Harvest Acres Nursing and Rehab

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to complete and document care conferences after admission for two of three residents (Residents #5 and #11) and quarterly for two of three residents (Residents #3 and #5). The facility failed to document the following; the planning of care should include and assessment of the resident's current condition, needs that the resident requires, and updates which should be shared and communicated to the resident and or resident representative. A copy of the care plan should also be available to the resident, and or resident representative for review which the facility failed to do. The facility reported a census of 25 residents.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to notify residents' guardian/power of attorney of changes for 2 out of 4 residents reviewed (Residents #5, with medication changes) and failed to notify the physician of Resident #6's continued problem with abdominal pain and distention until 6 days later. The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff and resident responsible party interviews, the facility failed to implement an effective discharge planning process for 1 of 4 records reviewed for discharge plan, (Resident #4) that focused on the resident's discharge goals, prepared the resident to effectively transition to post-discharge care, and resulted in the resident's homelessness within 7 days of discharge, and the resident's return to substance abuse and hospitalization in critical condition from a drug overdose. The facility reported a census of 25 residents.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to address PASRR recommendations on the Care Plans for two of three residents reviewed with Level 2 PASRR evaluations. (Residents #4 and #5) and failed to include interventions identified in an interdisciplinary meeting after incident involving one resident entering another resident's room causing Resident #7 to fear Resident #8). The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to ensure their staff had basic competencies and skills sets that met the behavioral health needs for residents the facility has assessed and developed care plans for, in accordance with their Facility Assessment. The facility failed to provide the education, as specified in the Facility Assessment, to promote the staff's competency, and failed to document staff competency for behavioral health management as required. The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident responsible party interviews, the facility failed to incorporate care requirements into resident comprehensive care plans as directed for 2 of 5 residents reviewed with Level II PASRR's (Pre-admission Screening and Resident Review, an in-depth, person-centered evaluation triggered when there is a suspected or confirmed mental illness, intellectual disability, or related condition. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility staff failed to change gloves after completing incontinence care (of stool) and before applying Triad cream to a pressure ulcer to the coccyx area for one of one residents reviewed with a pressure ulcer. (Resident #3). The facility reported a census of 25 residents.

Inspectors wroteBased on record review, staff interviews, and the facility policy, the facility failed to complete the initial baseline care plan within 48 hours for 4 of 5 residents reviewed for baseline care plans (Resident #1, Resident #7, Resident 18, and Resident #34). The facility reported a census 27 residents.

Inspectors wroteBased on record review, staff interviews, the facility policy, and the Medicare Claims Processing Manual, the facility failed to provide resident ending skilled care with the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) Advanced Beneficiary Notice for one resident (Resident #37) and Notice of Medicare Non Coverage (NOMNC) documents for 3 of 3 residents reviewed for ABN (Resident #22, Resident #36, and Resident #37). The facility reported a census of 27 residents.

Inspectors wroteBased on observation, clinical record review, interviews, and policy review the facility failed to develop a comprehensive care plan for 2 of 5 residents reviewed (Residents #18 and #34). The resident's care plans contained focus areas, goals, and interventions that did not include person centered information. These sections were not updated when the comprehensive care plan was due at 14 days or with additional revisions. The facility reported a census of 27 residents. FIndings include: 1. The Minimum Data Set (MDS) for Resident #18 dated 9/10/25 documented diagnoses of hypertension, urinary tract infection within the past 30 days, anxiety and depression, and restlessness and agitation. The resident's Brief Interview for Mental Status (BIMS) score of 4/15 indicated she was severely cognitively impaired. [...]

Inspectors wroteBased on record review, staff interviews, and the facility policy, the facility failed to notify the provider for blood glucose levels over 400 mg/dl (milligrams per deciliter) for 1 of 3 residents reviewed for assessment/intervention (Resident #1). The facility reported a census of 27 residents.

Inspectors wroteBased on observation, clinical record review, interviews, and policy review the facility failed to maintain a medication administration error rate under 5% related to unprofessional standards and principles during the survey process. Of 31 medications observed 3 were not administered according to provider orders or medication inserts, and a missing medicated patch that was to be removed from a resident was not located. (Residents #1, 7,12, and 13) The facility reported a census of 27 residents.

Inspectors wroteBased on observation, clinical record review, interviews, and policy review the facility failed to administer medications in a sanitary manner during medication administration. A nurse was observed putting pills in her hand before putting them in medication cups, applying a medicated patch without washing her hands afterward, and touching personal items between medication passes without washing her hands. The facility reported a census of 27 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse for two of twelve residents reviewed for abuse (Resident #12, Resident #19). Resident #12, was a severely cognitively impaired resident with a previous history of unsolicited sexual touching. On 10/26/24, Resident #12, was touched on the breast underneath her clothing by Resident #19. On an unknown date, Resident #19 touched Resident #12 on the buttock. On an unknown date, staff reported Resident #19 grabbed/groped Resident #12. Resident #12's family explicitly instructed the facility staff that they did not consent to Resident #12 engaging in sexual contact with another resident. This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of residents. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure all allegations of abuse including allegations of staff to resident rough treatment resulting in fear, resident to resident physical altercations, injuries of unknown origin, and inappropriate touching of a resident's breast and buttocks by another resident, were reported timely to the facility administration for ten of twelve residents reviewed for abuse (Resident #7, Resident #11, Resident #12, Resident #13, Resident #15, Resident #16, Resident #19, Resident #20, Resident #21, Resident #22). This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/14/24 at 1:57 PM. The IJ began on 9/26/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct thorough investigations into allegations of abuse including injury of unknown origin, following concerns with staff rough treatment towards residents resulting in fear, following resident to resident incidents, and failed to ensure separation of alleged perpetrators following staff after becoming aware of allegations of abuse for eight of twelve residents reviewed for abuse (Resident #7, Resident #11, Resident #12, Resident #15, Resident #16, Resident #19, Resident #20, Resident #21). This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 26 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/14/24 at 1:57 PM. The IJ began on 9/26/24. Facility staff removed the Immediate Jeopardy on 11/18/24 at 12: [...]

Inspectors wroteBased on observation, interview, clinical record review, and facility policy review, the facility failed to provide adequate assessment and intervention for 3 of 4 residents reviewed for a change in condition. On 9/07/24 at approximately 12:30 PM, Resident #25 had difficulty transferring, which was a significant change in status, then at 2:35 PM the resident later had an unwitnessed fall, and was found face down in another resident's room, with laceration to the left forehead, Physician was sent a fax on 9/07/24, however, there was no response from physician until 9/09/2024 which noted they should could continue to monitor per facility protocol. There was no follow-up from the facility between 9/07/2024 and 9/09/2024. Staff acknowledged continued decline in Resident #25's condition when Resident #25 required assistance and cueing with all meals when independent prior. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure evaluation of a mobility device prior to resident use, failed to ensure gait belt utilized for transfer, failed to remain with a resident when a non-verbal resident suspected to have a seizure resulting in a fall, failed to ensure adequate supervision for resident with known history of falls when the resident was found multiple times post unwitnessed fall in the lobby of the facility, failed to ensure residents' feet were placed on wheelchair foot pedals when residents assisted via wheelchair, and failed to ensure residents remained free from environmental hazards when one resident ingested a [NAME] egg and another resident obtained access to a locked restroom without the knowledge of facility staff for six of ten residents reviewed for accidents (Resident #2, Resident #3, Resident #5, Resident #10, [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to provide the correct diet for 2 of 5 residents reviewed for nutrition(Residents #11 and #226). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to ensure sufficient nursing staff to provide care to residents in accordance with the care plan by failing to supervise 1 of 1 resident with a history of physical resident to resident altercations from other residents(Resident #22) and by failing to provide timely assistance for 1 of 1 resident reviewed with a history of falls and seizures(Resident #2). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to provide care and services according to accepted standards of clinical practice by preparing medications in advance for 4 of 9 residents(Residents #2, #9, #11, #12) observed during observations of the medication administration pass and the medication cart. The facility reported a census of 26 residents.

Inspectors wroteBased on previous 2567 review, staff interview, and facility policy review the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey that were previously identified during surveys completed in the last twelve months. The facility reported a census of 26 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to employ a required Quality Assurance(QA) committee member, a qualified Infection Preventionist, to perform infection control surveillance and report to the governing body. The facility reported a census of 26 residents.

Inspectors wroteBased on policy review and staff interviews the facility failed to provide an Infection Preventionist with specialized training or certification to monitor and provide oversight for the facility's Infection Prevention and Control Program. The facility reported a census of 26 residents.

Inspectors wroteBased on observation, interview, clinical record review, and facility policy review, the facility failed to ensure residents were treated in a manner to preserve dignity and respect for 1 of 2 residents reviewed for dignity (Resident #20) when staff failed to ensure residents had been kept clean and free from odors following episodes of incontinence in a timely manner (Resident #20), made unkind comments in the presence of residents in the dining room, and staff interview revealed concerns with a staff member being unkind. The facility reported a census of 26 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent documentation of code status to indicate whether to perform Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR) status for one of three residents reviewed for advanced directives (Resident #22). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, facility policy, and clinical record review, the facility failed to safeguard the resident ' s personal and medical information. The facility reported a census of 26 residents. Findings Include: On 11/06/24 between 08:23a.m. -8:26 a.m., State Agency (SA) observed the computer left on and no one at the nurses desk with the point click care system (electronic charting software) open to document on residents and several names displayed. On 11/06/24 between 09:22 a.m. -11/06/24 09:31 a.m. when the computer timed out, the point click care (PCC) was open with several residents ' names displayed and no one sitting at desk. On 11/06/24 at 12:54 p.m., PCC system was open on a resident ' s chart and no one was sitting at the desk. On 11/06/24 at 02:25 p.m., Staff D, LPN walked away and left the resident chart open. [...]

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of a hospital transfer for 1 of 4 residents reviewed for hospitalizations(Resident #3). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a significant change assessment following a resident starting hospice services for one of three residents reviewed for hospice (Resident #22). The facility reported a census of 26 residents.

Inspectors wrote3. The MDS assessment tool, dated 10/23/24, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, depression, and psychotic disorder. The MDS stated the resident was dependent on staff for toilet and chair transfers and listed his BIMS score as 0 out of 15, indicating severely impaired cognition. A 9/10/24 Care Plan entry stated the resident transferred independently. On 11/6/24 at 12:15 p.m., Staff C Certified Nursing Assistant(CNA) and Staff M CNA assisted the resident with a gait belt to stand up in order to pull down his pants and remove his brief. On 11/19/24 at 1:59 via phone, the Director of Nursing of a sister facility stated Care Plans should be up to date with regard to transfer status. [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to ensure timely assistance with incontinence cares and positioning for 3 of 3 residents reviewed for incontinence cares (Residents #3, #20, and #22) and failed to provide eating assistance for 1 of 3 residents reviewed for nutrition(Resident #20). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to provide ongoing, resident centered activities for 2 of 2 residents reviewed for activities(Residents #3, and #11). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat a urinary tract infection in a timely manner for one of two residents reviewed for urinary tract infection (Resident #12). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure the dimensions from the mattress to the bed rail or the bed rail gaps were less than 4 3/4 inches to ensure the bed rails did not pose a risk of entrapment or injury for 1 of 26 residents reviewed for bed rail safety(Resident #2). The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to provide necessary behavioral health care such as psychiatric services and the development and implementation of person-centered care plans that included and supported the behavioral health care needs for 1 of 2 residents reviewed for behaviors(Resident #17). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure its medication error rates were not 5 percent or greater. The facility's medication error rate calculated as 12% after staff administered an incorrect dose of Vitamin D3, failed to prime an insulin pen, and failed to administer insulin in a timely manner with regard to the meal time. The facility reported a census of 26 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to ensure residents were free of significant medication errors by failing to ensure a resident consumed food in a timely manner after the administration of rapid acting insulin(Resident #4) and by failing to prime insulin pens prior to administration The facility reported a census of 26 residents.

Inspectors wroteBased on observation, interview, clinical record review, and facility documents review, the facility failed to ensure all menu items were served to residents with an alternate diet for 2 of 2 residents (R#1 and R#226) on a pureed diet. The facility reported a census of 26 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure the accuracy of records for 1 of 2 residents receiving Hospice services(Resident #9) and for 1 of 5 residents reviewed for a change in condition(Resident #20). The facility reported a census of 26 residents.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to carry out infection control practices for 1 of 6 residents observed during medication pass observations(Resident #6). The facility reported a census of 26 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement an infection control surveillance plan to identify, track, monitor and report infections. The facility failed to provide documented evidence from February 2023 through January 2024 for an infection control surveillance program. The facility reported a census of 27 residents.

Inspectors wroteBased on review of facility policy, facility document review or lack of, and staff interviews the facility failed to maintain an Infection Prevention and Control Program (ICPC) that included a functional Antibiotic Stewardship Program. The failure to have a system in place that monitors antibiotic use in accordance with established protocols has the potential to affect all 27 residents of the facility. Findings Include: Review of a policy provided by the facility titled Antibiotic Stewardship revised October 2018, documented antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. [...]

Inspectors wroteBased on policy review and staff interviews the facility failed to provide an Infection Preventionist with specialized training or certification to monitor and provide oversight for the facility's Infection Prevention and Control Program. The facility reported a census of 27 residents.

Inspectors wroteBased on record review, staff interviews, and facility policy the facility failed to implement advanced directives per resident and family directives upon admission for 1 of 3 residents reviewed and failed to clarify conflicting orders for 1 of 3 residents reviewed (Resident#5). The facility reported a census of 27 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to ensure resubmission of the Preadmission Screening and Resident Review (PASRR) following new mental health diagnoses for 1 of 2 residents reviewed for PASRR (Resident #25). The facility reported a census of 27 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to complete a care plan within 48 hours of admission for one of one newly-admitted residents reviewed (Resident #25). The facility reported a census of 27 residents.

Inspectors wroteBased on clinical record review, facility policy, and staff interviews, the facility failed to update a Care Plan to include antipsychotic medication for 1 of 5 resident's care plan reviewed for unnecessary medications (Resident #25). The facility reported a census of 27 residents. Findings Include: The Quarterly, Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 documented diagnoses including, orthopedic conditions, diabetes, delirium due to known physiological condition. Major depressive disorder, recurrent, unspecified was added and encephalopathy diagnosis had been removed. The MDS coded that antipsychotic medications were given during the last seven days and resident received on a routine basis. BIMS Score coded 7 out of 15 which indicated severe cognitive impairment. [...]

Inspectors wroteBased on observation, staff interview, clinical record review and policy review, the facility failed to ensure resident is dry and free from odors for 1 of 3 reviewed for incontinent residents (Resident #3). The facility reported a census of 27.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to limit a As Needed (PRN) psychotropic medication to fourteen (14) day limit and failed ensure Gradual Dose Reduction (GDR) for 2 of 5 residents reviewed for unnecessary medications (Resident #15 & #25). The facility reported a census of 27 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to employ a required Quality Assurance(QA) committee member, a qualified Infection Preventionist, to perform infection control surveillance and report to the governing body, and the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. The facility reported a census of 27 residents. Findings Include: The QAPI Plan dated 9/1/22 revealed: a. QAPI meetings will be held no less than quarterly. b. Staff members with the most knowledge and commitment to QAPI efforts will participate. The Facility Assessment amended on date 1/3/23 listed Services and Care Offered Based on Resident Needs revealed infection prevention and control, identification and containment of infection and prevention of infections. [...]