Harbor Valley Health and Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to permit a resident to return to the facility after being hospitalized and failed to document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility for 1 (Resident #1) of 3 residents reviewed for transfer and discharge rights, in that:Resident #1 was issued a 30 day discharge letter on 12/01/2025 for nonpayment. Resident #1 was transferred to the hospital on [DATE] for a CT scan and was denied readmission to the facility. The facility did not document Resident 1's medical record the reason for not accepting Resident #1 to return to the facility. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on interview and record review the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response, for 3 of 6 anonymous residents who attended resident council meetings. (Resident council meeting). The facility failed to provide residents with requested copies of the documentation of their grievances and their resolution. This failure could result in the residents feeling that their grievances are not being acted upon and could place all residents who attend the Resident Council meetings at risk for feelings of powerlessness and decreased self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 5 residents (Resident #68, #10 and #74) reviewed for resident assessments: 1. The facility failed to ensure Resident #68's most recent quarterly MDS assessment was updated to include the resident did not receive insulin injections. 2. The facility failed to ensure Resident #10's most recent quarterly MDS assessment, dated 11/20/25, was updated to include the resident having a significant weight gain in the last 6 months. 3. The facility failed to ensure Resident #74's admission MDS assessments dated 04/09/25 and most recent quarterly MDS assessments dated 09/01/25 04/09/25 and most recent quarterly MDS assessment dated [DATE] were updated to include the resident had difficulty with chewing. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 18 residents (Resident #3, 68, #71, #45, #7 and #4) reviewed for care plans: 1. The facility failed to ensure a focus area for activities was reflected in Resident #3's comprehensive care plan. 2. The facility failed to ensure a focus area for activities was reflected in Resident #68's comprehensive care plan. 3. The facility failed to ensure a focus area for activities was reflected in Resident #71's comprehensive care plan.4. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, send the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged , and record the reason for the transfer or discharge in the resident's medical record in for 1 (Resident #99) of 2 residents reviewed for safe transfer or discharge.1. The facility failed to record the reasons for the transfer in Resident #99's medical record.2. The facility failed to send notice of transfers or discharges to the ombudsman.3. The facility failed to provide Resident #99 and/or the resident's representative with a thirty-day written notice of an impending transfer or discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change MDS assessment with 14 days after the facility determined, or should have determined, there had been a significant change in a resident's physical or mental condition for 1 of 24 residents (Resident #45) reviewed for assessments. The facility failed to complete a Significant Change MDS for Resident #45 within 14 days of the resident's discharge from hospice services. This failure placed residents who had a significant change in condition requiring an MDS assessment at risk of not receiving needed services.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan and quarterly review assessments were reviewed and revised by an interdisciplinary team that included, but was not limited to the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff responsible for the resident for 2 of 8 residents (Resident #68, and #10) reviewed for care plan timing and revision. 1. The facility failed to have a complete interdisciplinary team attend Resident #68's care plan meeting to include the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #10) reviewed for personal hygiene. The facility failed to keep Resident #10's toenails and fingernails trimmed. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. Record review of Resident #10's admission Record, dated 12/02/2025, reflected a [AGE] year-old resident with an initial admission date of 02/03/2025 and re-admission date of 03/21/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 2 of 2 resident (Resident #41, Resident #90), in the facility reviewed for accidents, in that: 1. The facility failed to ensure Resident #41 did not have a razor in his room. 2. The facility failed to ensure Resident #90 did not have scissors in her room. This failure could place residents at risk of injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure a drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 1 of 3 residents (Resident #2) reviewed for (DRR) Drug Regimen Review. The facility failed to have a record of Resident #2's DDR for November 2025. This failure could place residents at risk of not having their medications reviewed by a pharmacy consultant for appropriate doses or pharmacy recommendations.

Inspectors wroteBased on interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of walk-in refrigerator at or below 41 degrees F in November 2025.2. The facility failed to maintain the temperature of the milk refrigerator at or below 41 degrees F in December 2025.3. The facility failed to take temperatures for the cold foods (to include tossed salad on 12/03/25, milk and orange juice on 12/01/25, 12/02/25 and 12/04/25). These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 5 residents (Resident #10) reviewed for infection control:The facility failed to ensure LVN K cleaned an insulin pen's rubber seal with an alcohol swab prior to insulin administration for Resident #10. This failure could place residents at risk for cross contamination and infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 3 of 5 Residents (Resident #1, #2, and #3) reviewed for medication storage:1. The facility failed to ensure Resident #1 did not have medication cups with cough syrup at the bedside.2. The facility failed to ensure Resident #2 did not have a jar of medicated mentholated ointment (a combination product that is used to relieve itching, minor muscle, or joint pain. This product may also be used as a chest rub to soothe symptoms associated with the common cold) at the bedside.3. The facility failed to ensure Resident #3 did not have a jar of medicated mentholated ointment (a combination product that is used to relieve itching, minor muscle, or joint pain. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure [NAME] A wore a beard net on 11/12/25. This failure could place residents at risk of contaminated food and illness.

Inspectors wroteBased on observations, interviews and record reviews, 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 (Resident #1) of 6 residents reviewed for infection control. The facility failed to ensure staff wore PPE when entering Resident #1's room on 11/12/25 at 8:00 a.m. This failure could place residents at risk of cross-contamination and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 1 of 11 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse as evidence by on 08/05/2025, in the resident's room CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. The noncompliance was identified as a PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of serious injury, physical harm, serious impairment or death.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 (Resident #2) reviewed for care plans. CNA L and CNA X failed to follow the care plan for Resident #2 and transferred Resident #2 without a mechanical lift on 08/16/2025. This deficient practice could place residents who are transferred at risk for injury.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 Residents (Resident #1) reviewed for dignity. Nursing staff failed to greet Resident #1 upon entering her room; failed to engage with Resident #1 while she was attempting to talk with them in Spanish and failed to request the assistance from other staff who could understand Resident #1 so they could determine if she needed assistance. Resident #1 was Spanish speaking only. This deficient practice could affect any Resident who did not speak English and could result in the Residents needs not being met and contribute to feelings of unworthiness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 5 Residents (Resident #1) who needed assistance with meals. Nursing staff failed to set up Resident #1's meal tray to include raising the head of the bed, opening up condiments, ensuring the meat was cut when served and ensuring the bedside table was close to Resident #1 and in a position where she could reach the food on the meal tray. This deficient practice could affect any Resident who required set-up assistance during meals and could result in the resident having difficulties reaching the food and it could discourage the resident to eat their meal.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to each resident received assistance devices to prevent accidents for 2 of 2 Residents (Resident #2 and Resident #3) who were observed during mechanical lift transfers. 1. CNA F failed to lock the mechanical lift while raising and lowering Resident #2 during a transfer. He failed to widened the base of the mechanical lift which resulted in the wheelchair getting stuck between the legs while lifting Resident #2. CNA F failed to widened the base when transferring Resident #2 from the wheelchair to the bed while suspended in the air and when lowering Resident #2 onto the bed. 2. CNA I failed to lock the base of the mechanical lift while raising and lowering Resident #3 during a transfer. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 1 of 8 residents (Resident #192) reviewed for advanced directives, in that: The facility failed to ensure Resident #192's desire to formulate an advanced directive was properly documented in his electronic medical record. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 Residents (Resident #42) whose MDS records were reviewed for accuracy. 1. The facility failed to ensure Resident #42's Annual MDS assessment dated [DATE] was updated when the resident's insulin was discontinued on 12/15/2023. This failure could place residents at risk of improper or incorrect care or services necessary for their physical, mental, and psychosocial well-being due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 8 Residents (Resident #86) and 2 of 4 storage closets (Hall 100 and Hall 200) reviewed for accident hazards in that: 1. The facility failed to remove a potential hazard for Resident # 86's room. 2. The facility failed to ensure the storage clostes on Halls 100 and 200, which contained potential hazard items, were locked. This deficient practice could place residents at risk of remaining in an environment that was not free of accident hazards.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals under proper temperature controls, for 1 of 4 medication carts (100 hall cart) reviewed for storage. 1. The facility failed to ensure medications that required refrigeration were not stored on the 100 hall medication cart. This failure could place residents at risk for not receiving therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.45% based on 2 out of 31 opportunities, which involved 1 of 5 Residents (Residents #36) reviewed for medication administration, in that: The facility failed to ensure LVN H administered Resident #36's insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) and insulin glargine (a long-acting insulin pen that lowers blood sugar levels in adults with diabetes) correctly. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #30) reviewed for hospice services, in that: The facility failed to ensure Resident #30's most recent Physician Certification of Terminal Illness and Hospice election form were completed and part of the hospice documents. The most recent plan of care, list of hospice personnel involved in the care, and hospice physician orders were not available at the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections involving 2 of 6 staff (LVN) reviewed for infection control, in that: The facility failed to ensure MA G cleaned the blood pressure cuff between resident #9 and Resident #80. These deficient practices could place residents at-risk for infections.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 1 (Resident #193's room) of 16 rooms reviewed for full visual privacy. The facility failed to provide Resident #193 with a privacy curtain. Resident #193's buttocks was visible from the hallway during incontinent care. This failure could cause a decrease in feelings of self-worth by being exposed during cares.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was free of any significant medication errors for 1 of 6 residents (Resident #4) reviewed for medications. The facility failed to prevent Resident #4 from being administered incorrect medications of Seroquel 50 mg PO and Ativan 0.5 mg PO. This deficient practice could result in a risk to the residents' health and complications which can lead to an infection, injury or death.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 1 of 12 residents (Resident #77) reviewed for call lights. The facility failed to ensure Resident #77's emergency call button in the bedroom was operating properly. This failure could place residents at risk of injury, pain, and hospitalization.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admissions, at least once every 60 days thereafter for 1 of 5 residents (Resident #1) whose care was reviewed in that: The facility failed to ensure Resident #1 was seen by her physician within 60 days. This deficient practice could affect residents and could lead to a decline in health status or untreated conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments for 1 of 1 medication cart (100 Hall medication cart) reviewed for storage of drugs. Agency LVN A left the 100 Hall medication cart unlocked. This deficient practice could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased 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 for 1 of 1 kitchen, in that: The facility failed to ensure the bottle of eyewash solution was within its expiration date. These deficient practices could place staff at risk for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 2 residents (R#6 and R#5) reviewed for abuse. The facility did not properly monitor or put in place preventative measures for R #1 to prevent an act of sexual abuse on 09/27/23, when R#1 was found without a brief laying in the bed of R#6 without the consent of R#6. The facility did not properly monitor or put in place preventative measures for R #1 to prevent further acts of sexual abuse on 10/14/23, when R#1 was found on top of R#5, in her bed, without the consent of R#5. An IJ was identified on 10/26/23. The IJ template was provided to the facility on [DATE] at 3:50 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation is made to the State Survey Agency for 1 of 3 residents (R #1) reviewed for sexual abuse. The facility did not report to the State Survey Agency (HHSC) two incidents of R #1 sexually abusing two other residents (R#6 and R#5) on two separate occasions (09/27/23 and 10/14/23). This failure could place residents at risk for sexual abuse and could lead to a diminished quality of life, and psychosocial harm

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the dry storage were dated and labeled. This failure could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #3) reviewed for feeding tubes in that: The facility failed to ensure RN A properly checked for residual prior to administering medications to Resident #3's gastrostomy tube. This deficient practice could place residents who received medications via a gastrostomy tube at risk for medical complications or a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 2 of 2 residents (Resident #45 and #43) reviewed for respiratory therapy in that: Resident #45's and #44's oxygen concentrator filters were covered in a white substance. This deficient practice could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery.

Inspectors wroteBased on observations, interviews, and record reviews, 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 1 Resident (Resident #228) reviewed for infection control practices, in that: The facility failed to ensure CNA B utilized appropriate infection control practices when entering Resident #228's room who was on isolation for an infection. This failure could place residents on contact isolation for infection at risk for spreading the infection or a decline in health.