Harlingen Nursing and Rehabilitation Center

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 for 3 of 4 medication carts (Hall 400 Med-Aide cart, Hall 300 Med-Aide cart, and Hall 100 Nurse Med-Cart) reviewed for pharmacy services.1. The facility failed to ensure medications in Hall 400 Med-Aide cart, Hall 300 Med-Aide cart, and Hall 100 Nurse Med-cart were labeled with an Open Date on 2/23/2026.2. The facility failed to ensure medication in Hall 300 Med-Aide cart were free of loose pills on 2/23/2026. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.

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 reviewed for sanitation in that: The facility failed to ensure the juicer's dispenser gun was clean. This failure could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews 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 need that were identified in the comprehensive assessment for 2 of 9 residents (Resident #1 and Resident #69) reviewed for comprehensive person-centered care plans.1. The facility failed to ensure Resident #69's care plan included her level of care for ADLs.2. The facility failed to ensure Resident #1's comprehensive care plan included activities to be done with resident. These deficient practices could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the comprehensive care plan for 1 (Resident #106) of 5 residents reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #106's comprehensive person - centered care plan's oxygen interventions to reflect current order of 2 LPM.This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview, observation, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 3 residents (Resident #1) reviewed for activities. The facility failed to provide Resident #1 with in-room activities. This failure could place residents at risk for boredom, depression, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #106) residents reviewed for respiratory care. The facility failed to ensure Resident #106's oxygen was being administered on 02/22/26 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased observations, interviews, and record reviews the facility failed to ensure no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident agrees to this meal span for residents eating meals in their rooms, for 2 (Resident #4 and Resident #69) of 8 residents reviewed for food and nutrition services. 1. The facility failed to ensure that no more than 14 hours lapsed between a substantial evening meal and breakfast the following day and provide a nourishing snack to Resident #84 who ate in her room. 2. The facility failed to ensure that no more than 14 hours lapsed between a substantial evening meal and breakfast the following day and provide a nourishing snack to Resident #69 who ate in her room. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #70) of 5 residents. LVN J documented changing of Resident #70's oxygen tubing on 2/15/2026, however, she did not carry out the order due to lack of tubing. The failure could place residents at risk for errors by staff when reading information in the clinical record that was inaccurate or incomplete.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interview, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey and post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public for 1 of 1 facility in that: The facility failed to post the most recent surveys in a place viewable and readily accessible to residents, family members, and legal representatives of residents. This failure could place residents at risk of not being able to fully exercise their rights and at risk of not being aware of the facility's past deficiencies.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care. The nurse practitioner failed to recognize and place orders for treatment for Resident #1 who was experiencing significant increased glucose levels. Resident #1 did not have orders in place for glucose checks and had an episode of high blood sugar beginning on 02/04/26 through 02/13/26 that required her to be hospitalized . An IJ was identified on 02/17/26. The IJ began on 02/04/26 and removed 02/14/26. The facility took action to remove the IJ before survey began. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene, for one (Resident #16) of 3 residents reviewed for activities of daily living. The facility failed to provide Resident #16 with nasal grooming. This failure could result in decrease in resident self-esteem, embarrassment, and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standard or food service safety for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure all food items were labeled and dated in freezer. One bag of nuggets was not labeled or dated. This failure could place residents at risk of foodborne illnesses.

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 two (Resident #69, and Resident #1) of eight residents observed for infection control. 1. LVN A touched multiple surfaces and did not perform hand hygiene prior to checking Resident #69's blood sugar. 2. LVN A placed an insulin pen inside his scrub top pocket prior to administering Resident #69's insulin. 3. RN B failed to perform hand hygiene in between glove changes during a g-tube feeding administration for Resident #1. These failures place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on and was found by the police department approximately 2 miles away from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/08/2023 and ended on 10/08/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining serious injury, harm and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for one Resident (R #3) of three residents reviewed for care plans, in that: The facility did not follow R #3's care plan which indicated to keep R #3's fingernails short. This failure could place residents at risk of not receiving the care and services as indicated by their comprehensive care plan.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 3 residents (R #2 and R #3) reviewed for accuracy of records. The facility did not document R #2 and R #3's wound care treatments in the MAR/TAR on 10/07/23, 10/14/23, 10/15/23, and 10/22/23. This failure could place residents with wound care at risk of not receiving adequate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated 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, for one Resident (Resident #202) of eight residents reviewed for dignity issues. The facility failed to monitor Resident #202's behavior when resident had her hand with feces while in her wheelchair in the dining room. This failure could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 1 of 6 residents (Resident #151) reviewed for activities in that: The facility failed to provide Resident #151 activities designed to meet his interests and promote physical, mental, and psychosocial well-being. This deficient practice could affect residents at the facility who require assistance to activities to decline in mental acuity due to lack of stimulation, boredom, and depression.

Inspectors wroteBased on observation, interview, and record review 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 two residents (Resident #105 and Resident #209) of twenty-four residents observed for infection control, in that: 1. The facility failed to post Droplet Precautions sign on Resident #105's door when Resident #105 was in isolation due to being COVID-19 positive. 2. CNA A did not use one wipe per swipe on Resident #209's buttocks during incontinent care. This failure could place residents at risk for infections and cross contamination.