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 Treasure Hills Healthcare And Rehabilitation Cente during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with assessment and referral requirements.
A medication cart was found unlocked and unattended in a hallway, with an RN later acknowledging responsibility and stating she had left it unsecured while using another cart's computer. The DON confirmed that all staff are expected to lock medication carts when unattended, in accordance with facility policy requiring all drugs and biologicals to be stored in locked compartments.
Two separate resident-to-resident altercations occurred, resulting in one resident being struck and another sustaining a skin tear, with staff and administration demonstrating confusion about the classification of abuse and the required timeframe for reporting such incidents. Despite assessments and notifications being completed, the facility's policy lacked clarity on current regulatory reporting requirements, and staff relied on outdated guidance.
The facility did not report two separate resident-to-resident altercations involving physical contact and a minor injury to the state agency within the required two-hour timeframe. Although residents were assessed and found to have no or minor injuries, and notifications were made to medical and administrative staff, the incidents were not reported promptly due to confusion about regulatory requirements and lack of specific guidance in the facility's abuse policy.
The facility failed to serve meals according to the established menus, leading to discrepancies in the food provided to residents. Observations revealed that meals did not match the posted or cycle menus, and staff interviews highlighted a lack of communication and oversight in the meal service process. The RD and ADM acknowledged the issues, attributing them to inadequate supervision by the FPM.
The facility's kitchen was found to have multiple sanitation and maintenance deficiencies, including unclean equipment, dented pans, improperly sealed spices, expired canned goods, and personal items in the kitchen. Staff interviews revealed a lack of adherence to food safety protocols, with risks of cross-contamination and foodborne illness. Ongoing issues with water on the floor and a leaking freezer condenser were also noted.
A resident with sleep apnea and hypertension was receiving oxygen therapy at a higher rate than prescribed by the physician, with the concentrator set at 3 Lpm instead of the ordered 2 Lpm. This discrepancy was observed and confirmed by nursing staff, highlighting a failure to adhere to physician orders and facility policy, potentially risking the resident's health.
A resident with dementia and neurocognitive disorder with Lewy bodies was prescribed Zyprexa, an antipsychotic, without a proper diagnosis of psychosis. The medication was intended to manage aggression and anxiety, but the facility's policy requires a specific documented condition for such prescriptions. Interviews revealed that the DON and Administrator were unaware that antipsychotics should not be prescribed solely for dementia.
A facility failed to properly store and label insulin, resulting in an expired vial being found in a medication cart. Staff interviews confirmed that insulin should be discarded after 28 days, but the vial remained in use past this period, contrary to facility policy.
The facility failed to serve meals at an appetizing temperature, affecting two residents during lunch. Observations showed that food items were below the required temperature due to delays in meal service. Staff interviews revealed a lack of clarity and responsibility for ensuring timely meal distribution, leading to cold food being served. Residents expressed dissatisfaction, and staff acknowledged the potential negative impact on nutritional status.
A resident with severe cognitive impairment and multiple medical conditions had a non-functioning call light, which was not within reach. Facility staff, including the Maintenance Supervisor, Dietary Manager, and a CNA, failed to ensure the call light was operational, despite the facility's policy requiring such checks. This oversight could prevent the resident from obtaining necessary assistance.
A resident with severe cognitive impairment and multiple medical conditions was found to have a non-functional call light in their room, which could prevent them from obtaining assistance when needed. Despite staff being assigned to check on residents and their rooms daily, the issue was not identified or reported. Interviews revealed that the Maintenance Supervisor was unaware of the problem, and the Dietary Manager and CNA did not verify the call light's functionality, contrary to facility policy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart on the A Wing Hall was observed to be left unlocked and unattended against the nurse's station. During the observation, RN A approached the cart and noticed it was unlocked, subsequently securing it. In an interview, RN A acknowledged responsibility for the cart and stated that it was her expectation to lock the cart whenever she walked away. She admitted to leaving the cart unlocked because she went to another cart to use the computer. Further interviews with the DON confirmed that multiple staff, including herself and the ADON, were responsible for ensuring medication carts were locked. The DON reiterated that staff are expected to lock the medication cart when leaving it unattended. Facility policy review indicated that all drugs and biologicals are to be stored in locked compartments accessible only to authorized personnel. The failure to secure the medication cart was directly observed and acknowledged by staff, in contradiction to facility policy and professional standards.
Failure to Protect Residents from Abuse and Timely Reporting of Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse, neglect, and misappropriation of property, as evidenced by two separate resident-to-resident altercations involving four residents. In the first incident, a resident with severe cognitive impairment and a history of schizophrenia and dementia struck another resident, who had intact cognition, on the upper shoulder and neck. The event was witnessed via video surveillance, and both residents were assessed with no injuries found. The incident was reported to the appropriate parties, but there was confusion among staff and administration regarding the required timeframe for reporting such events, with the administrator and staff referencing outdated guidance and facility policy that did not specify the current regulatory requirement for reporting within two hours. In the second incident, two residents, both with cognitive impairments and histories of dementia and psychiatric disorders, engaged in a physical altercation over a towel in the dining room. One resident sustained a skin tear with scant bleeding to her hand, which was treated by nursing staff. Both residents were separated, assessed, and notifications were made to the physician, DON, and administrator. Video surveillance and staff interviews confirmed the altercation, but there was again a lack of clarity among staff and administration regarding the classification of the event as abuse and the appropriate reporting timeframe. The facility's policy did not provide a specific timeframe for reporting, and staff relied on their understanding of previous guidance, which was not aligned with current regulations. Throughout both incidents, staff and administration demonstrated inconsistent understanding of abuse reporting requirements, particularly regarding the two-hour reporting window for allegations of abuse. Training records indicated that staff had received education on abuse, neglect, and exploitation, but interviews revealed gaps in knowledge about current regulatory expectations. The facility's policy referenced following applicable regulations but did not specify the required reporting timeframe, contributing to the deficiency.
Failure to Timely Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including resident-to-resident altercations—were reported to the administrator and State Survey Agency within the required timeframes. Specifically, the facility did not report two separate resident-to-resident altercations within two hours as required by regulation. In the first incident, two female residents were involved in an altercation in the hallway, with one resident alleging she was hit by the other. Both residents were assessed and found to have no injuries, and notifications were made to the medical doctor, responsible parties, DON, and administrator. However, the self-report to the state was not submitted until more than two hours after the incident occurred. In the second incident, two other female residents were involved in a physical altercation in the dining room over a towel, resulting in a skin tear to one resident's hand. Both residents were separated, assessed, and notifications were made to the appropriate parties. The incident was not reported to the state within the required two-hour timeframe, as the self-report was submitted more than two hours after the event. Interviews with staff and the administrator revealed a lack of clarity and training regarding the specific two-hour reporting requirement for abuse allegations, with some staff and the administrator believing that a 24-hour timeframe was sufficient if there was no major physical injury. The residents involved in these incidents had varying degrees of cognitive impairment, as indicated by their BIMS scores and diagnoses such as dementia, schizophrenia, and bipolar disorder. Despite the absence of significant injuries and the residents' own reports of feeling safe, the facility's failure to report these altercations within the mandated timeframe constituted a deficiency. The facility's abuse policy did not specify the required reporting timeframe, and staff training records indicated that while abuse and neglect training had been provided, there was confusion about the regulatory requirements for timely reporting.
Failure to Adhere to Nutritional Menus
Penalty
Summary
The facility failed to ensure that the meals served to residents met their nutritional needs and adhered to the established menus. During observations on two consecutive days, it was noted that the meals served did not match the posted or cycle menus. On the first day, the menu called for beef enchiladas with Spanish rice and peach cobbler, but residents received dry beef enchiladas with pinto beans or green beans with carrots, apple pie, and cornbread. On the second day, the menu called for Mexican meatloaf with buttered corn and banana, but residents were served meatloaf with corn, carrots, and a banana. These discrepancies were not communicated to the residents or staff, and there was no indication that substitutions were noted or justified. Interviews with staff revealed a lack of communication and oversight in the meal service process. RN A, responsible for checking trays, did not verify the menu items against the trays and was unaware of any substitutions. The Registered Dietitian (RD) acknowledged that substitutions might occur but did not ensure that these were communicated or documented. The Administrator (ADM) indicated that the Food Production Manager (FPM) was responsible for overseeing menu adherence but failed to do so. The facility's Quality Assurance and Performance Improvement (QAPI) records identified issues with meal service, including cold food, late trays, and non-compliance with menus, attributing these problems to inadequate supervision by the dietary manager.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility was found to have multiple deficiencies in its kitchen operations, which were observed during a survey. The kitchen had issues with cleanliness and maintenance, including steam wells with a flaking whitish substance, and a shelf above the steam table with dark brown and reddish substances. Additionally, there were dented food holding pans, one of which had a sticky yellowish stain. Spices were not properly sealed, and expired canned goods were found in the dry storage area. Plastic dishes on the clean rack were found with debris, and personal items such as a paper plate with pizza and a soda can were improperly stored in the kitchen. Interviews with staff revealed a lack of adherence to food safety protocols. The dietary worker admitted to not having time to remove personal food items from the kitchen, acknowledging the risk of cross-contamination. The dietary aide was aware of the improper placement of her personal cup in the kitchen and admitted to not following handwashing protocols. The food production manager was unaware of the proper disposal of dented pans and the potential contamination risks of open spices. He also failed to check the use-by dates on canned goods upon delivery. Further investigation showed ongoing issues with water on the floor in the dry storage area and around the ice machine, which required continuous mopping. The walk-in freezer had significant icicles due to a leak in the condenser. The facility's administration was aware of these issues, and the food production manager was responsible for ensuring food safety and equipment maintenance. However, the deficiencies in kitchen operations and staff practices posed a risk of food contamination and illness among residents.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #293, who required oxygen therapy. The resident's physician had ordered oxygen to be administered at 2 liters per minute (Lpm) via nasal cannula to alleviate symptoms of hypoxia related to shortness of breath. However, during an observation, it was noted that the oxygen concentrator was set at 3 Lpm, which did not align with the physician's orders. This discrepancy was confirmed through interviews with the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and Director of Nursing (DON), who acknowledged the importance of adhering to physician orders to prevent potential harm to the resident. Resident #293, a female with a history of sleep apnea and hypertension, was receiving continuous oxygen therapy as part of her care plan. The facility's oxygen administration policy mandates that oxygen therapy be administered as per the physician's orders. The failure to comply with these orders could lead to adverse effects, such as hyperoxygenation or increased carbon dioxide levels in the blood, as noted by the nursing staff. The facility's oversight in ensuring the correct oxygen flow rate was a significant lapse in maintaining the standard of care for the resident.
Inappropriate Prescription of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #68, was not prescribed the antipsychotic medication Zyprexa without an appropriate diagnosis for its use. Resident #68, a male with diagnoses including dementia with behavioral disturbance and neurocognitive disorder with Lewy bodies, was administered Zyprexa despite not having a diagnosis of psychosis. The medication was prescribed to manage aggression and anxiety, as noted in the consent for antipsychotic treatment signed by the Director of Nursing (DON) and a Nurse Practitioner (NP). However, the facility's policy requires that psychotropic drugs are only given when necessary to treat a specific condition documented in the clinical record. Interviews with the DON and the Administrator revealed a lack of awareness that antipsychotic medications should not be given solely based on a dementia diagnosis. The DON acknowledged that Resident #68 had been receiving Zyprexa for a long time for aggression, and the Administrator admitted to confusion about the appropriateness of prescribing antipsychotics for dementia. The facility's psychotropic medication policy emphasizes the necessity of a specific diagnosis for administering such medications, which was not adhered to in this case.
Expired Insulin Found in Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles, specifically concerning the expiration of insulin in one of the medication carts located in the A wing hallway. During an observation, it was found that an insulin vial had been opened on 8/12/2024 and was still in use past the 28-day expiration period. This oversight was confirmed through interviews with the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN) A, and Registered Nurse (RN) A, who all acknowledged that insulin vials should be discarded after 28 days from the opening date. The ADON and nursing staff expressed concerns that administering expired insulin could lead to adverse reactions or reduced potency, potentially affecting the therapeutic levels for residents. The facility's policy, revised in May 2023, mandates that medications be stored safely and securely, with expired or deteriorated medications removed immediately from storage. Despite this policy, the expired insulin was not discarded, indicating a lapse in adherence to the facility's medication storage and labeling procedures.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to provide residents with food at an appetizing temperature, specifically affecting two residents during a lunch meal. Observations revealed that meal trays were not served at the preferred temperature, with food items such as enchiladas and vegetables being significantly below the required temperature. The issue was compounded by delays in meal service, as trays were left on meal carts for extended periods, leading to cold food being served to residents. Interviews with staff indicated a lack of clarity and responsibility regarding the process for ensuring food was served warm, with no specific individual assigned to oversee the timely distribution of meal trays. Residents expressed dissatisfaction with the temperature of their meals, and staff acknowledged that the cold food could lead to decreased food intake, potentially affecting residents' nutritional status. The Registered Nurse (RN) and Registered Dietitian (RD) both recognized the potential negative impact of cold food on residents' health, including weight loss and dehydration. However, there was no immediate action taken to reheat the food or address the issue promptly, highlighting a gap in the facility's meal service process.
Failure to Ensure Resident's Call Light Functionality
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach and functioning properly, which could place residents at risk of being unable to obtain assistance when needed. The resident in question, a male with severe cognitive impairment and various medical conditions including dysphagia, unspecified convulsions, and muscle weakness, was observed to have his call light on the floor and not working. Despite being non-verbal, the resident was able to press the call light when handed to him, indicating his reliance on it for communication and assistance. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's call light functionality. The Maintenance Supervisor was unaware of the issue, and the Dietary Manager, responsible for checking the resident's room, admitted to not verifying the call light's functionality. Additionally, a CNA acknowledged the importance of checking call lights but did not confirm if it was working. The facility's policy requires staff to ensure call lights are within reach and functioning, yet this was not adhered to, leading to the deficiency.
Non-Functional Call Light Puts Resident at Risk
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, identified as Resident #10, which could potentially place residents at risk of being unable to obtain assistance or help when needed. Resident #10, a male with severe cognitive impairment and various medical conditions including dysphagia, unspecified convulsions, and muscle weakness, was observed to have a non-functional call light in his room. The call light was found on the floor and did not activate the light outside the room when pressed. Despite being non-verbal, Resident #10 was able to press the call light when handed to him, indicating his ability to use it for communication. Interviews with facility staff revealed a lack of awareness and oversight regarding the non-functional call light. The Maintenance Supervisor was unaware of the issue, and the Dietary Manager, responsible for checking Resident #10's room, admitted to not verifying the call light's functionality that morning. The CNA also confirmed that she did not check if the call light was working, despite being trained to do so. The Administrator stated that department heads were assigned to check on residents and their rooms daily, including ensuring call lights were within reach and operational. The facility's policy requires immediate reporting of defective call lights, but this procedure was not followed in Resident #10's case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harlingen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Palms Rehabilitation And Retirement | 0.3 mi | — | 5 | 0 |
| Sun Valley Rehabilitation And Healthcare Center | 0.7 mi | — | 0 | 0 |
| Windsor Nursing And Rehabilitation Center Of Harli | 0.8 mi | — | 2 | 0 |
| Harlingen Nursing And Rehabilitation Center | 0.9 mi | — | 11 | 1 |
| Windsor Atrium | 0.9 mi | — | 3 | 0 |
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