Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Valley Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple psychiatric and cognitive diagnoses, but intact cognition per BIMS, had an established expectation to remain for LTC. The facility issued a 30‑day discharge notice for nonpayment, informed the resident of appeal rights, and listed alternate discharge locations. Before the effective discharge date, the resident was sent to a hospital by EMS for a CT and evaluation of neck and spine pain. When the hospital attempted to return the resident, the administrator, following a corporate directive, refused readmission, stating the facility could not meet the resident’s needs, even though neither the resident nor the hospital had been informed at the time of transfer that she would not be allowed back. The medical record did not contain documentation of the reason for refusing readmission or the specific basis for transfer/discharge as required by facility policy, and there was no documented preparation or orientation for a permanent discharge at the time of the hospital transfer.
Resident council concerns about food quality and other grievances were not consistently documented or shared with residents. Three residents stated they did not receive copies of their grievances or the resolutions, and follow-up was often only verbal or not documented. Interviews with the Administrator, SW, DON, and ADON showed inconsistent processes for grievance handling, resolution documentation, and providing written summaries upon request.
A facility failed to keep MDS assessments accurate for three residents. One resident’s MDS incorrectly stated she received insulin injections even though she and an LVN said she did not, another resident’s MDS failed to reflect a significant weight gain shown in the weight summary, and a third resident’s MDS omitted chewing difficulty despite the resident’s limited teeth and need for a mechanically altered/dysphagia diet. The DON, MDS nurse, and MDS Coordinator all acknowledged issues with the accuracy or completion of the assessments.
Incomplete Comprehensive Care Plans Missing Activities and Hospice Focus Areas: The facility failed to include activities focus areas in the comprehensive care plans for several residents and failed to include hospice coordination in one resident’s plan. Multidisciplinary care conference notes referenced daily activity of choice as tolerated, but that information was not incorporated into the care plans. One resident on hospice had only the hospice contact information listed, while the care plan lacked a hospice focus. Interviews with the Activities Director, Regional RN, and DON confirmed the care plans were expected to include these details.
A resident with severe cognitive impairment, malnutrition, and other diagnoses was discharged to another facility, but the chart did not record the basis for the transfer. The facility also did not send notice to the Ombudsman and did not provide the resident and/or representative with the required 30-day written discharge notice; interviews showed the ADM was unaware of the Ombudsman notification requirement, the LVN sometimes omitted discharge documentation, and the BOM said the discharge was for payment reasons.
Failure to complete a sig change MDS after a resident was discharged from hospice. The resident had stroke-related diagnoses, vascular dementia, aphasia, dysphagia, and G-tube care needs. A prior sig change assessment had been done when hospice began, but after hospice was cancelled, no new MDS was completed to reflect the change. The DON and MDS Coordinator confirmed the omission.
Interdisciplinary Care Plan Meetings Lacked Required Team Members: The facility failed to ensure care plan meetings and quarterly review assessments were reviewed and revised by the required IDT for two residents. One resident with diabetes, MS, heart disease, and other diagnoses had a blank Multidisciplinary Care Conference form with no documented attendance, while another resident with depression, schizophrenia, diabetes, hypothyroidism, and hyperlipidemia had a meeting attended only by SW, AD, and LVNs. Staff interviews showed the DON, SW, MDS Coordinator, and others routinely held meetings without the attending MD, RN, CNA, or dietary staff being present.
Failure to provide needed nail care for a resident who was dependent for personal hygiene and had DM, depression, and polyneuropathy. Staff observed that the resident’s fingernails and toenails were long, and the resident said he had told the facility he needed a podiatrist because the nails could scratch him and brush against each other. CNA, LVN, DON, and SW all acknowledged the nails needed trimming, but records did not show the resident had been on the podiatry list for the prior 3 months.
Sharp Items Left in Residents' Rooms: A resident with encephalopathy, Parkinson's disease, and ADL assistance needs was observed with a razor in hand after staff gave it to him, while staff gave inconsistent answers about whether he could keep or use a razor alone. Another resident with stroke-related weakness, gait problems, and personal care needs was observed with scissors in her bedside drawer on two occasions, and staff were unsure whether scissors were allowed in her room.
Missing Monthly Pharmacist Drug Regimen Review: The facility failed to ensure a licensed pharmacist completed a monthly DRR for one resident whose chart showed dementia, heart disease, abnormal weight loss, reduced mobility, and psychotropic medication use. The resident had active orders for lorazepam, Seroquel, and trazodone, and the pharmacy consultant’s monthly review did not include the resident because staff believed respite residents were excluded; the pharmacist later stated all residents, including respite residents, were supposed to be included.
Failure to maintain and document safe cold food temperatures. The kitchen had repeated instances of the walk-in and milk refrigerators above 41 degrees F, and cold items such as tossed salad, milk, and orange juice were served without documented temperatures on the service line checklist. Staff gave conflicting accounts about who was responsible for checking cold food temps before meal service, and the CDM and Corporate Dietary Manager stated proper temperature control was important to prevent food borne illnesses.
Failure to clean an insulin pen rubber seal before insulin administration occurred when an LVN pierced the pen without wiping the seal with an alcohol swab first. The resident had type 2 DM and an active insulin lispro sliding-scale order. The LVN stated he was unsure of the requirement and acknowledged the action was a break in infection control; the DON stated nursing was expected to clean the seal before needle insertion.
Surveyors found that medications and medicated ointments were left unsecured at the bedside of three cognitively intact residents, despite facility policy prohibiting bedside storage and self-administration. Staff interviews confirmed that no residents were authorized to self-administer medications, and that all drugs and biologicals should be stored securely and only accessible to authorized personnel.
A staff member with facial hair was observed checking food temperatures in the kitchen without wearing a beard net, in violation of facility policy. Despite being reeducated on the policy and acknowledging its importance, the staff member did not comply, and the DM, who witnessed the incident, did not intervene. Other dietary staff confirmed the policy requirements and the need to prevent food contamination.
A deficiency was identified when a staff member entered a resident's room on droplet precautions for COVID-19 without wearing PPE, despite clear signage and available supplies. Interviews with the Infection Preventionist, ADONs, DON, and administrator revealed uncertainty about the timing of recent infection control training, and the facility could not provide its infection control policy to surveyors. The resident had severe cognitive impairment and was under isolation protocols, but staff failed to consistently follow required infection prevention measures.
A CNA used abrupt force to transfer a male resident with moderate cognitive impairment and behavioral symptoms to his bed, holding his arms behind him and pressing on his chest, rather than following the care plan interventions for managing resistive behaviors. The incident was captured on video and reported by the resident's family, confirming a failure to ensure the resident's right to be free from abuse.
A resident with Alzheimer's Disease and hypertension, admitted for hospice respite care, was transferred by two CNAs without the required mechanical lift, despite clear physician orders and care plan interventions documented in the Kardex. The CNAs did not review the Kardex or consult the charge nurse before performing the manual transfer, resulting in a failure to implement the comprehensive care plan as assessed.
A resident with severe cognitive impairment and primarily Spanish-speaking was not treated with dignity and respect by staff, who failed to engage or communicate effectively. Despite a care plan addressing the language barrier, staff did not greet the resident or seek translation assistance, leading to unmet needs and distress for the resident and family.
A resident with severe cognitive impairment and dysphagia did not receive necessary assistance during meals, as staff failed to set up meal trays properly, including raising the bed and cutting meat. Communication barriers due to language differences further hindered the resident's ability to express needs, leading to inadequate care during meal times.
The facility failed to ensure safe mechanical lift transfers for two residents, as staff did not lock or widen the base of the lift during transfers, leading to potential accident hazards. In one instance, a wheelchair got stuck, causing both the resident and the wheelchair to be lifted into the air. In another case, a CNA did not lock the lift's base, requiring intervention from another staff member. The DON confirmed the importance of following safety procedures to prevent falls and injuries.
A facility failed to document a resident's advance directive preferences in their electronic medical record. Despite the resident's admission packet indicating a preference for a DNR order and feeding restrictions, the social worker was unaware and considered the resident a full code. The oversight occurred because the director of marketing did not inform the social worker of the resident's wishes, leading to a potential risk of the resident's end-of-life preferences being dishonored.
A facility failed to update a resident's MDS assessment to reflect the discontinuation of insulin, leading to an inaccurate depiction of the resident's medication regimen. The MDS Coordinator confirmed the error, noting that the resident had no current insulin orders, contrary to what was recorded. This oversight could risk improper care due to inaccurate assessments.
A facility failed to ensure a safe environment by leaving a disposable razor in a resident's room and not securing storage closets containing hazardous items. The unlocked closets on two halls contained products that could be harmful if ingested, posing a risk to residents, especially those who wander. The DON acknowledged the oversight, noting the absence of a policy for storing hazardous items.
The facility failed to store medications requiring refrigeration properly, with lorazepam found on a medication cart instead of in a fridge. Additionally, expired medical supplies were discovered in storage rooms. An LVN expressed confusion about medication storage requirements, and the DON confirmed that lorazepam should be refrigerated to maintain effectiveness.
A medication error rate of 6.45% was identified in a facility due to improper insulin administration by an LVN. A resident with type 2 diabetes was administered insulin lispro and insulin glargine without priming the pens, contrary to manufacturer instructions. The facility lacked a specific policy for insulin pen use, contributing to the error.
A facility failed to coordinate hospice care and maintain necessary documentation for a resident with cerebral atherosclerosis and chronic kidney disease. The resident's hospice documents, including the Physician Certification of Terminal Illness and Hospice election form, were incomplete, and the most recent plan of care and hospice physician orders were unavailable. Despite being on hospice since 2021, the facility did not ensure proper documentation, risking inadequate end-of-life care.
A medical assistant in an LTC facility failed to sanitize a blood pressure cuff between uses on two residents, contrary to the facility's infection control policy. The assistant believed cleaning was only necessary after every two residents, which was incorrect. The Director of Nursing confirmed the need for sanitization between each use to prevent infections.
A resident's privacy was compromised when their buttocks were visible from the hallway during care due to the absence of a privacy curtain in their room. Staff were aware of the missing curtain and typically closed the door to provide privacy, but the door was left open during this incident.
A resident with chronic respiratory failure, type 2 diabetes, and hypertension was mistakenly given Seroquel and Ativan, which were not prescribed. The error occurred because the MA failed to properly identify the resident before administering the medications, despite the presence of the resident's RP who did not correct the MA. The facility's policy on verifying resident identity was not followed.
A resident's call button in their bedroom was found non-functional with exposed wires, posing a risk of harm. The resident, a 94-year-old male with dementia and other health issues, was dependent on staff for ADLs. The malfunction was due to disconnected wires, as confirmed by the maintenance director.
The facility failed to ensure that a resident was seen by a physician at least once every 60 days after the initial 90 days following admission. The resident had a gap of 188 days between physician visits, which was confirmed through record reviews and interviews. The DON was unable to recall the facility's policy on physician visit frequency.
A facility failed to ensure all drugs and biologicals were stored in locked compartments. An LVN left a medication cart unlocked and unattended while answering a call light. The LVN acknowledged the cart should have been locked and stated she was educated on medication security during orientation. The DON confirmed that medication carts should be locked when not in use and mentioned that hourly rounds are conducted to check if medication carts are locked.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. An expired bottle of eyewash solution was found above the handwashing sink in the kitchen. Cook B confirmed the expiration and was unaware of the frequency of checks. The facility's policy states that discontinued, outdated, or deteriorated drugs or biologicals should not be used.
Failure to Readmit Hospitalized Resident and Lack of Documented, Organized Discharge
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return following a hospital transfer and failure to document sufficient preparation and orientation to ensure a safe and orderly transfer or discharge. The resident was an adult female with delusional disorder, borderline personality disorder, bipolar disorder, dementia, depression, and anxiety, who had been admitted for LTC. Her most recent annual MDS showed a BIMS score of 13, indicating no cognitive impairment, and Section Q indicated there was no active discharge planning for community return. A care plan entry dated and cancelled on the same day stated that her discharge planning would honor her personal wishes and that, based on care plan meetings and discussions, the expectation was for her to remain in the facility for LTC. The facility issued a 30‑day discharge letter for nonpayment on 12/01/2025, citing failure to pay for the stay after reasonable and appropriate notice. The A/R statement showed an outstanding balance of $2017.60 and no payments since April 2025. Nursing notes documented that the administrator and another staff member delivered the discharge notice and that the resident responded by yelling, cursing, and stating she had a court order indicating she did not owe the facility anything. The discharge letter listed a home address or another nursing facility as the discharge locations, gave an effective discharge date of 01/01/2026, and informed the resident of her right to appeal through the state process within 90 days. The business office manager (BOM) stated that the resident was told she had 30 days to appeal and that she could have appealed any time between 12/01 and 12/31 to stop the discharge. On 12/10/2025, nursing notes documented that the resident was picked up by EMS and sent to a hospital for a CT scan and evaluation of neck and upper spine pain. The DON stated the CT had been ordered a week or two earlier but the resident had repeatedly cancelled or refused the appointment. When the hospital later called to give report and return the resident, the DON reported being told by the administrator that the resident was not allowed back because the facility could not meet her needs, and the hospital had not been informed at the time of transfer that the facility would refuse readmission. The administrator confirmed that the corporate office directed that the resident not be readmitted, acknowledged that the resident had not been notified before transfer that she would be refused return, and believed the DON had informed the hospital, which the DON denied. The ombudsman reported that the BOM told her corporate had directed that the resident not be allowed to return, and that she informed the BOM this was not permissible because the resident had the right to appeal the discharge. The facility’s own policies required that residents not be transferred or discharged while an appeal is pending unless remaining would endanger health or safety, and required documentation in the medical record of the reasons for any transfer or discharge, including specific unmet needs, facility attempts to meet those needs, and services available at the receiving facility. The survey record indicates that the facility did not document in the resident’s medical record the reason for not accepting her back after hospitalization. There is no documentation that the facility updated the discharge notice information when the decision was made not to readmit her from the hospital, nor is there documentation that the resident was prepared or oriented for a permanent discharge at the time she was sent out for a CT scan. Interviews with the resident, ombudsman, BOM, DON, and administrator consistently showed that the resident was transferred for diagnostic evaluation and then denied readmission based on a corporate directive, without prior notice to the resident or hospital and without the required documentation in the medical record.
Resident Council Grievances Not Properly Documented or Shared
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances and recommendations related to resident care and life in the facility, and failed to demonstrate its response and rationale for those concerns. Resident council minutes showed complaints about food waste, no flavor, and raw bacon being served, and later that the food was not good and had no flavor. However, the facility’s grievance records since 07/2025 did not reflect any grievances about food complaints from the resident council. During a confidential resident council interview, three residents stated they had not received copies of the grievances they filed or the resolutions. They stated they had to ask staff for grievance forms, knew how to file grievances, but once filed, nothing happened and no one followed up with them about a resolution. They reported that grievances were usually given to the SW or taken to the SW or Administrator by staff, and that when they asked the SW for follow-up, he said he was working on it and had given it to the Administrator. Facility interviews showed inconsistent handling of grievances and resolution documentation. The Administrator stated residents could get a copy of the resolution if they asked, but that staff usually only told the person filing the grievance verbally. The SW stated follow-up was usually done in the moment and often not documented, and he was unsure whether residents received paper copies of the grievance or resolution. The DON stated resolutions were not documented by nursing and that the last time a grievance form was completed, the resolution was not written down. The facility policy stated the resident or person filing the grievance would be informed of the findings and actions taken, with a written summary provided upon request.
Inaccurate MDS Assessments for Insulin Use, Weight Gain, and Chewing Difficulty
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for three residents reviewed. For Resident #68, the most recent quarterly MDS assessment stated the resident received insulin injections, but the resident stated she did not receive insulin injections and had never been treated with insulin while at the facility. An LVN also stated the resident was checked daily for blood sugars but was not treated with insulin, and the DON stated the resident had been treated with insulin back in March 2025 but did not know why the MDS still reflected insulin injections. Resident #68 had diagnoses including heart disease, multiple sclerosis, diabetes, hyperlipidemia, and hypotension, and her care plan addressed diabetes medication as ordered. For Resident #10, the quarterly MDS assessment dated 11/20/25 stated the resident had no significant weight gain in the last 6 months, but the weight summary showed the resident gained 15.6% in the last 6 months. Resident #10’s record reflected diagnoses including Type 2 diabetes, muscle wasting and atrophy, and dysphagia, and the care plan identified the resident as at risk for nutritional and/or hydration deficits. During interview, the MDS nurse stated significant weight changes needed to be documented in the MDS assessments but could not confirm the weight gain for Resident #10. For Resident #74, the admission and quarterly MDS assessments did not include difficulty with chewing in Section L-Oral/Dental Status, despite the resident stating she had only a few teeth in the back of her mouth and had trouble chewing food. The resident was on a mechanically altered diet and later a dysphagia puree diet. The MDS nurse stated the resident’s lack of teeth should be noted in the MDS because it can influence nutrition and oral hygiene, and the MDS Coordinator stated she relied on the MAR and physician orders when completing assessments. The Administrator stated it was important for the MDS to be accurate because it captured all care areas and services provided for residents.
Incomplete Comprehensive Care Plans Missing Activities and Hospice Focus Areas
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that included measurable objectives and timeframes for residents’ identified medical, nursing, mental, psychosocial, and activity-related needs. The deficiency was identified for 6 of 18 residents reviewed for care plans: Residents #3, #68, #71, #45, #7, and #4. The report states that these omissions could cause confusion for staff responsible for direct care and place residents at risk of receiving improper care and services. For Residents #3, #68, #71, #45, and #7, the comprehensive care plans did not reflect a focus area dedicated to activities. Each of these residents had multidisciplinary care conference documentation that included the statement, “engage resident in daily activity of choice as tolerated,” but that information was not incorporated into the comprehensive care plan itself. Resident #3 had diagnoses including schizophrenia, delusional disorders, hallucinations, and acquired absence of limb, and was moderately cognitively impaired. Resident #68 had diagnoses including heart disease, multiple sclerosis, diabetes, hyperlipidemia, and hypotension, and was cognitively intact. Resident #71 had diagnoses including reduced mobility, major depressive disorder, and osteoporosis with current pathological fracture, and was severely cognitively impaired. Resident #45 had diagnoses including cerebral infarction, vascular dementia, aphasia, dysphagia, and gastrostomy tube care needs, and was unable to complete a BIMS with staff indicating severe cognitive impairment. Resident #7 had diagnoses including COPD, rheumatoid arthritis, dysphagia, type 2 diabetes, depression, anxiety disorder, and peripheral vascular disease; during interview, the resident stated neither she nor her family had attended a care plan meeting, though she did participate in activities and Resident Council. For Resident #4, the comprehensive care plan did not include a focus for hospice services or coordination of care with hospice. The only hospice reference in the care plan was the hospice name and phone number listed under Special Instructions at the top of the first page. Resident #4 had diagnoses including infection and inflammatory reaction due to an internal joint prosthesis, peripheral vascular disease, atherosclerotic heart disease with angina pectoris, and a cardiac pacemaker, and the quarterly MDS indicated a BIMS score of 13 and hospice services in Section O. Interviews with the Activities Director, Regional RN, and DON confirmed that activities and hospice information needed to be incorporated into the comprehensive care plan and that the care plan was used by staff to guide resident care, but the identified resident care plans did not contain those focus areas.
Failure to Document Transfer Basis and Provide Required Discharge Notice
Penalty
Summary
The facility failed to document the basis for Resident #99’s transfer in the resident’s medical record, failed to send notice of the transfer or discharge to a representative of the Office of the State Long-Term Care Ombudsman, and failed to provide Resident #99 and/or the resident’s representative with a 30-day written notice of the impending transfer or discharge. Resident #99 was a [AGE]-year-old male admitted on 04/06/2025 and discharged on 09/23/2025 with diagnoses including dependence on wheelchair, mild protein-calorie malnutrition, cognitive communication deficit, need for assistance with personal care, and major depressive disorder. His quarterly MDS assessment dated 09/01/2025 showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. The record showed a progress note on 09/23/25 documenting that Resident #99 was discharged to another facility by stretcher, with medications sent with him and his representative notified, but it did not document the reason for the transfer in the medical record. Interviews revealed the SW stated nurses oversaw discharge documentation, the LVN stated he sometimes forgot to complete the Final Discharge Summary assessment, and the ADM stated he was not aware the ombudsman had to be notified of discharges or transfers. Email communication from the ombudsman stated she never received notice of Resident #99’s discharge and that the facility was not sending monthly discharge summaries. The BOM stated Resident #99 was discharged because of payment and that she worked with the family to transfer him elsewhere so the facility would not have to give a 30-day discharge notice.
Failure to Complete Significant Change MDS After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment within 14 days after determining, or when it should have determined, that Resident #45 had a significant change in condition. Resident #45 was admitted with diagnoses including cerebral infarction, vascular dementia, aphasia, dysphagia, and need for gastrostomy tube care. A Significant Change Assessment had been completed when the resident was placed on hospice, but nursing progress notes later documented that the family decided to discontinue hospice services and the resident was taken off hospice on 11/14/25. Record review showed no additional Significant Change MDS was completed to reflect that the resident was no longer on hospice. The hospice binder contained both the hospice election form and the cancellation form. The DON stated the resident was taken off hospice because the family could not agree about the need for hospice, and the MDS Coordinator stated she knew a significant change MDS should have been completed within 14 days but did not complete one on time.
Interdisciplinary Care Plan Meetings Lacked Required Team Members
Penalty
Summary
The facility failed to ensure that comprehensive care plan meetings and quarterly review assessments were reviewed and revised by an interdisciplinary team that included, at minimum, the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff for two residents. The deficiency was identified for Resident #68 and Resident #10 during record review and staff interviews. Resident #68 was a female admitted and re-admitted to the facility with diagnoses including heart disease, multiple sclerosis, diabetes, hyperlipidemia, and hypotension. Her quarterly MDS assessments reflected that she was cognitively intact for daily decision-making, had diabetes, and received insulin injections. Her Multidisciplinary Care Conference document dated 7/17/25 was unsigned, and the sections for attendance at the meeting, nursing summary, CNA contribution, dietary summary, social work summary, pharmacy summary, restorative care/PT/OT summary, physician summary, and resident/family were blank. Her care plan reflected diabetes and included an intervention to provide diabetes medication as ordered by the doctor. Resident #10 was a male admitted and re-admitted to the facility with diagnoses including major depressive disorder, schizophrenia, type 2 diabetes, hypothyroidism, and hyperlipidemia. His quarterly MDS assessment dated 11/20/2025 reflected a BIMS score of 9 out of 15, indicating moderate cognitive impairment. His Multidisciplinary Care Conference dated 10/23/25 showed that the staff present were the SW, AD, and two LVNs. Interviews with the DON, ADONs, CNA, Director of Rehab, MDS nurse, MDS Coordinator, SW, and Administrator showed that care plan meetings were generally attended by the SW, MDS Coordinator, Activities Director, and sometimes rehab or other staff, while the DON stated no RN went to those meetings and the SW stated he had never had the doctor invited. The facility policy stated that the care plan is developed by an interdisciplinary team that includes the attending physician, the RN responsible for the resident, the dietary manager/dietitian, the social services worker, the activity director/coordinator, and nursing assistants responsible for the resident's care.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to ensure Resident #10, who was dependent for personal hygiene and had a BIMS score of 9 out of 15, received needed assistance with nail care. Resident #10 had diagnoses including Type 2 Diabetes, Major Depressive Disorder, and Polyneuropathy. The resident’s care plan identified him as at risk for skin impairment and included an intervention to keep fingernails short, but observation on 12/02/2025 showed his fingernails were past his fingertips and he reported his nails had been long for about a month or two and that he had told the facility he needed a podiatrist. During interviews and observations, CNA H stated Resident #10 needed his fingernails trimmed and that staff could trim fingernails while nurses helped with toenails. LVN G observed that both fingernails and toenails needed trimming and said residents were typically cut once a week, while the DON also observed the nails needed trimming and stated he should be on the podiatry list. The SW reported he kept a list for ancillary services but could not find records showing Resident #10 had been on the podiatry list for the last 3 months, and the DON stated it was possible Resident #10 had not been seen by podiatry in November at least.
Sharp Items Left in Residents' Rooms
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for two residents. One resident with diagnoses including encephalopathy, depression, Parkinson's disease, muscle weakness, unsteadiness of feet, and cognitive communication deficit was observed in a wheelchair at the doorway with a razor in hand while a CNA walked away from the room. The resident stated the nurse had given him the razor to shave and that he normally kept his razor in his room and asked a CNA for help when needed. Record review for this resident showed a BIMS of 13 and care plan interventions indicating he required one staff member for personal hygiene and oral care. Staff interviews reflected inconsistent understanding of whether he could have a razor in his room or be left alone with one. The CNA stated residents were not allowed to keep razors in their rooms and were not allowed to be alone with them, while the LVN and ADON were unsure about the rules and documentation. The DON stated residents who requested to shave were given a razor by a CNA, that some residents could shave independently, and that this resident usually kept his razor in his drawer. A second resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction, rheumatoid arthritis, gait and mobility problems, need for assistance with personal care, and cognitive communication deficit was observed with scissors in her top bedside drawer on two separate observations. The resident stated staff knew she had scissors in her room and that no one had told her she could not have them. She said she kept them at her bedside for tasks such as opening soda cans or cutting things, but often needed help because of her hands. Staff interviews showed uncertainty about whether scissors were allowed, with one CNA assuming safety scissors were permitted and the DON stating residents kept items like scissors in their rooms and that the facility tried to keep residents without dementia from keeping sharp items in their rooms.
Missing Monthly Pharmacist Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review for each resident, including review of the medical chart, in accordance with its policies and procedures. For one resident, the record did not contain a drug regimen review for November 2025. The resident was an older female admitted with diagnoses that included senile degeneration of the brain, heart disease, abnormal weight loss, reduced mobility, dementia with anxiety, and palliative care needs. Her most recent MDS showed she was moderately cognitively impaired for daily decision-making and was receiving an antipsychotic and an antidepressant. Record review showed the resident had active orders for lorazepam as needed for anxiety/agitation, Seroquel for hallucinations, and trazodone for insomnia. Her care plan included psychotropic medication management, psychiatric services, medication administration as ordered, and pharmacy consultation. The pharmacy consultant’s November 2025 drug regimen review did not include this resident. During interviews, the DON stated the resident was not included because she was receiving respite care, and the pharmacist later stated she had been misinformed and assumed respite residents did not require a DRR. The pharmacist also stated that every resident in the facility, including respite residents, was supposed to be included in the DRR.
Failure to Maintain and Document Safe Cold Food Temperatures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Record review showed the walk-in refrigerator was above 41 degrees F on multiple occasions in November 2025, including 42 degrees F in the evening on 11/06, 43 degrees F in the evening on 11/07, 43 degrees F in the evening on 11/15, and 42 degrees F in the morning and 43 degrees F in the evening on 11/19. Record review also showed the milk refrigerator was 42 degrees F on the night shift on 12/02/25. The facility also failed to document temperatures for cold foods before service. The Week at a Glance reflected tossed salad was served on 12/03/25, but the Service Line Checklist for that date had no temperature documented and was unauthored. Milk and orange juice were served for breakfast on 12/01/25, 12/02/25, and 12/04/25, but no temperatures were documented on the Service Line Checklist for those dates. During interview, the line cook stated he took cold food temperatures and knew items above 41 degrees F required the door to be closed, someone notified, and the temperature retaken, but he also stated he did not take temperatures of cold foods/drinks before meal service and that the dietary aide would do this. The dietary aide stated she had not had any cold food temperatures above 41 degrees F and said she did not take temperatures of cold items right before meal service, stating the line cook did this. The CDM and Corporate Dietary Manager stated it was important to ensure temperatures were within the appropriate range to prevent food borne illnesses.
Failure to Clean Insulin Pen Rubber Seal Before Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when LVN K did not clean the rubber seal of Resident #10’s insulin pen with an alcohol swab before inserting the needle and administering insulin. Resident #10 was a male with diagnoses including type 2 diabetes, metabolic encephalopathy, and gout, and he had an active order for insulin lispro injection 100 unit/ml to be given subcutaneously three times a day per sliding scale. During the medication pass observation, LVN K prepared Resident #10’s insulin lispro and pierced the insulin pen’s rubber seal without first cleaning it with an alcohol wipe. When interviewed, LVN K stated he was unsure whether the rubber seal should be cleaned before piercing it and acknowledged that it was a break in infection control that could result in cross contamination and infection. The DON stated it was her expectation that nursing clean the rubber seal with an alcohol wipe before needle insertion because it needed to be clean and was an infection control issue.
Unsecured Medications and Medicated Products Found at Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by professional standards and facility policy. During observations and interviews, it was found that three residents had medications or medicated products at their bedsides, despite not being authorized for self-administration. Specifically, one resident had two medication cups containing cough syrup at her bedside for three days, and two other residents each had a jar of medicated mentholated ointment on their bedside tables, which they reported using on their feet. Record reviews confirmed that all three residents were cognitively intact and received their medications from nursing staff, with no authorization for self-administration. Interviews with staff, including medication aides, LVNs, and the DON, consistently indicated that medications were not to be left at the bedside for any resident, as this could allow access by other residents or result in improper use. The facility's own policy required all drugs and biologicals to be stored securely and only accessible to authorized personnel. The observations and interviews demonstrated that the facility did not follow its own medication storage policy, resulting in medications and medicated products being left unsecured at residents' bedsides. This practice was identified for three residents during the survey and was acknowledged by staff as not being in accordance with facility procedures.
Failure to Enforce Beard Net Policy During Food Handling
Penalty
Summary
A deficiency was identified when a staff member with facial hair was observed in the kitchen checking food temperatures without wearing a beard net, as required by the facility's policy. The staff member acknowledged being reeducated on the beard net policy a year prior and stated that all kitchen staff were responsible for following this policy. Despite this, he did not wear a beard net before checking food temperatures, citing allergies as the reason, and admitted to notifying the Dietary Manager (DM) about his allergies before his shift. The staff member also confirmed that he was still required to wear a beard net regardless of the length of his facial hair. Other dietary staff interviewed confirmed their understanding of the beard net policy and the importance of its adherence to prevent hair from contaminating food. The DM stated that all kitchen staff and anyone entering the kitchen were required to wear a beard net or be clean-shaven when handling food, and that he conducted rounds to ensure compliance. However, the DM observed the staff member not wearing a beard net while checking food temperatures and did not intervene or provide a reason for not taking action. The facility's Staff Attire policy, revised in January 2025, specifies that all staff must have hair confined in a hair net or cap and facial hair properly restrained.
Failure to Ensure Staff Compliance with PPE Protocols for Resident on Droplet Precautions
Penalty
Summary
A deficiency occurred when staff failed to follow established infection prevention and control protocols for a resident who was on droplet precautions due to a COVID-19 diagnosis. On the morning of 11/12/25, electronic monitoring footage showed a staff member entering the resident's room without donning any personal protective equipment (PPE), placing a meal tray on the bedside table, interacting with the resident, and then exiting the room. This was despite clear signage on the door indicating droplet precautions and the presence of a PPE supply bin outside the room. The resident's care plan specifically required isolation with droplet precautions, including proper donning and doffing of PPE when entering and exiting the room. Interviews with facility staff, including the Infection Preventionist, ADONs, DON, and the administrator, revealed inconsistencies and uncertainty regarding the frequency and timing of staff reeducation on infection control practices. While staff members acknowledged the importance of donning PPE before entering and exiting rooms under droplet precautions, several were unable to recall when the most recent infection control training or in-service had occurred. The Infection Preventionist and other leaders stated that oversight was conducted through rounds and periodic competencies, but could not provide specific details or documentation of recent staff education on infection control. Additionally, the facility was unable to provide the requested infection control policy to the surveyor before the exit. The resident involved had a history of dementia, weakness, and COVID-19, and was assessed as having severe cognitive impairment. The failure to ensure staff compliance with PPE protocols, as well as the lack of clear documentation and timely reeducation on infection control, contributed to the deficiency identified during the survey.
Failure to Protect Resident from Physical Abuse During Transfer
Penalty
Summary
A certified nursing assistant (CNA) used abrupt force to place a male resident with moderate cognitive impairment and behavioral symptoms onto his bed. The resident, who had diagnoses including hepatic encephalopathy, dementia, anxiety disorder, and delusional disorder, was known to be resistive to care and exhibited aggressive behaviors such as threatening and attempting to strike staff. On the day of the incident, the resident was observed ambulating in the hallway without proper clothing, entered another resident's room, and became aggressive when redirected by staff. During the attempt to guide the resident back to his room, the CNA held both of the resident's arms behind him, pushed him forcefully onto the bed, and pressed on his chest when the resident tried to get up. The incident was captured on video and witnessed by the resident's family member, who reported it to the facility administrator. Interviews with staff and review of video footage confirmed that the CNA used forceful physical contact during the transfer, which was not in accordance with the resident's care plan interventions for managing resistive and aggressive behaviors. The care plan specified the use of reassurance, clear explanations, and leaving and returning later if the resident resisted care, rather than physical force. The CNA did not request assistance from other staff during the incident, despite the resident's known behavioral challenges. The facility's investigation and interviews with other staff and residents indicated that this was the only incident of abuse involving this resident, and no physical injury was noted upon assessment. However, the use of forceful physical contact constituted a failure to ensure the resident's right to be free from abuse, neglect, and physical punishment, as required by facility policy and regulatory standards.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with Alzheimer's Disease and hypertension, who was admitted for hospice respite care. The resident had physician orders and care plan interventions specifying the use of a mechanical lift with two staff for all transfers. These requirements were documented in the resident's care plan and Kardex, which staff are trained to review prior to providing care. On one occasion, two CNAs transferred the resident from bed to a high-back wheelchair without using the required mechanical lift. Neither CNA reviewed the resident's Kardex or consulted the charge nurse to confirm the transfer status before performing the transfer. The family member of the resident observed the transfer and confirmed that a mechanical lift was not used. Both CNAs later acknowledged that they did not check the Kardex prior to the transfer and proceeded with a manual transfer involving two staff members. Interviews with facility staff, including the DON, MDS Nurse, and Administrator, confirmed that the resident's transfer status was clearly documented and that staff had been trained to use the Kardex to determine transfer requirements. The MDS Nurse indicated that the transfer status was entered into the Kardex the day after admission. The failure to follow the care plan and physician orders for mechanical lift transfers was identified as a deficiency, as it did not meet the resident's assessed needs and placed the resident at risk.
Failure to Respect Resident's Communication Needs
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by multiple instances where nursing staff did not engage with the resident in a manner that recognized her individuality and communication needs. The resident, who was primarily Spanish-speaking and had severe cognitive impairment, was not greeted or engaged by staff upon entering her room. Staff members did not introduce themselves or explain the purpose of their visits, and they failed to seek assistance from Spanish-speaking staff to facilitate communication. The resident's care plan indicated a communication problem due to a language barrier, with a family request for a Spanish-speaking CNA each shift. Despite assurances from the Director of Nursing (DON) that Spanish-speaking staff were available, video evidence showed staff ignoring the resident's attempts to communicate in Spanish. The resident expressed her needs, such as requesting different food or assistance with her cell phone, but staff did not respond appropriately or seek translation help. Interviews with family members and staff confirmed the communication issues, with family members expressing distress over the lack of engagement and understanding from staff. The DON acknowledged that staff did not follow protocol, which required greeting the resident and seeking translation assistance. The facility's policy on residents' rights emphasized the right to be treated with dignity and respect, which was not upheld in this case.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically during meal times. The resident, who had severe cognitive impairment, dysphagia, and other health issues, required assistance with meal setup, including raising the head of the bed, cutting meat, and positioning the bedside table for easy access. However, staff consistently neglected these tasks, leaving the resident unable to comfortably and effectively consume meals. Observations and video reviews revealed that staff members, including a CNA and an AD, did not follow proper protocol when delivering meal trays to the resident. They failed to remove the plate cover, open condiments, or set up utensils, and did not ensure the resident's bed was positioned correctly for eating. The resident, who primarily spoke Spanish, also faced communication barriers as not all staff members could understand or communicate in her language, further complicating her ability to express her needs. Interviews with family members and staff confirmed these deficiencies. Family members expressed concerns about the lack of Spanish-speaking staff and the inadequate assistance provided during meals. The DON acknowledged that staff did not adhere to the facility's policy on meal assistance, which required setting up the meal tray and ensuring the resident could access her food easily. This oversight resulted in the resident struggling to eat independently and comfortably, highlighting a significant lapse in care for residents requiring assistance with meals.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents received proper assistance during mechanical lift transfers, leading to potential accident hazards. In the case of Resident #2, CNA F did not lock the mechanical lift or widen its base while transferring the resident from a wheelchair to a bed. This resulted in the wheelchair getting stuck between the legs of the lift, causing both the resident and the wheelchair to be lifted into the air until CNA G intervened. Despite the intervention, CNA F continued the transfer without locking or widening the base, which could have led to a fall. For Resident #3, CNA I operated the mechanical lift without locking its base during the transfer from a wheelchair to a bed. CNA H noticed the oversight and applied the brake with her foot while Resident #3 was being lowered. CNA I acknowledged the failure to lock the base, which is necessary to prevent the lift from moving and ensure stability during transfers. Both CNAs involved in the transfer recognized that the resident could have been injured if a fall had occurred. The Director of Nursing (DON) confirmed that staff should lock the base of the mechanical lift and widen it for stability during transfers to prevent falls and injuries. The manufacturer's instructions also emphasized the importance of keeping the base legs in the widest position and ensuring that the lift's casters are not locked during lifting and lowering. These practices were not followed, leading to the deficiencies observed during the survey.
Failure to Document Resident's Advance Directive Preferences
Penalty
Summary
The facility failed to ensure that a resident's desire to formulate an advance directive was properly documented in his electronic medical record. The resident, who was admitted with several chronic conditions including type 2 diabetes, hypertension, atrial fibrillation, and chronic kidney disease stage 4, was initially documented as a full code in his baseline care plan. However, the admission packet contained an Advanced Directive Acknowledgement form indicating the resident's preference for a Do Not Resuscitate (DNR) order and feeding restrictions, which was signed by the legal representative and a facility representative. During interviews, the social worker (SW) was unaware of the resident's advance directive preferences and stated that the resident was a full code. The SW mentioned that the director of marketing, who filled out the paperwork with the resident and his family, failed to notify him of the resident's wishes. The resident and his representative confirmed that they had completed the paperwork to reflect the resident's preferences. The oversight in communication and documentation could lead to the resident's end-of-life wishes being dishonored.
Inaccurate MDS Assessment for Resident's Medication
Penalty
Summary
The facility failed to ensure that a resident's Annual Minimum Data Set (MDS) assessment accurately reflected their current medication regimen. Specifically, the MDS assessment indicated that the resident was receiving insulin injections, despite the fact that the resident's insulin had been discontinued several months prior. This discrepancy was identified during a review of the resident's records, which showed that the last insulin order was discontinued on December 15, 2023, and there were no active orders for insulin as of August 28, 2024. During an interview, the MDS Coordinator confirmed that the resident did not have any current orders for insulin and acknowledged that the MDS should accurately depict the medications and care the resident receives. The facility's policy on the Resident Assessment Instrument (MDS 3.0) emphasizes the importance of conducting comprehensive assessments to describe the resident's capabilities and identify impairments, which are crucial for planning appropriate care. The failure to update the MDS assessment could potentially place residents at risk of receiving improper or incorrect care due to inaccurate assessments.
Failure to Secure Hazardous Items and Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for Resident #86 and in two storage closets. During an observation, a disposable razor was found in a basin by Resident #86's bedside. The resident, who was in bed at the time, stated that staff would bring supplies for a bed bath and assist with shaving, but he was unaware of how long the razor had been there. This oversight posed a potential hazard to the resident, who did not notice the razor's presence. Additionally, the facility did not secure storage closets on Hall 100 and Hall 200, which contained potentially hazardous items such as perineal skin cleanser, lotion, zinc oxide skin protectant, shave gel, mouthwash, fluoride toothpaste, hand sanitizer, germicidal wipes, and disposable razors. These closets were observed to be unlocked and lacked locking mechanisms. The supply coordinator confirmed that the closets were not locked, posing a risk if residents accessed and ingested the products. The Director of Nursing acknowledged the risk, especially for residents who wandered, such as those residing on Hall 200. No policy for the storage of potentially hazardous items was provided.
Improper Storage of Medications and Expired Supplies
Penalty
Summary
The facility failed to store medications and biologicals under proper temperature controls, specifically on the 100 hall medication cart. During an observation, it was found that the cart contained nine glucometers stored in individual boxes, with logs for testing that did not match the serial numbers of four glucometers. An insulin lispro pen with an open date was being used for a resident, and there were three bottles of lorazepam with refrigerate stickers stored on the cart. LVN E, during an interview, expressed uncertainty about whether medications labeled for refrigeration needed to be refrigerated and mentioned confusion about the frequency of glucometer checks. Additionally, expired medical supplies were found in various storage rooms, including gauze, peristoma cleanser, adhesive remover, IV catheters, and peroxide. The Director of Nursing (DON) stated that the expired supplies were not used and needed to be discarded. The DON also mentioned that the glucometers were checked weekly, following manufacturer guidelines, and that insulin expiration dates varied. The DON acknowledged that lorazepam should be refrigerated and could lose therapeutic effectiveness if not stored properly. The facility's policy required medications needing refrigeration to be stored in a refrigerator located in a secured location.
Medication Error Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 6.45% due to errors in insulin administration for a resident. The resident, an elderly female with diagnoses including senile degeneration of the brain and type 2 diabetes mellitus, was prescribed insulin lispro and insulin glargine. During an observation, a Licensed Vocational Nurse (LVN) administered these insulins without priming the insulin pens, which is a necessary step to ensure accurate dosing. The LVN did not follow the manufacturer's instructions for priming the insulin pens, which involves turning the dose knob to select 2 units and ensuring insulin is visible at the needle tip. This oversight was confirmed during interviews with the LVN and the Director of Nursing (DON), who acknowledged the importance of priming to ensure accurate insulin administration. The facility lacked a specific policy for insulin pen administration, which contributed to the medication error.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not ensure that the most recent Physician Certification of Terminal Illness and Hospice election form were completed and included in the hospice documents for the resident. Additionally, the most recent plan of care, list of hospice personnel involved in the care, and hospice physician orders were not available at the facility. This lack of documentation and coordination could potentially place residents receiving hospice services at risk of inadequate end-of-life care. The resident in question was admitted with diagnoses including cerebral atherosclerosis and chronic kidney disease stage 2, and had been receiving hospice care since 2021. Despite this, the facility's medical records department had not ensured that all necessary hospice documents were obtained and maintained. Interviews revealed that the medical records staff had contacted the hospice company for the documents but did not follow up to ensure receipt. The Director of Nursing (DON) was unaware that records were still pending and had instructed nursing staff to update hospice binders. The facility's policy outlined specific responsibilities for coordinating hospice care, but these were not fulfilled, leading to the deficiency.
Infection Control Lapse with Blood Pressure Cuff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA G) who did not sanitize a blood pressure cuff between uses on different residents. During an observation, MA G was seen taking the blood pressure of one resident and then placing the cuff back on the cart without sanitizing it. Subsequently, MA G used the same unsanitized cuff on another resident, again failing to clean it afterward. This practice was contrary to the facility's policy, which requires the cleaning and disinfection of reusable resident care equipment between each use according to CDC recommendations and OSHA standards. In an interview, MA G expressed a misunderstanding of the facility's policy, believing that the blood pressure cuff only needed to be cleaned after every two residents. The Director of Nursing (DON) confirmed that the staff should sanitize the blood pressure cuff between each resident to prevent infections. The facility's policy, dated March 1, 2022, clearly states that reusable resident care equipment must be decontaminated and/or sterilized between residents according to the manufacturer's instructions, highlighting a lapse in adherence to established infection control protocols.
Failure to Ensure Visual Privacy for Resident
Penalty
Summary
The facility failed to ensure full visual privacy for a resident in one of the rooms reviewed. During an observation, a resident was seen lying on their side in bed with their back and buttocks exposed and visible from the hallway. This occurred while a staff member was holding the resident on their side, and another staff member was standing in the doorway, with a treatment nurse in the hallway. The lack of a privacy curtain in the resident's room contributed to this exposure. Interviews with staff members revealed that there was no privacy curtain installed in the resident's room, and it was acknowledged that nursing staff and maintenance were aware of this absence. The staff typically provided privacy by closing the door, but in this instance, the door was left open while waiting for wound care to be administered. The Director of Nursing confirmed that being visible from the hallway did not provide privacy, aligning with the resident's rights to dignity and respect.
Medication Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A medication aide (MA) administered incorrect medications, Seroquel 50 mg PO and Ativan 0.5 mg PO, to a resident who did not have orders for these medications. The error occurred because the MA did not correctly identify the resident before administering the medications. The MA entered the resident's room, asked for the resident's name, and proceeded with the administration without proper verification, despite the presence of the resident's responsible party (RP) who neither corrected nor verified the MA's question. The resident involved had a medical history of chronic respiratory failure, type 2 diabetes, and hypertension. The facility's policy on administering medications requires verification of the resident's identity through methods such as checking an identification band, a photograph attached to the medical record, calling the resident by name, or verifying with other facility personnel. However, these procedures were not followed, leading to the medication error.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available in the bedroom of a resident, which is a critical requirement for resident safety and communication. During an observation, it was noted that the call button in the resident's room was not functioning and had exposed wires. This deficiency was confirmed by a Licensed Vocational Nurse (LVN) who verified that the call light was not operational, acknowledging the potential risk of harm to the resident, including injury, pain, or hospitalization. The resident involved was a 94-year-old male with a history of dementia, atherosclerosis, and a cerebral ischemic attack. He was moderately cognitively impaired, as indicated by a BIMS score of 09, and was dependent on staff for activities of daily living (ADLs) due to incontinence. The maintenance director later identified that the call light wires were not connected, which was the cause of the malfunction. The facility's policy on answering call lights, dated June 2012, requires that call lights be plugged in at all times and that any defects be reported promptly to the Nurse Supervisor.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that Resident #1 was seen by a physician at least once every 60 days after the initial 90 days following admission. Resident #1, who was admitted with diagnoses including unspecified dementia, generalized anxiety disorder, and muscle weakness, had a significant gap of 188 days between physician visits. The resident was last seen by Physician C on 9/29/23 and was not seen again until 4/2/24. This gap in care was confirmed through record reviews and interviews with Resident #1's family member and Physician C. During interviews, the Director of Nursing (DON) was unable to recall the facility's policy on the frequency of physician visits and acknowledged that a process to ensure regular physician visits was in progress. The facility's policy, dated April 2008, mandates that attending physicians must visit their patients at least once every 30 days for the first 90 days following admission and at least every 60 days thereafter. The failure to adhere to this policy could lead to adverse effects on residents' health, as noted by the DON.
Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments. Agency LVN A left the 100 Hall medication cart unlocked and unattended while answering a call light in another hall. During an interview, Agency LVN A acknowledged that the medication cart should have been locked and stated she was educated on medication security during her orientation. The Director of Nursing (DON) confirmed that medication carts should be locked when not in use and mentioned that the DON, ADON, medical records, and the treatment nurse conduct hourly rounds to check if medication carts are locked. The facility's policy on the storage of medications, dated April 2007, requires that compartments containing drugs and biologicals be locked when not in use.
Expired Eyewash Solution in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a bottle of eyewash solution above the handwashing sink in the kitchen was found to be expired. During an observation and interview, Cook B confirmed the eyewash solution was expired and admitted to not knowing how frequently the eyewash solution was checked. A review of the facility's policy on the storage of medications revealed that the facility should not use discontinued, outdated, or deteriorated drugs or biologicals.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 822 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Mission At Blue Skies Of Texas East | 3.2 mi | ★★★★★ | 0 | 0 |
| Avir At San Antonio | 4.2 mi | ★★★★★ | 34 | 1 |
| Legend Oaks Healthcare And Rehabilitation - West S | 4.4 mi | ★★★★★ | 11 | 0 |
| Legend Oaks Healthcare And Rehabilitation Center - | 4.7 mi | ★★★★★ | 17 | 0 |
| Hunters Pond Rehabilitation And Healthcare | 4.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Harbor Valley Health And Rehabilitation.
100% money-back within 48 hours.
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.