Harvest Acres Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Harvest Acres Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF600Nov 19, 2024

  Based 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. […]

• Immediate jeopardy, patternF609Nov 19, 2024

  Based 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. […]

• Immediate jeopardy, patternF610Nov 19, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF684Nov 19, 2024

  Based 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 [DATE] 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 [DATE], however, there was no response from physician until [DATE] which noted they should could continue to monitor per facility protocol. There was no follow-up from the facility between [DATE] and [DATE]. […]

• Actual harm, patternF689Nov 19, 2024

  Based 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… […]