Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Harbour View Senior Living Corp during CMS and state inspections, most recent first.
A resident admitted with no documented wounds and at risk for skin breakdown later developed a sacral pressure injury and bilateral heel injuries that were not promptly captured or treated in the record. The wound consult documented an unstageable sacral wound and deep tissue injuries to both heels, but key orders such as medihoney, heel offloading, and skin prep were delayed, and the resident’s wounds worsened to stage 4 and additional sites of injury. Surveyors also found no admission care plan for skin risk and no documented evidence of a functional air mattress when the resident’s mattress was found to be low pressure.
The facility failed to ensure that performance reviews were available for 5 of 5 CNA files reviewed. Surveyors requested annual education, competencies, and performance reviews for five randomly selected CNAs, but the facility only produced skills checklists, competency forms, and in-service sign-in sheets. The DON stated she could not locate the performance evaluations and that they may not be in the building if not with HR.
The facility failed to assure required QAPI committee members attended quarterly QA meetings. Review of the QAPI binder showed the Medical Director and Infection Preventionist were absent from multiple meetings, and the DON was also missing from some meetings or did not provide a report. Facility leadership stated meeting dates were announced in morning meetings and that the Medical Director was informed verbally when present, but attendance records did not reflect consistent participation by the required members.
Incomplete COVID-19 Staff Testing During Outbreak: During a COVID-19 outbreak involving two residents on one unit, the facility did not test all staff with contact to the residents as described by the DON and required by the facility’s policy. Surveyors found that only selected CNAs and nurses were tested on days 1, 3, and 5, while staffing assignments showed multiple additional CNAs and nurses worked the affected shifts. The IP/LPN could not explain the limited testing, and the LNHA and DON had no response when questioned.
Pneumococcal vaccine assessment, offering, and documentation were incomplete for multiple residents. Records showed one resident had only an old refusal on file, another had consent but no administration yet, and two others had no documented vaccine status, declination, or order. The IP/LPN and MDSC described inconsistent documentation practices, including reliance on outdated immunization entries and lack of notes on attempts to contact residents or representatives.
The facility failed to ensure that 5 of 5 CNA education files showed at least 12 hours of required in-service training and included mandatory topics such as abuse prevention and QAPI. The DON said the IP/LPN handled staff education, but the records reviewed showed no hours on competency forms and only eight 60-minute in-service sheets that did not include abuse-related or QAPI topics. The IP/LPN stated education was tracked on paper without a log or tracker and believed it was annual by calendar rather than by hire date.
Unsafe and unclean resident areas were observed in multiple rooms and shower rooms. In one room, the closet would not fully close because of excess clothing, a dresser drawer was uneven from overflowing clothes, and the toilet room lacked paper towels; in shower rooms, ceiling vents had visible dust accumulation. In another room, two containers of disinfecting spray labeled with a resident’s name were found behind the curtains, and an LPN stated such sprays should not be in the room. A separate resident room had a discolored, uneven ceiling area that appeared damaged, and staff gave inconsistent explanations for how maintenance issues were reported, with no repair order available for the ceiling concern.
The facility failed to complete comprehensive MDS assessments within the required 14-day timeframe for two residents. An RN/MDSC acknowledged the assessments were late and confirmed the admission MDS must be completed within 14 days, counting the admission date as day 1; the facility policy matched this requirement.
The facility failed to transmit comprehensive MDS assessments within the required timeframe for three residents. Survey review found that each assessment was completed but sent late, and the RN/MDSC acknowledged the submissions were overdue. The facility policy required timely completion and transmission of MDS assessments in accordance with CMS RAI guidance.
Care Plan, Medication Documentation, and Order Carryout Failures: A resident with severe cognitive impairment had a psychotropic med order changed, but the care plan was not updated to match the corrected diagnosis and behavior monitoring did not capture the number of behavior episodes. Multiple ordered treatments and assessments for several residents were left blank on the eTAR, and an LPN and the DON stated there should be no omissions. In another case, a resident with severe cognitive impairment had donepezil discontinued without documentation explaining why, even though a psych consult recommended continuing it and the DON acknowledged the missing documentation.
Improper Administration of Ranolazine via G-Tube: A resident with dysphagia, CVA history, and a G-tube had an order for ranolazine ER for angina, but staff administered it by dissolving the tablet in water for PEG/G-tube use even though the manufacturer stated it should not be crushed, broken, or chewed. An LPN confirmed this practice was used by multiple shifts and acknowledged there was no call to clarify the order with the cardiologist, despite repeated pharmacy consultant recommendations to review for an alternative.
Controlled substance documentation was not completed correctly when an LPN administered scheduled meds to a resident with cancer-related pain, as the CDS accountability sheet was not signed when the doses were removed. The facility also failed to properly complete DEA 222 forms for Schedule II narcotics, leaving received quantities and dates blank on executed forms and keeping several pre-signed blank forms with the MD’s signature already on them.
Improper Storage of Alcohol and Zinc Oxide Ointment: A surveyor found two containers of 91% alcohol and a container of zinc oxide ointment with a resident's name stored behind a curtain in a resident room. An LPN stated the zinc oxide belonged in the treatment cart and that both residents in the room were cognitively impaired. The resident's order for the zinc oxide had already been discontinued, and the DON acknowledged the alcohol and ointment were not being stored as expected.
The facility failed to properly contain trash in a closed dumpster, resulting in trash overflowing the dumpster area and spilling onto the ground. Despite the Dietary Manager's statement that trash would be picked up the next day, the issue persisted over several days. The Administrator confirmed there was no specific policy for trash disposal, although it was acknowledged that trash is picked up twice a week and the area is required to be kept clean and contained.
The facility failed to prominently post daily nurse staffing information in areas accessible to residents and visitors, affecting 59 census residents. Observations and interviews revealed that the staffing data was not posted in the front lobby or near the nurse's stations, and staff were unaware of the posting requirement.
Failure to timely identify and treat pressure injuries
Penalty
Summary
The facility failed to ensure that a resident who was admitted without a documented pressure ulcer and who was identified as at risk for skin breakdown received care and services in accordance with professional standards to prevent pressure injuries. The resident was admitted with incontinence, was chair-fast, had a Braden score of 17, and had a turning and positioning program noted on admission. Hospital records reviewed by surveyors indicated the resident’s skin had no impairment before discharge, and the admission summary documented no wounds on the body. However, the resident later developed a sacral wound that was first reported by a CNA, and the nurse documented cleansing the area and notifying the MD for a wound consult. Surveyor review showed that the resident’s sacral wound and bilateral heel injuries were not identified and treated promptly in the record. The wound consult on the sacrum and heels documented an unstageable sacral pressure injury and deep tissue injuries to both heels, with recommendations including medihoney for the sacrum, skin prep for the heels, floating the heels, limiting sitting to 60 minutes, offloading, and repositioning. The order audit showed that medihoney for the sacrum was not ordered until after the wound was identified, float heels was not ordered until later, and skin prep for the heels was not ordered until much later. The record also showed no documented evidence that the recommendation to limit sitting to 60 minutes was followed. The resident’s wounds worsened over time and additional wounds developed. The sacral wound progressed from unstageable to a stage 4 pressure wound after surgical excisional debridement removed necrotic tissue, and later wound notes described increasing size and depth with ongoing debridements. The bilateral heel wounds progressed from deep tissue injury to open stage 2 pressure injuries, and a left lateral ankle wound and later a left lateral lower leg stage 1 pressure injury were also documented. Surveyors also found no care plans initiated on admission for the resident’s risk of skin breakdown or when the sacral and heel wounds were first identified, and the facility had no documented evidence that a functional air mattress was provided when the resident’s mattress was found to have low pressure and replacement mattresses were reported as not working.
Missing CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received performance reviews for 5 of 5 CNA files reviewed. During the survey, the Licensed Nursing Home Administrator and Director of Nursing were asked to provide annual education, competencies, and performance reviews for five randomly selected CNAs. The facility produced Nursing Assistant Clinical Skills Checklist and Competency forms, along with in-service education sign-in sheets, but did not provide performance reviews for any of the five CNAs. When asked whether the CNA performance evaluations were available, the DON stated she could not locate them and said that if they were not with Human Resources, they may not be in the building. The survey team later met with the DON, LNHA, and Regional Director of Nursing, and the DON stated that the performance reviews were not available.
QAPI Committee Meetings Lacked Required Attendance
Penalty
Summary
The facility failed to assure that the required members attended quarterly Quality Assurance (QA) meetings as required by regulation and the facility’s own QAPI plan. Review of the QAPI binder showed multiple quarterly meetings where the Medical Director did not sign the attendance sheet, including the meetings dated 8/29/24, 12/18/24, 3/27/25, and 6/26/25. The DON also did not sign or provide a report for some meetings, and the Infection Preventionist did not sign or provide a report for the meetings dated 3/27/25 and 6/26/25. During interview, the Infection Preventionist stated she attended the 5/29/25 QAPI meeting but did not attend the 6/26/25 meeting. Facility leadership, including the LNHA and DON, stated that QAPI meeting dates were announced in morning meetings and that the Medical Director was informed verbally when present in the facility, but there was no response from the Medical Director when surveyors attempted to interview him. The facility’s QAPI plan stated that the committee would include the Administrator, DON, Assistant DON, Social Service Director, Director of Rehab Services, Director of Food Service, Activities Director, Medical Director, Human Resources Director, Director of Support Services, Director of Maintenance, and at least two non-licensed staff or a community representative.
Incomplete COVID-19 Staff Testing During Outbreak
Penalty
Summary
The facility failed to follow appropriate COVID-19 testing practices for staff during an outbreak involving two residents on the same unit who tested positive for COVID-19. The Director of Nursing stated that the facility’s practice was to test the COVID-positive resident, the roommate, and all staff who had contact with the resident on days 1, 3, and 5, usually those staff who worked within 24 hours or three shifts. However, the Infection Preventionist/LPN could not explain why only a limited number of CNAs and nurses were tested for the affected residents, and the LNHA and DON had no response when asked about the testing concerns. Survey review of the facility’s contact tracing and staffing assignments showed that for one resident’s positive COVID-19 case, only two CNAs and two nurses were tested, and for the other resident’s positive case, only one CNA and one nurse were tested. The line listing also showed that two residents and four therapists were tested for both dates of COVID-19 cases, with negative results on days 1, 3, and 5. The facility’s CNA assignment records identified multiple CNAs and nurses assigned to the unit across the relevant shifts, including RN#1, LPN#1, LPN#2, LPN#3, LPN#4, LPN#5, CNA#1 through CNA#8, and others, but the testing records did not reflect testing of all staff who had contact with the residents. The facility’s COVID-19 Testing Policy stated that it would implement testing of facility residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19, and defined close contact as being within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Despite this policy and the CDC guidance reviewed by surveyors, the facility’s testing documentation showed that only selected staff were tested for the two COVID-19 cases, and the facility did not provide an explanation for the limited testing.
Pneumococcal Vaccine Assessment and Documentation Failure
Penalty
Summary
The facility failed to offer and administer pneumococcal vaccination to multiple residents, with deficient practice identified for 4 of 5 residents reviewed for immunizations. The report documented that the facility’s immunization records, MDS coding, and chart documentation did not consistently show that the pneumococcal vaccine had been assessed, offered, or recorded for residents with varying cognitive status and medical histories. For one resident with schizoaffective disorder, heart failure, anemia, and severely impaired cognition, the record showed a prior pneumococcal vaccine refusal from 2022, but there was no documented evidence that the vaccine was offered during the current admission in July 2025. The IP/LPN stated that the vaccine should be offered upon admission and said she was still trying to obtain consent from the resident’s representative, but she had not documented the attempted phone call. The MDSC stated she coded the resident as offered and declined based on the immunization section, even though the date in that section reflected the older refusal. For another resident with intact cognition and diagnoses including low back pain, spinal stenosis, pressure ulcer, and malignant neoplasm, the record showed the pneumococcal vaccine as pending with consent confirmed by the IP/LPN, but the vaccine had not yet been administered. The IP/LPN stated she had obtained consent, planned to administer it later, and would place an order to the pharmacy, while also stating she did not document attempts to obtain records from the hospital. The MDSC stated she coded the resident as offered and declined because the EMR showed the vaccine as pending and she believed there was no other MDS option. For two additional residents, one with Parkinson’s disease, hypertension, and peripheral vascular disease, and another with type 2 diabetes, hypertension, and peripheral vascular disease, the records contained no documentation of pneumococcal vaccination status, administration, declination, or an order for the vaccine. Their MDS assessments indicated the vaccine was not up to date and not offered, and the IP/LPN stated that immunization information should be documented in the EMR. For the resident with severe cognitive impairment, the IP/LPN stated she had not yet discussed the pneumococcal vaccine with the resident or representative and had not followed up because she was working on other residents’ consents.
CNA In-Service Training Records Missing Required Hours and Topics
Penalty
Summary
The facility failed to ensure that 5 of 5 CNA education files reviewed reflected at least 12 hours of mandatory in-service training and included required topics such as abuse prevention, facility assessment, and QAPI. On 8/18/25, the surveyor requested employee files for five randomly selected CNAs, and the DON stated that the IP/LPN was responsible for staff education. On review, the Nursing Assistant Clinical Skills Checklist and Competency evaluations for all five CNAs had no hours listed and did not include abuse prevention topics. The facility also provided eight in-service attendance sheets dated 1/28/25, 2/5/25, 3/3/25, 4/8/25, 5/13/25, 6/3/25, 8/1/25, and 8/4/25, each showing 60 minutes of education, but none reflected abuse, abuse prevention, or QAPI topics. During interview, the IP/LPN stated that staff education was kept on paper, that education was provided to staff on the schedule across shifts, and that there was no tracker or log to monitor the training. The IP/LPN also stated she believed the education was annual by calendar and was not aware it was based on hire date for CNA mandatory in-service monitoring. When asked for a policy on mandatory staff in-services, the facility did not provide one. The DON later stated there were no electronic education records for 2024 and that previous employees had been responsible for keeping the documents current. The facility's Prohibition of Resident Abuse and Neglect Policy, dated 7/18/22, stated that employees would receive abuse prevention training at orientation and annually.
Unsafe and Unclean Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in multiple resident areas, including Resident Rooms 7, 11, and 29 and one shower room. During a unit tour, the Housekeeping Director and surveyor observed in Room 11 that the closet could not fully close because of too many resident clothes inside, the toilet room had no paper towels, and a dresser drawer was uneven because of overflowing clothes. In the same room, the shower room vents had grayish accumulation identified by the Housekeeping Director as dust, and the Housekeeping Director stated it was housekeeping’s responsibility to clean the vents. In Room 7, the surveyor and Housekeeping Director observed two containers of disinfecting spray with a resident’s name on them behind the window curtains. The Infection Preventionist/LPN later stated that there should be no disinfecting sprays inside the room. In another shower room on the East unit, the ceiling vent also had grayish accumulation that the Housekeeping Director confirmed was dust and stated should have been cleaned daily. When asked, the Housekeeping Director stated the vents did not look like they were cleaned every day and acknowledged there was no accountability log for cleaning the vents. In Room 29, the surveyor observed a brownish discolored area and a rectangular section of ceiling over the resident’s TV and dresser that appeared uneven and possibly missing a thin section of ceiling material. The same condition was observed again several days later with no change. Staff gave differing explanations for how maintenance concerns were reported, including an electronic reporting system, calling the front desk, or paging maintenance. The Director of Maintenance stated workers had a printout of maintenance requests but could not show a repair order for Room 29, and the facility leadership stated there was no separate policy for Maintenance or Homelike Environment.
Late Completion of Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete the comprehensive MDS assessment within the required timeframe for 2 of 17 residents reviewed for comprehensive resident assessments. Resident #62 had a comprehensive MDS with an ARD of 7/30/25, but it was dated and signed as complete on 8/11/25, which was more than 14 days after the 7/23/25 admission date. Resident #57 had a comprehensive MDS with an ARD of 6/1/25, but it was dated and signed as complete on 6/8/25, which was more than 14 days after the 5/25/25 admission date. During the survey, the RN/MDS coordinator acknowledged that the admission comprehensive MDS assessment should be completed within 14 days from the admission date, counting the admission date as day 1, and confirmed that the identified assessments were completed late. The facility policy also stated that the admission assessment must be completed within 14 days of admission, counting the day of admission as day #1.
Late MDS Transmission for Three Residents
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required timeframe for 3 of 17 residents reviewed: Residents #4, #5, and #19. Survey review showed that Resident #19 had a comprehensive MDS with an ARD of 7/18/25 that was transmitted on 8/11/25, Resident #4 had a comprehensive MDS with an ARD of 3/19/25 that was transmitted on 4/12/25, and Resident #5 had a comprehensive MDS with an ARD of 7/7/25 that was transmitted on 7/31/25. The report cited CMS RAI manual guidance stating that comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. During interview, the RN/MDS coordinator initially stated she would need to confirm the transmission timeframe, then later acknowledged that the identified MDS assessments were late and stated the timeframe for submission was care plan completion plus 14 days. The facility’s policy also stated that both completion and transmission deadlines must be met for compliance. The DON later stated that in-service education had been provided to staff about completing MDS sections timely and that the facility would initiate a QAPI project related to the concern.
Care Plan, Medication Documentation, and Order Carryout Failures
Penalty
Summary
The facility failed to keep Resident #5’s care plan aligned with changes in the resident’s psychotropic medication documentation and behavior monitoring process. Resident #5 was admitted with diagnoses including schizoaffective disorder, heart failure, and anemia, and had severe cognitive impairment with a BIMS score of 6. The resident was receiving risperidone for schizophrenia, then the medication order was changed to reflect schizoaffective disorder. The resident’s comprehensive care plan still reflected psychotropic medication use related to schizophrenia and was not updated to match the corrected diagnosis. The facility also used a behavior monitoring order for the resident’s antipsychotic medication, but the order did not include a section for the number of behavior episodes in a shift, and the monthly psychotropic review did not indicate the amount of target behaviors exhibited for the month. The facility also failed to document administration or omission of multiple ordered treatments and assessments on the electronic treatment record for several residents. For Resident #5, several entries were left blank for ordered hydrocortisone cream, symptom assessments, Nystop powder, and pain assessments. For Resident #24, blank entries were found for wound care, air mattress use, symptom assessments, Nystatin powder, and pain assessments. For Resident #31, blank entries were found for ordered symptom assessments. When interviewed, an LPN stated that if an order was to be carried out on the shift, it was expected to be done and that there should not be any blanks. The DON also stated that there should be no omissions. The facility’s physician medication orders policy did not include information regarding administration and omissions. The facility further failed to document the rationale for discontinuing donepezil for Resident #62. The resident had diagnoses including type 2 diabetes mellitus, hypertension, and peripheral vascular disease, and had severe cognitive impairment with a BIMS score of 3. The record showed donepezil was discontinued, and later Seroquel was started and then discontinued. Nursing notes documented medication refusals and behavioral issues, but there was no documentation explaining why donepezil was stopped. A psychiatric consultant note in the record recommended discontinuing Seroquel, continuing donepezil, and continuing melatonin. The DON acknowledged there was no additional documentation in the medical record by nurses or the physician regarding the discontinuation of donepezil, and the facility did not have a policy related to physician consultants or their recommendations.
Improper Administration of Ranolazine via G-Tube
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures related to tube feeding and medication administration. The resident had diagnoses including dysphagia following a CVA, hemiplegia and hemiparesis, CAD, NSTEMI, and gastrostomy tube dependence. The resident was NPO and had an order for Jevity 1.5 via G-tube at 65 ml/hr for 20 hours, with instructions to check tube placement before medication administration and flush the tube before and after meds. The resident also had orders for ranolazine ER for angina, including administration via G-tube. The manufacturer label stated that Ranexa/ranolazine tablets should be swallowed whole and not crushed, broken, or chewed. Despite this, the LPN stated that the medication was being given by placing the tablet in water and dissolving it for G-tube administration, and that night shift nurses were doing the same. The LPN acknowledged that ranolazine could not be crushed and stated that there had been no call to clarify the order with the cardiologist. The pharmacy consultant repeatedly documented recommendations over several months stating not to crush ranolazine and to review for an alternative, but the record showed no action taken on several of those recommendations. The IP nurse stated that the cardiologist should have been contacted to clarify the order, and the DON stated that the order should have been clarified. The report also noted that the facility did not have a policy on contractors/consultants.
Controlled Substance Documentation and DEA 222 Form Errors
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards for controlled substances during a medication administration observation. While an LPN was administering medications to a resident with diagnoses including malignant neoplasm of the left kidney and neoplasm-related pain, the LPN removed OxyContin ER 20 mg and pregabalin 75 mg from the locked controlled substance drawer, administered them, and then signed the eMAR. The surveyor did not observe the LPN sign the CDS Accountability sheet for either medication before or after administration, and the sheets did not reflect that either dose had been documented as removed. When asked, the LPN stated that controlled substances should be signed out when removed from the package and before giving them to the resident. The consultant pharmacist also stated that the nurse should sign the CDS Accountability sheet immediately after removing the dose. The facility’s medication administration policy did not include information related to controlled substances or when to sign for them. The resident involved had a BIMS score of 14 out of 15, indicating intact cognition, and had active physician orders for OxyContin ER and pregabalin. The surveyor reviewed the situation with the DON and LNHA after the observation, and the facility did not provide additional pertinent information. The facility also failed to accurately complete DEA Form 222 records for Schedule II narcotic medications. Two executed DEA 222 forms reviewed did not include the number of packages received or the date received for the ordered medications. The DON stated that she would fill out the form for the narcotic medication needed, have the MD sign it, fax it to the pharmacy, and that the nurse receiving the medications would sign a requisition/declining sheet rather than the DEA 222 form. She also stated that she did not usually fill out the received portion of the DEA 222 form. In addition, four unexecuted DEA 222 forms were found with the MD’s signature already on the forms while the rest of the forms were blank. The DON confirmed that the forms had been signed before being filled out and stated that she had asked the MD to sign them because she was going to place an order and he was going on vacation.
Improper Storage of Alcohol and Zinc Oxide Ointment
Penalty
Summary
Drugs and biologicals were not properly stored in Resident room [ROOM NUMBER] when the surveyor and the Housekeeping Director observed two containers of 91% alcohol and a container of zinc oxide ointment skin protectant with a resident's name on it placed behind the window curtain. The Housekeeping Director did not know why the items were there. When the Infection Preventionist/LPN came to the room, she stated that the zinc oxide should be stored in the nurse's treatment cart and that the nurse administers it; she also stated that both residents in the room were cognitively impaired. She further said the alcohol and zinc oxide should not be stored inside residents' rooms for safety and suggested the resident representative may have brought them in. Review of the resident's record showed that the order for the zinc oxide had been discontinued on 8/10/23, yet the container remained in the room with the resident's name on it. During the survey, the DON stated that zinc oxide was expected to be kept in the treatment cart and alcohol stored in residents' respective drawers, and acknowledged that alcohol could cause harm if grabbed by a resident. The facility policy provided by the DON stated that all drugs and biologicals must be stored in a safe, secure, and orderly manner, that discontinued drugs or biologicals should not be used, and that external-use drugs, antiseptics, disinfectants, and germicides must be clearly labeled and stored separately from regular medications.
Improper Trash Containment
Penalty
Summary
The facility failed to properly contain trash in a closed dumpster, resulting in trash overflowing the dumpster area and spilling onto the ground. During multiple observations, the dumpster area was seen with trash, including plastic wrappings, cardboard boxes, and pieces of boxes, overflowing and the lid left open. Despite the Dietary Manager's statement that trash would be picked up the next day, the issue persisted over several days. The Administrator confirmed there was no specific policy for trash disposal, although it was acknowledged that trash is picked up twice a week and the area is required to be kept clean and contained.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to prominently post daily nurse staffing information in areas readily accessible to residents and visitors, affecting 59 census residents. Observations conducted over three days in the front lobby area and near the East and [NAME] Hall nurse's stations revealed that the staffing data was not prominently posted. During an interview, the receptionist was unaware of the requirement to post nursing data. Further observations confirmed the absence of staffing data in the designated areas. The Director of Nursing (DON) believed the information was posted in the front lobby, but this was not the case. The Administrator later confirmed that there was no specific policy for posting the staffing information, although it was understood that it should be posted.
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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 North Bergen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Harborage Llc | 1.3 mi | ★★★★★ | 8 | 1 |
| Hudsonview Health Care Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Manhattanview Ctr For Rehabilitation And Healthcar | 1.6 mi | ★★★★★ | 6 | 0 |
| Optima Care Castle Hill | 1.8 mi | ★★★★★ | 2 | 1 |
| Optima Care Fountains | 2.1 mi | ★★★★★ | 12 | 0 |
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