Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Terrace Senior Living during CMS and state inspections, most recent first.
Kitchen and dishwashing areas had widespread buildup of debris, grease, grime, and food residue on floors, equipment, sinks, drain boards, and storage areas. The fryer oil was black with food debris, the microwave and other equipment were heavily soiled, a hand sink was used as a dump sink, and the dish machine was out of soap with sanitizing water only reaching 158°F. A leaking overhead sprayer and sticky residue around beverage dispensers were also observed.
Premises Not Maintained and Repaired: Surveyors observed multiple cracks and damaged areas in the dining room handsink wall, a conference room wall, and the spa room, including ceiling-to-floor and horizontal cracks, a monitored crack above the spa entrance, and a floor dip by the toilet that left a gap at the wall coving. FMS stated the cracks were due to building settling and were being monitored by an engineering team, with some cracks approved for patching.
Failure to Provide Discharge Notice, Bed Hold Information, and Ombudsman Notifications: The facility did not provide written discharge notice to a resident’s family when the resident was discharged after a respite stay that became private pay, and staff told the family the resident had to leave or pay a large monthly amount after Medicaid was pursued. The facility also did not give a resident transferred to the hospital a clear written bed hold policy or documentation showing the resident could accept or decline the bed hold and its cost. In addition, the NHA stated the facility had not been sending monthly discharge notifications to the Ombudsman.
A facility failed to follow policy and timely pursue POA activation for a resident with severe cognitive impairment, aphasia, and stroke-related deficits. The resident was listed as her own responsible party, but admission paperwork contained illegible signatures, including on the DNR, and the SW verified the POA had not been activated or discussed with the physician. The resident could not clearly communicate her wishes, appeared confused about her DNR and POA status, and the DON stated staff should recognize severe cognitive impairment and address competency and POA activation promptly.
Improper Wound Care During Dressing Change: A resident with necrotizing fasciitis, bacteremia, and morbid obesity had ordered wound care for a right gluteal wound. During the dressing change, an LPN and the ADON cleansed the wound, applied zinc barrier cream around it, and then packed the wound with Vashe-soaked kerlix gauze, which came into contact with the barrier cream. The LPN continued the dressing change, and the DON stated the zinc barrier cream would be the last thing applied.
Lack of Hospice Communication Documentation: A resident with Alzheimer's disease, dementia, and depression was documented as being on hospice and receiving hospice services, but the EMR contained no hospice services documentation. The DON stated that hospice communicated verbally and acknowledged that no hospice communication information was present in the EMR.
A resident with CVA, vascular dementia, depression, anxiety, and palliative care needs was admitted for respite with plans for LTC placement, but the facility later told the family the resident had to leave or pay a large private-pay amount after Medicaid paperwork was filed. Staff said they did not assist with Medicaid enrollment and discussed limited Medicaid beds, while the family reported being told there was no choice but to move the resident and that a 30-day notice was refused. The discharge paperwork reflected the resident was ready for LTC and a higher level of care.
Kitchen and Dishwashing Areas Not Cleaned or Maintained
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and related kitchen areas during survey observations and interviews. During an initial kitchen tour, the flooring throughout the kitchen was observed with debris, dust, dirt, and greasy food residue, including heavy buildup under cooking equipment, shelving, and along floor/wall junctures. The fryer oil was black with crispy food debris floating on the surface, the microwave had multiple layers of stuck-on food debris and grime inside and on the door, top, sides, and bottom, and the cooking equipment beneath the hood system, standing mixer, and can opener all had visible buildup of grease, grime, and food debris. Additional observations showed the side boards on the well steamer unit were down, and when lifted, the underside and surrounding area were covered in food debris, grease, grime, and drip marks. Hand sinks and prep sinks throughout the kitchen were soiled, and the hand sink in the dishwashing area was being used as a dump sink with yellow liquid eggs at the bottom of the basin. In the dishwashing area, the dish machine alarm was sounding, the machine was out of soap, and the hot water during the sanitizing cycle only reached 158 degrees. Staff interviewed during the event were unable to explain the alarm or the sanitizing issue, and the cook identified herself as in charge but stated she did not know what the beeping meant. The survey also found grime, slime, and debris on the clean and soiled drain boards, and the shelving area where soiled cups and bowls were stored before washing had black, brown, and pink grime/slime. In the dining area, the exterior cabinet around the beverage dispensers had a heavy buildup of sticky brown residue, which the Dining Services Assistant Director confirmed appeared to come from the pop dispenser. Later observation identified water leaking from the pipe connection of the overhead sprayer in the dishwash area, and the Director of Plant Operations stated the fixture continued to leak despite prior work on the flexible arm, attributing the leak to the backflow preventer and noting it would stop only when the water was turned off.
Premises Not Maintained and Repaired
Penalty
Summary
The facility failed to maintain and repair the premises, with multiple cracks and damaged areas observed in several locations. On 03/10/2026, surveyors observed a horizontal crack about four feet long in the wall area at the dining room handsink, a four-foot crack on the outside wall in a conference room across from the kitchen, and several cracks in the spa room on Angler Avenue hall, including a ceiling-to-floor crack at the wall juncture by the spa tub, horizontal cracks above the entrance door, and a vertical crack in the corner by the toilet. Monitoring tape was in place on the crack above the spa room entrance door to measure movement. In the spa room, the flooring by the toilet dipped before meeting the wall, leaving about a one-quarter inch space where the wall coving was not in contact with the flooring. Facilities Management Support stated the cracks were due to settling of the building and were being monitored by an engineering team, and later stated that the department had approved the construction team to patch cracks that were not being actively monitored.
Failure to Provide Discharge Notice, Bed Hold Information, and Ombudsman Notifications
Penalty
Summary
The facility failed to follow discharge policies and procedures for a resident who had originally entered for a 5-day respite stay and later remained private pay for 49 days before being discharged to another SNF. The resident had diagnoses including cerebral infarction, vascular dementia, major depressive disorder, anxiety disorder, and encounter for palliative care. The resident’s family reported that after they began pursuing Medicaid assistance, the facility told them the resident would have to move out by the end of the month or pay $12,000 for the next month, and that the facility would not honor the resident’s Medicaid status because he was not in an LTC bed. For this resident, the facility’s record did not reflect that the family was notified in writing of the discharge. The facility policy required written notice to the resident and, if known, a family member or legal representative 30 days in advance of transfer or discharge, including the effective date, destination, and reasons for the discharge. The complainant stated that a request for a 30-day eviction notice was refused, and the facility said the resident was not being evicted and could stay if the family paid the private-pay amount. The facility also failed to provide a bed hold policy to a resident transferred to the hospital. The resident had diagnoses of hemiplegia and hemiparesis and was moderately cognitively impaired. Staff reported they did not recall providing a written bed hold form or policy before transfer, and the documentation reviewed did not clearly show that the resident was offered the option to reserve the bed, decline the bed hold, or understand the associated cost. In addition, the facility had not been providing the Ombudsman with monthly discharge notifications for several months, and the NHA and interim social worker stated they were only educated on that requirement during the survey.
Failure to Activate POA for Severely Cognitively Impaired Resident
Penalty
Summary
The facility failed to follow its policies and procedures and did not pursue timely guardianship activation for a resident who was severely cognitively impaired. The resident was admitted with diagnoses including hemiplegia/hemiparesis, aphasia following cerebral infarction, and dysphagia, and the MDS identified the resident as severely cognitively impaired. The face sheet listed the resident as her own responsible party, while admission paperwork contained illegible signatures and signatures that were not on the signature line, including on the DNR document. During observation and interviews, the resident was seen crying in a wheelchair and could not explain what was wrong. The resident’s daughter stated the resident had not been the same since a prior stroke and said another sister would be the POA, but she was unsure whether it had been activated. The Interim SW verified the POA was not activated, had not yet asked the resident if she wanted it activated, and had not spoken with the physician about activating it. The resident later stated she did not remember signing the admission contracts, was unsure about her healthcare decisions, thought her daughter was already activated as POA, and nodded yes when asked if it would be beneficial for her daughter to make decisions for her. The DON stated staff should recognize a resident with a low BIMS as severely cognitively impaired and look into deeming the resident incompetent and activating the POA timely, especially for a newer admission.
Improper Wound Care During Dressing Change
Penalty
Summary
The facility failed to provide appropriate wound care for one resident with diagnoses of necrotizing fasciitis, bacteremia, and morbid obesity. The resident reported concerns about wound care over the weekend. Orders required cleansing and irrigating the right gluteal wound with normal saline, applying zinc barrier cream around the wound, and packing the wound with Vashe-soaked kerlix gauze twice daily. During observation of wound care, an LPN and the ADON removed the packing, cleansed the wound and surrounding tissue with normal saline, applied zinc barrier cream around the wound, and then packed the wound with a kerlix gauze soaked with the ordered wound solution. As the packing was being placed, the kerlix gauze came into contact with the zinc barrier cream surrounding the wound, and the LPN continued the dressing change and covered the wound with an ABD pad. When questioned later, the LPN stated she could understand how packing the wound before applying the zinc barrier cream could prevent the cream from getting into the wound, and the DON stated she would not apply the zinc barrier cream first because if the kerlix gauze contacted it, it would be hard to get it out of the wound.
Lack of Hospice Communication Documentation
Penalty
Summary
The facility failed to have a system for hospice communication and services provided for one resident who was on hospice. Resident #27 had diagnoses of Alzheimer's disease, dementia, and depression. Review of the care plan showed the resident was on hospice, and a physician progress note dated 2/19/26 documented that the resident was receiving hospice services. However, review of the EMR found no hospice services documentation for the resident. During an interview on 3/11/26 at 2:19 PM, the DON stated that hospice communicates verbally and acknowledged that there was no hospice communication information in the EMR for the resident.
Improper discharge tied to Medicaid status
Penalty
Summary
The facility failed to ensure an appropriate transfer and discharge process based on resident rights and medical needs for one resident, who had diagnoses including cerebral infarction, vascular dementia, major depressive disorder, anxiety disorder, and palliative care needs. The resident was admitted for an initial respite stay, with the family initially planning to pay privately while the facility and family discussed possible long-term care placement and Medicaid eligibility. Documentation showed the resident’s discharge plan was to remain on campus for long-term care, and the family was involved in discharge planning. The record also showed that the resident’s family and attorney were working on Medicaid, including an Assets Declaration and Medicaid application filed with the county health and human services office. The resident’s lawyer’s letter was later attached to the medical record. During interviews, admissions staff stated the facility did not assist with Medicaid enrollment, only gathered information and referred families to an elder law attorney or business office manager. An admissions coordinator stated that if a resident wanted long-term care, the facility would inform them how many beds were available and that Medicaid discussions occurred before admission. The complainant stated that once the facility learned Medicaid had been applied for, the family was told the resident would have to move out by the end of the month or pay $12,000 for the next month, and that the facility said there were no Medicaid beds available. The complainant also stated the facility refused to provide a 30-day eviction notice and said the resident could stay only if the private-pay amount was paid. The nursing home administrator stated the resident was moved to another LTC facility because it was closer to family, while the discharge summary and narrative goals of stay reflected that the resident was ready to move to LTC and to a higher level of care.
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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 Muskegon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health & Rehabilitation Of Muskegon | 1.7 mi | ★★★★★ | 40 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Roosevelt Park Nursing And Rehabilitation Communit | 2.4 mi | ★★★★★ | 3 | 0 |
| Hillcrest Nursing And Rehabilitation Community | 2.6 mi | ★★★★★ | 12 | 0 |
| Christian Care Nursing Center | 3.5 mi | ★★★★★ | 5 | 0 |
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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.