honor resident choices for one (#8) of thre.. Based on observations, record review and interviews, the facility failed to provide a clean, comfortable and homelik.. Based on observations, record review and interviews, the facility failed to provide the necessary treatment and servi.. Based on record review and interviews, the facility failed to develop a comprehensive care plan for one (#25) of two .. Based on record review and interviews, the facility failed to ensure one (#34) of five out of 45 sample residents were.. Based on record review and interviews, the facility failed to ensure that one (#8) of one out of 45 sample residents w.. Based on record review and interviews, the facility failed to notify the resident' s representative when required for on.. Based on record review and interviews, the facility failed to report a resident to resident altercation that resulted in.. Based on record review, observations and interviews, the facility failed to ensure two (#91 and #66) of two residents ..