Harmony at West Shore.

“Suspected abuse involving one resident barricading a room door with another resident inside and blocking staff from administering medications was not reported to the local area agency on aging as required by the Older Adult Protective Services Act.”

“Multiple incidents were not reported to the Department within 24 hours: a resident fall with head injury and ER transport, missed medication administrations on multiple dates, a resident found on floor with head wound requiring ER admission and hospitalization, and suspected abuse allegations involving room barricading and medication access blocking.”

“A resident fell out of a chair, hit their head, and was transported to the ER. After discharge early the next morning, the home failed to conduct an assessment for ongoing dizziness and low blood pressure or to evaluate the resident's mobility status. The resident subsequently fell again and fractured their hip requiring surgery. Additionally, one resident barricaded a room door with another resident inside and blocked staff from administering medications.”

“A resident was hospitalized and diagnosed with severe protein malnutrition, requiring assistance with eating and a walker upon discharge. The home did not obtain a physician evaluation for these new needs and failed to complete an assessment and support plan documenting the resident's changed medical condition. The resident subsequently suffered two falls resulting in injury and hospitalization.”

“Multiple routine medications were not administered to a resident on specified dates and times, failing to follow the prescriber's medication orders.”

“The nurse's station on the second floor was unlocked and unattended with a 3-tier file holder containing residents' confidential information accessible on the desk.”

“Resident-home contracts were not signed by the residents as required.”

“Resident records did not contain statements signed by the residents acknowledging receipt of a copy of the resident rights and complaint procedures.”

“Multiple resident enabler bars were improperly installed with uncovered openings exceeding regulatory requirements, and one enabler bar was not securely fastened to a resident's bed, creating entrapment hazards.”

“An unlabeled spray bottle containing an unknown substance was located in a buffet cabinet in the Secure Dementia Care Unit.”

“Multiple poisonous materials were observed unlocked and unattended in the Secure Dementia Care Unit and stored near food and dining surfaces, including bottles with hazard labels stored in the dining room buffet cabinet.”

“Trash in kitchens and/or bathrooms was not kept in covered trash receptacles that prevent the penetration of insects and rodents.”

“A staff-to-resident abuse incident occurred on 5/3/2024 at 7:15PM. The home did not report this incident to the Department within 24 hours; it was not reported until 5/6/2024 at 5:00PM, a delay of approximately 3 days.”

“Department agents requested access to resident records, staff records, and contracts on 7/2/2024. Multiple records were not provided immediately: resident records for Residents #1 and #2 were delayed until 2:00PM, staff records for multiple staff members until 2:15PM, resident records for Residents #3, 5, 8 were found on a shelf, records for Residents #6 and #7 delayed until 3:40PM, and staff record for Staff Member B, resident contracts, and records for Residents #3, 4, 5, 8 were not submitted by 5:40PM on 7/2/2024. Contracts were not available until 7/3/2024 at 9:00AM.”

“A staff-to-resident abuse incident occurred on 5/3/2024 at 7:15PM. The Act 13 Mandatory Abuse Reporting form was not completed and submitted to AAA until 5/8/2024 at 1:12PM, creating a delay in the mandated reporting timeline.”

“Following a staff-to-resident abuse incident on 5/3/2024 at 7:15PM involving Staff Member B, the home did not immediately develop and implement a plan of supervision or suspend the staff member. Staff Member B was only reassigned to a different floor to continue their shift, and the home could not confirm whether the staff member was supervised during this time or whether they worked again prior to termination.”

“Department agents requested access to resident records, staff records, and contracts on 7/2/2024. Multiple records were not provided immediately: resident records for Residents #1 and #2 were delayed until 2:00PM, staff records for multiple staff members until 2:15PM, resident records for Residents #3, 5, 8 were found on a shelf, records for Residents #6 and #7 delayed until 3:40PM, and staff record for Staff Member B, resident contracts, and records for Residents #3, 4, 5, 8 were not submitted by 5:40PM on 7/2/2024. Contracts were not available until 7/3/2024 at 9:00AM.”

“A staff-to-resident abuse incident occurred on 5/3/2024 at 7:15PM. The Act 13 Mandatory Abuse Reporting form was not completed and submitted to AAA until 5/8/2024 at 1:12PM, creating a delay in the mandated reporting timeline.”

“Following a staff-to-resident abuse incident on 5/3/2024 at 7:15PM involving Staff Member B, the home did not immediately develop and implement a plan of supervision or suspend the staff member. Staff Member B was only reassigned to a different floor to continue their shift, and the home could not confirm whether the staff member was supervised during this time or whether they worked again prior to termination.”

“A staff-to-resident abuse incident occurred on 5/3/2024 at 7:15PM. The home did not report this incident to the Department within 24 hours; it was not reported until 5/6/2024 at 5:00PM, a delay of approximately 3 days.”

“A resident was self-administering prescribed medication as needed; however, the resident had not been assessed by a physician, physician's assistant, or certified registered nurse practitioner regarding their ability to self-administer medications.”

“A discontinued medication (memory support dietary supplement) for a resident was found in the medication cart after the resident moved from the secured dementia care unit to personal care. This was a repeated violation from 12/20/23.”

“Loose pills were observed in multiple medication carts including the Secure Dementia Care Unit med cart, second-floor med cart, and fourth-floor med cart, indicating improper storage practices. This was a repeated violation from 2/22/24 and 12/20/23.”

“Staff persons A, B, and C did not receive required fire safety and emergency preparedness orientation on their first day of work, including evacuation procedures, staff duties during fire drills and emergency evacuation, designated meeting places, smoking safety procedures, fire extinguisher use, smoke detectors and fire alarms, and telephone/emergency services notification.”

“The home failed to report an incident of resident-to-resident violence (Resident 6 hitting Resident 10 on the head) to the Department within 24 hours. The incident occurred on 11/24/23 at approximately 12:15 pm, but was not reported until 11/27/23. This is a repeated violation from 7/20/23.”

“Resident 6 was observed in multiple altercations with other residents including hitting Resident 10 on the face (11/24/23), grabbing Resident 7 by the shirt and smacking in the face (12/01/23), hitting Resident 5 on the shoulder (12/3/23), and slapping and slamming Resident 2 against the wall causing bruising under the right eye (12/10/23). This is a repeated violation from 10/17/23 and 7/20/23.”

“On 12/9/23 from 11:00 pm to 7:00 am, 72 residents were present in the home with no staff persons certified in first aid and CPR. At least one staff person for every 50 residents must be trained in first aid and certified in CPR at all times. This is a repeated violation from 3/8/23.”

“The home failed to report an incident of resident-to-resident violence (Resident 6 hitting Resident 10 on the head) to the Department within 24 hours. The incident occurred on 11/24/23 at approximately 12:15 pm, but was not reported until 11/27/23. This is a repeated violation from 7/20/23.”

“Resident 6 was observed in multiple altercations with other residents including hitting Resident 10 on the face (11/24/23), grabbing Resident 7 by the shirt and smacking in the face (12/01/23), hitting Resident 5 on the shoulder (12/3/23), and slapping and slamming Resident 2 against the wall causing bruising under the right eye (12/10/23). This is a repeated violation from 10/17/23 and 7/20/23.”

“On 12/9/23 from 11:00 pm to 7:00 am, 72 residents were present in the home with no staff persons certified in first aid and CPR. At least one staff person for every 50 residents must be trained in first aid and certified in CPR at all times. This is a repeated violation from 3/8/23.”

“Staff persons A, B, and C did not receive required fire safety and emergency preparedness orientation on their first day of work, including evacuation procedures, staff duties during fire drills and emergency evacuation, designated meeting places, smoking safety procedures, fire extinguisher use, smoke detectors and fire alarms, and telephone/emergency services notification.”

“The home failed to submit an Act 13 form to the local Area Agency on Aging following a resident-to-resident abuse incident. The facility was required to immediately report suspected abuse in accordance with the Older Adult Protective Services Act.”

“Resident 1 and Resident 2 were involved in an incident where Resident 2 struck Resident 1 on the legs with a decorative wooden block in the Secure Dementia Care Unit, resulting in Resident 1's transfer to the emergency room for back and side pain. This is a repeated violation from 7/20/23.”

“A staff member photographed a resident on a private cell phone after the resident sustained injuries from an unwitnessed fall. The photograph was circulated among staff members, violating the resident's right to privacy of self and possessions.”

“The home submitted an incident report on 7/17/23 that inaccurately described a resident's injury in the secured courtyard. The report failed to document that the resident had eloped for approximately 2 hours (between 2:30 p.m. and 4:30 p.m.), suffered heat stroke, dehydration, second-degree burns to both feet, and had an internal body temperature of 102.5 degrees Fahrenheit upon hospital arrival.”

“Resident 1 was inadequately supervised in the secured courtyard, eloping for approximately 2 hours (2:30 p.m. to 4:30 p.m.) during 87-degree weather and suffering multiple injuries including second-degree burns to lower extremities, heat exhaustion, and dehydration with a rectal temperature of 102.5 degrees Fahrenheit upon hospital admission.”

“Resident 1's support plan dated 04/24/2023 did not identify the resident's documented behaviors (manic episodes including constant movement, exit-seeking, sleep/eating issues, and attempting to remove clothing) or the services required to address them.”