Harvest Manor Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Harvest Manor Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 11, 2025

  Based 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. […]

• Immediate jeopardy, patternF609Jul 11, 2025

  Based 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. […]

• Immediate jeopardy, patternF689Jul 11, 2025

  Based 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. […]

• Immediate jeopardy, patternF835Jul 11, 2025

  Based 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. […]

• Immediate jeopardy, patternF600Feb 26, 2025

  Based 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. […]