Harbor Valley Health and Rehabilitation
6211 Old Pearsall Road, San Antonio, TX 78242 · Bexar County · 120 certified beds · avg 82 residents/day · certified since Jan 15, 2020
Abuse citation flag (CMS)
Part of chain: FANNIN COUNTY HOSPITAL DISTRICT (5 facilities, chain avg rating 3.0★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 12, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
▲ Immediate jeopardy, one-off · Oct 27, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 28, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (40)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Dec 5, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Dec 5, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 5, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 21, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Nov 14, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Sep 12, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jan 12, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jan 12, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 12, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility's bedrooms did not give residents visual privacy — such as curtains or dividers — when privacy is needed. |
| Aug 9, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Aug 9, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · from a complaint |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 27, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jun 16, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 16, 2023 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jun 16, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 16, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 1 | J ▲ |
| 2024 | 13 | 0 | D |
| 2025 | 19 | 1 | J ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $18,989.
| Date | Type | Amount / length |
|---|---|---|
| Sep 5, 2025 | Fine | $8,281 |
| Oct 27, 2023 | Fine | $10,708 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.71 | 3.46 | 3.95 | top 24% in Texas; bottom 47% in the U.S. |
| Registered Nurse hours | 0.10 | 0.44 | 0.69 | bottom 1% in Texas; bottom 1% in the U.S. |
| Weekend total nurse staffing | 3.28 | 3.04 | 3.50 | top 25% in Texas; bottom 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.11 | 0.34 | 0.48 | bottom 3% in Texas; bottom 1% in the U.S. |
| Total nursing staff turnover (%) | 43.8 | 55.3 | 45.8 | top 30% in Texas; top 47% in the U.S. |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.58, RN 0.10, weekend 3.16. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 5/5 · short-stay residents: 1/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Fannin County Hospital Authority | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/01/2026 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2026 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2026 |
| Jones, Justin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2026 |
| Jones, Justin | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2026 |
| Jones, Justin | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2026 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Martinez, Fernando | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2026 |
| Martinez, Fernando | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2026 |
| Martinez, Fernando | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2026 |
| Pearsall Road Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2026 |
| Redberry Canyon Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2026 |
| Redberry Canyon Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/09/2026 |
| Sanderson, Clark | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2026 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2026 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| The Mission at Blue Skies of Texas East | 3.2 mi | San Antonio, TX | ★★★★★ | 4/5 | |
| Avir at San Antonio | 4.2 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | |
| Legend Oaks Healthcare and Rehabilitation - West S | 4.4 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| Legend Oaks Healthcare and Rehabilitation Center - | 4.7 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| Hunters Pond Rehabilitation and Healthcare | 4.8 mi | San Antonio, TX | ★★★☆☆ | 2/5 | |
| San Antonio West Nursing and Rehabilitation | 6.0 mi | San Antonio, TX | ★☆☆☆☆ | 1/5 | |
| Lakeside Nursing and Rehabilitation Center | 6.5 mi | San Antonio, TX | ★★★★★ | 4/5 | |
| San Jose Nursing Center | 6.5 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| Westover Hills Rehabilitation and Healthcare | 8.1 mi | San Antonio, TX | ★★★★☆ | 3/5 | |
| Windsor Mission Oaks | 8.4 mi | San Antonio, TX | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676478.