Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 578 citations issued within 25 miles in the last 12 months — including the 11 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 | — | 3 | 0 |
| Legend Oaks Healthcare And Rehabilitation - West S | 4.4 mi | — | 11 | 0 |
| Legend Oaks Healthcare And Rehabilitation Center - | 4.7 mi | — | 10 | 0 |
| Hunters Pond Rehabilitation And Healthcare | 4.8 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.