The facility had placed Resident #1 on droplet precautions after a recent COVID-19 diagnosis. Yet inspectors observed staff members failing to don proper personal protective equipment before entering the room, according to the November 14 inspection report.
Multiple administrators acknowledged the serious risks this created. The nurse practitioner told inspectors that anyone entering the droplet precaution room should wear full protective gear "in order to keep COVID-19 from spreading and to protect everyone." She warned that residents could be at risk for "COVID-19 spread and epidemic."
The facility's Director of Nursing stated that staff were responsible for donning and doffing PPE before entering and exiting droplet precaution rooms "to prevent infection spread." She admitted that "residents could be infected" if protocols weren't followed.
Assistant Director of Nursing E explained that full PPE included "gown, gloves, mask and face shield." He said the equipment was necessary "primarily for infection control, and to prevent spread of infection, such as COVID-19." Without proper precautions, he noted, "residents could be at risk of possible infection."
Despite universal agreement on the importance of these safety measures, the facility's infection control oversight appeared fragmented. The Director of Nursing could not recall when she had most recently trained staff on infection control procedures.
Assistant Director of Nursing F was "unsure when staff were most recently reeducated on infection control." The administrator similarly stated he was "unsure when staff were most recently in-serviced on infection control" and was "unsure if any reeducations were given related to infection control."
The facility designated its Wound Care Nurse as the Infection Preventionist, according to multiple staff members. However, this person was not interviewed during the inspection, and their training schedule remained unclear.
Staff members who spoke with inspectors demonstrated knowledge of proper procedures when asked directly. A Licensed Vocational Nurse explained that PPE was necessary "to protect yourself and the resident" and acknowledged that "residents could be at risk of developing infection if staff were not donning and doffing."
The administrator told inspectors that proper PPE use was essential "to minimize the spread of infection and ensure resident safety from cross contamination." He said the Director of Nursing, assistant directors, and he oversaw infection control compliance "by conducting morning rounds and taking reports from staff."
Yet these oversight mechanisms apparently failed to prevent the violations inspectors witnessed. The facility claimed to conduct quarterly competencies on staff regarding infection control procedures, but the timing and effectiveness of this training remained questionable given the observed lapses.
When inspectors requested the facility's infection control policy to review written protocols, administrators could not produce the document. The surveyor noted that "the facility's infection control policy" was requested from both Assistant Director of Nursing F and the administrator during separate interviews.
Harbor Valley Health failed to provide the infection control policy before inspectors completed their exit on November 14. This missing documentation compounded concerns about the facility's systematic approach to preventing disease transmission.
The violations occurred at a time when COVID-19 continued to pose significant risks to nursing home residents, who remain among the most vulnerable populations for severe outcomes from the virus. Proper use of personal protective equipment serves as a critical barrier to prevent infected residents from transmitting the virus to staff, other residents, and visitors.
The inspection found that while facility leadership understood the importance of infection control measures and could articulate proper procedures when questioned, their implementation and oversight systems failed to ensure consistent compliance among direct care staff.
The administrator acknowledged that "all direct care staff were responsible for following the infection control donning and doffing policy," yet the facility's inability to demonstrate recent training or produce written policies raised questions about how effectively these responsibilities were communicated and enforced.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the failure to maintain proper infection control protocols in a COVID-positive resident's room created risks that could have escalated quickly in a congregate care setting where vulnerable residents live in close proximity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harbor Valley Health and Rehabilitation from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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