The facility's discharge notices omitted essential details that residents need to contest unwanted transfers.
Nursing Home News — Page 271
All Stories
The oversight violated the facility's own policy requiring such monitoring.
Federal inspectors discovered the oversight during an April 2026 review of employee files.
The resident was cognitively intact but completely dependent on staff for care, with limited range of motion in her arms and legs.
Staff documented multiple incidents showing the resident's need for both items.
The facility missed mandatory 14-day deadlines for four residents, waiting until April 1 to submit evaluations that should have been transmitted by late March.
State screening results from July 2024 clearly indicated this resident required a specialized federal assessment before admission to any nursing facility.
Staff called hospice during that episode, but documentation failed to include notification of the resident's guardian about his deteriorating condition.
When inspectors observed the resident on April 6 at 10:27 AM, she had a pill cup containing two pills on her bedside table.
CNA C began the care properly, washing her hands and putting on gloves before cleaning the resident's perineal area with three wipes.
Federal inspectors watched the assistant work through the multi-step cleaning process, documenting each glove change and the complete absence of hand hygiene.
Federal inspectors found the breakdown in basic safety procedures at Harmony River Living Center during an April inspection.