Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbor Lakes Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Medication Order Reconciliation Error: A resident admitted after left hip surgery with neuropathy and osteoporosis had a pregabalin order that did not match the medication label or controlled substance log. Staff documented that the resident received pregabalin 50 mg BID for several days while the EMR showed a different dose, and a CMA stopped the dose when he noticed the discrepancy and reported it to the nurse and DON.
The facility failed to ensure proper hand hygiene during food preparation, as observed when a dietary aide handled lettuce with bare hands, contrary to professional standards. The CDM confirmed that gloves were required, and the ADMN acknowledged the risk of contamination due to this oversight. The facility's policy and FDA guidelines on hand hygiene were not adhered to, highlighting a lapse in infection control monitoring.
The facility failed to update comprehensive care plans for three residents, leading to deficiencies in care. A resident with a Foley catheter did not have her care plan updated, another resident's aggressive behavior was not documented, and a third resident's care plan was not reviewed quarterly. The MDS Coordinator admitted to errors in updating care plans, and the DON acknowledged the lack of documentation for significant changes.
The facility failed to serve food at safe and appetizing temperatures, as evidenced by a test tray showing spaghetti at 106.8 degrees F and tough breadsticks at 94 degrees F. The Dining Manager acknowledged the food should have been warmer, and the Administrator noted that residents should inform staff if their food is cold. The facility's policy requires hot food to be held at temperatures greater than 135 degrees F.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hand hygiene and equipment sanitization protocols. An LVN and a CMA were observed not sanitizing hands or equipment during medication administration. CNAs reused disposable wipes and handled ice with bare hands, contrary to policy. Staff acknowledged lapses, citing nervousness during observations.
A resident's Oxycodone tablets were misappropriated due to a CMA's failure to follow medication handling protocols. The resident, with chronic pain, missed 11 doses and received an alternative medication that was less effective. The CMA had a history of medication errors and was terminated after the incident. Facility staff did not adhere to policies for controlled substances, contributing to the deficiency.
The facility failed to develop baseline care plans within 48 hours of admission for two residents, as required. A resident's care plan was completed late, and summaries were not provided to the residents or their representatives. Interviews with staff revealed a lack of awareness and adherence to the policy, potentially leading to unmet care needs.
A resident experienced medication administration errors, resulting in a 16% error rate at the facility. LVN A incorrectly administered Tylenol and failed to give other prescribed medications. The resident, with conditions including diabetes and GERD, did not notice increased pain. The DON and Administrator emphasized the importance of following protocols to prevent such errors.
A facility failed to properly secure Tramadol, a controlled substance, when two pills were left unlabeled and not double locked in a medication cart. The LVN responsible acknowledged the error, and the DON confirmed the breach of protocol. The resident involved, who has chronic pain, reported receiving medication late but manageable pain levels.
A facility failed to ensure a dietary staff member had a current Food Handler Certificate, leading to potential risks in food safety. The deficiency was identified through observation and interviews, revealing inadequate monitoring of staff certifications by the Dietary Manager and Certified Dietary Manager.
A facility failed to maintain accurate medical records for a resident with specific physician orders for intermittent catheterization. Despite the order to monitor and document urine output every three hours, the MAR showed no evidence of such documentation. Interviews with the ADON and DON confirmed the expectation for regular documentation, which was not met, potentially impacting the resident's care.
Medication Order Reconciliation Error
Penalty
Summary
The facility failed to maintain pharmacy services procedures that ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one resident reviewed for medication administration. Resident #114 was a [AGE]-year-old female admitted for after care following left hip joint replacement surgery, with diagnoses including idiopathic neuropathy and osteoporosis. Her medication order dated 9-4-2025 listed Lyrica 150 mg (pregabalin) to be given as 1 capsule by mouth twice daily for neuropathy, with a start date of 9-5-2025 and a discontinue date of 9-10-2025 by LVN A. Record review showed the resident received pregabalin 50 mg twice daily from 9-5-2025 through 9-9-2025. On 9-10-2025, a CMA obtained the resident’s pregabalin from the medication cart and noticed the EMR dosage did not match the medication label or the controlled substance sign-out logbook, so he did not administer it and reported the discrepancy. The DON later stated the order was clarified with the PMD and NP, the incorrect order was discontinued in the computer, and a new order for the correct dosage was entered. The facility policy stated pharmacy services include developing and revising procedures for ordering, delivery, acceptance, storage, distribution, preparation, dispensing, administration, disposal, documentation, and reconciliation of medications and biologicals.
Failure in Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene during meal preparations. During an observation, a dietary aide was seen chopping lettuce and placing it into a plastic bag with bare hands, acknowledging that gloves should have been worn to prevent possible contamination. The Certified Dietary Manager (CDM) confirmed that staff were required to wear gloves when handling food and ice, and that touching food with bare hands was unacceptable. The CDM also noted that it was the Dietary Manager's responsibility to monitor infection control in the kitchen. The Administrator (ADMN) stated that it was never acceptable for dietary staff to touch food with bare hands, although he mentioned that the situation might depend on the regulations and the type of food being handled. He acknowledged that the failure to ensure proper hand hygiene could lead to contamination of residents' food. The ADMN also pointed out that the dietary manager should have been more vigilant in monitoring staff and their training. The facility's policy and FDA Food Code guidelines emphasize the importance of proper handwashing and glove use to prevent contamination, which was not followed in this instance.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise comprehensive care plans for three residents, leading to deficiencies in their care. Resident #9, a female with multiple diagnoses including anemia, muscle weakness, and neuromuscular dysfunction of the bladder, had a Foley catheter ordered on July 16, 2024, but her care plan was not updated to reflect this change. Additionally, her care plan was not reviewed quarterly between November 22, 2023, and June 19, 2024. Observations confirmed the presence of the catheter, yet the care plan lacked documentation of this significant change. Resident #15, a female with diagnoses such as seizures, dementia, and anxiety disorder, exhibited aggressive behavior by hitting another resident on July 23, 2024. Despite this incident, her care plan was not updated to include this behavior, and quarterly reviews were not conducted between January 30, 2023, and November 8, 2023, as well as between November 8, 2023, and July 17, 2024. The failure to document and address her aggressive behavior in the care plan was noted during the review. Resident #75, a female with conditions including hypothyroidism, muscle weakness, and a history of falling, also did not have her care plan reviewed quarterly between December 5, 2023, and May 31, 2024. The MDS Coordinator admitted to errors in updating the care plans, which resulted in the lack of documentation for quarterly reviews. The Director of Nursing acknowledged the expectation for quarterly reviews and the inclusion of significant changes such as behaviors and medical devices in the care plans, but these were not documented in the electronic medical records.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that residents received food that was palatable, attractive, and served at a safe and appetizing temperature. During an observation, a test tray was placed on a hall cart for transport and was not taken directly to the conference room, resulting in the food being cold by the time it was tested. The spaghetti with meat sauce was found to be at 106.8 degrees F, and the breadsticks were at 94 degrees F and were tough, making them difficult to cut or pull apart. The Dining Manager (DM) acknowledged that the spaghetti and meat sauce should have been at 135 degrees F when served to residents and agreed that the bread was too tough, which could negatively impact residents, especially those with dentures. The Administrator (ADMN) stated that the facility had sufficient staff to deliver trays and that charge nurses monitored the trays as they were passed to residents. However, the ADMN could not comment on what led to the failure and stated that residents were expected to inform staff if their food was cold so it could be reheated. The facility's policy on food preparation requires that all foods be held at appropriate temperatures, greater than 135 degrees F for hot holding, which was not adhered to in this instance.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene and equipment sanitization protocols. During medication administration, a Licensed Vocational Nurse (LVN) was observed not sanitizing her hands after taking a resident's pulse oxygen level and using an unsanitized blood pressure cuff on different residents. Similarly, a Certified Medication Aide (CMA) did not perform hand hygiene before and after glove use while administering medications, including eye drops and oral medications. Further observations revealed that a Certified Nursing Assistant (CNA) reused disposable incontinent wipes during resident care and failed to perform hand hygiene after glove removal. Another CNA did not sanitize her hands between assisting two residents with feeding, and both a CNA and an LVN were seen handling ice with bare hands, which was against the facility's infection control policy. These actions were confirmed through interviews with the staff involved, who acknowledged their lapses in following proper procedures. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) highlighted the expectations for staff to sanitize equipment and hands between resident interactions and not to reuse disposable wipes. The DON noted that the failure to adhere to these protocols could lead to cross-contamination and infections among residents. Despite training in infection control, staff members cited nervousness during observations as a reason for their non-compliance.
Misappropriation of Resident's Medication Due to Staff Error
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their medication, specifically Oxycodone tablets, which were not found after being misplaced or mishandled by a Certified Medication Aide (CMA). The resident, an elderly female with a history of chronic pain and other medical conditions, did not receive 11 scheduled doses of Oxycodone over a period of several days. Instead, she was given an alternative pain medication that did not fully alleviate her pain, leading to increased discomfort and distress. The investigation revealed that the medication was missing from the medication cart, and the facility confirmed the misappropriation of the controlled substance. The CMA responsible for the medication was found to have previously committed multiple medication errors and failed to follow proper procedures for drug disposal. Despite being warned that further errors would result in termination, the CMA did not count the medication cart at the end of their shift, contributing to the loss of the medication. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, highlighted lapses in following established protocols for handling controlled substances. The DON acknowledged that the involved CMAs did not count the narcotics at shift change, and the Administrator expressed an expectation for staff to adhere to medication administration policies. The facility's policies on controlled substances and reporting abuse were not adequately followed, leading to the misappropriation incident.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. Resident #81's baseline care plan was not completed within the required timeframe, as it was signed more than 48 hours after admission. Additionally, there was no evidence that a summary of the baseline care plan was provided to Resident #81 or her representative. Similarly, Resident #291's baseline care plan was completed well after the 48-hour requirement, and no summary was provided to the resident or her representative. Interviews with facility staff, including the MDS Coordinator, Social Worker, and DON, revealed a lack of awareness and adherence to the policy requiring the provision of baseline care plan summaries to residents or their representatives. The MDS Coordinator acknowledged the delay in completing Resident #81's baseline care plan and the absence of documentation provided to residents. The DON admitted to not being aware of the requirement to provide care plan summaries and attributed the failure to the facility's process, which could lead to unmet care needs and goals for residents.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate during the survey. This was based on four errors out of 25 opportunities, involving one resident. The errors included the incorrect administration of Tylenol and the failure to administer famotidine, a multivitamin, and magnesium oxide as per physician orders. Specifically, LVN A administered two 325 mg Tylenol tablets instead of the prescribed two 500 mg tablets and omitted the other medications entirely. Resident #67, a female with diagnoses including diabetes, GERD, and shoulder pain, was affected by these errors. Despite the errors, the resident did not report an increase in pain beyond her usual level and was unaware of her medication regimen. The Director of Nursing (DON) and the Administrator both expressed expectations of zero medication errors and adherence to protocols, highlighting that the errors could lead to ineffective pain management. The facility's policy on administering oral medications was not followed, contributing to the deficiency.
Improper Storage of Controlled Substance
Penalty
Summary
The facility failed to ensure proper storage and security of controlled substances, specifically Tramadol, for one of the medication carts reviewed. During an observation, two Tramadol pills were found in a medication cup in the top drawer of a medication cart, not labeled and not double locked, which is against the facility's policy for controlled substances. The pills were intended for a resident who was not present at the time, and the medication was signed out as administered despite not being given at the scheduled time. The resident involved was an elderly male with a history of back disk degeneration, spinal stenosis, lung disease, and diabetes, who was receiving scheduled pain medication. His care plan included monitoring and managing his chronic pain. The resident reported experiencing manageable pain and sometimes receiving his medication late, but always receiving it eventually. The LVN responsible for the medication acknowledged the error, stating she should have either found the resident to administer the medication or discarded it. The DON confirmed that the medication should not have been left unsecured and emphasized that controlled substances require double locking and counting every shift. The administrator expressed that medication errors should not occur and that staff should adhere to protocols, although he did not perceive a risk of drug diversion or harm to the resident.
Deficiency in Dietary Staff Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies, skills set, and accreditations to carry out the functions of the food and nutrition service department. Specifically, one of the dietary staff members, identified as DA-D, was found to be working in the kitchen without a current Food Handler Certificate. This deficiency was identified through observation, interview, and record review. During an observation, DA-D was seen preparing a lunch meal in the kitchen. A subsequent review of DA-D's employee file revealed that their Food Handler Certificate had expired. Interviews with the Certified Dietary Manager (CDM) and the Dietary Manager (DM) indicated that there was a lack of monitoring and oversight regarding the certification status of dietary staff. The CDM was unaware of why the updated certificate was not in the food handlers binder, and the DM admitted to assuming the certificate was valid based on a misreading of the date. The DM acknowledged the potential negative impact on residents due to the possibility of unsafe food handling practices. The Administrator (ADMN) stated that it was the CDM's responsibility to monitor the dietary staff's certifications and acknowledged that the failure occurred due to inadequate monitoring by the DM. The facility's policy on education and training emphasized the importance of ensuring staff have the necessary competencies and skills, but this was not adhered to in this instance.
Failure to Document Physician Orders for Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically in following and documenting physician orders. The resident, a female with diagnoses including hydronephrosis, difficulty walking, obstructive and reflux uropathy, and hypertension, was admitted and later discharged from the facility. Her medical records indicated a physician's order for intermittent catheterization if she was unable to void every three hours. However, the Medication Administration Record (MAR) for February 2024 showed no evidence of urine output monitoring or documentation every three hours as required by the physician's order. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's expectation was for nurses to document every three hours whether the resident had voided or required catheterization, and to record the urine output. The DON acknowledged that the failure to document could have led to a negative outcome for the resident. The facility's policy on charting and documentation emphasized the need for complete and accurate records, including details of procedures and treatments provided, which were not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Granbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Nursing & Rehab Of Granbury | 1.5 mi | ★★★★★ | 3 | 0 |
| Granbury Care Center | 1.9 mi | ★★★★★ | 13 | 1 |
| Granbury Rehab & Nursing | 2.9 mi | ★★★★★ | 20 | 0 |
| Glen Rose Nursing And Rehab Center | 13.4 mi | ★★★★★ | 10 | 0 |
| Cherokee Rose Nursing And Rehabilitation | 13.9 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.