Harbor Valley Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Harbor Valley Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 12, 2025

  Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 1 of 11 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse as evidence by on 08/05/2025, in the resident's room CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. The noncompliance was identified as a PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began. […]

• Immediate jeopardy, isolatedF600Oct 27, 2023

  Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 2 residents (R#6 and R#5) reviewed for abuse. The facility did not properly monitor or put in place preventative measures for R #1 to prevent an act of sexual abuse on 09/27/23, when R#1 was found without a brief laying in the bed of R#6 without the consent of R#6. The facility did not properly monitor or put in place preventative measures for R #1 to prevent further acts of sexual abuse on 10/14/23, when R#1 was found on top of R#5, in her bed, without the consent of R#5. An IJ was identified on 10/26/23. The IJ template was provided to the facility on [DATE] at 3:50 PM. […]

• No harm, potential for more than minimal, widespreadF812Nov 14, 2025

  Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure [NAME] A wore a beard net on 11/12/25. This failure could place residents at risk of contaminated food and illness.Findings include:During an observation of the kitchen on 11/12/25 at 12:20 p.m., [NAME] A had facial hair and was not wearing a beard net and was checking food temperatures before lunch meal service. During an interview on 11/12/25 at 12:24 p.m., [NAME] A stated he was most recently reeducated on the beard net policy one year ago by the former DM. He stated all kitchen staff were responsible for following the facility's beard net policy. […]

• No harm, potential for more than minimal, patternF565Dec 5, 2025

  Based on interview and record review the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response, for 3 of 6 anonymous residents who attended resident council meetings. (Resident council meeting).The facility failed to provide residents with requested copies of the documentation of their grievances and their resolution. […]

• No harm, potential for more than minimal, patternF641Dec 5, 2025

  Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 5 residents (Resident #68, #10 and #74) reviewed for resident assessments: 1.The facility failed to ensure Resident #68's most recent quarterly MDS assessment was updated to include the resident did not receive insulin injections. 2. The facility failed to ensure Resident #10's most recent quarterly MDS assessment, dated 11/20/25, was updated to include the resident having a significant weight gain in the last 6 months. 3. […]