Inspection Reports for
Harlingen Nursing and Rehabilitation Center
3810 Hale Ave, Harlingen, TX 78550, United States, TX, 78550
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 3
Date: Nov 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, food service safety, and infection prevention and control at Harlingen Nursing and Rehabilitation Center.
Findings
The facility was found deficient in providing necessary grooming services to a resident, specifically nasal hair trimming, failing to label and date food items in the freezer, and lapses in infection prevention practices including improper hand hygiene and unsafe handling of insulin pens by staff.
Deficiencies (3)
Failure to provide Resident #16 with nasal grooming, specifically nasal hair trimming.
Failure to ensure all food items were labeled and dated in the freezer; one bag of chicken nuggets was unlabeled and undated.
Failure to establish and maintain an infection prevention and control program, including improper hand hygiene by LVN A and RN B and unsafe handling of insulin pen.
Report Facts
Residents reviewed for activities of daily living: 3
Residents observed for infection control: 8
Food kitchens reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in infection prevention and control deficiencies related to hand hygiene and insulin pen handling |
| RN B | Registered Nurse | Named in infection prevention and control deficiencies related to hand hygiene during g-tube feeding |
| CNA L | Certified Nursing Assistant | Mentioned in relation to grooming care for Resident #16 |
| Dietary Manager | Mentioned in relation to food labeling and storage deficiencies | |
| Administrator | Mentioned in relation to oversight of kitchen staff and policies | |
| DON | Director of Nursing | Interviewed regarding infection control policies and staff training |
| ADON | Assistant Director of Nursing | Interviewed regarding infection control policies and staff training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision of Resident #1, who eloped from the facility and was found approximately 2 miles away by police.
Complaint Details
The complaint investigation found that Resident #1 eloped from the facility on 10/08/2023 and was found by police approximately 2 miles away. The Immediate Jeopardy began and ended on 10/08/2023. The facility corrected the noncompliance before the survey began.
Findings
The facility failed to provide adequate supervision to prevent elopement of Resident #1, who eloped on 10/08/2023. Immediate Jeopardy was identified but corrected before the survey began. The facility implemented interventions including one-to-one monitoring, transfer to a memory care unit, staff education, and elopement drills.
Deficiencies (1)
Failure to ensure adequate supervision to prevent accidents and elopement for Resident #1.
Report Facts
Wandering Evaluation Score: 7
Brief Interview for Mental Status Score: 3
Date of elopement: Oct 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding Resident #1's last seen time and missing person protocol | |
| DON | Interviewed about Resident #1's admission, risk assessment, and facility response | |
| Administrator | Interviewed about elopement protocol, staff education, and security measures |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans and medical record documentation, including wound care and nail care for residents.
Findings
The facility failed to follow a resident's care plan regarding nail care, resulting in nails being too long, which posed a risk of skin injury. Additionally, the facility failed to maintain accurate and complete medical records for wound care treatments for two residents, with missing documentation on multiple dates, although treatments were reportedly provided.
Deficiencies (2)
Failed to develop and implement a comprehensive person-centered care plan including measurable objectives and time frames for one resident, specifically not following the care plan to keep fingernails short.
Failed to maintain medical records in accordance with accepted professional standards for two residents by not documenting wound care treatments on specified dates.
Report Facts
Dates of missing wound care documentation: 6
Length of resident's nails: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Interviewed regarding nail care procedures and resident #3's nail length |
| DON | Director of Nursing | Interviewed about resident #3's nail care and missing wound care documentation |
| LVN A | Licensed Vocational Nurse | Interviewed about nail care responsibilities and resident #3's care plan |
| LVN B | Licensed Vocational Nurse | Interviewed about wound care treatments and documentation for resident #3 |
| LVN D | Licensed Vocational Nurse | Interviewed about wound care treatments and documentation for resident #3 |
| ADON | Assistant Director of Nursing | Interviewed about missing wound care documentation and audit processes |
| ADM | Administrator | Interviewed about facility awareness and corrective actions regarding nail care and wound care documentation |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 3
Date: Aug 2, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to treat residents with dignity, failure to provide appropriate activities, and failure to maintain infection prevention and control.
Complaint Details
The complaint investigation found substantiated issues including dignity violations for Resident #202, inadequate activity provision for Resident #151, and infection control lapses involving Residents #105 and #209.
Findings
The facility failed to monitor a resident with feces on her hand in the dining room, failed to provide activities meeting a resident's needs, and failed to maintain infection control practices including missing isolation signage and improper incontinent care.
Deficiencies (3)
Failed to ensure residents were treated with respect and dignity; Resident #202 had feces on her hand in the dining room unmonitored.
Failed to provide activities designed to meet Resident #151's interests and promote well-being.
Failed to establish and maintain an infection prevention and control program; missing Droplet Precautions sign on Resident #105's door and improper use of wipes during incontinent care for Resident #209.
Report Facts
Residents in dining room during observation: 18
Days of droplet isolation: 10
Stage 3 pressure ulcer size: 3.3
Stage 3 pressure ulcer size: 3.1
Stage 3 pressure ulcer size: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN G | Licensed Vocational Nurse | Interviewed regarding Resident #202's feces on hand incident |
| CNA A | Certified Nursing Assistant | Interviewed regarding Resident #202 and observed incontinent care for Resident #209 |
| Activity Aide | Responsible for monitoring residents in dining room including Resident #202 | |
| DON | Director of Nursing | Interviewed about Resident #202 incident and infection control practices |
| LVN F | Licensed Vocational Nurse | Interviewed about Resident #202 placement in dining room |
| Activity Director | Interviewed about activities provided to Resident #151 | |
| CNA H | Certified Nursing Assistant | Interviewed about Resident #151's participation in activities |
| CNA I | Certified Nursing Assistant | Interviewed about Resident #151's mobility and activity participation |
| CNA J | Certified Nursing Assistant | Interviewed about Resident #151's activity participation and mobility |
| LVN K | Licensed Vocational Nurse | Interviewed about activities provided to Resident #151 |
| Administrator | Interviewed about activities provided to Resident #151 | |
| LVN C | Licensed Vocational Nurse | Interviewed about droplet precautions signage for Resident #105 |
| ADON E | Assistant Director of Nursing | Responsible for placing isolation signage and infection control in-services |
| CNA B | Certified Nursing Assistant | Interviewed about incontinent care practices |
| WCN | Wound Care Nurse | Interviewed about incontinent care and infection control |
Inspection Report
Routine
Deficiencies: 8
Date: May 26, 2022
Visit Reason
The inspection was conducted to assess compliance with resident rights, care planning, assessment submissions, medication administration, and other regulatory requirements at Harlingen Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to dignified existence and self-determination related to smoking schedules, failure to submit timely MDS assessments to CMS for VA-funded residents, inaccurate MDS assessments, delayed baseline care plan completion, failure to implement dietary recommendations timely, failure to develop a care plan addressing smoking for a resident, failure to check vital signs before administering blood pressure medication, and inaccurate medical record documentation regarding isolation precautions.
Deficiencies (8)
Failed to ensure residents' right to dignified existence and self-determination by not providing a consistent smoking schedule and failing to cover a urinary catheter bag with a privacy bag.
Failed to submit quarterly MDS assessments to CMS timely for 2 of 3 residents reviewed, resulting in incomplete records.
Failed to ensure accurate MDS assessments reflecting weight loss and PASRR status for 2 residents.
Failed to develop and implement a baseline care plan within 48 hours of admission for one resident.
Failed to develop and implement a comprehensive care plan addressing smoking for a resident who smokes.
Failed to provide a therapeutic diet as ordered and did not act upon dietitian recommendations timely for one resident.
Failed to check blood pressure or pulse rate before administering blood pressure medication as ordered for one resident.
Failed to maintain accurate medical records regarding isolation precautions for one resident.
Report Facts
Weight loss percentage: 20.28
Number of residents on smoking list: 2
Number of residents with missing MDS submissions: 2
Number of residents reviewed for care plans: 6
Number of residents observed for medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN G | Case Manager/RN | Responsible for completing MDS assessments for Resident #86 and acknowledged inaccurate MDS data. |
| LVN A | Overseeing residents' weights and dietician recommendations; called physician about dietary recommendations. | |
| LVN B | Responsible for ensuring catheter bags are placed in privacy bags; called Resident #10's physician about dietician recommendations. | |
| Medication Aide H | Administered medications to Resident #104 without checking blood pressure or pulse rate. | |
| DON | Director of Nursing | Provided multiple interviews regarding care plans, MDS submissions, smoking policies, dietary recommendations, and medication administration. |
| Maintenance Director | Took residents out to smoke and provided information about smoking schedule. | |
| Case Manager G | Responsible for submitting MDS assessments to VA and CMS; admitted some assessments were not submitted to CMS. | |
| Case Manager I | Responsible for submitting MDS assessments to VA and CMS; confirmed PASRR status coding error for Resident #35. | |
| Staff K | Stated baseline care plan is viewed by all care staff and that DON is responsible for completing baseline care plans. | |
| Dietary Manager | Discussed dietary recommendations and meal tray preparation. |
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