Inspection visit
Health inspection
38 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 38 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, record review and staff interview, the facility failed to ensure residents were not
served meals in disposable Styrofoam food boxes. This affected 11 (Residents #12, #18, #20, #32, #47,
#54, #76, #84, #89, #93 and #303) of 11 observed for meal services. Additionally, the facility failed to
ensure a resident's urinary catheter bag was covered for dignity. This affected one (Resident #361) of one
resident observed for catheter bag coverage. The facility census was 108.
Findings include:
1. Observation of tray line in the kitchen on 12/06/23 at 11:41 A.M. revealed Dietary [NAME] #64 served
lunch to Residents #12, #18, #20, #32, #47, #54, #76, #84, #89, #93 and #303 in disposable Styrofoam
food boxes.
During an interview on 12/06/23 at 11:41 A.M., Dietary [NAME] #64 and Dietary Supervisor #80 revealed
the kitchen was out of plate covers and had to serve Residents #12, #18, #20, #32, #47, #54, #76, #84,
#89, #93 and #303 lunch in disposable Styrofoam food boxes.
2. Review of the medical record for Resident #361 revealed an admission date on 11/29/23. Diagnoses
included malignant neoplasm of prostate, type two diabetes, and overactive bladder.
Observation on 12/04/23 at 11:30 A.M. revealed Resident #361 in the lounge area seated in a wheelchair.
Resident #361's urinary catheter bag was not covered and was visible to facility staff and residents.
Interview on 12/04/23 at 12:35 P.M. with Licensed Practical Nurse (LPN) #127 verified Resident #361's was
sitting in the main lounge area and the resident's urinary catheter bag was uncovered.
Review of facility titled protocol, Resident Rights and Dignity, dated 01/05/22 revealed the facility recognizes
the resident's right to a quality of life that supports privacy, confidentiality, dignity, independent expression,
choice, and decision making, consistent with State law and Federal regulation.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 66
Event ID:
366220
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
medical record for Resident #42 revealed an admission date of 04/28/23. Diagnoses included joint
replacement surgery, opioid dependence, depression, hypokalemia, paroxysmal atrial fibrillation,
thyrotoxicosis, hypertension, pain in lower back and right hip, spinal stenosis, gastro-esophageal reflux
disease, anemia, hypercholesteremia, insomnia, and neuromuscular dysfunction of bladder.
Residents Affected - Few
Review of the MDS assessment dated [DATE] revealed Resident #42 was cognitively intact. Resident #42
required one-person assistance with bed mobility, transfers, toileting, and bathing.
Interview on 12/04/23 at 12:10 P.M. with Resident #42 and family revealed the curtains over the window
were not hung properly to be used for privacy. Resident #42's family stated it had been like that for some
time.
Observation on 12/04/23 at 12:10 P.M. of Resident #42's room revealed the window had a curtain that was
not latched on the curtain rod, and unable to provide privacy. The window overlooked a garden where
residents smoke and Resident #42 could have been visible to outside residents.
Interview on 12/04/23 at 1:00 P.M. with Licensed Practical Nurse (LPN) #93 confirmed that Resident #42's
curtains were damaged and did not provide privacy.
Based on observation, record review, and interview, the facility failed to ensure a resident's call light was
within reach and a resident's privacy curtain were in good repair. This affected two (#42 and #62) residents
out of 35 residents reviewed for call lights. The facility census was 108.
Findings include:
1. Review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE]
with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left
non-dominant side.
Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had moderate cognitive impairment and required one-person extensive assistance with transfers,
dressing, toileting, and bathing. Resident #62 also required supervision with eating.
Review of Resident #62's care plan dated 08/03/23 revealed interventions in place for falls including the call
light should be kept accessible.
Observation on 12/05/23 at 9:17 A.M. revealed Resident #62's call light was on the ground and was out of
reach while Resident #62 was lying in bed.
Interview with State Tested Nurse Aide (STNA) #08 on 12/05/23 at 9:17 A.M. verified Resident #62's call
light was on the ground and out of reach.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 2 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure a resident's code status was accurate in the medical
record. This affected one (Resident #62) of one reviewed for advanced directives. The facility census was
108.
Findings include:
Review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE] with
diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant
side.
Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had moderate cognitive impairment and required one-person extensive assistance with transfers,
dressing, toileting, and bathing. Resident #62 also required supervision with eating.
Review of the care plan dated 04/17/23 revealed Resident #62 had chosen to be a full code. Interventions
included complete and update advanced directives document and for staff to review advanced directives on
file.
Review of the physician order dated 04/17/23 revealed Resident #62 was ordered to be a full code.
Review of the medical record for code status for Resident #62 revealed a full code.
Review of the Do-Not-Resuscitate (DNR) order form dated 04/28/23 revealed Resident #62 signed to be a
Do-Not-Resuscitate-Comfort Care-Arrest (DNR-CCA).
Interview on 12/06/23 at 9:47 A.M. with Licensed Practical Nurse (LPN) #121 verified Resident #62 had
orders for a full code and had a DNR-CCA signed on 04/28/23 but did not know which code status was
correct.
Review of the facility's advanced care directives policy dated January 2022 revealed the facility will
recognize and implement the resident's rights under the state law to make decisions concerning medical
care including the right to accept or refuse medical treatment and the right to formulate advanced
directives.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 3 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to ensure a resident's family member was made aware of
an injury the resident incurred. The facility also failed to ensure the resident's primary care physician was
consulted when the resident had a change of condition. This affected one (Resident #87) of one reviewed
for notification. The facility census was 108.
Findings include:
Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses
including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance,
protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred
to the hospital on [DATE] at 5:30 P.M.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe
cognitive impairment and at that time she was assessed as not having pain. She was noted as being under
hospice care.
Review of Resident #87's facesheet revealed her son was listed as being her designated Healthcare Power
of Attorney (POA).
Review of Resident #87's progress note, written by Licensed Practical Nurse (LPN) #120 dated 12/03/23 at
8:00 A.M., revealed an aide advised LPN #120 of the resident's left and being discolored. LPN #120 called
hospice and told the nurse who answered about Resident #87's hand. There was no documentation to
show Resident #87's POA was notified of her hand being discolored. Additionally, there was no
documentation the physician was notified of the change in condition.
Review of the progress note, written by LPN #118 dated 12/04/23 at 3:39 P.M., revealed Resident #87's left
hand was found to have swelling, fingers discolored (dark bruising). Hospice was notified awaiting a return
call. There was no documentation showing the resident's POA was made aware of the discolored fingers.
Additionally, there was no documentation the physician was notified of the change in condition.
Interview on 12/13/23 at 11:52 A.M. with Hospice Nurse #171 revealed Resident #87's POA told her the
nursing home staff did not get in touch with him on Sunday 12/03/23 when they found the bruising to the
resident's left hand. Resident #87's POA was surprised and angry he was not informed.
Interview on 12/14/23 with Primary Care Physician #600 revealed he was unaware of the bruising to
Resident #87's hand.
This deficiency represents non-compliance investigated under Complaint Number OH00148957.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 4 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Few
Based on record review, staff interview, and policy review, the facility failed to ensure residents were given a
Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) when being cut from
skilled services and remaining in the facility. This affected two (Residents #154 and #155) of three residents
reviewed for beneficiary notices. The facility census was 108.
Findings included:
1. Review of the clinical record revealed Resident #154 was admitted to the facility on [DATE] and
discharged on 10/18/23. His diagnoses included type II diabetes with foot ulcer, hypertensive chronic
kidney disease, end stage renal disease, hypertension secondary to endocrine disorders, atherosclerotic
heart disease of the native coronary artery, diabetic polyneuropathy, chest pain, and personal history of
transient ischemic attack and cerebral infarction without residual deficits.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #154's
Brief Interview for Mental Status (BIMS) score was 15, indicating he was cognitively intact. He needed
supervision of staff for activities of daily living (ADLs).
Review of the Notice of Medicare Non-Coverage revealed Resident #154's last covered day was 09/07/23
and the cut letter was provided on 09/05/23. He did not discharge until 10/18/23. There was no SNF ABN
completed.
2. Review of the clinical record revealed Resident #155 was originally admitted on [DATE], readmitted on
[DATE], and discharged on 09/29/23. Her diagnoses included acute respiratory failure with hypoxia,
dysphagia, end stage renal disease, morbid obesity, alcoholic cirrhosis of the liver, bipolar disorder,
hypertension, type II diabetes with diabetic chronic kidney disease, acute on chronic diastolic (congestive)
heart failure, alcohol abuse, generalized anxiety disorder, depression, hypothyroidism, seizures, acute
kidney failure, thrombocytopenia, bacterial pneumonia, severe sepsis without septic shock, and
gram-negative sepsis.
Review of the admission MDS assessment dated [DATE] revealed Resident #155 had a BIMS score of 15,
indicating she was cognitively intact. She needed extensive assistance to being totally dependent upon staff
for ADLs.
Resident #155's last covered day was 08/24/23 with a Notice of Medicare Non-Coverage given on 08/22/23
(dated 07/22/23 in error). She remained in the facility until 09/29/23, but did not receive a SNF ABN.
An interview was conducted with Social Services Director #156 on 12/11/23 at approximately 11:00 A.M.
revealed Residents #154 and #155 stayed in the facility after being cut from services, but did not receive a
SNF ABN.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 5 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #60's medical record revealed Resident #60 was admitted on [DATE] with diagnoses including
atherosclerotic heart disease of native coronary artery, chronic obstructive pulmonary disease, dementia,
heart failure, hypertension, major depressive disorder, chronic kidney disease, hyperlipidemia, bipolar
disorder, polyosteoarthritis, venous insufficiency, panic disorder, insomnia, and anxiety disorder.
Review of Resident #60's admission MDS dated [DATE] revealed she had moderate cognitive impairment
and required set up assistance with ADLs.
Observation on 12/05/23 at 10:50 A.M. of Resident #60's room revealed there was no call light cord.
Interview on 12/05/23 at 10:52 A.M. with Resident #60 revealed she did not have a call light cord and did
not have a bell.
Interview with LPN #93 on 12/05/23 at approximately 10:55 A.M. verified there was no call light cord and
the resident did not have a bell to ring in place of the call light.
3. Review of Resident #16's medical record revealed Resident #16 was admitted originally on 04/22/08 and
readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebrovascular
disease affecting the right dominant side, cerebellar stroke syndrome, chronic kidney disease,
hypertension, iron deficiency anemia, vascular dementia, frontotemporal neurocognitive disorder, paranoid
schizophrenia, schizoaffective disorder, delusional disorders, diabetes mellitus, peripheral vascular disease,
schizoaffective disorder bipolar type, and acute kidney failure.
Review of Resident #16's annual MDS assessment dated [DATE] revealed she had moderate cognitive
impairment.
Observation of Resident #16's room on 12/05/23 at 12:05 P.M. revealed there was a dark substance around
and on the vent. There was also water damage on the ceiling over the sliding door with what appeared to
be mildew.
Interview with LPN #93 on 12/05/23 at 12:06 P.M. verified the observations of the dark substance on and
around the vent, the water damage on the ceiling, and the mildew over the sliding door.
Review of the Mold Inspection and Testing report for inspection date of 12/06/23 revealed there was no
evidence of black mold in Resident #16's room. A visual inspection was done and two air samples were
collected from inside the facility and outside of the facility. The air sample from Resident #16's room was
found to have basidiospores, cladosporium, and penicillum/Aspergillus. The report indicated elevated mold
conditions did not exist at the property and it was their professional opinion that professional mold
remediation was not required.
Interview with the Director of Clinical Services and the Administrator on 12/12/23 at 3:04 P.M. revealed the
black substance in Resident #16's room would be cleaned with Odoban Disinfectant which is a Fungoscidal
and noted to be effective for mold and mildew control. They said it was verified to be effective with the mold
testing company.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 6 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Review of the policy entitled, Cleaning of Residents' Rooms, updated 07/22 revealed the policy stated
walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly
contaminated or soiled.
This deficiency represents non-compliance investigated under Complaint Number OH00147516.
Residents Affected - Few
Based on observation, record review, and interview, the facility failed to ensure a resident's walls were free
from patches and a resident's vent and ceiling were free of debris. This affected three (Resident #16, #60,
and #69) residents of three residents reviewed for environment. The facility census was 108.
Findings include:
1. Review of the Resident #69's medical record revealed Resident #69 was admitted to the facility on
[DATE] with diagnoses including chronic obstructive pulmonary disease unspecified, respiratory disorders
in diseases classified elsewhere, type two diabetes mellitus, Alzheimer's disease with early onset and adult
failure to thrive.
Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident was cognitively intact and required set up assistance with bathing and was independent with all
other activities of daily living (ADLs).
Observation of Resident #69's room on 12/04/23 at 12:25 P.M. revealed several large patches on his wall
including a patch that was approximately two foot by two foot that was not completed or painted.
Interview with Resident #69 on 12/04/23 at 12:25 P.M. revealed he had always had patches on the walls in
his room.
Interview with Licensed Practical Nurse (LPN) #121 on 12/07/23 at 9:05 A.M. verified Resident #69's room
had several large patches on his wall including a patch that was approximately two foot by two foot that was
not completed or painted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 7 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, review of hospital records, review of hospice notes, review of a
transportation report, observations, and review of facility policy, the facility failed to ensure one resident
(Resident #87) did not experience neglect. This resulted in Immediate Jeopardy and the potential for
serious harm, injury, and/or negative health outcomes when on 12/03/23 Resident #87, whose left hand
was discolored and painful, did not receive an x-ray as ordered, was not medicated for pain, and was not
assessed by a physician or appropriately assessed by a nurse. She was not seen by a physician, and the
primary care physician was not made aware of her condition. There was no documentation that Resident
#87's radial pulse or capillary refill was assessed for appropriate blood flow to her left hand. X-rays were
ordered on 12/03/23 but not completed until 12/07/23. Pain medication was ordered on 12/03/23 but not
given until 12/06/23. The hospice physician ordered Resident #87 to be sent to the emergency room (ER)
on 12/07/23 at 2:30 P.M. for evaluation, but she was not transported until 5:30 P.M. when she went by
non-emergent transport. After being assessed in the emergency room, Resident #87 was diagnosed having
left limb ischemia and dry gangrene, and her hand may not be salvageable. This affected one (Resident
#87) of three residents identified by the facility as having a significant change in condition. The facility
census was 108.
On 12/14/23 at 1:09 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical
Operations #16 were notified Immediate Jeopardy began on 12/03/23 when Resident #87 was observed
with a discolored left hand, which became swollen, more painful and darkened in color. Upon assessment
at the hospital on [DATE] Resident #87's hand was found to be painful and cold, with no left radial pulse
detected. Her left hand was flaccid. Resident #87 had a hemoglobin level of 4.5 requiring a transfusion of
three units of packed red blood cells. After being assessed in the emergency room, Resident #87 was
diagnosed having left limb ischemia and dry gangrene, and her hand may not be salvageable.
The Immediate Jeopardy was removed on 12/15/23 when the facility implemented the following corrective
actions:
· On 12/07/23 at 5:30 P.M., Resident #87 was sent to the hospital by non-emergency transport.
· On 12/13/23, the DON began immediate education with all nurses to educate on the following and
to be completed by 12/15/23:
a. Facility protocol of Episodic and Narrative Documentation and physician and responsible party
notification.
b. Physician Orders and timely implementation and follow-up.
c. Pain Management Protocols
d. Any nurse who was not scheduled or who could not be educated will receive education prior to working
their next scheduled assignment.
· On 12/14/23 at 1:10 P.M., the facility reviewed the 24-hour summary report up to 5:00 P.M.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 8 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
for current residents to verify that any other residents who had/may have had a change of condition that
appropriate documentation, notification, and follow-up occurred. Two residents were identified with a
change of condition and appropriate documentation and notification had occurred.
· On 12/14/23, the DON had phone conversations with our other contracted Hospices to make
them aware of our expectations of communication of injuries of unknown origin, communication of new
orders, and physician notification.
· On 12/14/23, the Licensed Nursing Home Administrator (LNHA) began immediate education for
all current staff on the facility protocols for Abuse, Neglect, Misappropriation, and Injury of Unknown Origin.
This will be completed by 12/15/23. Any staff member who was unable to be educated will be educated
prior to their next scheduled assignment.
· On 12/14/23, the Medical Director was notified of the Immediate Jeopardy once the facility was
notified.
· On 12/15/23, the facility will conduct ongoing monitoring for condition change and documentation
during the daily clinical morning meeting by reading the 24-hour summary report in the Electronic Health
Record (EHR) Monday through Friday, and the 72-hour report on Mondays for Friday through Sunday to
verify appropriate assessment/documentation and notification has occurred and will follow up as indicated.
The DON/Designee will complete a condition change audit tool daily Monday through Friday to verify that
condition change protocols, notification and documentation have been followed.
· On 12/15/23, the LNHA will query five random staff members daily Monday through Friday weekly
times four weeks, and then three times per week for four weeks, and then weekly for two weeks. Results
will be reviewed at the Quality Assurance and performance Improvement meetings.
· On 12/18/23 from 3:15 P.M. to 3:32 P.M., interviews conducted with Licensed Practical Nurse
(LPN) #93, LPN #106, State Tested Nursing Assistant (STNA) #10, and STNA #38 verified they had
received in-servicing as specified in the corrective action plan.
Although the Immediate Jeopardy was removed on 12/15/23, the facility remains out of compliance at a
Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is
in the process of implementing their corrective action and monitoring for effectiveness and on-going
compliance.
Findings include:
Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses
including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance,
protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred
to the hospital on [DATE] at 5:30 P.M.
Review of Resident #87's care plan dated 03/21/23 revealed Resident #87 had the potential for pain with a
goal to be free of pain/discomfort. One of the interventions was to evaluate for non-verbal indicators of pain.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe
cognitive impairment and at that time she was assessed as not having pain. She was noted as being under
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 9 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
hospice care.
Level of Harm - Immediate
jeopardy to resident health or
safety
Review of a progress note dated 12/03/23 at 8:00 A.M., written by LPN #120, documented the aide advised
me about (the) res (resident's) left hand being discolored. It noted the nurse called hospice and told the
nurse who answered about Resident #87's hand. She asked if the resident had any pain medication
ordered. The nurse charted that she looked up her Medication Administration Record (MAR) and saw that
she did not. The nurse (Hospice Nurse #171) stated she would call the doctor and would give her a call
back. A couple hours later Hospice Nurse #171 came to the facility and looked at Resident #87. She said
she had called the doctor and was waiting for them to call her back to see what pain medicine he could
prescribe. She stated she would call the facility when she had an order. The note documented Hospice
Nurse #171 did not call back during the shift. The progress note revealed the nurse let the following nurse
know that they were waiting for a return call from hospice to see what they suggested.
Residents Affected - Few
Review of the hospice note dated 12/03/23 revealed Hospice Nurse #171 was in on 12/03/23 at 11:30 A.M.
to 12:05 P.M. The pain medication order on the hospice file at that time was Acetaminophen 500 milligrams
(mg) to give two tablets every morning as needed for pain that started on 06/21/23. The Acetaminophen
order was not on the facility's MAR or in the resident's electronic record. The note said the visit was
completed at that time and Resident #87 was in bed complaining of left hand pain. The facility staff reported
that she had blue and purple fingers. The physician was notified, and hospice staff were awaiting directions.
Review of the hospice case note dated 12/03/23 at 8:55 P.M. documented a return call was received from
Hospice Physician #172. Hospice Nurse #171 reported to the physician that Resident #87's hand was
discolored at the fingertips. Resident #87 was able to move her fingers at that time and complained of
discomfort and some swelling. Hospice Physician #172 gave orders for Tylenol 325 mg every six hours as
needed and Norco 5/325 mg every four to six hours as needed. The physician was requesting an
anteroposterior (AP) and lateral x-ray of her hand. The orders were called to the facility. Hospice Physician
#172 would sign and send the orders for medication to the pharmacy. The orders were called and faxed to
the facility.
Review of the hospice case note dated 12/04/23 at 9:10 A.M. revealed a call was made to the facility by
Hospice Nurse #171 to receive the results of the X-ray per request of Hospice Physician #172. The floor
nurse stated the results were still pending. The nurse reported the pain intervention was effective.
Review of a progress note dated 12/04/23 at 3:39 P.M. written by LPN #118 documented Resident #87's left
hand was swollen, and the fingers were discolored (dark bruising). It further documented hospice was
notified, awaiting a return call. The note indicated she was told verbally that Hospice came out the day
before (12/03/23) for an evaluation and there were no new orders.
Review of a nursing progress note dated 12/04/23 at 11:56 P.M. revealed Resident #87 refused her evening
medication.
Review of the narcotic count sheet for Norco 5-325 mg revealed it was signed as being received by the
facility on 12/04/23.
Review of a change of condition note dated 12/05/23 at 5:00 P.M. revealed Resident #87's condition had
gotten worse. Her weight had dropped from 72 pounds on 11/03/23 to 60 pounds on 12/02/23. She
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 10 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
had increased confusion and decreased mobility. She had edema, but the location was not documented.
She had discoloration to her left hand, and her intensity of pain
was rated a nine on a zero to ten scale. She had called for Hospice Nurse #171 to come out and reevaluate
her on 12/05/23 at 3:00 P.M. Resident #87's responsible party was notified of her decline and change to her
left hand.
Residents Affected - Few
Review of the hospice note dated 12/05/23 at 9:15 P.M. revealed that a call was made to Resident #87's
responsible party due to his concern that she was refusing medication. He was advised the facility reported
the patient was taking Norco on the previous day and that she had relief.
Review of the MAR revealed on 12/05/23 night shift, Resident #87 had a pain rating score of six with no
pain medication given.
Review of a progress note dated 12/06/23 at 8:55 A.M. by LPN #93 revealed a call was placed to the
hospice nurse requesting her to come and reevaluate Resident #87.
Review of the hospice visit note dated 12/06/23 at 10:15 A.M. revealed Resident #87 was in her room with
her hand elevated on a pillow. Her hand had previously been assessed with plus one edema (a 2 millimeter
indentation that rebounds immediately), now non-pitting. Resident #87's hand was still hurting to touch. She
said she just needed some sleep and was tired. The facility reported she was not eating at all except small
snacks left in her room. The staff reported the X-ray was completed but are still awaiting results of the X-ray.
It stated, Patient has decreased range of motion still able to move fingers, just painful.
Review of the MAR revealed on 12/06/23 at 4:49 P.M., Resident #87 was given Norco 5-325 mg after she
reported her pain was rated a seven.
Review of Resident #87's order recap report revealed the order for a two-view X-ray of the hand was
ordered on 12/07/23.
During an observation on 12/07/23 at 10:54 A.M., Resident #87 was sitting in a reclining wheelchair in the
dining room. Her hand appeared to have a dark bruise on her thumb and fingertips. During an interview at
this time, Resident #87 stated she hit her hand on a door. When asked if it hurt, she said It hurts so bad! A
nearby nurse said she had given Resident #87 pain medication that was ordered after her injury.
Review of the progress note dated 12/07/23 at 11:50 A.M. by LPN #92 revealed Resident #87 had swelling
to her left hand with discolored fingers (bluish black colored). Hospice was informed over the past weekend.
Resident #87 had complaints of pain and the as needed Norco pain medication was given. The pain
subsided for about an hour, but the pain came back, and Resident #87 wasn't due for more pain medication
until 2:46 P.M. Her pain was rated a four out of ten but did not interfere with her activities of daily living at
that time. A call was made to the hospice provider and the nurse would come out that day to re-evaluate
Resident #87's hand.
Review of the MAR revealed Resident #87 was medicated for pain on 12/07/23 at 8:44 A.M. after rating her
pain a four.
Review of the hospice skilled nursing visit note dated 12/07/23 at 1:10 P.M. revealed Resident #87
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 11 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
was present in a chair. Her fingers were more swollen than the previous visit with a slight change in color.
Orders were given to the facility on Sunday evening (12/03/23), and no results and no orders were put in by
the facility nurse. The DON ordered an X-ray at that time. She informed Hospice Physician #172 and he
stated he did not want to wait for results and to send her to the hospital. The orders to send her to the
hospital were given directly to the DON at that time. The DON demonstrated understanding. The
responsible party was present and acknowledged understanding also.
Residents Affected - Few
Review of the transport record revealed she was picked up on 12/07/23 at 5:30 P.M. by non-emergent
transport.
Review of Resident #87's two-view X-ray to her left hand dated 12/07/23 revealed the findings that the hand
demonstrated slightly decreased bony ossification. There was no evidence of acute fracture, or dislocation.
Diffuse arthritic changes were noted throughout the hands and digits. No significant soft tissue swelling was
identified and there was no evidence of osteomyelitis.
Review of the hospital records for Resident #87 revealed on 12/07/23 at 11:00 P.M. results from a
computed tomography-angio of the upper extremity with and without hypoattenuation revealed she had
severe 90 percent atherosclerotic stenosis of the left subclavian artery shortly after its origin with mural
thrombus. It showed patent left axillary, brachial, and radial arteries. The left ulnar artery was patent at its
origin and no longer visualized along the proximal to mid forearm. A vascular surgery consultation was
recommended.
Review of the medical intensive care unit history and physical, dated 12/08/23 at 1:22 A.M., documented
the resident was admitted on [DATE] at 8:57 P.M. Her left hand was painful and cold. Her blood pressure
was in the 120s/40s and she was tachycardic. Her hemoglobin was 4.6
(normal level for females 11.6 to 15 per Mayo Clinic). She had no left radial pulse detected. She was
admitted to the Surgical Intensive Care Unit (SICU) for anemia in setting of limb ischemia. She had left limb
ischemia and dry gangrene.
Review of the SICU flow sheet dated 12/08/23 at 5:17 A.M. revealed she had complaints of pain at a level
of eight in her left hand. Her hand was black at the fingertips and the patient was unable to perform fine
motor skills. She had to be given as needed Haldol one time so staff could safely and effectively provide
treatments. She had mitt restraints in place.
Review of the hospital Vascular Surgery Daily Progress note dated 12/08/23 at 7:01 A.M. revealed her
pulses were palpable at the left brachial only and absent in the radial and ulnar. Her left hand was flaccid.
They could not perform surgery with her hemoglobin of 4.5 and her hand may not be salvageable.
During an interview on 12/11/23 at 2:30 P.M., the DON said the resident went to the hospital on [DATE].
She spoke to Resident #87's responsible party who said he was going to meet her at the hospital.
Non-emergency transport was called to take her and drop her off. She said the facility sent the X-ray
results, face sheet, and orders. She stated the hospice nurse was out to see her on 12/04/23 at around
1:00 P.M. to 2:00 P.M. The hospice nurse told the responsible party and the nurse that there was nothing
they could do. There were no new orders from hospice at that time. The DON said she went through the
hospice notes finding there was an order for an X-ray. She spoke with the hospice nurse and she said she
spoke with a nurse about the X-ray order. She was unable to provide the name of the nurse, but said it was
requested from the day shift nurse. The DON saw that an order for an X-ray
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 12 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
was not obtained until 12/03/23 at 8:30 P.M. She said the facility did not get the order and requested the
resident be seen again on Tuesday and asked for the hospice notes. When she found the order, she called
to have it done on 12/07/23. The results were that she did not have any fractures.
During an interview on 12/11/23 at 4:36 P.M., LPN #120 stated she worked day shift on 12/03/23 and the
aide told her she should look at Resident #87's hand. She stated Resident #87's hand was discolored, and
when LPN #120 touched her hand, Resident #87 was in pain. She stated she called the physician and he
said she had to contact hospice. She said she called the hospice provider and spoke with the nurse telling
her that Resident #87's left hand fingers were discolored. Hospice Nurse #171 asked if Resident #87 had
any as needed pain medication. LPN #120 looked at her orders and there were no orders for as needed
pain medication. Hospice Nurse #171 said she would have to contact the doctor to see what they could do
about it. About one and a half to two hours later, Hospice Nurse #171 came out to see Resident #87. She
revealed Hospice Nurse #171 said yes it does look bad and told her she was waiting for the doctor to call
back to see what she could prescribe. She believed Hospice Nurse #171 came out on 12/03/23 about 1:00
P.M. She said Resident #87 stayed in her room and did not want to come
out. She stated Hospice Nurse #171 did not call back with a pain medication order during the shift. LPN
#120 said she did not call the physician again but felt she should have. She revealed Resident #87 did not
complain of pain anymore that shift. She said Hospice Nurse #171 did not say they were ordering an X-ray.
She also stated the bruising was not reported to management, and she was not aware of the proper
procedure regarding a bruise.
During an interview on 12/13/23 at 12:57 P.M., LPN #119 stated she worked on the 200 unit that night and
stated Resident #87 complained of pain when her left hand was touched or if she moved it. She said
Resident #87's hand was turning blue. She was not aware of Hospice Nurse #171's visit and thought they
were still waiting for her. She stated she did not receive a call for an order for an X-ray or pain medication.
She stated when the State Tested Nursing Assistant (STNA) tried to move her hand she said it hurt. She
said she tried to call hospice and did not get an answer. She said Resident #87 could move her arm, wiggle
fingers, and had a pulse. She stated Resident #87 did not get any pain medicine but did not complain if her
hand was not touched. She said Resident #87 slept through the night. She passed on to day shift that she
did not hear from hospice. She said the supervisor was Registered Nurse (RN) #157.
During an interview on 12/13/23 at 1:24 P.M., RN #157 said he was not aware of any concerns regarding
Resident #87's left hand and did not receive a call from hospice.
During an interview on 12/13/23 at 12:37 P.M., LPN #118 stated Resident #87's responsible party came in
and got her. He said she was really complaining about her hand. She said the night shift nurse said they
were not going to do an X-ray. She said she talked to LPN #93 and was told they were not going to do
anything due to her being on hospice. She said she tried to contact the hospice by trying several numbers
(due to one of the numbers not being a good contact number). The hospice staff did not know what to do
and said they would send someone out. She revealed Resident #87 was in pain at that time. She said she
looked to see if there was anything ordered for pain. She revealed they were supposed to get a prescription
for her for pain medications, so she looked for a prescription and did not find one. She said Resident #87
was able to wiggle her fingers very little due to pain and Resident #87 told her she slammed it in the door.
She stated the complaint of pain was after lunch. LPN #118 did not remember checking her wrist for a
pulse. She said she did not hear from the hospice nurse and was taught that all orders were to go through
hospice.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 13 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
During an interview on 12/13/23 at 12:28 P.M., LPN #88 stated she was told Hospice Nurse #171 had been
called and she came to evaluate her. She said she did not send her out. She said she did not remember if
Resident #87 complained of pain or not. She said one finger was discolored and swollen. She thought there
was pain medication in the cart but did not administer any. She was not aware of any order for an X-ray.
She did not remember Resident #87 having
any changes out of the ordinary. She believed she checked her pulse but was not sure and the resident
could move her hand and arm.
During a telephone interview on 12/13/23 at 11:36 A.M., LPN #128 said the resident did not have pain
medication on the MAR, but she did not remember her having pain. She revealed she did not check
Resident #87's pulse, but her hand looked contracted with her fingers turning in. She said Resident #87
was moving the arm, but her fingers were discolored. The behavior that she observed was Resident #87
being agitated and refusing her medication. She said Resident #87 did not cry out in pain, she just wanted
ice chips.
During an interview on 12/13/23 at 10:22 A.M., LPN #92 said she worked on the 200 unit caring for
Resident #87 often. She said Resident #87 was right-handed and was able to feed herself. She noticed the
resident was declining to come to the dining room around the end of November. Resident #87 could use
both hands but her appetite was poor. She said she did not see Resident #87's bruised hand until 12/05/23.
She did a change of condition assessment on 12/05/23, taking her vitals but she did not check for a pulse
in her left hand. She had said Resident #87 had edema, pain, and discoloration in her left hand. She
revealed she called hospice on 12/05 and talked to Resident #87's responsible party. She was letting him
know that Resident #87's appetite was poor, she had weight loss, and swelling in her hand. She stated she
called hospice out to reevaluate her, and the on-call nurse said Hospice Nurse #171 would call her back or
come out. She stated she did not get a call back on 12/05/23, so she called hospice again on 12/06/23. She
revealed Resident #87 could use both hands at that time. She said Resident #87 said her left hand hurt but
she did not recall the pain rating. She believed Resident #87 had Norco for pain. She said the prescription
was not put on the MAR until 12/06/23. She said the hospice on call was not sure when, but the doctor had
sent over the prescription for Norco. She revealed the orders were usually electronically sent directly to the
pharmacy. She said Resident #87 did not have any pain medication from 12/03/23 to 12/05/23, but she did
not think the hand looked worse.
During an interview on 12/13/23 at 11:52 A.M., Hospice Nurse RN #171 said on Sunday 12/03/23 she
came to see Resident #87. She said Resident #87's index and ring finger were a purplish color around the
nail bed like a bruise. She had slight edema and complained of severe pain, wincing, and screaming when
touched. She said Resident #87 did not have any pain medication ordered on file. She said usually
Resident #87 did not like taking pain medications and would not take them. She revealed that evening
(12/03/23) she received orders for Norco and Tylenol. There was also an order for an X-ray of the left hand
that evening. She said she called the facility, and the orders were given to a nurse, but she didn't know her
name. She said they do not call the pharmacy with orders. They use an application called Arcopia which
goes straight to the pharmacy. Their physician signs for the narcotic and she was able to see this was done
on the computer. She said she was in constant contact with the doctor. She revealed it would have been the
night shift nurse that she talked to. She said at that time Resident #87 had a
pulse in that hand and good capillary refill. She was able to flex her fingers, and she could lift her left arm.
She called the next day (12/04/23) for the results of the x-ray and the facility staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 14 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
nurse said they were waiting for the results. The nurse said they put in the orders, and she also said a pain
pill was given and was effective. She did not see her 12/04/23, but on 12/05/23 Resident #87's responsible
party told her the hand was about to fall off. He said the nursing home did not get in touch with him on
Sunday. He was surprised and angry he was not informed. The responsible party was to come on Saturday,
but she asked if he wanted to meet her on Wednesday. She said she came and saw Resident #87 on
Wednesday 12/06/23 in the early morning. She said Resident #87 was asleep, not appearing to be in pain.
She said Resident 87's left hand was not severely different than Sunday. She stated she did not see a
change and was told the X-ray had not gotten back. She talked to third shift staff briefly, and there were no
complaints. They said she slept all night. She stated she checked Resident #87's pulse and her capillary
refill and vitals were within normal limits. On 12/07/23, facility staff called the responsible party and then
called her saying her hand was black and falling off. She said she came to the facility and met with Resident
#87's responsible party. She said Resident #87's left hand was not black but darker and more swollen. She
said there was a pulse, and she was able to move arm, wrist, and elbow. Hospice Nurse #171 said
Resident #87 appeared to be in pain when she came in. She revealed the DON pulled her aside and asked
what happened on Sunday, telling her there was no documentation. She asked why she did not come in to
facilitate the X-ray, but hospice would usually give orders for the facility to schedule the X-ray. She talked to
the social worker and responsible party, who was saying the resident never talked to him about the
resident. A facility nurse reported to Resident #87's responsible party that she was mottling, and he was
beginning to get family together. She said Resident #87 was not mottling. She stated she called Hospice
Physician #172 from the facility to ask if he wanted to wait for X-ray or send her to the hospital to make sure
there was no deep vein thrombosis. His orders were to send her to the hospital on [DATE] at 2:30 P.M. She
called the hospital at 8:30 P.M. to 9:00 P.M. The responsible party called and told her he had just left the
hospital at about 8:45 P.M. She said the DON was calling report. She stated Resident #87 was admitted to
the Intensive Care Unit (ICU) and she was taken off hospice service when admitted .
During an interview on 12/13/23 at 3:01 P.M., Hospice Physician #172 stated on 12/03/23 Hospice Nurse
#171 sent him a picture of Resident #87's left hand saying her hand was smashed in a door. The note said
she could move her fingers, and the original treatment was to apply ice at first every 20 minutes and use
Naproxen or Ibuprofen for pain. He ordered Norco due to Resident #87 not keeping the ice on. He said he
also ordered an X-ray for her hand. Her pain level was rated 10. He sent a verbal order which the system
notified him to sign. He stated he would sign for narcotics immediately, and the electronic prescription went
to the pharmacy. He would later sign all other verbal orders, including the X-ray order, on Tuesdays. He
received another call from Hospice Nurse #171 on 12/04/23 at 9:37 A.M. but did not recall the conversation.
He said there was a picture sent to him by Hospice Nurse #171 on Thursday at 2:23 P.M. He said Resident
#87's left hand looked swollen but wrinkled, not stretched, slightly curled fingers, showing her index finger
having a darker color and a whitish nail bed. He compared the pictures from 12/03/23 and 12/07/23. He
said Resident #87's left hand looked worse and due to not having anything else to go by, he ordered her be
sent to the emergency room for evaluation on 12/07/23 at 2:23 P.M.
During an interview on 12/14/23 at 11:00 A.M., the DON said Resident #87 went into the hospital where
she was found to have a blockage on 12/07/23. She said the hospital tried to get in touch with her
responsible party for options, but when they got in touch with him, he refused to have a stent placed to
improve circulation to the arm. She said after two days, once the fingers developed dry gangrene they were
talking about palliative care. She said Resident #87 was in the emergency room waiting area for several
hours prior to being seen. She
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 15 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
said Resident #87 was scheduled to return on 12/08/23, but the responsible party wanted more options
done before sending her back.
Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, and Injury of
Unknown Origin, revised on 08/01/22 stated the facility prohibits the mistreatment, neglect, and abuse of
residents/patients and misappropriation of resident/patient property by anyone including staff, family,
friends, etc.
This deficiency represents non-compliance found during the investigation of Complaint Number
OH00148957.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 16 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, interview, observation, and facility policy review, the facility failed to ensure a
resident was free from restraints. This affected one (Resident #355) of one resident reviewed for the use of
restraints. The facility census was 108.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #355 revealed an admission date 12/01/23. Diagnoses included
cerebral infarction, chronic respiratory failure, tracheostomy, gastric tube, fracture of part of body of right
mandible, cocaine abuse, and psychoactive substance abuse.
Review of the baseline care plan dated 12/01/23 revealed no interventions in place for the use of a restraint
to Resident #355's right hand.
Further review of the medical record from 12/01/23 through 12/03/23 revealed no assessments for the use
of restraints/mitt to the resident's right hand.
Review of Resident #355's physician orders revealed no orders for restraint use or monitoring.
Review of the physician order dated 12/04/23 revealed an order to discontinue the hand mitt.
Review of the health status note dated 12/02/23, documented by Licensed Practical Nurse (LPN) #116,
revealed the on-call Nurse Practitioner (NP) reviewed and approved Resident #355's medications. A new
order was received to keep a hand mitt on the resident's right hand related to increased anxiety and
resident attempting to dislodge his tracheostomy.
Review of the respiratory note dated on 12/04/23 documented, by Respiratory Therapist #211, revealed
Resident #355 was assessed. Resident #355 was in bed and had six flex cuffed tracheostomy. He also had
a mitt on his right hand. The facility later in the day discontinued the mitt to the right hand.
Observation on 12/04/23 at 12:28 P.M. revealed Resident #355 had a mitt on his right hand. The mitt was
secured to his right hand. Resident #355 was observed trying to use to right hand.
Interview and observation on 12/04/23 at 12:28 P.M. with Licensed Practical Nurse (LPN) #101 revealed
Resident #355 had a mitt on his right hand to prevent him from taking out his tracheostomy or gastric tube.
Interview and observation on 12/04/23 at 3:50 P.M. with the Director of Nursing (DON) revealed she put the
physician orders in for the hand mitt and reported the resident came from the hospital with the mitt and
orders. The DON stated she just found out today that the resident had a hand mitt on his right hand. The
DON verified there was no order to follow and check for placement.
Review of facility policy titled, Restraint Least Restrictive Protocol, dated 01/2023 revealed complete and
review the restraint UDA. Obtain physician's order for restraint including medical symptoms requiring
restraint, type of restraint, length of time restraint is to be used, and plan for resident's reduction and or
reduction. Check and release at least every two hours and according to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 17 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0604
facility protocol.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 18 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #87's chart revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including
Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance,
protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis.
Review of Resident #87's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had severe cognitive impairment.
Review of Resident #87's progress note, written by Licensed Practical Nurse (LPN) #120 dated 12/03/23 at
8:00 A.M., revealed an aide reported the resident's left hand was discolored.
Review of a progress note by LPN #118 dated 12/04/23 at 3:39 P.M., revealed Resident #87's left hand was
found to have swelling, fingers discolored (dark bruising).
An observation was made on 12/07/23 at 10:54 A.M. of Resident #87 sitting in a reclining wheelchair in the
dining room. Her hand was observed to have what appeared to be a dark bruise on her thumb and
fingertips.
Interview on 12/07/23 at 10:57 A.M. with Resident #87 revealed she hit her hand on a door. When asked if it
hurt, she said, It hurts so bad! A nearby nurse said she had given Resident #87 pain medication that was
ordered after her injury.
Interview on 12/11/23 at 4:36 P.M. with LPN #120 revealed she worked on 12/03/23 day shift. An aide told
her to look at Resident #87's hand. When LPN #120 looked at the resident's hand, it was observed to be
discolored. When LPN #120 touched the resident's hand, the resident was clearly in pain. The bruising was
not reported to management and she was unaware of the procedure when finding a resident with bruising.
Interview with the Administrator on 12/07/23 at 4:00 P.M. verified he was not aware of Resident #87 having
bruising and did not submit a SRI for an injury of unknown origin. The incident had also not been
investigated.
Review of SRIs revealed no SRI was completed related to Resident #87's bruising.
Review of the facility policy entitled, Abuse, Neglect, Misappropriation of Resident Property, and Injury of
Unknown Origin, revised on 08/01/22 revealed the facility prohibits the mistreatment, neglect, and abuse of
residents by anyone including staff, family, friends, etc. Injuries of unknown origin are to be reported to the
state agency immediately and no later than 24 hours upon discovery. The results of a thorough investigation
of the allegation will be reported to the department of health within five working days of the incident and in
accordance with state and federal laws.
This deficiency represents non-compliance investigated under Complaint Number OH00148957.
Based on record review, interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the
facility failed to ensure an allegation of misappropriation and an allegation of injury of unknown origin were
reported to the state agency. This affected two (Residents #69 and #87) of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 19 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
two residents reviewed for abuse. The facility census was 108.
Level of Harm - Minimal harm
or potential for actual harm
Findings include:
Residents Affected - Few
1. Review of the Resident #69's chart revealed Resident #69 was admitted to the facility on [DATE] with
diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease
with early onset, and adult failure to thrive.
Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident was cognitively intact and required set up assistance with bathing and was independent with all
other activities of daily living (ADLs).
Interview with Resident #69 on 12/04/23 at 12:25 P.M. revealed Resident #69's sister stole 6500 dollars
from him by taking out 500 dollars a day on 05/18/23, 05/19/23, 05/20/23, 05/21/23, 05/23/23, 05/24/23,
05/26/23, 05/27/23, 05/28/23, 05/29/23, 05/30/23 and 05/31/23.
Interview on 12/05/23 at 4:36 P.M. with State Tested Nurse Aide (STNA) #10 revealed Resident #69 has
stated that his sister took his money, but she did not know any additional details.
Interview on 12/06/23 at 4:46 P.M. with Business Office Manager (BOM) #138 revealed Resident #69 had a
bank account in the community and it was alleged that Resident #69's sister took money out of the bank
account. BOM #138 stated the facility was made aware of the alleged stolen money around October 2023
and Resident #69's guardian and Ombudsman were aware. BOM #138 reported the bank notified adult
protective services (APS) of the alleged stolen money and APS notified the Ombudsman. BOM #138 stated
the Ombudsman notified the facility of the alleged stolen money.
Interview on 12/06/23 at 5:00 P.M. with the Administrator verified the facility never reported the alleged
misappropriation of Resident #69's money to the state survey agency and the facility had never investigated
Resident #69's alleged stolen money after the facility was made aware of the alleged stolen money around
October 2023.
Review of Self-Reported Incidents (SRIs) revealed no SRI was completed related to Resident #69's
allegation of misappropriation.
Review of the facility's abuse policy dated 08/01/22 revealed the facility prohibits misappropriation by
anyone including staff, family, and friends. Allegations or suspicions of misappropriation of resident property
or exploitation are to be reported to the state agency immediately and no later than 24 hours upon
discovery. The results of a thorough investigation of the allegation will be reported to the department of
health within five working days of the incident and in accordance with state and federal laws.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 20 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #87's chart revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including
Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance,
protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis.
Residents Affected - Few
Review of Resident #87's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had severe cognitive impairment.
Review of Resident #87's progress note, written by Licensed Practical Nurse (LPN) #120 dated 12/03/23 at
8:00 A.M., revealed an aide reported the resident's left hand was discolored.
Review of a progress note by LPN #118 dated 12/04/23 at 3:39 P.M., revealed Resident #87's left hand was
found to have swelling, fingers discolored (dark bruising).
An observation was made on 12/07/23 at 10:54 A.M. of Resident #87 sitting in a reclining wheelchair in the
dining room. Her hand was observed to have what appeared to be a dark bruise on her thumb and
fingertips.
Interview on 12/07/23 at 10:57 A.M. with Resident #87 revealed she hit her hand on a door. When asked if it
hurt, she said, It hurts so bad! A nearby nurse said she had given Resident #87 pain medication that was
ordered after her injury.
Interview on 12/11/23 at 4:36 P.M. with LPN #120 revealed she worked on 12/03/23 day shift. An aide told
her to look at Resident #87's hand. When LPN #120 looked at the resident's hand, it was observed to be
discolored. When LPN #120 touched the resident's hand, the resident was clearly in pain. The bruising was
not reported to management and she was unaware of the procedure when finding a resident with bruising.
Interview with the Administrator on 12/07/23 at 4:00 P.M. verified he was not aware of Resident #87 having
bruising and did not submit a SRI for an injury of unknown origin. The incident had also not been
investigated.
Review of SRIs revealed no SRI was completed related to Resident #87's bruising.
Review of the facility policy entitled, Abuse, Neglect, Misappropriation of Resident Property, and Injury of
Unknown Origin, revised on 08/01/22 revealed the facility prohibits the mistreatment, neglect, and abuse of
residents by anyone including staff, family, friends, etc. Injuries of unknown origin are to be reported to the
state agency immediately and no later than 24 hours upon discovery. The results of a thorough investigation
of the allegation will be reported to the department of health within five working days of the incident and in
accordance with state and federal laws.
This deficiency represents non-compliance investigated under Complaint Number OH00148957.
Based on record review, interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the
facility failed to ensure an allegation of misappropriation and an allegation of injury of unknown origin were
thoroughly investigated. This affected two (Residents #69 and #87) of two residents reviewed for abuse. The
facility census was 108.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 21 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Findings include:
Level of Harm - Minimal harm
or potential for actual harm
1. Review of the Resident #69's chart revealed Resident #69 was admitted to the facility on [DATE] with
diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease
with early onset, and adult failure to thrive.
Residents Affected - Few
Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident was cognitively intact and required set up assistance with bathing and was independent with all
other activities of daily living (ADLs).
Interview with Resident #69 on 12/04/23 at 12:25 P.M. revealed Resident #69's sister stole 6500 dollars
from him by taking out 500 dollars a day on 05/18/23, 05/19/23, 05/20/23, 05/21/23, 05/23/23, 05/24/23,
05/26/23, 05/27/23, 05/28/23, 05/29/23, 05/30/23 and 05/31/23.
Interview on 12/05/23 at 4:36 P.M. with State Tested Nurse Aide (STNA) #10 revealed Resident #69 has
stated that his sister took his money, but she did not know any additional details.
Interview on 12/06/23 at 4:46 P.M. with Business Office Manager (BOM) #138 revealed Resident #69 had a
bank account in the community and it was alleged that Resident #69's sister took money out of the bank
account. BOM #138 stated the facility was made aware of the alleged stolen money around October 2023
and Resident #69's guardian and Ombudsman were aware. BOM #138 reported the bank notified adult
protective services (APS) of the alleged stolen money and APS notified the Ombudsman. BOM #138 stated
the Ombudsman notified the facility of the alleged stolen money.
Interview on 12/06/23 at 5:00 P.M. with the Administrator verified the facility never reported the alleged
misappropriation of Resident #69's money to the state survey agency and the facility had never investigated
Resident #69's alleged stolen money after the facility was made aware of the alleged stolen money around
October 2023.
Review of Self-Reported Incidents (SRIs) revealed no SRI was completed related to Resident #69's
allegation of misappropriation.
Review of the facility's abuse policy dated 08/01/22 revealed the facility prohibits misappropriation by
anyone including staff, family, and friends. Allegations or suspicions of misappropriation of resident property
or exploitation are to be reported to the state agency immediately and no later than 24 hours upon
discovery. The results of a thorough investigation of the allegation will be reported to the department of
health within five working days of the incident and in accordance with state and federal laws.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 22 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure a resident's dental status was
accurately coded on the Minimum Data Set (MDS) assessment. This affected one (Resident #38)of one
resident reviewed for accuracy of resident assessments. The facility census was 108.
Residents Affected - Few
Findings include:
1. Review Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with
diagnoses including paranoid schizophrenia, other low back pain, phantom limb syndrome with pain,
acquired absence of left leg above knee, bipolar disorder, major depressive disorder, heart failure, type two
diabetes mellitus without complications, unspecified convulsions, and muscle weakness.
Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident
#38 was independent with eating and required limited assistance with transfers. Personal hygiene only
occurred once or twice on the MDS and Resident #38 was not listed as having no natural teeth or tooth
fragments or being edentulous (lacking teeth).
Review of Resident #38's dental care plan dated 08/08/22 revealed Resident #38 was edentulous.
Interventions included dental consults as needed.
Interview with Resident #38 on 12/05/23 at 9:23 A.M. revealed Resident #38 had no natural teeth and she
wanted dentures. Resident #38 stated she had never been seen by a dentist since she was admitted to the
facility.
Observation of Resident #38 on 12/05/23 at 9:23 A.M. revealed Resident #38 was edentulous.
Interview with the Director of Nursing (DON) on 12/06/23 at 3:29 P.M. verified Resident #38 was edentulous
and Resident #38's 07/03/23 MDS did not accurately reflect Resident #38's dental status.
Review of the facility's MDS process policy dated January 2022 revealed they facility will complete the MDS
process according to and in compliance with federal and state mandates.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 23 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to ensure a resident's baseline care plan
addressed a resident's risk for skin impairment. This affected one (Resident #62) of three residents
reviewed for care planning. The facility census was 108.
Findings include:
Review of the medical record for Resident #62 revealed an admission date of 04/14/23. Diagnoses included
hemiplegia and hemiparesis, major depressive disorder, dementia, dependence on wheelchair, and
cognitive deficit.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively
intact. Resident #62 required extensive one-person physical assistance for bed mobility, transfers, dressing,
toileting, and personal hygiene.
Review of the admission skin assessment dated [DATE] revealed Resident #62 had skin issues including a
skin tear.
Review of the weekly skin assessment dated [DATE] revealed Resident #62 had a stage one pressure ulcer
tot he left heel measuring 3.0 centimeters (cm) by 3.0 cm by 0.0 cm with 100% necrotic tissue.
Review of the baseline care plan and comprehensive care plan revealed the care plan did not reflect
Resident #62's potential for skin impairment until 08/03/23 (approximately four months after admission).
Interview on 12/12/23 at 10:20 A.M. with the Director of Nursing (DON) verified Resident #62's care plan
was not updated in a timely manner to reflect Resident #62's risk for skin impairment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 24 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to ensure care plans reflected the resident's current
status. This affected two (Residents #57 and #42) of five residents reviewed for care planning. The facility
census was 108.
Findings include:
1. Review of Resident #57's clinical record revealed an admission date of 05/09/23. Diagnoses included
hydronephrosis with renal and ureteral calculous obstruction, liver cell carcinoma, type II diabetes, and
gastritis.
Review of Resident #57's quarterly Minimum Data Set (MDS) assessment completed on 11/03/23 revealed
she was cognitively intact. The assessment revealed she was on insulin seven days during the look back
period and was receiving the following medication: an antianxiety, antidepressant, anticoagulant, antibiotic,
and a hypoglycemic.
Review of Resident #57's physician orders revealed she was prescribed Docusate Sodium Capsule 100
milligrams (mg) to give one capsule by mouth two times a day for constipation, MiraLax Powder
(Polyethylene Glycol 17 grams) to give one scoop by mouth one time a day for constipation, and Eliquis
(anticoagulant) Oral Tablet 5 mg to give one tablet by mouth two times a day for blood thinner.
Review of Resident #57's care plan revealed the care plan did not address and did not have goals or
interventions in place for constipation or anticoagulant use.
Interview on 12/14/23 at 11:00 A.M. with the Administrator and Director of Nursing (DON) verified there was
no evidence the care plan addressed Resident #57's risk for constipation or anticoagulant use.
2. Review of the medical record for Resident #42 revealed an admission date of 04/28/23. Diagnosis
included joint replacement surgery, opioid dependence, depression, hypokalemia, paroxysmal atrial
fibrillation, thyrotoxicosis, hypertension, pain in lower back and right hip, spinal stenosis, gastro-esophageal
reflux disease, anemia, hypercholesteremia, insomnia, and neuromuscular dysfunction of bladder.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively
intact and have verbal behavioral symptoms directed towards others, threatening others, screaming at
others, and cursing at others. The resident had Other behavioral symptoms not directed towards such as
hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing
food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds.
Review of progress notes dated 11/10/23 through 11/27/23 revealed multiple instances of Resident #42
displaying behaviors. Resident #42 required Halperidol (antipsychotic medication) on multiple occasions.
Further review of the medical record revealed Resident #42 received psych services with psychotropic
medications prescribed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 25 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of Resident #42's care plan revealed no goals or inventions in place for behaviors or psychotropic
medication use.
Review of the policy for Comprehensive Care Planning reviewed 01/22 revealed the purpose of the policy
was to develop and maintain and individualized care plan for residents residing in the facility. The policy
stated the comprehensive care plan, once completed, will be reviewed and updated as
appropriate/determined by the Interdisciplinary Team.
Event ID:
Facility ID:
366220
If continuation sheet
Page 26 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to ensure a comprehensive care plan was
updated to reflect a resident's risk for skin impairment. This affected one (Resident #62) of three residents
reviewed for care planning. The facility census was 108.
Findings inlcude:
Review of the medical record for Resident #62 revealed an admission date of 04/14/23. Diagnoses included
hemiplegia and hemiparesis, major depressive disorder, dementia, dependence on wheelchair, and
cognitive deficit.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively
intact. Resident #62 required extensive one-person physical assistance for bed mobility, transfers, dressing,
toileting, and personal hygiene.
Review of the admission skin assessment dated [DATE] revealed Resident #62 had skin issues including a
skin tear.
Review of the weekly skin assessment dated [DATE] revealed Resident #62 had a stage one pressure ulcer
tot he left heel measuring 3.0 centimeters (cm) by 3.0 cm by 0.0 cm with 100% necrotic tissue.
Review of the baseline care plan and comprehensive care plan revealed the care plan did not reflect
Resident #62's potential for skin impairment until 08/03/23 (approximately four months after admission).
Interview on 12/12/23 at 10:20 A.M. with the Director of Nursing (DON) verified Resident #62's care plan
was not updated in a timely manner to reflect Resident #62's risk for skin impairment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 27 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure residents received routine nail care
and assistance with grooming. This affected three (#38, #49 and #62) residents out of six residents
reviewed for activities of daily living (ADL) care. The facility census was 108.
Residents Affected - Few
Findings include:
1. Review of the Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with
diagnoses including paranoid schizophrenia, other low back pain, phantom limb syndrome with pain,
acquired absence of left leg above knee, bipolar disorder, major depressive disorder, heart failure, type two
diabetes mellitus without complications, unspecified convulsions, and muscle weakness.
Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident
#38 was independent with eating and required limited assistance with transfers. Personal hygiene only
occurred once or twice during the assessment period.
Review of Resident #38's podiatry visits from 07/28/22 to 12/07/23 revealed Resident #38 had not received
any podiatry services since she was admitted to the facility.
Review of Resident #38's Activities of Daily Living (ADL) care plan dated 08/08/22 revealed Resident #38
had a functional deficit. Interventions included nail care daily and as needed.
Interview with Resident #38 on 12/05/23 at 9:23 A.M. revealed Resident #38 was a diabetic and had not
been seen by podiatry services.
Interview on 12/07/23 at 8:41 A.M. with the Director of Nursing (DON) and Social Services Director (SSD)
#156 verified Resident #38 was a diabetic and had not received any podiatry services since being admitted
to the facility on [DATE]. The DON stated residents with diabetes were sent out of the facility for podiatry
services.
Observation of Resident #38's toe nails on her right foot on 12/07/23 at 11:53 A.M. with Licensed Practical
Nurse (LPN) #121 revealed Resident #38's toe nails to be long with the big toe nail being approximately 0.5
inches above the end of the toe.
Interview with LPN #121 on 12/07/23 at 11:53 A.M. verified Resident #38's toe nails appeared to be long.
Review of the facility's undated dental policy revealed the facility will assess and evaluate a resident's
dental needs and assist residents in obtaining routine and 24 hour emergency dental care.
2. Review of Resident #62's chart revealed Resident #62 was admitted to the facility on [DATE] with
diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant
side.
Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had moderate cognitive impairment and required one-person extensive assistance with transfers,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 28 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
dressing, toileting, and bathing. Resident #62 also required supervision with eating.
Level of Harm - Minimal harm
or potential for actual harm
Review of the care plan dated 08/03/23 revealed Resident #62 had an activity of daily living self-care
performance deficit related to dementia and left hemiplegia. Interventions included discussing with
resident/family/and power of attorney (POA) care of any concerns related to loss of independence and
decline in function, staff to discuss feelings about self-care deficit, staff to encourage to the resident to
participate to the fullest extent possible with each interaction and staff to encourage the resident to use bell
to call for assistance.
Residents Affected - Few
Interview on 12/06/23 at 9:29 A.M. with Resident #62 revealed he wanted his nails trimmed but the facility
had only trimmed his nails one time.
Observation of Resident #62 on 12/06/23 at 9:30 A.M. revealed Resident #62's nails were a quarter to a
half inch extended passed his fingers with yellowing to the nail bed.
Interview on 12/06/23 at 9:31 A.M. with State Tested Nurse Aide (STNA) #53 verified Resident #62's nails
were long and needed cut.
Review of the facility's personal care needs policy dated January 2022 revealed the facility will provide the
needed support when the resident performs their activities of daily living.
3. Review of medical record for Resident #49 revealed an admission date 06/07/23. Diagnoses included
chronic respiratory failure with hypoxia, cerebral infarction, respiratory disorders, iron deficiency, and adult
failure to thrive.
Review of the MDS assessment dated [DATE] revealed Resident #49 was severely cognitively impaired.
Resident #49 required supervision or touching assistance for eating, oral hygiene, upper and lower body
dressing, sitting, lying, and standing, and chair to bed transfer.
Review of plan of care dated 11/07/23 revealed Resident #49 was at risk for activity of daily living self-care
performance deficit related chronic respiratory failure, chronic obstructive pulmonary disease, right
hemiparesis, and impaired cognition. Interventions included avoiding scrubbing and patting dry sensitive
skin, check nail length, discuss with resident or family any concerns related to loss of independence decline
in function, encourage the resident to discuss feelings about self-care deficit, encourage to use call light,
praise all efforts, and monitor and document any potential for improvement and reasons deficit and decline
in function.
Observation on 12/04/23 at 12:55 P.M. revealed Resident #49 was a female resident with a full dark
shadow of a beard/facial hair.
Interview on 12/04/23 at 12:58 P.M. with Resident #49 revealed she would like her face groomed and was
unable to do so for herself in the past years.
Interview on 12/05/23 at 3:55 P.M. with LPN #127 verified Resident #49 had a full-length beard/facial hair
and needed to be shaved.
Review of facility protocol titled, Personal Care Needs, dated 01/2022 revealed the facility strives to
promote a healthy environment and prevent infection by meeting the personal care needs of the residents.
Personal care and activity of daily living support will be provided according to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 29 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
resident's plan of care. This included bath, shower, shave, shampoo, mouth care, and grooming.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 30 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff interview, and review of facility policy, the facility failed to
reposition and check dependent residents to see if they needed incontinence care in a timely manner. This
affected two (Residents #77 and #96) of two residents reviewed for repositioning. The facility census was
108.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #77 revealed an admission date of 12/23/21. Diagnoses
included anoxic brain damage, epilepsy, tracheostomy, and altered mental status.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was severely
cognitively impaired. The resident was totally dependent upon staff for bed mobility, transfers, dressing,
toileting, and personal hygiene.
Review of the plan of care dated 10/14/23 revealed Resident #77 was at risk for incontinence with
interventions including the use of a condom catheter, providing incontinence care every two hours, and as
needed, keep call light within reach, monitor of signs and symptoms, monitor for skin breakdown.
Interview on 12/04/23 at 4:05 P.M. Resident #77's family revealed staff were not repositioning the resident
in a timely manner.
Observation on 12/06/23 at 8:00 A.M. revealed Licensed Practical Nurse (LPN) #148 and State Tested
Nurse Aide (STNA) #6 turned and repositioned Resident #77.
Observations on 12/06/23 from 8:00 A.M. through 11:10 A.M. revealed STNA #6 was working on Resident
#77's hall. STNA #6 was never observed entering Resident #77's to reposition or provide incontinence care.
Interview on 12/06/23 at 11:10 A.M. with STNA #6 verified she had not checked Resident #77 to see if they
required incontinence care since 7:00 A.M. and she had not repositioned the resident since 8:00 A.M.
(approximately three hours earlier).
2. Review of the medical record revealed Resident #96 had an admission date of 09/29/23. Diagnoses
included chronic respiratory failure, end stage renal disease, anoxic brain damage, anemia, dependence on
respirator, tracheostomy, gastric tube, and respiratory arrest.
Review of the MDS assessment dated [DATE] revealed Resident #96 was severely cognitively impaired.
Resident #96 had impairment of range of motion on upper and lower both sides. Resident #96 was
dependent upon staff for bed mobility, toileting, dressing, and personal hygiene.
Review of the plan of care dated 11/07/23 revealed Resident #96 was at risk for urinary bladder
incontinence related to anoxic brain damage. Interventions included administer medication, cleanse
peri-area with each incontinence episode, check resident on routine rounds and as needed for
incontinence, monitor and document intake and output, monitor for signs and symptoms of urinary tract
infection.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 31 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Further review of the plan of care revealed Resident #96 had Moisture Associated Skin Damage (MASD)
related to being bed bound on vent in hospital and having respiratory arrest. Interventions included avoid
exposure to extreme temperatures, avoid mechanical trauma, carefully dry between toes but do not apply
lotion, ensure appropriate protective devices are applied to affected areas, position resident off affected
area and change position every two hours and as needed, wound care per orders, and weekly treatment
documentation.
Observations on 12/06/23 from 8:00 A.M. through 11:20 A.M. revealed STNA #6 was working on Resident
#96's hall. STNA #6 was never observed entering Resident #96's to reposition or provide incontinence care.
Interview on 12/06/23 at 11:20 A.M. with STNA #6 verified she had not checked Resident #77 to see if they
required incontinence care since 7:00 A.M. and she had not repositioned the resident.
Review of facility policy titled Turning and Positioning Dependent Residents, dated 01/2023 revealed
residents unable to turn and reposition themselves shall be assigned by staff. This shall be identified on the
resident's plan of care. During routine rounds, the resident shall be turned and or repositioned at least
every two hours and as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 32 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0687
Provide appropriate foot care.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview, the facility failed to ensure a resident received routine podiatry
care. This affected one (Resident #38) of one resident reviewed for podiatry services. The facility census
was 108.
Residents Affected - Few
Findings include:
Review of the Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with
diagnoses including paranoid schizophrenia, other low back pain, phantom limb syndrome with pain,
acquired absence of left leg above knee, bipolar disorder, major depressive disorder, heart failure, type two
diabetes mellitus without complications, unspecified convulsions, and muscle weakness.
Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident
#38 was independent with eating and required limited assistance with transfers. Personal hygiene only
occurred once or twice during the assessment period.
Review of Resident #38's podiatry visits from 07/28/22 to 12/07/23 revealed Resident #38 had not received
any podiatry services since she was admitted to the facility.
Review of Resident #38's Activities of Daily Living (ADL) care plan dated 08/08/22 revealed Resident #38
had a functional deficit. Interventions included nail care daily and as needed.
Interview with Resident #38 on 12/05/23 at 9:23 A.M. revealed Resident #38 was a diabetic and had not
been seen by podiatry services.
Interview on 12/07/23 at 8:41 A.M. with the Director of Nursing (DON) and Social Services Director (SSD)
#156 verified Resident #38 was a diabetic and had not received any podiatry services since being admitted
to the facility on [DATE]. The DON stated residents with diabetes were sent out of the facility for podiatry
services.
Observation of Resident #38's toe nails on her right foot on 12/07/23 at 11:53 A.M. with Licensed Practical
Nurse (LPN) #121 revealed Resident #38's toe nails to be long with the big toe nail being approximately 0.5
inches above the end of the toe.
Interview with LPN #121 on 12/07/23 at 11:53 A.M. verified Resident #38's toe nails appeared to be long.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 33 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure
fall interventions were in place for two residents (#2 and #14) of two residents reviewed for falls. Facility
census was 108.
Findings include:
1. Review of the medical record for Resident #14 revealed an admission date of 04/11/23. Diagnoses
included chronic kidney disease, vascular dementia, and epilepsy.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively
impaired. Resident #14 was dependent upon staff for Activities of Daily Living (ADLs) and utilized a
wheelchair.
Review of the plan of care dated 11/02/23 revealed Resident #14 was at risk for falls. Interventions included
anticipate and meet resident's needs, educate the resident and family about safety, encourage to wear
nonskid footwear, follow facility fall protocol, keep the call light accessible, and give reacher to allow
resident to pick up objects.
Observation on 12/13/23 at 2:10 P.M. revealed Resident #14's call light was on the floor, under the bed,
unable to be reached.
Interview on 12/13/23 at 2:13 P.M. with Licensed Practical Nurse (LPN) #93 verified Resident #14's call light
was out of reach.
2. Review of the medical record for Resident #22 revealed an admission date of 01/08/21. Diagnoses
included chronic obstructive pulmonary disease, type two diabetes, and anxiety disorder.
Review of the MDS assessment dated [DATE] revealed Resident #22 was cognitively intact. Resident #22
required assistance with ADLs.
Review of the plan of care dated 12/13/23 revealed Resident #22 was at risk for falls with interventions to
have resident up in Broda chair during awake hours as tolerated, Dycem to top and bottom of wheelchair
cushion, have commonly used articles in reach, anticipate needs, and call light and personal items within
reach when in his room.
Review of the incident note dated 11/28/23 documented by LPN #122 revealed a State Tested Nurse Aide
(STNA) reported the resident was on the floor. Resident #22 was halfway out of the wheelchair with his
back up against the footrest. Resident #22 couldn't explain what happened. The call light was not in reach.
A head-to-toe assessment was completed. Resident #22's range of motion was within normal limits.
Resident #22 had no injuries noted. Resident #22 denied pain at the time, family and hospice notified.
Immediate interventions were to make sure call light was in reach.
Observation and interview on 12/04/23 at 1:10 P.M. with LPN #93 revealed Resident #22 was sleeping in
bed. The resident's call light was under the bed and unable to be reached.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 34 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of facility protocol titled, Call Light Protocol, dated 01/2022 revealed the facility would answer call
lights in a reasonable amount of time and the call light would be in reach.
Review of facility policy titled, Falls Program Policy and Procedure, dated 10/2023 revealed the MDS nurse
was responsible for completing the Comprehensive Plan of Care for falls. After each fall, the MDS nurse will
be responsible for updating the fall care plan with new interventions.
Event ID:
Facility ID:
366220
If continuation sheet
Page 35 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on review of the medical record, observation, interview, and facility policy, the facility failed to provide
safe positioning of a urinary Foley catheter bag. This affected one (Resident #355) of two residents
reviewed for positioning of a catheter bag. The facility census was 108.
Findings include:
1. Review of the medical record for Resident #355 revealed an admission date 12/01/23. Diagnoses
included cerebral infarction, chronic respiratory failure, tracheostomy, gastric tube, fracture of part of body
of right mandible, cocaine abuse, and psychoactive substance abuse.
Interview and observation on 12/04/23 at 12:28 P.M. with Licensed Practical Nurse (LPN) #101 revealed
Resident #335's catheter bag was lying flat on the floor at the foot of the bed.
Interview and observation on 12/04/23 at 3:50 P.M. with the Director of Nursing (DON) revealed Resident
#355's catheter bag was on the floor at the foot of the bed.
Interview on 12/06/23 at 6:30 A.M. with the DON revealed Resident #355's catheter was discontinued
because there was no reason for him to have the catheter.
Further review of the medical record revealed no diagnoses to support the use of catheter use.
Review of the physician order dated 12/05/23 revealed Resident #355 had an order to discontinue the
urinary catheter.
Review of facility protocol titled, Foley Catheter Care, dated 01/2022, stated to check catheter to make sure
positioning promotes proper flow of urine, no pulling was present, and catheter bag was below level of
bladder. Urinary foley bags should not be on the floor. Catheter bags should be placed in a dignity bag
and/or cover.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 36 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and facility policy review, the facility failed to administer
supplemental tube feeding as ordered. This affected one (#43) of three residents reviewed for tube
feedings. The facility census was 108.
Findings included:
Review of the medical record for Resident #43 revealed an admission date 11/07/23. Diagnoses included
end stage renal disease, dependence on renal dialysis, anemia, gastrostomy status, dysphagia, and
tracheostomy status.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was assessed as
severely cognitively impaired. Resident #43 was dependent for toileting, dressing, putting on and and taking
off footwear, and oral care.
Review of a plan of care dated 11/07/23 revealed Resident #43 required tube feeding related to dysphagia.
Interventions included the resident needed the head of bed elevated 45 degrees during and thirty minutes
after tube feed, discuss with the resident and family any concerns about tube feeding, monitor and
document, and the resident was dependent with tube feeding and water flushes.
Review of a dehydration risk evaluation dated 11/07/23 revealed Resident #43 was on a modified diet, was
incontinence of bowel and bladder, and required feeding assistance. Resident #43 had a dehydration risk
score of 6.0. Further review of the dehydration risk evaluation revealed when a score was above 4.0, the
resident was placed at risk for dehydration.
Review of a physician order dated 11/07/23 revealed Resident #43 had an order to have 30 milliliters water
flushes every four hours.
Review of a physician order dated 11/11/23 revealed Resident #43 was ordered enteral feed every shift for
the nutritional supplement NPO Novasource 35 milliliter every hour.
Observation on 12/04/23 at 11:55 A.M. revealed Resident #43 was in his room dressed and sitting in a
wheelchair. Further observation revealed the resident's tube feeding was unhooked and was watching
television with family.
Observation on 12/04/23 at 12:36 P.M. through 1:00 P.M. revealed Resident #43 was sitting at the television
in the main lounge area. No feed tube was running at this time.
Interview on 12/05/23 at 3:55 P.M. with Licensed Practical Nurse (LPN) #127 verified Resident #43 was in
the lounge area on 12/04/23 for some time without his feed tube hooked up.
Review of facility policy titled, Enteral Feedings, dated 01/2022, revealed to administer intermittent or
continuous feeding by means of a tube when the oral route or oral intake was not sufficient.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 37 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, resident and staff interview, and facility policy review, the facility failed
to ensure a resident's oxygen tubing was dated and changed timely, and failed to ensure oxygen tubing
was appropriately connected to the concentrator. This affected two (#49 and #69) of two residents reviewed
for oxygen therapy. The facility census was 108.
Residents Affected - Few
Findings include:
1. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses including unspecified chronic obstructive pulmonary disease, respiratory disorders in diseases
classified elsewhere, type two diabetes mellitus, Alzheimer's disease with early onset, and adult failure to
thrive.
Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident was cognitively intact, required set up assistance with bathing, and was independent with all other
activities of daily living (ADLs). Resident #69 was on oxygen therapy.
Observation of Resident #69 on 12/04/23 at 12:25 P.M. revealed Resident #69's oxygen tubing was not
dated, and the extended tubing that was connected to the concentrator and nasal cannula tubing had a
cloudy appearance.
Interview with Resident #69 on 12/04/23 at 12:25 P.M. stated the oxygen tubing had not been changed in
two months.
Observation of Resident #69 on 12/07/23 at 9:05 A.M. revealed the oxygen tubing remained undated, and
the extended tubing that was connected to the concentrator and nasal cannula tubing had a cloudy
appearance.
Interview with Licensed Practical Nurse (LPN) #121 on 12/07/23 at 9:05 A.M. verified Resident #69's
oxygen tubing was not dated, and the tubing was cloudy in appearance.
2. Review of the medical record for Resident #49 revealed an admission date 06/07/23. Diagnoses included
chronic respiratory failure with hypoxia, cerebral infarction, respiratory disorders, iron deficiency, and adult
failure to thrive.
Review of MDS assessment dated [DATE] revealed Resident #49 was assessed as severely cognitively
impaired. Resident #49 required supervision or touching assistance for eating, oral hygiene, upper and
lower body dressing, sitting, lying, and standing, and chair to bed transfer.
Review of a plan of care dated 11/07/23 with Resident #49 revealed the resident was at risk for respiratory
concerns related to chronic pulmonary disease and chronic respiratory failure. Interventions included to
elevate the head of bed as needed to prevent shortness of breath, encourage adequate nutritional and fluid
intake, give aerosols and medication as ordered, monitor for difficulty breathing, monitor for signs and
symptoms of acute respiratory insufficiency, observe for anxiety, offer support, administer oxygen
supplement, and remind the resident to keep oxygen flow at ordered rate.
Review of a physician order dated 06/08/23 revealed Resident #49 had and order for continuous
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 38 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
supplemental oxygen at two liters per minute with instructions to titrate at two liters per minute to keep
oxygen saturation at 90 percent (%) or higher.
Observation on 12/05/23 at 12:55 P.M. of Resident #49 revealed the resident was short of breath while
talking to surveyor.
Residents Affected - Few
Interview and observation on 12/05/23 at 1:00 P.M. with LPN #93 revealed Resident #49's oxygen tubing
was unplugged and laying on the floor and not connected to the oxygen concentrator.
Review of facility policy titled Oxygen Safety Precautions dated 07/2022, revealed oxygen was very safe
when you use it properly. Administer oxygen per medical director orders.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 39 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, resident and staff interview, and review of a facility policy, the facility
failed to ensure residents were provided interventions for pain management in a timely manner. This
affected one (#87) of 32 residents reviewed for pain control. The facility census was 108.
Residents Affected - Few
Findings included:
Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses
including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance,
protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred
to the hospital on [DATE] at 5:30 P.M.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had
severe cognitive impairment and was assessed to have no pain. Resident #87 was noted as being under
hospice care.
Review of Resident #87's care plan dated 03/21/23 revealed the resident had the potential for pain with a
goal to be free of pain and discomfort. One of the interventions was to evaluate for non-verbal indicators of
pain.
Review of Resident #87's order recapitulation report revealed on 12/04/23 the resident was ordered the
narcotic pain medication Norco 5-325 milligrams (mg) one tablet every six hours as needed for pain with a
start date of 12/06/23.
An observation was made on 12/07/23 at 10:54 A.M. of Resident #87 sitting in a reclining wheelchair in the
dining room. The resident's left hand was observed to have what appeared to be a dark bruise on her
thumb and fingertips.
An interview was conducted with Resident #87 on 12/07/23 at 10:57 A.M. who stated she hit her hand on a
door. Further interview with Resident #87 stated the hand hurt badly.
Observation on 12/07/23 at 10:57 A.M., during interview with Resident #87, a nearby nurse said she gave
Resident #87 pain medication that was ordered after her injury.
Review of Resident #87's medical record revealed a progress note, written by Licensed Practical Nurse
(LPN) #120, dated 12/03/23 at 8:00 A.M. revealed a nurse aide advised LPN #120 about Resident #87's left
hand being discolored. Further review revealed the nurse called hospice and told the nurse who answered
about Resident #87's hand, and asked if the resident had any as needed pain medication. LPN #120
charted she looked up Resident #87's medication administration record (MAR) and verified the resident
had none ordered. The nurse (Hospice Nurse #171) stated she would call the doctor and would give her a
callback.
Review of the hospice note dated 12/03/23 revealed Hospice Nurse #171 was in on 12/03/23 from 11:30
A.M. to 12:05 P.M. The pain medication order on the hospice file at that time was acetaminophen 500 mg to
give two tablets every morning as needed for pain that started on 06/21/23 (this was not on the MAR or in
the resident's electronic record as an order). The note indicated the visit was completed at that time and
Resident #87 was in bed complaining of left hand pain and the physician was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 40 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
notified and the nurse was awaiting directions.
Level of Harm - Minimal harm
or potential for actual harm
Review of the hospice case note dated 12/03/23 at 8:55 P.M. revealed a return call was received from
Hospice Physician #172, and Hospice Nurse #171 reported to the physician that Resident #87's hand was
discolored at the fingertips. There was a complaint of discomfort and some swelling noted. Hospice
Physician #172 gave orders for Tylenol 325 mg every six hours as needed and Norco 5-325 mg every four
to six hours as needed. It was also noted the orders were called and faxed to the facility.
Residents Affected - Few
Review of the hospice case note dated 12/04/23 at 9:10 A.M. revealed a call was made to the facility by
Hospice Nurse #171. The facility nurse reported the pain intervention was effective, although review of
Resident #87's MAR and review of the narcotic sheet for the Norco 5-325 mg tablets revealed she had not
been given any medication on 12/03/23 or 12/04/23.
Review of the narcotic count sheet for hydrocodone-acetaminophen (Norco) 5-325 mg to give one by mouth
every four to six hours as needed for pain revealed the medication was filled by the pharmacy on 12/03/23
and was signed as being received on 12/04/23.
Review of a change of condition note dated 12/05/23 at 5:00 P.M. revealed Resident #87's condition had
gotten worse with discoloration to the left hand, and pain intensity of a nine on a ten-point pain scale with
ten being the highest level of pain.
Review of the hospice note dated 12/05/23 at 9:15 P.M. revealed a call was made to Resident #87's son
and reported the patient took Norco on the previous day and she had relief, although she did not receive
any pain medication on 12/04/23.
Review of the narcotic count sheet for the Norco 5-325 mg revealed a dose was given on 12/05/23 at 6:00
P.M. (prior to being on the MAR and not documented).
Review of the December 2023 MAR revealed on 12/05/23 on night shift Resident #87 had a pain rating
score of six on a ten-point scale and no pain medication was documented as being given.
Review of the narcotic count sheet for Norco 5-325 mg revealed a dose was given on 12/06/23 at 9:00 A.M.
Review of the hospice visit note dated 12/06/23 at 10:15 A.M. revealed Resident #87 was in her room with
her hand elevated on a pillow. Resident #87's hand was still hurting to touch. Further review revealed the
resident had decreased range of motion and was able to move the fingers, however, it was painful. The
dose of Norco given on 12/06/23 at 9:00 A.M. was not completely effective and Resident #87 was
continuing to experience pain.
Review of Resident #87's medical record revealed it was documented the resident was given Norco 5-325
mg on 12/06/23 at 4:49 P.M. after she reported her pain was seven on a ten-point scale. The documentation
did not match the narcotic count sheet.
Review of the narcotic count sheet for the Norco 5-325 mg revealed a dose was given on 12/07/23 at 8:45
A.M., and was also documented on the December 2023 MAR as having pain medication on 12/07/23 at
8:44 A.M. after reporting her pain was a four on a ten-point scale.
Review of the progress note, written by LPN #92, dated 12/07/23 at 11:50 A.M. revealed Resident #87
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 41 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Level of Harm - Minimal harm
or potential for actual harm
had complaints of pain and the as needed Norco pain medication was given. The note revealed the pain
subsided for about an hour, but the pain came back, and Resident #87 was not due for more pain
medication until 2:46 P.M. The note revealed the resident's pain was a four on a ten-point scale, but did not
interfere with her activities of daily living at that time. The note stated a call was made to the hospice
provider and the nurse would come out that day to re-evaluate Resident #87's hand.
Residents Affected - Few
Review of the clinical record revealed an order from Hospice Physician #172 on 12/07/23 at approximately
2:30 P.M. to send Resident #87 to the emergency room for evaluation.
Interviews conducted on 12/13/23 at 12:57 P.M. with LPN #119 (who cared for Resident #87 on 12/03/23
on the night shift) and on 12/13/23 at 12:37 P.M. with LPN #118 (the nurse working on 12/04/23 on the day
shift) revealed Resident #87 was experiencing pain on their shifts on 12/03/23 and 12/04/23, but was not
administered any pain medication.
Review of the a policy titled, Pain Management Policy and Procedure, revised 07/11/22, revealed the
purpose was to assess all residents for pain and to provide our residents with the highest level of comfort
possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 42 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on personnel file review, staff interview, and policy review, the facility failed to ensure state tested
nurse aides (STNAs) received performance evaluations at least every 12 months. This affected two (#03
and #24) of two STNA personnel files reviewed for performance evaluations. The facility census was 108.
Residents Affected - Few
Findings include:
1. Review of STNA #24's personnel file revealed STNA #24 was hired at the facility on 06/14/00. Further
review of STNA #24's personnel file revealed STNA #24 did not receive an annual evaluation from 06/14/22
to 06/14/23.
Interview on 12/11/23 at 10:17 A.M., with Human Resource #90 verified STNA #24 did not receive an
annual evaluation from 06/14/22 to 06/14/23.
2. Review of STNA #03's personnel file revealed STNA #03 was hired at the facility on 03/04/09. Further
review of STNA #03's personnel file revealed STNA #03 did not receive an annual evaluation from 03/04/22
to 03/04/23.
Interview on 12/11/23 at 10:17 A.M., with Human Resource #90 verified STNA #03 did not receive an
annual evaluation from 03/04/22 to 03/04/23.
Review of the facility's undated personnel policy revealed performance evaluations are typically completed
annually.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 43 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on observation and staff interview, the facility failed to post the daily nurse staffing data. This d the
potential to affected all 108 residents residing in the facility. The facility census was 108.
Residents Affected - Many
Findings include:
Observation of the facility on 12/11/23 at 11:27 A.M. revealed the daily nurse staffing data was not posted.
Interview with Administration on 12/11/23 at 11:27 A.M. verified the daily nurse staffing data was not
posted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 44 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #57's chart revealed the resident was admitted to the facility on [DATE]. Diagnoses included
hydronephrosis with renal and urethral calculus obstruction, liver cell carcinoma, type II diabetes,
hyperlipidemia, major depressive disorder, and restless legs syndrome.
Review of Resident #57's quarterly MDS assessment completed on 11/03/23 revealed the resident was
assessed as cognitively intact.
Review of the monthly list of pharmacy reviews with no recommendation revealed there were
recommendations made for Resident #57 in the review for September, October, and November 2023.
These recommendations and physician responses were requested on 12/14/23 at 5:30 P.M. and no
evidence that they were addressed was provided by the facility prior to survey exit.
Review of the consultant pharmacist report policy, dated December 2019, revealed the consultant
pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at
least monthly. All findings and recommendations are reported to the DON, attending physician, medical
director, and administrator.
Based on medical record review, staff interview, and policy review the facility failed to ensure pharmacy
recommendations and irregularities were addressed by the physician in a timely manner. This affected two
(#09 and 57) of five residents reviewed for unnecessary medications. The facility census was 108.
Findings include:
1. Review of Resident #09's chart revealed the resident admitted to the facility on [DATE]. Diagnoses
included psychotic disorder with hallucinations due to known physiological condition, obsessive compulsive
disorder, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity
with agitation, and anxiety disorder.
Review of Resident #09's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had moderate cognitive impairment and required extensive assistance with bed mobility, dressing,
and toileting. Resident #09 required total dependence with transfers and personal hygiene, and supervision
with eating.
Review of Resident #09's pharmacy recommendation dated 06/23/22 revealed Resident #09 was on the
antipsychotic olanzapine five (5) milligrams (mg) at night. The order was discontinued on 09/25/23.
Review of Resident #09's pharmacy recommendation dated 06/02/23 revealed Resident #09 was on
olanzapine 5 mg at night for psychotic disorder. The pharmacy recommendation indicated the facility should
attempt a gradual dose reduction (GDR) unless clinically contraindicated. Resident #09's physician did not
respond to the pharmacy recommendation.
Interview on 12/11/23 at 3:57 P.M. with the Director of Nursing (DON) verified Resident #09's physician did
not address the pharmacy recommendation dated 06/02/23, and the facility did not document Resident
#09's olanzapine 5 mg at night for psychotic disorder was contraindicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 45 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and policy review, the facility failed to ensure gradual dose reductions
were attempted in a timely manner and failed to ensure residents had appropriate indications for use of
antipsychotic medications. This affected two (#09 and #42) of five residents reviewed for unnecessary
medications. The facility census was 108.
Findings include:
1. Review of Resident #09's chart revealed the resident admitted to the facility on [DATE]. Diagnoses
included psychotic disorder with hallucinations due to known physiological condition, obsessive compulsive
disorder, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity
with agitation, and anxiety disorder.
Review of Resident #09's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had moderate cognitive impairment and required extensive assistance with bed mobility, dressing,
and toileting. Resident #09 required total dependence with transfers and personal hygiene, and supervision
with eating.
Review of Resident #09's pharmacy recommendation dated 06/23/22 revealed Resident #09 was on
olanzapine five (5) milligrams (mg) at night for psychotic disorder. The order was discontinued on 09/25/23.
Review of Resident #09's pharmacy recommendation dated 06/02/23 revealed Resident #09 was on
olanzapine 5 mg at night for psychotic disorder. The pharmacy recommendation indicated the facility should
attempt a gradual dose reduction (GDR) unless clinically contraindicated. Resident #09's physician did not
respond to Resident #09's pharmacy recommendation.
Interview on 12/11/23 at 3:57 P.M. with the Director of Nursing (DON) verified Resident #09's physician did
not address Resident #09's pharmacy recommendation dated 06/02/23, and the facility did not document
Resident #09's olanzapine 5 mg at night for psychotic disorder was contraindicated. The DON also verified
Resident #09's olanzapine 5 mg at night for psychotic disorder did not have any GDRs from 06/23/22 until
the medication was discontinued on 09/25/23.
Review of the facility's psychoactive drug program protocol policy, dated 07/08/22, revealed any prescribed
antipsychotic medications are subject to the gradual dose reduction for psychotropic medications.
2. Review of the medical record for Resident #42 revealed an admission date of 04/28/23. Diagnoses
included joint replacement surgery, opioid dependence, depression, hypokalemia, paroxysmal atrial
fibrillation, thyrotoxicosis, hypertension, pain in lower back and right hip, spinal stenosis, gastro-esophageal
reflux disease, anemia, hypercholesteremia, insomnia, and neuromuscular dysfunction of the bladder.
Review of the MDS assessment dated [DATE] revealed Resident #42 was assessed with intact cognition.
Resident #42 was assessed with verbal behavioral symptoms directed towards others, threatening
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 46 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
others, screaming at others, and cursing at others one to three days of the look-back period. Additionally,
the resident was assessed with other behavioral symptoms not direct towards others such as physical
symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public,
throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, and disruptive
sounds one to three days of the look-back period.
Residents Affected - Few
Review of a care plan dated 11/08/23 revealed Resident #42 had no care plan or interventions for
psychotropic medication or behavior monitoring.
Review of a physician progress note dated 11/08/23, by Medical Director (MD) #201, revealed Resident
#42 was assessed and developed a plan to address Resident #42's increased confusion and delusional
disorder consistent with acute delirium most likely from hospitalization needing a safe supervised
environment. Resident #42 was started on the antipsychotic Haldol 5 mg twice a day for one week, then
decrease to once a day and will closely monitor the resident. Resident #42 had a status post right total hip
arthroplasty, with no concerns to the incision site, and was to continue working with therapy. There was no
mention Resident #42 exhibited behaviors or staff reporting presence of behaviors.
Review of a physician order dated 11/08/23 revealed Resident #42 was ordered haloperidol (Haldol) 5 mg
taken two times a day at 9:00 A.M. and 5:00 P.M. for delirium until 11/15/23, and Haldol 5 mg by mouth at
bedtime at 9:00 P.M. for delirium. The order was discontinued on 12/05/23.
Review a nurse progress note dated 11/10/23, documented by Licensed Practical Nurse (LPN) Manager
#148 revealed the interdisciplinary team (IDT) met to discuss Resident #42's hip procedure done on
10/31/23, and came back with a wound vacuum that was removed on 11/09/23. Resident #42 was
constantly yelling and with new orders for the antipsychotic haloperidol (Haldol) related to delirium.
Review of a progress noted dated 11/15/23, documented by Physical Therapy Aide (PTA) #305, revealed
the IDT met to discuss Resident #42's return from the hospital having surgery. There was a recent order for
haloperidol for 5 days and stop on 11/15/23. Resident #42 had an improvement in behaviors noted.
Review of a psychiatric progress noted dated 11/27/23, documented by Psychiatric Physician (PP) #203,
revealed Resident #42 was not noted to be depressed at that time. PP #203 indicated Resident #42 was a
fall risk and had experienced two more falls in last month.
Review of psychiatric progress note 12/04/23 documented by PP #204 stated Resident #42 was seen as
follow up for depression, anxiety, and psychotropic medication management. Resident #42 had recurrent
mild major depressive disorder that was unstable. Resident #42 should be encouraged to participate in
activities and be out of the room.
Review of a physician order dated 12/05/23 revealed Resident #42 was ordered haloperidol two (2) mg to
take one tablet at bedtime. The order was discontinued on 12/11/23.
Review of the medication administration record for the month of November and December 2023 revealed
Resident #42 received haloperidol 5 mg twice a day starting on 11/09/23 through 11/15/23. Also, Resident
#42 received haloperidol 5 mg at 9:00 P.M. from 11/08/23 through 12/07/23.
Further review of Resident #42's medical record revealed no documentation of behavioral monitoring
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 47 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
for continued use of Haldol.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 12/07/23 at 4:00 P.M. with Medical Director (MD) #201 stated she prescribed haloperidol 5 mg
twice a day for Resident #42 after her hip surgery for delirium. MD #204 stated she was a geriatric and
internal medicine physician who practiced at another place. MD #201 verified her notes indicated to closely
monitor Resident #42, and both her and Physician Assistant #210 were in the facility every two to three
days. MD #201 stated she was not aware the facility was not charting any behaviors for Resident #42 or
monitoring the medication being taken by Resident #42. MD #201 stated she was going to discontinue the
haloperidol on 12/08/23.
Residents Affected - Few
Review of facility procedure titled, Specific Medication Administration Procedures, dated 01/2018, revealed
to administer medication in a safe and effective manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 48 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and review of a facility policy, the facility failed to timely
administered medications as ordered resulting in a medication error rate greater than five percent (%).
There were two medication errors observed out of 27 opportunities for a medication error rate of 7.4%. This
affected one (#98) of five residents observed during medication administration. The census was 108.
Residents Affected - Few
Findings included:
Review of the medical record for Resident #98 revealed an admission date 08/25/23. Diagnoses included
human immunodeficiency virus (HIV) disease, respiratory failure, feeding difficulties, and major depressive
disorder.
Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #98 had a Brief Interview Mental
Status of 09 that indicated the resident was moderately cognitively impaired. Resident #98 required
extensive one-person physical assistance for bed mobility, dressing, eating, toilet use, and personal
hygiene.
Review of a plan of care dated 12/01/23 revealed Resident #98 had HIV/AIDS (Acquired Immunodeficiency
Syndrome) and was at risk for rapid physical or mental decline related to HIV/AIDS disease process.
Interventions included administer medications as ordered and monitor for side effects, allow the resident to
verbalize concerns, fears, and issues, encourage activities as tolerated, monitor for new onset of signs and
symptoms as the disease process progresses, monitor laboratory values, provide emotional support, teach
the resident ways to promote a healthy immune system, and provide psychological and mental health
interventions and referrals as needed.
Review of a physician order dated 08/25/23 revealed Resident #98 was ordered the medication to treat low
magnesium levels, magnesium gluconate 500 milligrams (mg) take one tablet by mouth twice a day.
Review of a physician order dated 08/25/23 revealed Resident #98 was ordered for the medication to treat
HIV/AIDS bictegravir-emtrictab-tenofov 50-200-25 mg take one tablet by mouth one time a day.
Observation on 12/06/23 between 6:58 A.M. and 7:10 A.M. revealed Licensed Practical Nurse (LPN) #107
administered medication to Resident #98. LPN #107 administered Resident #98 all morning medication
except magnesium gluconate 500 mg and bictegravir-entucitab-tenofov 50-200-25 mg to Resident #98.
Interview on 12/06/23 at 10:55 A.M. with LPN #107 confirmed the facility did not have
bictegravir-entucitab-tenofov 50-200-25 mg and magnesium gluconate 500 mg available to administer to
Resident #98. LPN #107 stated she checked and magnesium gluconate 500 mg was in stock at the facility.
Review of facility procedure titled, Specific Medication Administration Procedures, dated 01/2018, revealed
to administer medication in a safe and effective manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 49 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, and review of a facility policy, the facility failed to
administer medications as ordered by the physician resulting in significant medication errors. This affected
two (#42 and #98) out of five residents reviewed for medications. The facility census was 108.
Residents Affected - Few
Findings included:
1. Review of the medical record for Resident #98 revealed an admission date 08/25/23. Diagnoses included
human immunodeficiency virus (HIV) disease, respiratory failure, feeding difficulties, and major depressive
disorder.
Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #98 had a Brief Interview Mental
Status of 09 that indicated the resident was moderately cognitively impaired. Resident #98 required
extensive one-person physical assistance for bed mobility, dressing, eating, toilet use, and personal
hygiene.
Review of a plan of care dated 12/01/23 revealed Resident #98 had HIV/AIDS (Acquired Immunodeficiency
Syndrome) and was at risk for rapid physical or mental decline related to HIV/AIDS disease process.
Interventions included administer medications as ordered and monitor for side effects, allow the resident to
verbalize concerns, fears, and issues, encourage activities as tolerated, monitor for new onset of signs and
symptoms as the disease process progresses, monitor laboratory values, provide emotional support, teach
the resident ways to promote a healthy immune system, and provide psychological and mental health
interventions and referrals as needed.
Review of a physician order dated 08/25/23 revealed Resident #98 was ordered the medication to treat low
magnesium, magnesium gluconate 500 milligrams (mg) take one tablet by mouth twice a day.
Review of a physician order dated 08/25/23 revealed Resident #98 was ordered for the medication to treat
HIV/AIDS bictegravir-emtrictab-tenofov 50-200-25 mg take one tablet by mouth one time a day.
Observation on 12/06/23 between 6:58 A.M. and 7:10 A.M. revealed Licensed Practical Nurse (LPN) #107
administered medication to Resident #98. LPN #107 administered Resident #98 all morning medication
except magnesium gluconate 500 mg and bictegravir-entucitab-tenofov 50-200-25 mg to Resident #98.
Interview on 12/06/23 at 10:55 A.M. with LPN #107 confirmed the facility did not have
bictegravir-entucitab-tenofov 50-200-25 mg and magnesium gluconate 500 mg available to administer to
Resident #98. LPN #107 stated she checked and magnesium gluconate 500 mg was in stock at the facility.
2. Review of the medical record for Resident #42 revealed an admission date of 04/28/23. Diagnoses
included joint replacement surgery, opioid dependence, depression, hypokalemia, paroxysmal atrial
fibrillation, thyrotoxicosis, hypertension, pain in lower back and right hip, spinal stenosis, gastro-esophageal
reflux disease, anemia, hypercholesteremia, insomnia, and neuromuscular dysfunction of the bladder.
Review of the MDS assessment dated [DATE] revealed Resident #42 was assessed with intact cognition.
Resident #42 was assessed with verbal behavioral symptoms directed towards others, threatening others,
screaming at others, and cursing at others one to three days of the look-back period.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 50 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Additionally, the resident was assessed with other behavioral symptoms not direct towards others such as
physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in
public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, and
disruptive sounds one to three days of the look-back period.
Review of a care plan dated 11/08/23 revealed Resident #42 had no care plan for use of psychotropic
medication or behavior monitoring.
Review of a physician progress note dated 11/08/23 by Medical Director (MD) #201 revealed an
assessment and plan for Resident #42 as the resident had increased confusion and delusional disorder
consistent with acute delirium, needing a safe supervised environment. Further review revealed MD #201
documented to start the antipsychotic medication Haldol five (5) mg twice a day for one week then
decrease to once a day with close monitoring. There was no mention of Resident #42 exhibiting behaviors
or staff reporting what behaviors.
Review of a physician order dated 11/08/23 revealed Resident #42 was ordered haloperidol (Haldol) 5 mg
taken two times a day at 9:00 A.M. and 5:00 P.M. for delirium until 11/15/23, and give 5 mg by mouth at
bedtime at 9:00 P.M. for delirium. The order was discontinued on 12/05/23.
Review of a physician order dated 12/05/23 revealed Resident #42 was ordered haloperidol two (2) mg to
take one tablet at bedtime. The order was discontinued on 12/11/23.
Review of the medication administration record for November and December 2023 revealed Resident #42
received haloperidol 5 mg twice a day starting on 11/09/23 through 11/15/23. Also, Resident #42 received
haloperidol 5 mg at 9:00 P.M. from 11/08/23 through 12/07/23.
Interview on 12/07/23 at 3:00 P.M. with Clinical Director #16 who confirmed Resident #42 received
haloperidol 5 mg at bedtime by error and was not order by physician.
Interview on 12/18/23 at 5:50 P.M. with the Director of Nursing (DON) stated the nurse that entered the
physician order for haloperidol 5 mg dated 11/08/23 will be educated on not using the AND to add a second
order accidentally.
Review of facility procedure titled, Specific Medication Administration Procedures, dated 01/2018, revealed
to administer medication in a safe and effective manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 51 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0791
Provide or obtain dental services for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, resident and staff interview, and review of facility policy, the facility
failed to ensure a resident received routine dental care. This affected one (#38) of two residents reviewed
for dental services. The facility census was 108.
Residents Affected - Few
Findings include:
Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included paranoid schizophrenia, other low back pain, phantom limb syndrome with pain,
acquired absence of the left leg above the knee, bipolar disorder, major depressive disorder, heart failure,
type two diabetes mellitus without complications, unspecified convulsions, and muscle weakness.
Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident
#38 was independent with eating and required limited assistance with transfers. Further review of the MDS
assessment revealed personal hygiene only occurred once or twice during the review period and Resident
#38 was not assessed as having no natural teeth, tooth fragments, or being edentulous.
Review of Resident #38's dental care plan dated 08/08/22 revealed Resident #38 was edentulous.
Interventions included dental consultations as needed.
Review of Resident #38's dental visits from 07/28/22 to 12/06/23 revealed Resident #38 had not seen by
the dentist or received dental services at the facility.
Interview with Resident #38 on 12/05/23 at 9:23 A.M. revealed Resident #38 had no natural teeth and she
wanted dentures. Resident #38 stated she had never been seen by a dentist since she was admitted to the
facility.
Observation of Resident #38 on 12/05/23 at 9:23 A.M. confirmed the resident was edentulous.
Interview with the Director of Nursing (DON) on 12/06/23 at 9:37 A.M. verified Resident #38 had not been
seen by dental services since she admitted to the facility.
Review of the facility's undated dental policy revealed the facility will assess and evaluate a resident's
dental needs and assist residents in obtaining routine and 24 hour emergency dental care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 52 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, review of a food menu, review of a food substitution log, staff interview, and policy
review, the facility failed to ensure approved menus were followed. This affected all residents except seven
(#43, #75, #77, #96, #353, #354, and #359) residents that received no food by mouth. The facility census
was 108.
Findings include:
Review of the facility's menu for 12/06/23 revealed regular diets were to receive three (3) ounces (oz) of
barbeque chicken, four (4) oz of macaroni and cheese, 4 oz of baked beans, one square of cornbread, and
4 oz of seasoned fruit. Mechanical diets were to receive 3 oz of ground barbeque chicken, 4 oz of macaroni
and cheese, 4 oz of mashed baked beans, one square of cornbread, and one piece of fresh banana.
Pureed diets were to receive 3 oz of pureed barbeque chicken, 4 oz of pureed macaroni and cheese, 4 oz
of pureed baked beans, two (2) oz of pureed bread, and 4 oz of puree banana.
Review of the facility's undated substitution log revealed potatoes were substituted instead of macaroni and
cheese and vegetables were used as a substitute for green beans on 12/06/23. The substitution of
barbeque chicken and pureed bread or fruit was not listed on the substitution log.
Observation of the kitchen on 12/06/23 at 11:41 A.M. revealed [NAME] #64 served residents receiving
regular diets one piece of fried chicken, 4 oz of au gratin potatoes, 4 oz of green beans, and a piece of
cornbread. Further observation revealed [NAME] #64 served residents receiving mechanical soft diets 4 oz
of mechanical chicken, 4 oz of au gratin potatoes, 4 oz of green beans, and a piece of corn bread. [NAME]
#64 also served residents receiving pureed diets 4 oz of pureed chicken, 4 oz of pureed mashed potatoes,
and 4 oz of pureed green beans.
Interview with [NAME] #64 on 12/06/23 at 11:41 A.M. verified she served regular diets one piece of fried
chicken, 4 oz of au gratin potatoes, 4 oz of green beans, a pudding, and a piece of cornbread. [NAME] #64
also confirmed she served mechanical soft diets 4 oz of mechanical chicken, 4 oz of au gratin potatoes, 4
oz of green beans, a pudding, and a piece of corn bread; and served pureed diets 4 oz of pureed chicken,
4 oz of pureed mashed potatoes, a pudding, and 4 oz of pureed green beans. [NAME] #64 stated the fried
chicken was a substitute for the barbecue chicken, the au gratin potatoes and mashed potatoes were a
substitute for the macaroni and cheese, the pudding was a substitute for the fruit or banana, and the green
beans were a substitute for the baked beans. [NAME] #64 verified pureed diets did not receive any pureed
bread and they never received a substitute for the pureed bread.
Interview with Dietary Manager #80 on 12/06/23 at 11:50 A.M. verified residents were not notified of the
substitutions made to the meal on 12/06/23 and the substitution of barbeque chicken and pureed bread or
fruit were not listed on the substitution log.
Interview with Registered Dietician (RD) #58 on 12/06/23 at 4:27 P.M. revealed he was not made aware of
any substitutes for lunch on 12/06/23 and stated the pudding would not be an appropriate substitute for
fruit.
Review of the facility's undated menus policy revealed menu changes must provide equal nutritive value
when menus are changes. Menu changes are reviewed and approved in advance by the dietician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 53 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, review of a food recipe, and review of a facility list of residents by diet
type, the facility failed to ensure pureed food items were prepared following an approved recipe to conserve
the nutritional value. This affected five (#19, #31, #34, #44, and #98) of five residents identified by the
facility that receive pureed diets. The facility census was 108.
Residents Affected - Some
Findings include:
Review of the recipe for seasoned green beans, dated 11/22/15, revealed staff should remove the desired
number of servings and add nutritive liquid, milk, or broth and blend until the desired consistency for pureed
diets. Further review revealed approved thickener could be added to achieve the desired consistency.
Observation of the kitchen on 12/06/23 at 11:41 A.M. revealed the pureed green beans appeared thick and
light green in color with streaks of dark green throughout the food.
Interview with [NAME] #64 on 12/06/23 at 11:41 A.M. revealed the pureed green beans were mixed with
mashed potatoes. [NAME] #64 stated the facility was out of thickener and she added the mashed potatoes
to thicken the pureed green beans.
Interview with Registered Dietician (RD) #58 on 12/06/23 at 4:27 P.M. revealed pureeing green beans with
mashed potatoes would change the nutritional value and thickener should have been added instead of
mashed potatoes.
Review of a list of residents by diet type dated 12/04/23 revealed Resident 19, #31, #34, #44, and #98
received pureed diets.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 54 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, review of a facility provided list of residents by diet type, and policy
review, the facility failed to ensure the kitchen and equipment were clean and sanitary, and resident food
and drink items were stored in a manner to prevent spoilage. This affected all resident with the exception of
seven (#43, #75, #77, #96, #353, #354, and #359) residents identified by the facility that received no food
by mouth. The facility census was 108.
Findings include:
1. Observation of the facility's kitchen on 12/04/23 at 10:29 A.M. revealed yellow debris on the top of the
dishwasher, a pink substance on the ledge of the ice machine that came off on a paper towel when Dietary
Supervisor (DS) #80 wiped the ledge, a black substance built up around the rim of the ice cream cooler that
came off on a paper towel when DS #80 wiped the ledge, and a brown and black substance on the floor
below the preparation sink. There was also an area in the ceiling that appeared to have paint film hanging
down above the plate storage cart.
Interview with DS #80 on 12/04/23 at 10:29 A.M. verified the yellow debris on the top of the dishwasher, a
pink substance on the ledge of the ice machine that came off on a paper towel when wiped, a black
substance built up around the rim of the ice cream cooler that came off on a paper towel when wiped, a
brown and black substance on the floor below the preparation sink, and an area in the ceiling that had paint
film hanging down above the plate storage cart. DS #80 stated the preparation sink had a leak that was
repaired causing the brown and black substance, and there was a leak in the roof that caused the ceiling to
have paint film hanging down above the plates.
2. Observation of the 300-B unit nutritional refrigerator on 12/11/23 at 11:38 A.M. revealed three undated
lunch meat sandwiches in plastic wrap and an open and an undated bottle of water in the refrigerator.
Further observation of the refrigerator revealed the seal on the bottom of the refrigerator door was broken
and hanging off the refrigerator.
Interview with the Director of Nursing (DON) on 12/11/23 at 11:40 A.M. verified the three undated lunch
meat sandwiches in plastic wrap, and an open and an undated bottle of water in the 300-B unit refrigerator.
The DON also verified the seal on the bottom of the 300-B unit refrigerator door was broken and hanging
off the refrigerator.
3. Observation of the 300-A unit nutritional refrigerator on 12/11/23 at 11:40 A.M. revealed there were six
undated lunch meat sandwiches in plastic wrap in a gallon sized bag. The DON was observed to remove
the sandwiches and an unidentified liquid substance spilled from the bag. There was also a brown
substance spilled inside the freezer.
Interview with the DON on 12/11/23 at 11:40 A.M. verified the six undated lunch meat sandwiches in plastic
wrap in a gallon sized bag in the 300-A unit refrigerator, and the brown substance spilled inside the 300-A
unit freezer.
Review of a list of residents by diet type dated 12/04/23 revealed Resident #43, #75, #77, #96, #353, #354,
and #359 received no food by mouth.
Review of the facility's cleaning and disinfection of environmental surfaces and equipment policy
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 55 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
dated July 2022 revealed the facility will ensure surfaces are cleaned and disinfected according to the
Centers for Disease Control recommendations. Ice machines are to be emptied and cleaned monthly using
an approved surface disinfectant solution, and kitchen/appliances will be cleaned and disinfected per
cleaning schedule using and approved surface disinfectant wipe/solution.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 56 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications
administered to residents were accurately documented in the medical record. This affected one (#87) out of
32 residents reviewed for medical record documentation. The facility census was 108.
Findings included:
Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses
including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance,
protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred
to the hospital on [DATE] at 5:30 P.M.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was
assessed with severe cognitive impairment and was assessed as not having pain. The resident was noted
as being under hospice care.
Review of Resident #87's narcotic count sheet for the pain medication Norco 5-325 milligrams (mg) to give
one tablet by mouth every four to six hours as needed for pain revealed the medication was signed out on
12/05/23 at 6:00 P.M.
Review of Resident #87's December 2023 medication administration record (MAR) revealed no
documentation of the Norco 5-325 mg tablet given on 12/05/23 at 6:00 P.M.
Review of Resident #87's hospice notes and orders revealed an order written by Hospice Physician #172
on 12/03/23 for Norco, but not taken off and put in effect until 12/06/23.
An interview was conducted with Hospice Physician #172 on 12/13/23 at 3:01 P.M., and verified the order
was given on 12/03/23 and sent to the pharmacy.
Interview on 12/14/23 at 11:00 A.M. with the Director of Nursing (DON) verified Resident #87's December
2023 MAR did not reflect documentation of Norco 5-325 mg being administered on 12/05/23.
Review of the document titled, Pain Management Policy and Procedure, reviewed 01/05/22, revealed the
procedure was when PRN (as needed) pain medications are administered the nurse will document pain
level on the MAR and effectiveness.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 57 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, medical record review, staff interview, review of water management logs, review of
infection control logs, review of staff personnel files, review of a water management plan, and review of
facility policies, the facility failed to ensure newly hired employees and residents admitted to the facility were
timely screened for tuberculosis, failed to ensure resident personal use items were clean and sanitary,
failed to ensure testing measures were maintained to prevent bacteria growth in the water system, failed to
adequately track resident infections, and failed to maintain proper infection control measures when
performing resident care. This directly affected Resident #96 observed during tracheostomy care, Resident
#355 observed with an unsanitary personal fan in use, three (#02, #83, and #90) of five residents reviewed
for tuberculosis screening, and one (State Tested Nurse Aide #15) of five newly hired staff members at the
facility. Additionally, the failure to maintain a program to prevent and monitor for bacteria growth in the water
system, and a system to adequately track resident infections in the facility had the potential to affect all
residents. The census was 108.
Residents Affected - Many
Findings include:
1. Review of hot water temperature logs from 01/05/23 through 11/07/23 revealed the facility was not
checking hot water temperatures per facility policy. Water temperatures and flushing were documented as
taken from the water source in every resident's bathroom for every month with adequate temperatures.
Interview on 12/12/23 at 2:25 P.M., Maintenance Director (MD) #147 stated that he tested water
temperatures every month, and prior to testing let the water run for 20 seconds. MD #147 verified he had
no hard records to provide documentation that the water was flushed.
Interview on 12/12/23 at 2:30 P.M. with Clinical Director #16 stated the facility did not have a Legionella
(bacteria that can cause a pneumonia-like illness) outbreak. Clinical Director #16 stated the facility was
monitoring and flushing the water pipes for 10 minutes per requirements.
Interview on 12/12/23 at 2:50 P.M. with MD #147 stated he monitored all resident's water temperatures in
their rooms every month and flushed the water for 20 seconds.
Interview on 12/12/23 at 3:52 P.M. with MD #147 verified he did not test the hot water tanks for
temperatures, and he did not run the water for 10 minutes in all resident's rooms. MD #147 stated he ran
water for 20 seconds in a resident's bathroom every month.
Review of the facility Legionella Policy and Water Management Plan, dated 01/2022, revealed that
prevention and control was to include maintenance will log control measures, requiring control measures,
frequency of monitoring, control limit and corrective action if indicated. Resident room water temps will be
recorded as a minimum monthly and as needed temps to be maintained at a minimum of 105 degrees
Fahrenheit (F) to a maximum of 120 degrees F. Water testing will be via monthly water temperature from
the hot water heater to ensure water was being maintained at a minimum or maximum of 120 degrees F. All
resident's rooms and other areas in the facility that have not been used in the past month will have the
appropriate output devices flushed for a minimum of 10 minutes.
2. Review of infection control logs and interview on 12/12/23 at 10:23 A.M. with Licensed Practical Nurse
Infection Control (LPNIC) #131 revealed there was no monitoring of resident infections for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 58 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
the months of April through July 2023 who stated there was antibiotics at the facility.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 12/12/23 at 1:00 P.M., with the Director of Nursing (DON) verified the facility was not
monitoring residents with infections from April 2023 through 07/31/23. The DON stated the timeframe was
before she came to the facility and then changed the process.
Residents Affected - Many
Review of facility records provided dated from 04/01/23 through 07/31/23 revealed there was no
documentation supplied by the facility that showed that infections and antibiotic use by residents were
being followed.
Review of facility title policy, Infection Prevention and Control Program, dated 07/2022, revealed
surveillance tools are used for recognizing the occurrence of infections, recording their number and
frequency, detecting outbreaks and epidemics, monitoring employee infections, monitoring adherence to
infection prevention and control practices, and detecting unusual pathogens with infection control
implications. Data gathered during surveillance is used to oversee infections and spot trends.
3. Review of the medical record revealed Resident #96 had an admission date of 09/29/23. Diagnoses
included chronic respiratory failure, end stage renal disease, anoxic brain damage, anemia, dependence on
respirator, tracheostomy, gastric tube, and respiratory arrest.
Review of a plan of care dated 11/07/23 revealed Resident #96 had risk for respiratory and ventilator
complications related to ventilator dependence. Interventions included to administer aerosol treatments as
ordered, administer medication with the head of the bed elevated, keep the call light in reach, maintain a
spare tracheostomy at the bedside, maintain ventilator settings as ordered, monitor tracheostomy tube and
strap for securement, observe for hypoxia and altered level of consciousness, observe skin color, and
provide oral care every shift.
Observation and interview on 12/06/23 at 11:10 A.M. revealed Licensed Practical Nurse (LPN) #107 wiped
mucous off Resident #96's tracheostomy and chest with gloved hands and a four-by-four inch pad. LPN
#107 did not perform hand hygiene, and applied the soiled gloves into sterile gloves to provide
tracheostomy care. LPN Unit Manager (LPNUM) #148 was observed in the room at this time assisting LPN
#107.
Interview with LPN #107 at the time of the observation on 12/06/23 at approximately 11:10 A.M. confirmed
she did not perform hand hygiene and applied sterile gloves on top of dirty gloves for tracheostomy care.
LPN #107 stated she double gloved because the sterile gloves were too small, and another part of gloves
made her slid easily in the sterile gloves.
Interview on 12/06/23 at 11:15 P.M. with LPNUM #148 stated she would never use dirty gloves to apply her
sterile gloves for tracheostomy care. LPNUM #148 stated she used to order larger gloves some time ago
and had them stocked at the facility.
Review of facility title policy, Infection Prevention and Control Program, dated 07/2022, revealed an infection
and control program was established and maintained to provide a safe, sanitary, and comfortable
environment and to help prevent the development and transmission of communicable disease and infection.
4. Review of the medical record for Resident #355 revealed an admission date 12/01/23. Diagnoses
included cerebral infarction, chronic respiratory failure, tracheostomy, gastric tube, fracture of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 59 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
part of body of right mandible, cocaine abuse, and psychoactive substance abuse.
Level of Harm - Minimal harm
or potential for actual harm
Observation on 12/04/23 at 3:50 P.M. revealed Resident #355 was in his room lying in bed, and was noted
to have a tracheostomy (an artificial opening into the trachea from outside the neck) and a ventilator for
breathing. Further observation revealed at the foot of Resident #355's bed was a pedestal standing floor fan
that was covered in approximately one inch of grey, fuzzy matter. The fan was blowing dangling grey matter
at Resident #355 face, tracheostomy, and chest.
Residents Affected - Many
Interview on 12/04/23 at 3:50 P.M. with the DON confirmed the fan in Resident #355's room was covered in
dust and dirt. Observation on 12/04/23 at 3:55 P.M. revealed the DON turned off the fan blowing on
Resident #355.
Review of facility policy titled, Cleaning and Disinfection of Environmental Surfaces and Equipment Policy
Statement, dated 07/22, revealed reusable items are cleaned and disinfected or sterilized in between
residents.
5. Review of the medical record for Resident #02 revealed an admission date of 04/28/23. Diagnoses
included chronic obstructive pulmonary disease and dementia. Further review of the medical record
revealed Resident #02 was admitted from another long-term nursing home.
Review of Resident #02's immunizations revealed the resident received a one-step tuberculin test on
09/18/23 and a two-step tuberculin test on 09/25/23.
6. Review of the medical record for Resident #83 revealed an admission date of 11/21/22. Diagnoses
included disorder of the brain, amnesia, and dementia. Further review of the medical record revealed the
resident was admitted from the hospital.
Review of Resident #83's immunizations revealed the resident received a one-step tuberculin test on
09/18/23 and a two-step tuberculin test on 09/25/23.
7. Review of the medical record for Resident #90 revealed an admission date of 01/30/23. Diagnoses
included type two diabetes mellitus and dementia. Further review of the medical record revealed the
resident was admitted from another skilled nursing facility.
Review of Resident #90's immunizations revealed the resident received a one-step tuberculin test on
09/18/23 and a two-step tuberculin test on 09/25/23.
Interview on 12/12/23 at 1:49 P.M. with Clinical Director #16 revealed the tuberculin skin tests were not
completed timely for Resident #02, Resident #83, and Resident #90.
Review of the undated facility policy titled, Risk Procedure and Policy, revealed residents admitted at the
facility will be assessed for M. tuberculosis via tuberculin skin test (TST) or chest x-radiation (x-ray). If
having no previous TST then perform a two-step test.
8. Review of State Tested Nurse Aide (STNA) #15's personnel file revealed STNA #15 was hired at the
facility on 10/26/23. STNA #15 did not receive a first-step or second-step tuberculin skin test upon hire to
the facility.
Interview on 12/11/23 at 10:17 A.M. with Human Resource #90 verified STNA #15 did not receive a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 60 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
first step or second step tuberculin skin test upon hire to the facility.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's undated personnel policy revealed all staff will have a two-step tuberculosis test
completed prior to having contact with residents.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 61 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Review of record review, staff interviews, and facility policy reviews, the facility failed to implement the
antibiotic stewardship program routinely to ensure infections and antibiotics were monitored. This had the
potential to affect all 108 residents in the facility.
Residents Affected - Many
Findings include:
Interview on 12/12/23 at 10:23 A.M. with Licensed Practical Nurse Infection Control (LPNIC) #131 stated
the facility didn't monitor any residents who utilized antibiotics four months, which included April 2023, May
2023, June 2023, and July 2023. LPNIC #131 stated she was hired in August 2023, and she started the
monitoring of residents who were on antibiotics in August 2023.
Interview on 12/12/23 at 1:00 P.M. with the Director of Nursing (DON) verified the facility was not monitoring
the antibiotic stewardship and residents with infections from 04/2023 through 07/31/23.
Review of the facility's records dated from 04/01/23 through 07/31/23 revealed there was no documentation
supplied by the facility that showed that infections and antibiotics used by residents were being followed.
Review of the facility policy titled Antibiotic Stewardship, dated 07/2022, revealed the purpose of our
antibiotic stewardship program was to monitor the use of antibiotics in facility residents. The infection control
nurse was to review antibiotic utilization as part of the antibiotic stewardship program and identify specific
situations that are not consistent with the appropriate use of antibiotics.
Review of the facility policy titled Infection Prevention and Control Program, dated 07/2022, revealed an
infection and control program was established and maintained to provide a safe, sanitary, and comfortable
environment and to help prevent the development and transmission of communicable disease and infection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 62 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, and staff interview, the facility failed to ensure the kitchen hood was
maintained in a safe condition. This affected all residents except seven residents (#43, #75, #77, #96, #353,
#354, and #359) who received no food by mouth. The facility census was 108.
Residents Affected - Some
Findings include:
Observation of the facility's kitchen on 12/04/23 at 10:29 A.M. revealed metal pieces of the kitchen hood
appeared to be flaking off above the stove.
Interview with Dietary Supervisor #80 on 12/04/23 at 10:29 A.M. verified metal pieces of the kitchen hood
appeared to be flaking off above the stove.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 63 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
Resident #60's medical record revealed Resident #60 was admitted on [DATE]. Her diagnoses included
chronic obstructive pulmonary disease, dementia, heart failure, bipolar disorder, polyosteoarthritis, panic
disorder, and anxiety disorder.
Residents Affected - Few
Review of Resident #60's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the
resident had moderate cognitive impairment and required set up assistance with activities of daily living
(ADLs).
An observation was made on 12/05/23 at 10:50 A.M. of Resident #60's room revealed there was no call
light cord.
An interview was conducted with Resident #60 on 12/05/23 at 10:52 A.M. revealed she did not have a call
light cord and did not have a bell.
Interview with Licensed Practical Nurse (LPN) #93 on 12/05/23 at 10:55 A.M. verified there was no call light
cord for Resident #60 to utilize and Resident #60 did not have a bell to ring in place of the cord and call
light.
Based on observations, record reviews, and resident and staff interviews, the facility failed to ensure
resident call lights were in working order. This affected three (#38, #60, and #69) of 35 residents reviewed
for call lights. The facility census was 108.
Findings include:
1. Review of Resident #38's medical record revealed Resident #38 was admitted to the facility on [DATE].
Diagnoses included paranoid schizophrenia, other low back pain, acquired absence of left leg above knee,
bipolar disorder, and muscle weakness. Review of Resident #38's annual Minimum Data Set (MDS)
assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance
with bed mobility, dressing, and toileting.
Observation of Resident #38's room on 12/05/23 at 9:27 A.M. revealed Resident #38's call light was not
functioning or turning on in the room, hallway, or nursing station.
Interview with Resident #38 on 12/05/23 at 9:27 A.M. revealed her call light had not worked for a couple of
days.
Interview on 12/05/23 at 4:49 P.M. with Maintenance Director #147 verified Resident #38's call light was not
functioning due to it not being attached to the box in the wall properly.
2. Review of Resident #69's medical record revealed Resident #69 was admitted to the facility on [DATE].
Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease
with early onset and adult failure to thrive. Review of Resident #69's quarterly Minimum Data Set (MDS)
assessment dated [DATE] revealed the resident was cognitively intact and Resident #69 required set up
assistance with bathing and was independent with all other activities of daily living (ADLs).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 64 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation of Resident #69's call light on 12/04/23 at 12:25 P.M. revealed Resident #69's call light was not
functioning and the box where Resident #69's call light was plugged into the wall was broken and the wires
from inside the wall were hanging out and attached to the call light cord.
Interview with Resident #69 on 12/04/23 at 12:25 P.M. revealed Resident #69's call light did not work and
wires from the call light system were exposed due to the call light box on the wall being broken.
Interview on 12/05/23 at 4:49 P.M. with Maintenance Director #147 verified Resident #69's call light was not
functioning due to it having a short in the cord from the wiring being exposed outside the call light box
attached to the wall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 65 of 66
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366220
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Court Rehab and Nursing
6969 Glenmeadow Lane
Cincinnati, OH 45237
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0947
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in
dementia care and abuse prevention.
Based on record review, review of the facility policy, and staff interview, the facility failed to the facility failed
to ensure a state tested nurse aide (STNA) received a minimum of 12 hours of in services or training per
year. This affected one of two STNAs reviewed for STNA in services. This had the potential to affect all 108
residents residing in the facility.
Findings include:
Review of State Tested Nurse Aide (STNA) #24's personnel file revealed STNA #24 was hired at the facility
on 06/14/2000. Further review of STNA #24's personnel file revealed STNA #24 did not receive any in
services or training from 06/14/22 to 06/14/23.
Interview on 12/11/23 at 10:17 A.M. with Human Resource #90 verified STNA #24 did not receive any in
services or training from 06/14/22 to 06/14/23.
Review of the facility's undated personnel policy revealed STNAs are required to complete twelve hours of
in services per calendar year.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366220
If continuation sheet
Page 66 of 66
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Back to topCitations
38 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F584 - Safe Environment
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.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F687 - Foot care
Provide appropriate foot care.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F791 - Dental Services
Provide or obtain dental services for each resident.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F758 - Medication Errors
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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the December 26, 2023 survey of HARMONY COURT REHAB AND NURSING?
This was a inspection survey of HARMONY COURT REHAB AND NURSING on December 26, 2023. The surveyor cited 38 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HARMONY COURT REHAB AND NURSING on December 26, 2023?
Yes, 38 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.