Harvest Manor Healthcare and Rehabilitation Center

Inspectors wroteBased on observation and interviews, the facility failed to prepare and serve food in accordance with professional standards for food safety by failing to ensure staff wore a facial hair restraint while serving residents' food from the steam table. This deficient practice had the potential to affect 164 residents who received food from the facility's kitchen.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an effective pest control program so the facility was free of roaches in the facility's kitchen. This deficient practice had the potential to affect 164 residents who received food from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident group had a private space large enough for all residents who wanted to attend resident council meetings. This deficient practice had the potential to affect all residents who wished to attend resident council meetings. The facility had a current census of 165.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2 (#5 and #24) of 3 (#5, #24, and #36) residents reviewed for PASARR.Resident #5A review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hereditary and Idiopathic Neuropathy. Further review revealed an additional medical diagnosis of Manic Episode with an onset date of 06/01/2023. Further review revealed no review for a PASARR Level II evaluation and determination had been submitted for Resident #5 following her diagnosis of Manic Episode. Resident #24A review of Resident #24's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Depression. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the risks and benefits were reviewed with the resident and/or resident representative, and informed consent was obtained prior to bed rail installation for 2 (#3 and #70) of 3 (#3, #70 and #146) residents reviewed with bed rails. Review of the facility's policy dated 11/25/2014 and titled Side Rail Policy and Procedure revealed the following:Purpose: To provide intervention as warranted to assist resident in reaching the highest level of functioning. Policy: We use side rails as appropriate to resident need in creating better bed mobility and positioning, as ordered by the physician. Procedure: 1. Obtain a physician's order and consent for use of side rails. Essential Points:A.) Always explain the purpose to the resident and family before obtaining an order for side rails. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's medical record was complete and accurate by failing to ensure baths were documented as provided for 1 (#149) of 4 (#9, #56, #64, and #149) residents reviewed for activities of daily living. Review of Resident #149's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hereditary and Idiopathic Neuropathy, Muscle Wasting and Atrophy, Chronic Respiratory Failure, Heart Failure, and Chronic Pain Syndrome. Review of Resident #149's Quarterly MDS with an ARD of 06/11/2025 revealed she required substantial/maximal assistance from staff for bathing. Review of the Facility's CNA Schedules dated 08/04/2025, 08/06/2025, 08/08/2025, and 08/11/2025 revealed S9CNA was assigned to Resident #149's hall. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to promote and facilitate residents' self-determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (#11) of 36 residents in the initial pool. The facility failed to ensure Resident #11 had a choice to participate in a sewing activity. Review of the Medical Record for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Depressive Disorder, Mild Cognitive Impairment, and Type 2 Diabetes Mellitus. Review of the most recent MDS (Minimum Data Set) for Resident #11 with an ARD (Assessment Reference Date) of 07/23/2025 revealed Resident #11 had a BIMS (Brief Interview for Mental Status) of 12, which indicated the resident was moderately cognitively impaired. [...]

Inspectors wroteBased on interviews and record review, the facility failed to transmit Minimum Data Set (MDS) Assessments in the required timeframe for 1(#166) of 1 (#166) resident reviewed for resident assessment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#20) resident out of a total of 36 sampled residents by failing to ensure Resident #20 was accurately coded for pain medication and opioid use. Review of Resident #20's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Pain in Left Ankle and Joints of Left Foot and Pain Unspecified. Review of Resident #20's Significant Change MDS with an ARD of 05/21/2025 revealed Section J0100. B. Pain Management- Received PRN pain medications or was offered and declined, was coded 0. No, and Section N0415. H. Opioid: is taking, was coded No. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the services provided as outlined in the comprehensive care plan met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 2 (#106 and #114) of 3 (#86, #106, and #114) residents reviewed for insulin administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for a resident with Diabetes. The facility failed to schedule and complete podiatry appointments for toenail evaluation and care for 1 (#11) of 5 (#9, #11, #56, #64 and #149) residents sampled for Activities of Daily Living (ADLs). Review of the Medical Record for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnosis, which included Type 2 Diabetes Mellitus. Review of the most recent MDS (Minimum Data Set) for Resident #11 with an ARD (Assessment Reference Date) of 07/23/2025 revealed Resident #11 had a BIMS (Brief Interview for Mental Status) of 12, which indicated the resident was moderate cognitively impaired. Further review revealed Resident #11 required supervision for bathing. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident's food preferences were honored for 1 (Resident #31) of 19 (#2, #13, #19, #31, #37, #44, #52, #66, #74, #79, #80, #82, #83, #94, #117, #134, #143, #144, and #159) residents observed for dinning. This deficient practice had the ability to affect 166 residents served from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin pen stoppers prior to applying insulin pen needles for 2 (#86 and #114) of 3 (#86, #106, and #114) residents reviewed for insulin administration.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident remained free from physical and psychosocial abuse for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when Resident #4, a cognitively impaired resident, hit Resident #R1 on the back. The facility failed to ensure effective interventions were put into place to protect the resident's from abuse after the 02/22/2025 incident. Resident #4 exhibited continued aggressive and abusive behaviors, and was transferred to the facility's locked dementia care unit on 03/25/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged allegations involving physical and psychological abuse were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency, for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when the facility failed to report allegations of abuse to the State Agency. On 02/22/2025, Resident #4 hit Resident #R1. On 03/25/2025, Resident #4 attempted to pull Unknown Resident #1 out of her wheelchair by her feet. On 04/17/2025, Resident #4 hit Resident #3. On 5/20/2025, Resident #4 pushed Resident #5, causing her to fall then Resident #4 hit Resident #5 in the face. [...]

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents for 1 (#4) of 10 (#1, #2, #3, #4, #5, #6, #7, #R1, Unknown Resident #1, and Unknown Resident #2) residents review for incidents. This deficient practice resulted in an Immediate Jeopardy situation on 05/26/2025, when Resident #4, a cognitively impaired resident with a history of aggressive behaviors and was assessed to need 1:1 supervision, was left unattended by staff. Resident #4 was placed on 1:1 supervision from 05/26/2025 through 06/09/2025. On 05/26/2025, Resident #4 was observed grabbing and pulling Unknown Resident #2's hair. On 06/02/2025, Resident #4 grabbed Resident #1's wheelchair, spun her around forcefully and began telling her she was bothering her. [...]

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) sampled residents. The facility failed to:1. Protect Resident's #R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2 from physical and psychosocial abuse by Resident #4;2. Report allegations of physical and psychosocial abuse by Resident #4 to the State Agency in the required timeframe; and3. Ensure Resident #4 received consistent adequate staff supervision to manage the resident's known verbally and physically abusive behaviors. [...]

Inspectors wroteBased on interviews and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring was implemented to ensure corrective actions were put in place after identifying issues with inadequate supervision related to resident-to-resident incidents. This deficient practice had the potential to affect a census of 167 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1 (#3) of 2 (#2 and #3) residents reviewed for falls.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect the residents right to be free from verbal abuse for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse by S4CNA and S5CNA. This deficient Practice resulted in an Immediate Jeopardy situation on 01/22/2025 at 4:52 p.m. for Resident #1, a cognitively impaired resident who required staff assistance for care, when S5CNA was observed in video footage verbally abusing Resident #1 while providing care. On 01/29/2025 at 3:51 p.m., S4CNA was observed in video footage verbally abusing Resident #1 while providing care. On 01/30/2025 at 3:46 p.m., S4CNA was again observed in video footage verbally abusing Resident #1 while providing care. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 4 (#72, #84, #105, and #162) residents out of a total of 32 sampled residents. The facility failed to ensure: 1. Resident #72 was coded correctly for medications; 2. Resident #84 was coded correctly for dental; 3. Resident #105 was coded correctly for PASARR (Pre-admission Screening and Resident Review); and 4. Resident #162 was coded correctly for discharge.

Inspectors wroteBased on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 157 residents who were served from the kitchen.

Inspectors wroteBased on interviews and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice of when to get out of bed for 1 (#99) of 4 (#27, #93, #99, and #108) residents reviewed for resident rights.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure medications were administered to meet professional standards, by leaving the medications at the bedside for 1 (#101) of 32 residents observed during the initial screening of residents upon facility entrance.

Inspectors wroteBased on observation of video footage, interviews, and record review, the facility failed to protect the residents' right to be free from physical abuse by S4CNA for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to report an injury of unknown origin to the state survey agency for 1 (#91) of 6 (#31, #40, #54, #91, #120, and #157) residents reviewed for incidents/accidents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a thorough investigation was completed and documented for an injury of unknown origin for 1 (#91) of 6 (#31, #40, #54, #91, #120, and #157) residents reviewed for incidents/accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident's care plan was implemented for 1 (#53) of 2 (#53 and #42) residents reviewed with velcro alarming seat belts. The facility failed to ensure Resident #53's velcro alarming seat belt audibly alarmed when unfastened.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 2 (#92 and #100) of 6 (#7, #40, #92, #100, #120 and #126) residents reviewed for ADLs. The facility failed to provide fingernail care to Resident #92 and Resident #100.

Inspectors wroteBased on record review and interviews the facility failed to electronically submit accurate payroll information for direct care staffing as required.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of disease and infection. The facility failed to ensure staff practiced hand hygiene and proper glove use for 2(#9 and #55) of 2(#9 and #55) residents observed receiving perineal care and indwelling catheter care. There were 168 residents in the facility, according to the Resident Census and Conditions of Residents.