Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbor Post Acute Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and a recent hip fracture was able to leave the building and was later found standing outside near a stairwell door, dressed for cold weather but without shoes. Earlier that evening, an RN had heard a second-floor door alarm and silenced it without investigating the cause. The alarm had been triggered by the resident’s exit, and the lack of follow-up allowed the resident to remain outside unsupervised until staff discovered her, constituting a failure to prevent elopement and ensure adequate supervision.
Unlocked resident medication cabinets, pre-set medication cups, and an unsecured narcotic lock box were observed in the facility. A resident who was only approved for inhalers self-administered pill medications without nurse supervision, while other residents had unlocked room cabinets containing prescription meds such as lidocaine patches, eye drops, inhalers, and breathing treatment solutions. Staff stated that medications should not be pre-set and that resident room medication cabinets must remain locked.
Failure to develop person-centered care plans for two residents. One resident with dementia, incontinence, and skin concerns had care plan gaps including no toileting schedule, no MASD or pressure ulcer risk plan, and no plan for urinary retention despite an order for tamsulosin. Another resident with CKD, HF, dementia, and diabetes had repeated urine odor and toileting issues, but the care plan did not address urinary incontinence, toileting needs, pull-up use, diuretic-related frequency, or an order for levothyroxine.
Inadequate Showering and Toileting Documentation: A resident with dementia, mixed incontinence, and metabolic encephalopathy had an ADL care plan calling for bathing per schedule or as needed, but no shower schedule was implemented and only a few showers were documented. The record also lacked a toileting schedule, toileting/incontinence care was documented once per shift instead of each time, and the resident had MASD over the sacrum, coccyx, and buttocks before discharge.
Failure to Implement Person-Centered Toileting Program: A resident with CKD, HF, and dementia who could ambulate to the toilet with one-person assist had repeated strong urine odors in his room and bathroom, with urine noted in the toilet, on a urinal, and on the bathroom floor. Staff reported he wanted to be independent, forgot to use assistance, sometimes used a urinal or pull-up brief, and was toileted by staff without a toileting schedule despite frequent urination and morning Lasix use.
Inaccurate controlled substance documentation was identified for a resident receiving PRN MS and oxycodone. Review of the CSPUR and eMAR showed multiple doses signed out that were not documented as administered, doses signed out after MS had been discontinued, corrected remaining counts without matching MAR entries, and one oxycodone entry missing a nurse signature. The DON stated CSPUR and eMAR documentation should always match and discrepancies in controlled substance counts should be reported immediately.
A resident with a pressure ulcer experienced deterioration due to inadequate care at an LTC facility. The resident was not repositioned overnight, and her wound was left exposed without a dressing after a shower. Staff failed to update treatment orders to use wound cleanser instead of soap and water, as recommended by a wound specialist. The wound worsened, requiring urgent hospital intervention. Interviews revealed non-compliance with professional care standards.
A resident admitted with chronic conditions did not receive all prescribed medications timely due to delays in entering medication orders and lack of communication with the medical provider. The facility failed to utilize backup medication resources, resulting in missed doses, contrary to its policy requiring timely administration and documentation.
The facility failed to label chemical spray bottles and maintain water filters and cleanliness in food preparation areas, risking food contamination. Unlabeled spray bottles and undated water filters violated FDA codes, while dirt and debris in kitchenettes and ice machine build-up indicated inadequate cleaning, potentially affecting 52 residents.
A facility failed to implement its smoking policy for a resident who was observed with smoking materials in his room and smoking in a non-designated area. Additionally, a resident requiring assistance with transfers was moved by a single CNA, contrary to the care plan requiring two staff members. These deficiencies indicate a lack of adherence to policies, potentially compromising resident safety.
The facility failed to maintain respiratory equipment for four residents, including those with COPD and chronic respiratory failure. Observations revealed uncovered and improperly stored nebulizer and oxygen equipment, contrary to facility policy. This deficiency highlights a lack of adherence to procedures for safe respiratory care.
An LPN pre-poured medications for eight residents and documented their administration before they were given, violating the facility's medication administration policies. The DON and UM confirmed that medications should be administered at the time they are prepared, and the incident was identified during an observation of the medication pass.
The facility failed to properly assess and monitor two residents for self-administration of medication. One resident had access to an inhaler and Flonase without documented assessment or monitoring, while another resident, deemed safe to self-administer, did not document usage or have a physician order for self-administration. The facility's policy on medication self-administration was not followed, leading to deficiencies in medication management practices.
A resident with end-stage renal disease and CHF experienced significant weight gain, but the facility failed to notify the physician or measure abdominal girth as ordered. Despite policies requiring timely notification of condition changes, these were not followed, leading to a deficiency in care.
A resident was prescribed Risperidone without a documented diagnosis or rationale, despite not having a mental illness or dementia. The resident, who was moderately cognitively impaired and admitted with conditions like Covid-19 and COPD, exhibited wandering behaviors but was easily redirected. The facility's policy did not support antipsychotic use for such behaviors, and there was no behavior monitoring or behavioral health consultation, leading to a deficiency.
A facility failed to ensure proper PPE use for a resident under Enhanced Barrier Precautions. The resident required assistance with activities like transferring and toileting, which mandated gown and glove use. However, a CNA was observed not using PPE during a transfer, misunderstanding the requirement as only necessary for wound care. The LPN Unit Manager confirmed that PPE is required for all high-contact care activities, aligning with the facility's policy.
The facility failed to provide essential information to residents and their representatives regarding Medicaid/Medicare coverage, state agency contacts, and procedures for filing complaints and grievances. This deficiency affected all residents, as confirmed by interviews and record reviews. The Nursing Home Administrator admitted the lack of admission packets and policies for re-admitting residents after hospitalization, leading to confusion and stress for residents and their representatives.
The facility lacked an admission policy and failed to provide admission packets to residents, leaving them uninformed about their rights, costs, and bed hold policies. This deficiency was confirmed through interviews and record reviews, with the Nursing Home Administrator acknowledging the absence of necessary documentation and information for residents.
The facility failed to properly plan for the discharge of two residents, leading to unsafe discharges and the inability to readmit one resident post-hospitalization. One resident was discharged home without adequate support, resulting in a return to the hospital, while another faced financial and communication issues due to a lack of information about insurance and Medicaid resources. The facility's focus on being a Sub-Acute Rehab (SAR) rather than accommodating long-term care needs contributed to these deficiencies.
The facility failed to notify the Office of the State LTC Ombudsman about resident discharges as required by their policy. Despite the policy mandating written notification to the Ombudsman for all discharges, the facility did not report any facility-initiated discharges over the past ten months. The Nursing Home Administrator acknowledged the absence of a discharge notification list, and the LTC Ombudsman confirmed the last report was in mid-2023. The Director of Nursing only sought clarification on the regulation the day before the survey began.
The facility failed to provide Bed Hold policies to residents upon admission and during transfers, affecting all residents. Interviews and record reviews showed that 12 residents did not receive the necessary documentation, leading to confusion and distress for residents and their representatives. The Nursing Home Administrator admitted that admission packets did not include the Bed Hold policy.
The facility's telephone communication system was ineffective, preventing a resident's DPOA from reaching the resident and staff. The DPOA experienced issues with calls not being received in the resident's room and difficulties contacting the front desk and charge nurse. Staff interviews revealed problems with the phone system, including accidental activation of the 'Do Not Disturb' button and challenges in transferring calls. The NHA was unaware of these issues and reported no records of related concerns.
A resident's DPOA was not provided with necessary information on applying for Medicare and Medicaid benefits, leading to delayed Medicaid coverage and significant out-of-pocket expenses. The resident, with serious health conditions, faced financial stress when Medicare ended, and the facility attempted to discharge them despite needing two-person care. The facility failed to assist with Medicaid paperwork timely, resulting in a $14,000 bill, and did not have a policy for readmitting residents post-hospitalization.
A resident with Parkinson's disease and other conditions was not readmitted to the facility after hospitalization due to pending Medicaid status and lack of a payor source. The facility, designed for Sub-Acute Rehab, did not provide necessary information on bed hold policies or assist in timely Medicaid application, leading to the resident's placement in another facility.
The facility failed to provide adequate care for pressure ulcers for two residents, who required repositioning and wound vac care. One resident was not repositioned as needed, with missed dressing changes and no documentation of refusals or physician notification. The other resident's wound vac was not functioning due to refusal to be turned, and standard procedures for non-functioning wound vacs were not followed. The lack of documentation and communication led to a deficiency citation.
Failure to Prevent Elopement After Door Alarm Was Silenced Without Investigation
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and ensure adequate supervision to prevent accidents for a resident with known cognitive impairment. The resident was an elderly female with a recent hip fracture and Alzheimer’s disease who reported remembering being outside the building but could not explain why she had gone out. On the evening of the incident, she was found standing outside the facility next to the southeast stairwell door. At that time, she was dressed appropriately for the cold weather except for having only one sock and no shoes. A head-to-toe assessment was completed and revealed no concerns of physical harm, and the resident later stated she was not harmed, felt safe, and would not repeat the behavior. The events leading to the deficiency included a failure by staff to appropriately respond to a door alarm. At approximately 9:00 PM, an RN heard the second-floor door alarm sounding and silenced the alarm without further investigating the cause. About 15 minutes later, the resident was discovered outside near the stairwell door, indicating that the alarm had signaled an actual exit attempt that was not properly assessed. This sequence of events shows that the resident was able to leave the building unsupervised, resulting in an elopement and demonstrating that the area was not kept free from accident hazards with adequate supervision at the time of the incident.
Unlocked resident medication storage and unsecured narcotic compartment
Penalty
Summary
Drugs and biologicals were not secured in accordance with accepted professional principles and facility policy for multiple residents and one medication cart. Resident #25 had a self-medication safety screen that approved only Trelegy and an albuterol inhaler for unsupervised self-administration, but during observation a plastic medication cup containing pills was left on the nurse’s station counter and the resident took the cup and self-propelled away with the medications without nurse supervision. The resident stated the cup belonged to her and that she had been distracted after the nurse gave her the medications. The self-medication screen did not include approval for pill-form medications. In other observations, the medication cabinets in the rooms of Resident #10, Resident #39, Resident #56, and Resident #45 were unlocked and contained pre-set or stored prescription medications, including lidocaine patches, eye drops, breathing treatment solution, pain gel, rescue inhalers, fluticasone inhaler, atropine sulfate drops, and albuterol sulfate metered dose inhalers. Resident #10 and Resident #39 also had pre-set medication cups in their room cabinets, and staff stated that pre-setting medications was not standard practice and that resident room medication cabinets should be locked at all times. In addition, the narcotic lock box on the 300 high hall medication cart was observed unsecured and able to open without a key. Facility policy stated that only authorized personnel may access medications, medication carts and supplies must be locked or attended, controlled medications must be stored separately in a locked compartment, and medications may not be set up in advance.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to create and implement person-centered care plans for two residents reviewed for care plans. One resident had diagnoses including dementia, mixed incontinence, and metabolic encephalopathy, was incontinent of bowel and continent of bladder on admission, had a non-blanchable red area on the left medial buttock, and was assessed as at moderate risk for skin breakdown. Although the care plan included ADL self-care deficit and skin integrity-related interventions, it did not include a toileting schedule, a care plan for MASD or pressure ulcer risk, or a documented schedule for bathing. The care plan also did not address an order for tamsulosin for urinary retention, and no diagnosis of urinary retention was found in the electronic record. Another resident had diagnoses including chronic kidney disease, heart failure, dementia, and diabetes, with occasional urinary incontinence and bowel continence on the MDS. The resident had an order for levothyroxine, but hypothyroidism was not included in the care plan. Staff observed and reported a strong urine smell in the resident’s room and bathroom on several occasions, with reports that the resident toileted himself, may urinate on the floor, did not use the call light, used a urinal at times, and wore a pull-up brief. The care plan did not include toileting schedule, continence or incontinence interventions, or the use of pull-up briefs, and it did not reflect the resident’s diuretic use or the toileting patterns documented in task records.
Inadequate Showering and Toileting Documentation
Penalty
Summary
Failure to provide showers for one resident occurred despite the resident’s care plan calling for showering/bathing per schedule or as needed. The resident had diagnoses of dementia, mixed incontinence, and metabolic encephalopathy, and the care plan also identified an ADL self-care performance deficit. No shower schedule was implemented, and the record showed only 2 showers in October and 3 showers in November before discharge. The care plan also included brief use for incontinence management, but no toileting schedule was documented. Toileting task documentation from 11/5/25 to 11/24/25 showed the resident was documented as continent or incontinent one to two times a day on most days. The resident’s skilled charting on 11/23/25 documented moisture associated skin damage over the sacrum, coccyx, and buttocks. During interview, the DON stated the system did not trigger shower documentation for staff and that staff documented showers on an as-needed basis instead of a regular schedule. The DON also acknowledged staff should document every time they toilet a resident or provide incontinence care, but staff documented it once per shift, and acknowledged the resident had MASD on admission that cleared and later returned before discharge.
Failure to Implement Person-Centered Toileting Program
Penalty
Summary
The facility failed to implement a person-centered toileting program for a resident with chronic kidney disease, heart failure, and dementia who could ambulate to the toilet with one-person assistance using a wheeled walker. During multiple observations, the resident’s room and bathroom had a strong urine odor, the bathroom floor was sticky, urine was seen in the toilet and on a urinal hanging on the counter, and staff observed that the resident may have been missing the toilet and urinating on the floor. The resident was also observed wearing a pull-up brief and at times using a urinal, while the call light was within reach and the resident stated he never needed to use it and denied needing toileting assistance. Staff interviews reflected that the resident wanted to be independent, forgot to use assistance, and was being toileted by staff, but no toileting schedule had been put in place despite his frequent urination and daily morning Lasix 80 mg. The DON stated the facility was trying to respect the resident’s dignity, staff found him up trying to urinate again shortly after toileting assistance, and he missed the urinal and had tried different urinals without success. The resident’s wife was also reported to assist him with ADLs including toileting, and staff noted the bathroom and mattress had persistent urine odor.
Inaccurate Controlled Substance Documentation
Penalty
Summary
The facility failed to maintain accurate documentation regarding the disposition of controlled substances for one resident. The resident was admitted with orders for Morphine Sulfate oral solution 20 mg/5 mL, 0.25 mL every 3 hours as needed for pain and shortness of breath, and later an order for Oxycodone 5 mg one tablet every 4 hours as needed for pain. Review of the Controlled Substance Proof of Use Record (CSPUR) and the Electronic Medication Administration Record (eMAR) showed multiple discrepancies for Morphine Sulfate, including doses signed out on 08/04/25 and 08/05/25 that were not documented as given on the eMAR, and doses signed out after the medication had been discontinued with no documentation in the electronic health record showing whether the resident received them. The CSPUR also reflected corrected remaining amounts on later dates without corresponding eMAR documentation of additional doses administered. Similar discrepancies were identified for Oxycodone 5 mg tablets. The CSPUR showed doses signed out on 08/14/25, 08/22/25, and 08/22/25 again that were not documented on the eMAR as given to the resident, and one signed-out dose on 09/18/25 lacked a nurse signature on the CSPUR. During interview, the DON stated the expectation was that CSPUR and eMAR documentation should always match, that signatures should identify the nurse who signed out the medication, and that any discrepancy in the count or amount remaining of a controlled substance should be reported to the DON immediately.
Failure in Pressure Ulcer Care Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident, resulting in the deterioration of the resident's condition. The resident, who was cognitively intact and required assistance with toileting and repositioning, reported that the night shift CNA did not check or reposition her between 10:00 PM and 6:00 AM, leaving her brief soaked. Observations confirmed that the resident's wound was exposed without a dressing, and her brief was wet with urine. The LPN responsible for replacing the dressing after the resident's shower was too busy to do so, leaving the wound exposed for an extended period. The facility's staff did not follow the updated treatment orders for the resident's pressure ulcer. The wound specialist had recommended using wound cleanser instead of soap and water due to the wound's worsening condition. However, the staff continued to use soap and water, as the order was not updated in the electronic medical record. This oversight contributed to the deterioration of the resident's wound, which increased in depth and required urgent surgical intervention. Interviews with the facility's staff revealed a lack of adherence to professional standards of practice for pressure ulcer care. The LPN Unit Manager acknowledged that the dressing should be replaced immediately after a shower, and the Wound RN admitted to not updating the treatment order as recommended by the wound specialist. The Wound Specialist PA confirmed that the wound had worsened significantly and required hospital intervention, highlighting the facility's failure to provide appropriate care and prevent further harm to the resident.
Failure to Administer Medications Timely Upon Admission
Penalty
Summary
The facility failed to provide timely medication administration for a resident upon admission, which did not meet professional standards of practice. The resident, who was admitted with chronic obstructive pulmonary disorder and diabetes, reported not receiving all prescribed medications since admission. The Licensed Practical Nurse (LPN) responsible for the admission noted that the process of entering the resident's extensive medication list into the computer delayed the pharmacy delivery, resulting in medications being delivered later than expected. Consequently, several medications, including Aggrenox, carbamazepine, fiber capsules, Mometasone inhaler, and lamotrigine, were not administered as scheduled on the evening of admission. Further investigation revealed that the facility's nursing staff did not utilize available backup medication resources or notify the on-call medical provider about the unavailability of medications, as per facility policy. The LPN Unit Manager confirmed that some medications were available in the backup medication cart but were not administered, and there was no documentation of communication with the medical provider regarding the missed doses. The facility's policy requires medications to be administered within 60 minutes of the scheduled time and mandates documentation of reasons for any missed doses, which was not adhered to in this case.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper labeling and maintenance of equipment and cleanliness in food preparation areas, which could lead to food contamination and increased risk of foodborne illness. During a follow-up kitchen inspection, a working chemical spray bottle was found unlabeled, violating FDA 2017 Food Code Section 7-102.11, which requires that working containers for storing poisonous or toxic materials be clearly identified with the common name of the material. Additionally, water filters for the Combi Oven and ice machines were either undated or improperly labeled, failing to comply with FDA 2017 Food Code Section 5-205.15, which mandates that plumbing systems be maintained in good repair. Further observations revealed that the 2nd and 3rd floor kitchenettes/pantries had dirt and debris under equipment and along floor/wall junctures, and cooler doors and seals required cleaning to remove build-up. The 3rd floor ice machine had a slight pink/orange slime build-up, and the 2nd floor ice machine had scale build-up, indicating a failure to clean as often as necessary to prevent accumulation, as required by FDA 2017 Food Code Sections 6-501.12 and 4-602.13. These deficiencies potentially affected 52 residents who consume food from the kitchen and kitchenettes/pantries.
Failure to Implement Smoking Policy and Transfer Procedures
Penalty
Summary
The facility failed to implement its smoking policy and procedure for a resident who was reviewed for smoking. The resident, who was cognitively intact, was observed with cigarettes and a lighter in his room, contrary to the facility's policy that required smoking materials to be kept at the nursing station. The resident reported not being required to sign out when leaving the unit to smoke, and was observed smoking in a non-designated area outside the facility's front door, despite a no-smoking sign being present. Interviews with staff revealed inconsistencies in the enforcement of the smoking policy, with some staff indicating that the resident's smoking supplies were kept locked in his room, contrary to the policy. The facility also failed to ensure that residents were transferred according to their current care plan. A resident, who was cognitively intact and required assistance with transferring, was observed being transferred by a Lead CNA using a sit-to-stand lift without the assistance of another staff member, despite the care plan indicating that two staff members were required for such transfers. The Lead CNA acknowledged that the transfer was not in accordance with the care plan, and the LPN Unit Manager confirmed the requirement for two staff members during transfers. These deficiencies highlight a lack of adherence to established policies and procedures regarding smoking and resident transfers, potentially compromising resident safety and well-being. The discrepancies between the facility's stated policies and actual practices were evident in both the handling of smoking materials and the execution of resident transfers, as observed and reported by staff members.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment according to professional standards for four residents requiring respiratory care. Resident #26, diagnosed with chronic respiratory failure and COPD, had nebulizer equipment that was uncovered and appeared used, with droplets visible, and was sometimes cleaned by staff. Resident #27, with acute respiratory failure and COPD, had oxygen tubing hanging loose and unsecured, with no maintenance orders for the equipment. Resident #43, diagnosed with COPD, asthma, and emphysema, had nebulizer equipment that was uncovered and visibly dirty, and oxygen tubing was not stored properly. Resident #48, with end-stage renal disease and congestive heart failure, had oxygen tubing improperly draped and was not wearing supplemental oxygen during an interview. The facility's policy on respiratory therapy equipment outlined specific procedures for maintaining and storing oxygen and nebulizer equipment, including changing oxygen cannula and tubing every seven days, storing equipment in plastic bags when not in use, and cleaning nebulizer equipment after use. However, these procedures were not followed for the residents observed, leading to deficiencies in the care and maintenance of respiratory equipment. The lack of adherence to these procedures was evident in the observations and interviews conducted with the residents, highlighting a failure to ensure safe and appropriate respiratory care.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that licensed personnel adhered to medication administration policies and procedures, as evidenced by an incident involving an LPN who pre-poured medications for eight residents. During an observation, it was discovered that medications had been preset in plastic medication cups with paper cups placed over them, each marked with a number corresponding to room numbers. The LPN admitted to pre-pouring the medications and had already documented their administration in the Medication Administration Records (MARS), despite the medications not being given to the residents. The Director of Nursing (DON) and Unit Manager (UM) confirmed that the facility's policy prohibited pre-pouring medications and that medications should be administered at the time they are prepared. Upon further investigation, it was revealed that the LPN had documented the administration of these medications in the electronic MAR before they were actually given. The DON and UM took steps to correct the documentation and ensure the medications were properly administered, but the initial failure to follow protocol resulted in a deficiency.
Deficiency in Medication Self-Administration Assessment and Monitoring
Penalty
Summary
The facility failed to ensure proper assessment and monitoring for self-administration of medication for two residents, R20 and R26. R20, who was admitted with asthma and respiratory failure, was observed with an albuterol inhaler and Flonase on her over-the-bed table, which she reported having immediate access to since admission. Despite a policy requiring an interdisciplinary team assessment for self-administration, no documentation was found in R20's electronic medical record (EMR) indicating such an assessment had been conducted. Additionally, the medication administration record (MAR) did not reflect any self-administration documentation, and R20 reported using the inhaler several times a day without being asked by nursing staff about its usage. R26, admitted with chronic respiratory failure and COPD, had a completed self-administration evaluation deeming her safe to self-administer inhaled medications. However, observations revealed that R26 kept her inhaler at the bedside and used it up to four times a day without documenting its use or being asked by nurses about the frequency of use. The MAR did not indicate any PRN doses taken, and there was no physician order for R26 to self-administer inhaled medications. Furthermore, R26 reported not rinsing her mouth after using the medications, which was not addressed by the nursing staff. The facility's policy on self-administration of medications requires nursing staff to determine responsibility for ensuring medication intake, secure storage of medications, and documentation of self-administered doses in the MAR. However, these procedures were not followed for R20 and R26, leading to deficiencies in the facility's medication management practices. The Director of Nursing acknowledged the lack of documentation and indicated that such assessments should be present in the EMR and MAR, but no additional information was provided by the facility by the time of the survey exit.
Failure to Monitor and Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to adequately assess, monitor, and notify the physician of clinical changes in condition for a resident with end-stage renal disease and congestive heart failure. The resident was admitted with a care plan that included monitoring vital signs and notifying the physician of any abnormal readings, as well as monitoring changes in lung sounds, edema, and weight. Despite these directives, the facility did not measure the resident's abdominal girth as ordered, nor did they notify the physician of significant weight gains, which were critical indicators of the resident's heart failure condition. The resident experienced a significant weight gain of over 12 pounds in two days, which was not communicated to the physician. The Registered Dietitian, who was responsible for monitoring resident weights, did not note the weight gain on the monitoring spreadsheet. Additionally, the resident reported that nursing staff had not been measuring his abdominal girth, a key intervention for managing his condition. The Registered Nurse confirmed that there was no evidence of physician notification regarding the weight gains, and the Director of Nursing was unaware of why these critical assessments were not being performed. The facility's policies required timely notification of the physician and responsible parties in the event of significant changes in a resident's condition. However, these policies were not followed, as evidenced by the lack of documentation and communication regarding the resident's weight changes and abdominal girth measurements. This oversight in monitoring and communication contributed to the deficiency in providing appropriate care for the resident's complex medical needs.
Inappropriate Prescription of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that antipsychotic medications were prescribed appropriately for a resident, as there was no documented diagnosis or rationale for the use of Risperidone in the clinical record. The resident, who was admitted with conditions including Covid-19, acute respiratory failure, COPD, and a cognitive communication deficit, was moderately cognitively impaired. Despite not having a mental illness or dementia diagnosis, the resident was prescribed Risperidone for agitation without documented behavioral health diagnoses or a consultation with behavioral health providers. The care plan indicated the use of antipsychotic medications but lacked associated diagnoses. The resident exhibited wandering behaviors but was described as pleasant and easily redirected, with no significant behavioral concerns noted in the progress notes. The facility's policy specified conditions for antipsychotic use, which did not include wandering or non-dangerous agitated behaviors. The LPN Unit Manager confirmed that there was no behavior monitoring in place and that the resident's wandering was understandable due to unfamiliarity with the facility. The facility's failure to document a valid reason for the antipsychotic prescription and lack of behavior monitoring contributed to the deficiency.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) for a resident under Enhanced Barrier Precautions. Resident #37, who was admitted with chronic obstructive pulmonary disorder and peripheral vascular disease, was cognitively intact and required assistance with various activities such as toileting, transferring, and repositioning. The resident's care plan and physician's orders mandated the use of gown and gloves during high-contact care activities, including dressing, bathing, transferring, and toileting, to prevent the transmission of multidrug-resistant organisms. During an observation, a Lead Certified Nursing Assistant (CNA) was seen transferring Resident #37 without donning the required gown and gloves, despite signage indicating the need for enhanced barrier precautions. The CNA mistakenly believed that these precautions were only necessary during wound care. This misunderstanding was clarified by the Licensed Practical Nurse (LPN) Unit Manager, who confirmed that gown and glove use is required for all high-contact care activities for residents on enhanced barrier precautions. The facility's policy, reviewed in December 2020, supports this requirement, emphasizing the use of PPE during specific high-contact activities to prevent the spread of infections.
Failure to Provide Essential Admission Information
Penalty
Summary
The facility failed to provide residents with necessary information regarding Medicaid/Medicare coverage, state agency contacts, advocacy groups, and procedures for filing complaints and grievances. This deficiency was identified through interviews and record reviews involving four residents. The Power of Attorney for one resident reported not receiving an admission packet with information on Medicaid procedures or state agency contacts, leading to confusion when the facility refused to re-admit the resident after hospitalization. Another resident's Designated Power of Attorney also did not receive an admission packet, which resulted in a lack of resources to apply for Medicaid timely and understand bed hold policies, causing stress during the financial process. Additionally, two other residents reported not receiving information about bed hold policies upon admission. The Nursing Home Administrator acknowledged the facility's limited bed availability and the lack of a policy for re-admitting residents after hospitalization. The administrator also confirmed that the facility does not provide admission packets, except for the Admission Agreement, which contributed to the residents' and their representatives' lack of awareness about important procedures and resources.
Deficiency in Admission Policy and Procedure
Penalty
Summary
The facility failed to have an admission policy and procedure in place, resulting in residents being uninformed of their rights and resources. This deficiency was identified through interviews and record reviews for three residents. The Designated Power of Attorney for one resident reported not receiving an admission packet, which led to a lack of information about insurance, Medicaid resources, costs, fees, and bed hold policies. This lack of information caused financial stress and complications, as the resident was not allowed back to the facility after a hospital transfer due to unawareness of the bed hold policy. The Nursing Home Administrator confirmed the absence of an admission policy and the lack of admission packets for residents, which should include information on rights, bed hold policies, costs, and services. The facility only had a Consent to Treat & Admission Agreement, and the administrator was temporarily handling business office duties due to a vacancy. The review of electronic medical records for the residents revealed no Consent to Treat or Admission Agreement on file, further indicating the deficiency in the facility's admission process.
Inadequate Discharge Planning and Readmission Issues
Penalty
Summary
The facility failed to adequately prepare for the discharge of two residents, resulting in unsafe discharges and the inability to readmit one resident post-hospitalization. Resident #4, who was moderately cognitively impaired and required assistance with mobility and activities of daily living, was discharged home without proper support. Upon arrival at home, the resident was unable to care for himself, leading to a return to the hospital the following day. The discharge planning did not adequately consider the resident's needs for assistance, and the facility did not have a focus on discharge planning in the care plan. Resident #5, who had diagnoses including Parkinson's disease and congestive heart failure, was also discharged without proper planning. The resident's Durable Power of Attorney reported not receiving necessary information about insurance, Medicaid resources, or bed hold policies, which led to financial stress and complications in securing Medicaid. The facility attempted to discharge the resident when Medicare coverage ended, despite the resident requiring substantial assistance with ADLs. The facility did not provide a Notice of Medicare Non-Coverage or inform the resident's representative of the right to appeal the discharge decision. The facility's policies on discharge and transfer were not adequately followed, as evidenced by the lack of proper documentation and communication with residents and their representatives. The facility's focus on being a Sub-Acute Rehab (SAR) rather than accommodating long-term care needs contributed to the inadequate discharge planning and failure to readmit residents post-hospitalization. The facility did not have a policy on readmitting residents after hospitalization, and there was a lack of communication regarding bed hold policies and financial responsibilities.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to operationalize its policies and procedures regarding the notification of the Office of the State Long-Term Care Ombudsman about monthly discharges. The policy, dated January 1, 2023, mandates that residents and/or their responsible parties be notified in writing, in a language and manner they understand, prior to transfer or discharge. Additionally, the policy requires that the Ombudsman be notified via written communication of any discharge or transfer, with documentation related to the discharge or transfer included in the clinical record. However, the facility did not adhere to this policy, as evidenced by the lack of notification to the Ombudsman of all facility-initiated discharges over the past ten months. During an interview, the Nursing Home Administrator admitted that they did not maintain a list of LTC Ombudsman discharge notifications and had not reported discharges to the Ombudsman. An email from the LTC Ombudsman confirmed that the last Emergency Transfer Tracking reported was in June and July of 2023, with no communication of facility-initiated discharges since then. The Director of Nursing only reached out to the Ombudsman the day before the survey began to inquire about the regulation and the necessary information to proceed, indicating a significant lapse in compliance with the notification requirements.
Failure to Provide Bed Hold Policies to Residents
Penalty
Summary
The facility failed to provide Bed Hold policies to residents upon admission and during transfers to acute care or therapeutic leave, affecting all residents admitted to the facility. The deficiency was identified through interviews and record reviews, revealing that 12 residents did not receive the necessary documentation. The Notice of Bed Hold Policy, which should be signed by the patient or documented by the family or Designated Power of Attorney (DPOA), was not present in the Electronic Medical Records (EMR) for these residents. This lack of documentation indicates a systemic issue in the facility's admission and transfer processes. Specific cases highlight the impact of this deficiency. For instance, a resident with an acute condition was transferred to a hospital, and the facility refused to accept him back, leading to confusion and distress for the resident's Power of Attorney (POA). Another resident was not allowed to return after a hospital visit for a urinary tract infection, causing financial stress on the family. Interviews with residents and their representatives revealed a lack of awareness about the Bed Hold policy, and the Nursing Home Administrator admitted that admission packets did not include this policy, further contributing to the deficiency.
Deficient Telephone Communication System
Penalty
Summary
The facility failed to maintain an effective telephone communication system, impacting the ability of a resident's designated power of attorney (DPOA) to communicate with the resident and staff. The DPOA reported multiple instances where calls to the resident's room were not received, and attempts to contact the front desk resulted in an automated message without options to leave a message or redirect the call. The DPOA also experienced difficulties reaching the charge nurse, as calls to the facility would ring for extended periods without being answered, and attempts to contact the social worker resulted in poor call quality and disconnection. Interviews with facility staff revealed issues with the phone system, including problems with the 'Do Not Disturb' button being accidentally activated, preventing calls from going through. The Maintenance Director acknowledged a programming glitch in one room's phone system, which was resolved, but did not recall issues with the room where the resident resided. The LPN reported challenges in transferring calls to resident rooms and noted that the new phone system does not allow callers to leave messages if unanswered. The Nursing Home Administrator was unaware of the DPOA's communication issues and reported no records of concerns related to the phone system, although he acknowledged the facility's contract limitations with the current tech company.
Failure to Assist Resident with Medicaid Application
Penalty
Summary
The facility failed to provide necessary assistance and written information to a resident's designated power of attorney (DPOA) on how to apply for and use Medicare and Medicaid benefits. This resulted in the resident not having Medicaid coverage in a timely manner, leading to significant out-of-pocket expenses. The resident, who was admitted with diagnoses including Parkinson's disease, congestive heart failure, and cognitive communication deficit, faced financial challenges when Medicare coverage ended. The DPOA reported not receiving an admission packet with pertinent insurance and Medicaid information, leading to a stressful financial situation. The facility attempted to discharge the resident home, despite the resident requiring two-person assistance for care, and demanded advance payment for continued stay. The DPOA had to fill out Medicaid paperwork multiple times without assistance, resulting in a $14,000 bill. The facility's business office manager provided a Medicaid application only after receiving a check for three days of private pay. The facility did not have a policy for readmitting residents after hospitalization and did not provide admission packets. The resident's Medicaid application was delayed, and there was a lack of follow-up when Medicare coverage ended. The facility's regional business office manager consultant confirmed that the facility should have assisted the DPOA in applying for Medicaid sooner and that the NOMNC was not properly handled.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident, identified as Resident #5, after hospitalization, which resulted in the resident needing to find placement at another facility. Resident #5 was admitted to the facility with diagnoses including Parkinson's disease, congestive heart failure, and cognitive communication deficit. The resident was moderately cognitively impaired and required substantial to maximum assistance for most activities of daily living. The Designated Power of Attorney (DPOA) for Resident #5 reported not receiving an admission packet with information on insurance, Medicaid resources, costs, fees, or bed hold policies, which led to a lack of timely Medicaid application and awareness of bed hold policies. The facility's Social Worker informed the DPOA that Resident #5 would not be accepted back from the hospital as the resident required long-term care, which the facility was not equipped to provide. The Nursing Home Administrator (NHA) confirmed that the facility was designed for Sub-Acute Rehab (SAR) and not long-term care, and that Resident #5, who was pending Medicaid, would not have a payor source for readmission. The facility did not have a policy on permitting residents to return after hospitalization and did not provide admission packets upon admission. The Business Office Manager (BOM) and Regional BOM Consultant noted that Resident #5's Medicaid was pending upon discharge to the hospital, and the NOMNC (Notice of Medicare Non-Coverage) was not signed by the DPOA. The facility did not assist the family in applying for Medicaid in a timely manner. Additionally, there was no notice of transfer and discharge or bed hold policy on file for Resident #5, and the facility's bed hold policy document was not completed as required.
Deficient Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate care and services for pressure ulcers for two residents, Resident #8 and Resident #6, who required repositioning, assessment, and monitoring, as well as daily dressing care and wound vac care. Resident #8 was observed multiple times throughout the day lying in the same position without being repositioned, despite having a care plan that required regular repositioning to relieve pressure from his ulcers. Interviews with staff revealed a lack of documentation regarding the resident's refusals to be repositioned, and there was no evidence that the physician was notified of these refusals. Additionally, there were missed dressing changes for Resident #8's pressure ulcers, with no documentation of reapproach or physician notification. Resident #6 was readmitted to the facility with an unstageable pressure ulcer and was supposed to have a wound vac in place. However, there were no wound care orders in place upon his readmission, and the wound vac was not functioning properly due to the resident's refusal to be turned. The facility's standard procedure for a non-functioning wound vac was not followed, as there was no alternative dressing applied to prevent further deterioration of the wound. The Director of Nursing acknowledged the challenges with the wound vac but could not provide documentation that the physicians were aware of the issues or that the resident did not receive wound care over the weekend. The facility's policies and care plans for both residents were not adequately followed, leading to deficiencies in the care provided for their pressure ulcers. The lack of documentation and communication regarding the residents' refusals and the non-functioning wound vac contributed to the failure to provide necessary treatments and interventions. This resulted in a deficiency citation for the facility, highlighting the need for improved adherence to care plans and policies to ensure proper wound care management.
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What surveyors actually found near you
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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 Wyoming
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health & Rehabilitation Of Wyoming | 1.2 mi | ★★★★★ | 41 | 0 |
| Medilodge Of Wyoming | 2.6 mi | ★★★★★ | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 2.9 mi | ★★★★★ | 0 | 0 |
| Corewell Health Rehabilitation & Nursing Center - | 4.1 mi | ★★★★★ | 7 | 0 |
| Optalis Health And Rehabilitation Of Grand Rapids | 4.3 mi | ★★★★★ | 34 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.