Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
observation, interview, and record review, the facility failed to ensure all residents had the right to formulate
an advance directive for 1 (Resident #2) of 12 residents reviewed for DNR orders.
Resident #2 had an Out-of-Hospital DNR order that was not completed as the physician did not date it.
This failure could place residents with DNR orders at risk for receiving, or not receiving, life-saving
measures that align with their medical preferences.
Findings included:
Record review of Resident #2's face sheet, dated 08/06/2023 revealed an [AGE] year-old female admitted
to the facility on [DATE] with diagnoses that included major depressive disorder(a mental disorder
characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally
enjoyable activities), unspecified Dementia (loss of cognitive functioning-thinking, remembering and
reasoning), and Pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the
right side of the heart). Resident #2's face sheet revealed an advance directive of DNR.
Record review of Resident #2's quarterly MDS assessment, dated 05/17/23, revealed a BIMS score of 6
out of 15 which indicated severe cognitive impairment.
Record review of Resident #2's care plan dated 07/26/2023 revealed, in part: Resident has an active DNR
signed by resident and physician and placed in chart.
Record review of Resident #2's physician's orders revealed an active order for DNR dated of 05/28/21.
Record review of Resident #2 Out-of-Hospital DNR revealed the DNR document was not dated by the
signing physician.
In an interview on 08/07/23 at 04:11 PM with LVN A, LVN A looked at the DNR document for Resident #2
and said it was a valid DNR. LVN A could not identify the missing date on the DNR document. LVN A said a
possible negative outcome for having an incomplete DNR was The DNR would not be honored.
In an interview on 08/07/23 at 04:13 PM, DON looked at the DNR document for Resident #2. DON could
not identify the missing date on the DNR document. DON pointed to the physician's order on the
(continued on next page)
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 17
Event ID:
676370
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
following page of the resident's chart and stated that the orders proved that the physician ordered it. DON
stated only the DNR goes out with the resident. DON stated that the possible negative outcome for an
incomplete DNR would be that it may not be honored.
Record review of a portion of the facility's policy dated April 2017, Do Not Resuscitate Order revealed the
following:
.A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician .
Record review of the back of the previously mentioned Out-Of-Hospital Do-Not-Resuscitate document,
which was titled, INSTRUCTIONS FOR ISSUING AN OUT-OF HOSPITAL DNR ORDER revealed the
following:
.The original or a copy of a fully and properly completed Out-of-Hospital DNR order is sufficient evidence
and will be honored by responding health care professionals .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 2 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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, interview, and record review the facility failed to ensure the assessment accurately reflected
the resident's status for 1 (Resident #12) of 12 residents reviewed for accuracy of assessments.
Residents Affected - Few
Resident #12 received oxygen therapy but her MDS did not have oxygen therapy checked as a service
received.
This failure could place residents at risk of receiving inappropriate care due to inaccurate assessments.
Findings Included:
Record review of Resident #12's face sheet, dated 08/06/23, revealed a [AGE] year-old female admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, pulmonary embolism (blood clot
that blocks blood flow in a lung artery), high blood pressure, and shortness of breath.
Record review of Resident #12's Quarterly MDS, with a completion date of 06/16/23, revealed a BIMS of
12, which indicated moderately impaired cognition. Section G of the MDS noted Resident #12 needed
limited assistance from one staff member across all ADLs except eating and personal hygiene where she
was independent with a need for set up help only. Section O of the MDS indicated the resident had not
received oxygen therapy in the 14 days prior to completion of the MDS.
Record review of Resident #12's care plan with a most recent start date of 07/14/23 revealed no mention of
oxygen therapy.
Record review of Resident #12's Physician Orders, dated August 2023 revealed a PRN order for oxygen @
2-3 lpm to keep sats (saturation) above 90% via n/c (nasal cannula). The order had a start date of 03/22/23.
Record review of oxygen saturation for Resident #12 from June 2023's Daily Vital and BM Record revealed
Resident #12 received oxygen on 06/11/23, 06/14/23, and 06/15/23.
During an observation and interview on 08/07/23 at 12:00 PM Resident #12 was sitting in her recliner with
her legs elevated and under a blanket. She was receiving O2 via nasal cannula at 4 lpm. She stated she
has been on oxygen for about a year. Resident #12 said, I don't leave it off for long. I do better on it.
During an interview on 08/08/23 at 11:29 AM ADON stated she does the MDS Assessments for the facility.
She said she followed the RAI as the policy for the assessments. She stated the look back period for an
MDS assessment ends the day before completion of the MDS. When asked why June's Daily Vital and BM
Records revealed Resident #12 was receiving oxygen therapy in the days prior to completion of her MDS
but she was not coded on the MDS as receiving oxygen therapy, ADON said she was not sure. She said, If
she is the one I am thinking about, I think Hospice just brought in the O2, and then back dated their order
so when I did that MDS I didn't have any documentation of an order.
During an interview on 08/08/23 at 02:24 PM ADM stated a possible negative outcome of an MDS not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 3 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
reflecting the actual status of a resident was, Besides the fact that we don't get paid for giving extra care the
care plan would be incorrect.
During an interview on 08/08/23 at 02:35 PM DON stated there was absolutely a possible negative
outcome of an MDS not reflecting the actual status of a resident. She stated, For one thing, it's gonna affect
the level of that resident and we might not be receiving as much as we could be to care for that resident, or
we might be receiving too much which would be fraud. DON said she did not know why Resident #12's
MDS did not reflect her oxygen therapy.
Record review of Section O of the MDS revealed the following instructions:
Check all of the following treatments, procedures, and programs that were performed during the last 14
days . Respiratory Treatments C. Oxygen therapy .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 4 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
interview and record review the facility failed to develop and implement a comprehensive person-centered
care plan that described the services that are to be furnished to attain or maintain the resident's highest
practicable physical, mental, and psychosocial well-being for 1 (Resident #12) of 12 residents reviewed for
care plan accuracy.
Resident #12 had an order for and was receiving oxygen therapy and it was not mentioned in her care plan.
Resident #12 had an order for and was receiving hospice care and it was not mentioned in her care plan.
These failures could place residents at risk of not receiving the care or treatment needed.
Findings Included:
Record review of Resident #12's face sheet, dated 08/06/23, revealed a [AGE] year-old female admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, pulmonary embolism (blood clot
that blocks blood flow in a lung artery), high blood pressure, and shortness of breath.
Record review of Resident #12's Quarterly MDS, with a completion date of 06/16/23, revealed a BIMS of
12, which indicated moderately impaired cognition. Section G of the MDS noted Resident #12 needed
limited assistance from one staff member across all ADLs except eating and personal hygiene where she
was independent with a need for set up help only. Section O of the MDS indicated the resident had not
received oxygen therapy in the 14 days prior to completion of the MDS. Section O further indicated
Resident #12 was receiving hospice services.
Record review of oxygen saturation for Resident #12 from June 2023's Daily Vital and BM Record revealed
Resident #12 received oxygen on 06/11/23, 06/14/23, and 06/15/23.
Record review of Resident #12's care plan with a most recent start date of 07/14/23 revealed no mention of
oxygen therapy or hospice care.
Record review of Resident #12's Physician Orders, dated August 2023 revealed a PRN order for oxygen @
2-3 lpm to keep sats (saturation) above 90% via n/c (nasal cannula). The order had a start date of 03/22/23.
Resident #12's Physician Orders further revealed an order for admission to hospice care with a start date of
03/06/23.
During an interview on 08/08/23 at 09:25 AM LVN A said he was not sure who was responsible for care
plans, but he thought it was DON and ADON. He said the only part he played in care planning was to give
his feedback. When asked for a possible negative outcome of a care plan that did not accurately reflect a
resident's hospice care status he said, Someone could send them to the hospital instead of calling hospice
first. He said an inaccurate care plan kind of affects [a resident's] overall care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 5 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
During an interview on 08/08/23 at 09:25 AM DON stated ADON and a PRN nurse work on the facility's
care plans. When asked who is responsible for the care plans, she said, Responsibility-wise I would say
ultimately myself. I mean I try to review them [care plans] when the MDS's come due. I add to them [care
plans]. When asked for a possible negative outcome of a care plan not accurately reflecting a resident
receiving hospice care, DON said, It will change their level of care. It will limit the care provided to the
facility rather than take into account the extra pair of eyes and hands that are here with hospice. It might
affect medications because Hospice is responsible for medications related to diagnoses and also pain
management and agitation management. She said she did not know why Resident #12's care plan did not
mention hospice care or oxygen therapy and she would correct that this morning.
During an interview on 08/08/23 at 09:37 AM ADON stated DON was responsible for care plans. ADON
said she updated care plans when she did the MDS. She said a possible negative outcome of a resident's
care plan not reflecting the resident was on hospice was, Staff not being aware that they [residents] are
receiving hospice care. She said a resident on hospice could be transferred out [for emergency care] rather
than having hospice called. She stated she did not know why Resident #12's care plan did not reflect her
hospice care.
Record review of a facility policy dated July 2017 and titled Hospice Program revealed the following:
. 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice
plan of care as well as the care and services provided by our facility (including the responsible provider and
discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental,
and psychosocial well-being. 15. The coordinated care plan shall be revised and updated as necessary to
reflect the resident's current status .
Record review of a facility policy dated September 2013 and titled Care Planning - Interdisciplinary Team
revealed the following:
Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized
comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive
assessment .
Record review of a facility policy dated December 2016 and titled Care Plans, Comprehensive
Person-Centered revealed the following:
. 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to
attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 13.
Assessments of residents are ongoing and care plans are revised as information about the residents and
the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan; . d.
At least quarterly, in conjunction with the required quarterly MDS assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 6 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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, interview, and record review the facility failed to ensure that a resident who needs respiratory
care is provided such care consistent with professional standards of practice, the person-centered care
plan, and residents' goals and preferences for 2 (Resident #9 and Resident #12) of 12 residents reviewed
for respiratory care.
Residents Affected - Few
1. Resident #9 had a physician's order for continuous oxygen via nasal cannula at 3 lpm and was receiving
oxygen at higher concentrations.
2. Resident #12 had a physician's order for PRN oxygen via nasal cannula at 2-3 lpm and was receiving
oxygen at higher concentrations.
These failures could place residents who receive oxygen at an increased risk for receiving oxygen at the
wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen
toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood,
decreasing the oxygen supply to vital organs), and shortness of breath.
Findings Included:
1. Record review of Resident #9's face sheet dated 08/06/23 revealed a [AGE] year-old male admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, high blood pressure, acute
kidney failure (sudden episode of kidney failure that happens in hours or days), and acute respiratory failure
with hypoxia (quick onset of a condition resulting from lower-than-normal levels of oxygen in the tissues of
the body).
Record review of Resident #9's Quarterly MDS completed on 05/23/23 revealed a BIMS of 13 which
indicated intact cognition. Section J of the MDS revealed Resident #9 had trouble with shortness of breath
or trouble breathing with exertion (e.g., walking, bathing, transferring) and when lying flat. Section O of the
MDS revealed Resident #9 received oxygen therapy while a resident.
Record review of Resident #9's care plan with a start date of 07/16/23 revealed a category entitled Active
Disease. In this category was an intervention of administer O2 as indicated .
Record review of Resident #9's Physician Orders, dated August 2023, revealed an order for continuous
oxygen @ 3 lpm via NC [nasal cannula]. The start date of this order was 06/28/23.
Record review of facility Daily Vital and BM Record for July revealed Resident #9 receiving O2 at 5 lpm on
07/10/23 and 4 lpm on 0720/23 and 07/22/23.
During an observation on 08/06/23 at 10:11 AM Resident #9 was sitting in his recliner asleep with a blanket
across his lap. He was receiving O2 via nasal cannula at 3.5 lpm.
During an observation on 08/06/23 at 11:56 AM Resident #9 was sitting in his w/c watching TV and
receiving O2 via nasal cannula at 3.5 lpm.
During an observation on 08/07/23 at 09:07 AM Resident #9 was sitting in his w/c receiving O2 via nasal
cannula at 3.75 lpm.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 7 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
Residents Affected - Few
During an observation on 08/08/23 at 09:13 AM Resident #9 was sitting in his recliner watching TV and
receiving O2 via nasal cannula at 3.75 lpm.
2. Record review of Resident #12's face sheet, dated 08/06/23, revealed a [AGE] year-old female admitted
to the facility on [DATE] with diagnoses that included, but were not limited to, pulmonary embolism (blood
clot that blocks blood flow in a lung artery), high blood pressure, and shortness of breath.
Record review of Resident #12's Quarterly MDS, with a completion date of 06/16/23, revealed a BIMS of
12, which indicated moderately impaired cognition. Section J of the MDS revealed Resident #12 had
trouble with shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).
Section O of the MDS indicated the resident had not received oxygen therapy in the 14 days prior to
completion of the MDS.
Record review of Resident #12's care plan with a most recent start date of 07/14/23 revealed no mention of
oxygen therapy.
Record review of Resident #12's Physician Orders, dated August 2023 revealed a PRN order for oxygen @
2-3 lpm to keep sats (saturation) above 90% via n/c (nasal cannula). The order had a start date of 03/22/23.
Record of facility Daily Vital and BM Record for July revealed Resident #12 received oxygen at 4 lpm on
07/27/23.
During an observation on 08/06/23 at 10:03 AM Resident #12 was lying in bed on her back asleep
receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 12:29 PM Resident #12 was lying in bed on her left side asleep
receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 12:37 PM Resident #12 was lying in bed on her left side asleep
receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 12:43 PM Resident #12 was lying in bed on her left side asleep
receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 1:09 PM Resident #12 was lying in bed on her back asleep receiving
O2 via nasal cannula at 4 lpm.
During an observation on 08/07/23 at 09:10 AM Resident #12 was sleeping in her recliner under a blanket
receiving O2 via nasal cannula at 4 lpm.
During an observation and interview on 08/07/23 at 12:00 PM Resident #12 was sitting in her recliner
watching TV and receiving O2 via nasal cannula at 4 lpm. She stated she had been receiving oxygen
therapy for about a year. Resident #12 said, I don't leave it off for long; I do better with it.
During an observation on 08/07/23 at 03:01 PM Resident #12 was asleep in her recliner receiving O2 via
nasal cannula at 4 lpm.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 8 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
Residents Affected - Few
During an observation on 08/08/23 at 08:51 AM Resident #12 was sitting in her recliner asleep and
slumped to her left. Her O2 concentrator was set to 4 lpm and her nasal cannula was sitting in her lap.
During an interview on 08/08/23 at 09:17 AM LVN A said the nurses were responsible for setting the lpm on
O2 concentrators. He said he looked at physician orders to determine what lpm to set the concentrator to.
When asked what a possible negative outcome of a resident receiving O2 at higher lpm than ordered LVN
A replied, It can damage the lungs. LVN A said he did not know why Resident #9 and Resident #12 were
receiving O2 at higher concentrations than those ordered
During an observation and interview on 08/08/23 at 09:21 AM CNA C said the nurses are responsible for
setting the lpm on O2 concentrators. She said the only part she plays in O2 administration was, I just
usually put the hose on. Here CNA C mimed putting nasal cannulas in her own nostrils.
During an interview on 08/08/23 at 09:25 AM DON stated the nurses were responsible for setting the
concentration levels of O2 for residents receiving O2 therapy. She said the nurses would refer to the
physician orders to find out what lpm to set the O2 to. She said the physician orders were in the computer
and in the paper charts. When asked for a possible negative outcome of a resident taking O2 at higher
concentrations than ordered, DON said, The body becomes dependent and it is not a good thing, then they
can't go back down [in concentration level]. When asked why Resident #12 was receiving O2 at higher
concentration than ordered she said she did not know. She said Resident #9 occasionally changes his.
During an interview on 08/08/23 at 09:37 AM ADON said the nurses were responsible for setting
concentration levels on O2 concentrators. She said they would refer to physician orders or the treatment
book to find the correct lpm. ADON stated a possible negative outcome of receiving O2 at higher
concentrations than ordered was the resident could get too much O2. ADON said she did not know why
Resident #12 was receiving O2 at higher lpm than ordered. She stated Resident #9 usually messes with his
[O2] constantly.
Record review of facility policy dated October of 2010 and titled; Oxygen Administration revealed the
following:
. The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is
a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen
administration. 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to
3 liters per minute. 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the
proper flow of oxygen is being administered.
Record review of facility policy dated July 2016 and titled; Medication and Treatment Orders revealed the
following:
. 1. Medications shall be administered only upon the written order of a person duly licensed and authorized
to prescribe medications in this state.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 9 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were
stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication
rooms.
Multiple loose pills and expired medication was found in the medication room.
The medication refrigerator was not kept at a temperature between 36 to 46 degrees.
The facility's failure could place all residents receiving medication that have lost integrity to not receive their
therapeutic dose.
Findings included:
Observation on 08/06/23 at 10:24am revealed the medication refrigerator was unlocked by the LVN, and
the lock box was unlocked within the refrigerator. The temperature on the thermometer read 22 degrees.
Observation and interview on 08/06/23 at 10:28am revealed multiple pills lose in the bottom medication
basket The LVN stated that they must have come out of the packaging, I think those are discontinued.
Observed on medication label that medication had a use by date of 08/02/2022
Record review of the temperature log revealed that the temperature has been under 36 degrees for
08/01/23-08/05/23 with no temperature check performed on 08/06/2023.
Observation of medication packaging on 08/07/23 at 9:20 AM revealed that medication in the medication
room refrigerator needed to be kept between 36 to 46 degrees. This includes Levemir Flex pen, Lorazepam
oral solution, and Lorazepam suppositories and all vaccines. The temperature was at 41 degrees.
Interview on 08/07/23 at 10:51 AM with DON. Interview revealed that medications should be kept at a
temperature of 36-46 degrees. DON stated that she ordered new medications for all residents with
medications in the medication refrigerator, as well as the vaccines. DON stated medications that were
expired were destroyed every 90 days.
Record review of policy named Storage of Medications, dated, April 2007 states the following:
Policy Statement
The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
Policy Interpretation and Implementation
1.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 10 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which
they are received. Only the issuing pharmacy is authorized to transfer medications between containers.
4.
The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be
returned to the dispensing pharmacy or destroyed.
9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses'
station or other secured location. Medication must be stored separately from food and must be labeled
accordingly.
Record review of policy named Discarding and Destroying Medications, dated October 2014 states the
following:
Policy Statement
Medications will be disposed of in accordance with federal, state and local regulations governing
management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.
1.
All unused controlled substances shall be retained in a securely locked area with restricted access until
disposed of.
2.
Non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance
with state regulations and federal guidelines regarding disposition of non-hazardous medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 11 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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, interview, and record review, the facility failed to store, prepare, distribute, and serve
food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen
sanitation.
1.
The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated.
2.
The facility failed to ensure dented cans were not in circulation.
3.
The facility failed to ensure pantry foods were properly stored, labeled and dated.
These failures placed residents who ate food served by the kitchen at risk of cross contamination and
food-borne illness.
Findings included:
In an observation of the walk-in pantry on 08/06/2023 at 09:45 AM the following was observed:
1-14.05 oz can of cut green beans dated 4/13 dented and stored with cans in circulation.
2-48 oz cans of Chicken of the Sea Tuna dated 4/13 dented and stored with cans in circulation.
1 open bag of brown gravy in its original packaging open to air with no seal-in a plastic clear
container with a blue lid; the blue lid was not sealed.
In an observation of the refrigerator on 08/06/2023 at 10:00 AM the following was observed:
1 gallon container 3/4 filled with orange liquid with no label or date.
1 gallon container 1/4 filled with purple liquid with no label or date.
1 gallon container 1/4 filled with yellow liquid with no label or date.
1 gallon container 1/2 filled with brown liquid with no label or date.
1 gallon container 1/8 filled with brown liquid with no label or date.
In an observation of the freezer on 08/06/2023 at 10:15 AM the following was observed:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 12 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
7-1lb blocks of margarine with no date.
Level of Harm - Minimal harm
or potential for actual harm
1 open clear package with no label or date with what appeared to have yeast rolls in the
package.
Residents Affected - Many
1 Ziplock bag with no label or date with what appeared to have corn in the package.
1 large clear package with no label or date with what appeared to have french-fries in the
package.
1 large clear package with no label or date with what appeared to have hushpuppies in the
package.
In an observation and interview on 08/06/2023 at 2:30 PM with DS, DS showed the surveyor a pantry away
from the dry storage pantry with a sign on the cans DO NOT USE. DS stated that she recently started
working at the facility. DS stated the negative outcome of having expired food or unlabeled food could cause
a resident to get sick. DS stated that she has not given an in-service concerning expired/unlabeled foods to
her employees but will work on it.
In an interview on 08/07/2023 at 8:34 AM with [NAME] B, [NAME] B stated that if she sees any items not
labeled or expired, she throws them away. [NAME] B stated that a possible negative outcome for having
unlabeled foods would be a resident getting sick.
In an interview on 08/07/2023 at 12:12 PM with DS, DS gave the surveyor policies concerning food storage
and dented cans, DS stated that she saw the three cans in the dry pantry and said She was sorry that she
missed them.
In an interview on 08/08/2023 at 9:33 AM with DS, DS stated that dented cans could cause botulism and is
dangerous for the residents.
Record Review of policy and procedure dated 08/07/2023 titled Dented Cans
All cans will be evaluated for damage upon receipt from the supplier. Cans found to be dented will be
removed from circulation and placed in a designated area with the label Dented Cans-Do not use
until the cans can be returned to the supplier for credit.
Record Review of policy dated October 2017 titled Food Receiving and Storage
Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use
by date).
All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 13 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
Beverages must be dated when opened and discarded after twenty-four hours.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 14 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on interview and record review, the facility failed to maintain complete, accurate, readily accessible,
and systemically organized records for 1 (Resident #6) of 12 residents reviewed for medical records.
Residents Affected - Few
The facility failed to accurately document Resident #6's information in the correct resident's chart.
This failure could place all residents at risk of not receiving appropriate care through inadequate
documentation, possibly resulting in the deterioration in condition, exacerbation of disease process, and
increased risk of harm or injury.
Finding included:
Record Review of Resident #8's paper chart revealed that Resident #6's records have been placed into
Resident #8's chart.
Interview on 08/07/23 at 10:44 AM with LVN A stated that the orders will come in on the fax in the business
office. Business office manager will deliver them to the LVN who enters the information into the computer
system and then places them in the paper chart. LVN A stated that the negative outcome would be that the
situation would be very confusing and raise a lot of questions.
Interview on 08/07/23 at 10:53 AM with DON states that the faxes are delivered to either DON or ADON
and the orders are placed in the computer system and then placed in the paper chart. DON stated that
there wound not be a negative outcome due to the orders being placed in the correct chart on the computer
system, but would be frustrating when looking for the paper copy of the order. DON stated that there is no
policy for documentation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 15 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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, interview, and record review, the facility failed to establish and maintain an infection
prevention and control program designed to provide a safe, sanitary, and comfortable environment and to
help prevent the development and transmission of communicable diseases and infections for 1 of 3
residents (Resident #1) reviewed for infection control.
Residents Affected - Few
The facility failed to ensure that facility staff perform hand hygiene appropriately during incontinent care.
This failure could place the residents at an increased risk for potentially exposing them to viral infections,
secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor
hygiene.
Findings included:
Observation on 08/07/23 at 11:17 AM revealed incontinent care of Resident #1. CNA C and NA D started
incontinent care by letting Resident #1 know that it was time for a brief change. CNA C sanitized hands
before donning the first set of gloves, but there was no observation of NA D performing hand hygiene. CNA
C started to remove blankets from Resident #1 and started to remove the front of Resident #1's brief. CNA
C then reached for a clean sheet to cover Resident #1 with the same gloves that she removed the front of
Resident #1's brief with. CNA C handed NA D the sheet to cover Resident #1. CNA C took peri-wipes that
had been set up previously to the start of peri-care. CNA C took a wipe and cleaned the thighs, reached for
more clean wipes and cleaned the pubic area of Resident #1. CNA C removed gloves at this time and
obtained clean gloves without performing hand hygiene. CNA C proceeded to perform Catheter care on
Resident #1. Once Catheter care was performed, dirty gloves were removed, and clean gloves were
obtained without hand hygiene being performed.
Interview on 08/07/23 at 11:29 AM with CNA C. CNA C was asked why hand hygiene wasn't performed
after the removal of dirty gloves and the placement of clean gloves. CNA C stated I just missed it. CNA C
was asked what a negative outcome would be for not performing hand hygiene at that time. CNA C stated
contamination.
Interview on 08/07/23 at 11:33 AM with NA D. NA D was asked if hand hygiene was performed before the
beginning of incontinent care for Resident #1. NA D stated that she had performed hand hygiene before
entering the room.
Record review of facility provided policy named Handwashing/Hand Hygiene, dated August 2015 states the
following:
Policy Statement
This facility considers hand hygiene the primary means to prevent the spread of infections.
Policy Interpretation and Implementation
1.
All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 16 of 17
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
676370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmonee House
1400 Main St
Amherst, TX 79312
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
preventing the transmission of healthcare-associated infections.
Level of Harm - Minimal harm
or potential for actual harm
2.
Residents Affected - Few
All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of
infections to other personnel, residents, and visitors.
3.
Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily
accessible and convenient for staff use to encourage compliance with hand hygiene policies.
7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or
non-antimicrobial) and water for the following situations:
.b. Before and after direct contact with residents;
.h. Before moving from a contaminated body site to a clean body site during resident care;
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676370
If continuation sheet
Page 17 of 17
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Back to topCitations
8 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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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.
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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
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.
FAQ · About this visit
Common questions about this visit
What happened during the August 8, 2023 survey of HARMONEE HOUSE?
This was a inspection survey of HARMONEE HOUSE on August 8, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HARMONEE HOUSE on August 8, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
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.