Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Harrogate Village during CMS and state inspections, most recent first.
Dish Machine Not Maintained at Required Sanitizing Temperatures: The facility failed to keep the high-temp dish machine operating at required wash and rinse temperatures during meal service. The DOCS and surveyor observed broken gauges, and a test strip run through the machine did not turn black, showing the required surface temp was not reached. The utility staff said he had relied on the gauges even though they were broken, and the facility had no documented corrective actions for the affected meal periods.
QAPI Committee Meeting Attendance Not Properly Documented: The facility failed to ensure required members were present during quarterly QAPI meetings. The DON stated the Medical Director was a required attendee and was usually present by conference call, but the attendance record for one quarterly meeting did not show the MD’s signature or document teleconference participation. The Administrator confirmed the MD was not signed in on the form, and the facility’s QAPI policy listed the MD as a committee member.
A nurse administered insulin intended for one resident to another, cognitively intact resident, after becoming distracted and failing to follow required identification and medication verification protocols. The nurse did not adhere to the facility's policy for verifying resident identity and medication details, resulting in a significant medication error.
Surveyors observed deficiencies in food handling and sanitation practices, including staff not wearing beard guards and multiple instances of improperly labeled and dated food items in the kitchen and satellite kitchen. These actions were contrary to the facility's policies on personal cleanliness, food storage, labeling, and dating.
A facility failed to accurately assess a resident's status in the MDS regarding a wander/elopement alarm. The resident, admitted with dementia and heart disease, had a physician order for a wander guard, but the MDS was incorrectly coded as not having the alarm. The MDS Coordinator acknowledged the error.
The facility failed to update care plans for residents, missing critical elements such as anticoagulant use, urinary catheter care, and Wander Guard monitoring. A resident's care plan did not include anticoagulant use despite a diagnosis of atrial fibrillation. Another resident's plan lacked focus on an indwelling urinary catheter, and a third resident's plan did not initially address Wander Guard use for elopement risk. Additionally, a resident's skin impairments were not included in their care plan, despite physician orders for wound care.
The facility failed to prevent UTIs in two residents with urinary catheters by not following its own catheter care policy. A resident's drainage bag was improperly stored without a cap, and another resident's catheter was flushed without a physician's order. The facility's policy requires specific cleaning and storage procedures, which were not followed, leading to this deficiency.
The facility failed to perform proper hand hygiene during wound care for a resident with a pressure ulcer, as an LPN changed gloves without sanitizing hands, contrary to facility policy. Additionally, the facility did not maintain a sanitary environment for another resident with Alzheimer's and on anticoagulants, as blood-stained sheets were not promptly changed, violating the infection prevention program.
Dish Machine Not Maintained at Required Sanitizing Temperatures
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner when the high temperature dish machine was not operating at required temperatures during meal service. On 02/05/2026, the surveyor reviewed the dish machine temperature record and found that for breakfast on 1/5/2026 the wash temperature was recorded at 180 degrees and the final rinse temperature at 165 degrees, with no corrective actions documented for the breakfast meal periods from 1/1/2026 through 1/5/2026. During observation of the dish room, the surveyor saw the dish machine gauges reading 130 F for rinse and 118 F for wash while the machine was in active service. The Director of Culinary Services stated the gauges had been broken for about one week and said staff had been using a temperature test strip to verify temperatures. When the surveyor had a test strip run through the machine, the strip remained white and did not turn black, indicating the machine did not meet the minimum required temperatures for proper ware washing. The DOCS then stopped the machine and told staff not to wash any more dishware. The utility staff told the surveyor he had checked the machine gauges before washing dishes and used the gauges to determine whether the machine met minimum temperature standards, but later stated the gauges were broken and that he had not ensured the machine was meeting minimum standards because they could not be accurately measured. Facility administration later told the surveyor the machine had been set up to run as a low temperature dish machine with chemical sanitizing until it could be repaired to run as a high temperature machine. The facility policy required wash and rinse temperatures to meet FDA guidelines and required a test strip to verify that the surface temperature of a dish reached 160 F.
QAPI Committee Meeting Attendance Not Properly Documented
Penalty
Summary
The facility failed to ensure that the required members were present during quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings. During interview, the Administrator stated that QAPI meetings were held quarterly on the third Tuesday of January, April, July, and October. The DON identified the required participants as the directors of admissions, social work, dietary, activities, maintenance, nursing, the Infection Preventionist, and vendors such as the Consultant Pharmacist and the lab, and stated that the Medical Director sometimes attended monthly QAPI meetings but definitely attended the quarterly meetings. When the surveyor reviewed the facility’s Employee Education Attendance Records for the quarterly meetings, the Medical Director did not sign in on the attendance sheet for the QAPI meeting dated 4/17/25. The Administrator confirmed that the Medical Director’s signature was absent. The DON stated that the Medical Director was usually phoned in on a conference call and that this should have been documented on the sign-in sheet to confirm attendance, but the form did not reflect that the Medical Director was present via teleconference. The facility’s QAPI policy, updated 1/20/2026, listed the QAPI Committee members as the Administrator/Abuse Coordinator, Medical Director, DON, and Infection Preventionist/Staff Educator.
Medication Error Due to Failure to Follow Identification Protocols
Penalty
Summary
A deficiency occurred when a registered nurse administered the wrong medication to a resident. The nurse prepared and gave 4 units of Novolog and 16 units of Lantus insulin to a resident who was not the intended recipient; the insulin was meant for the resident's roommate. The resident who received the medication in error had diagnoses including Type 2 Diabetes Mellitus, Respiratory Failure, Pneumonia, and Toxic Effect of Tobacco Cigarettes, and was cognitively intact according to a recent assessment. The nurse became distracted during the medication pass, failed to verify the resident's identity, and did not follow the facility's medication administration policy, which requires checking the resident's identification band, confirming the resident's name, and verifying the face sheet picture prior to administration. The nurse acknowledged not following the 5 Rights of Medication Administration and admitted to rushing and not properly checking the resident before giving the medication. The facility's policy, last revised in April 2019, specifies that medications must be administered safely and as prescribed, with verification of the resident's identity and medication details before administration. The incident was identified during interviews and record reviews, and it was confirmed that the nurse did not adhere to established protocols for medication administration, resulting in a significant medication error.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by surveyors. During an inspection of the kitchen, it was noted that the Dietary Director and a Food Service Worker had facial hair and were not wearing beard guards, contrary to the facility's policy on personal cleanliness and hygiene. Additionally, in the walk-in freezer, two pies were found without labels or dates, which the Dietary Director acknowledged should have been dated and subsequently discarded. Further observations in a satellite kitchen revealed multiple instances of improperly labeled and dated food items. Glasses of orange juice, milk, honey thick milk, and honey thickened apple juice, as well as pieces of sheet cake and cut watermelon, were found without labels or dates. A prepared ham and cheese sandwich and a tuna sandwich were also found without proper labeling. Additionally, containers of egg salad and tuna salad were past their use-by date. These findings indicate a failure to adhere to the facility's policies on food storage, labeling, and dating, which require all perishable items to be covered, labeled, and dated appropriately.
Inaccurate MDS Assessment for Wander/Elopement Alarm
Penalty
Summary
The facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), specifically regarding the use of a wander/elopement alarm. This deficiency was identified for a resident who was observed with a wander guard/elopement alarm on their left ankle. The resident was admitted with diagnoses including dementia and heart disease, and there was a physician order to apply a wander guard to the left ankle. However, the Admission MDS for the resident was incorrectly coded as not having a wander/elopement alarm. During an interview, the MDS Coordinator acknowledged that the Admission MDS should have been coded to reflect the presence of the alarm.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to reevaluate and update a resident-centered care plan upon readmission for several residents, leading to deficiencies in care planning. For Resident #15, the care plan did not include the use of an anticoagulant medication, despite the resident having a diagnosis of atrial fibrillation and being prescribed Eliquis. The Director of Nursing (DON) acknowledged that the anticoagulant was not documented in the care plan, and the facility had not realized the care plans were incomplete due to a recent conversion of care plan programs. Resident #17's care plan lacked a specific focus or interventions for an indwelling urinary catheter, despite the resident having a diagnosis of urinary tract infection and retention of urine. The Infection Preventionist and the DON both confirmed that a care plan focus for the catheter should have been initiated upon readmission. Additionally, Resident #43's care plan did not initially include a focus or interventions for a Wander Guard, which was necessary due to the resident's Alzheimer's Disease and dementia diagnoses. The DON admitted that the care plan for elopement should have been initiated when the Wander Guard was applied. For Resident #3, the care plan failed to include actual skin impairments identified on the forearms, despite physician orders for wound care. The RN Unit Manager stated that new issues should be added to the care plan promptly, but the DON was unsure if the skin impairments had been added. These deficiencies highlight the facility's failure to develop and implement comprehensive, person-centered care plans that address all aspects of the residents' needs.
Deficient Catheter Care and Lack of Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for two residents with urinary catheters. Resident #17, diagnosed with a urinary tract infection and urine retention, had a care plan in place to monitor urinary output and catheter care every shift. However, the facility did not adhere to its policy for cleaning and storing urinary catheter drainage bags. Observations revealed that Resident #17's catheter drainage bag was stored in a clear, untied trash bag without a cap, and it emitted an odor of urine. The Infection Preventionist confirmed the absence of a cap, which is against the facility's policy that requires the use of a bleach solution for cleaning and a cap for storage. Resident #42, who had moderate cognitive impairment and an indwelling catheter, was also affected by the facility's failure to follow proper procedures. The resident's catheter was flushed on several occasions to prevent debris buildup, but there was no physician's order for this procedure, as confirmed by the Registered Nurse and the Director of Nursing. The facility's policy states that catheter irrigation may be ordered to prevent obstruction, but no such order was documented for Resident #42. The facility's policy on catheter care, revised in August 2022, outlines specific steps for cleaning and disinfecting drainage bags, including the use of a bleach solution and the requirement to cap the drainage bag tubing between uses. The failure to follow these procedures for both residents indicates a deficiency in the facility's adherence to its own policies, potentially increasing the risk of UTIs and other complications for residents with urinary catheters.
Infection Control Deficiencies in Hand Hygiene and Sanitary Environment
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during wound care for a resident with a stage 2 pressure ulcer. An LPN was observed changing gloves without performing hand hygiene in between, which is against the facility's policy. The resident had been admitted with severe protein-calorie malnutrition and chronic atrial fibrillation, and had a physician's order for specific wound care on the sacrum. Despite the facility's policy requiring hand hygiene before and after glove use, the LPN admitted to forgetting to sanitize hands, and this was confirmed as a breach of protocol by the RN Unit Manager, Infection Preventionist, and Director of Nursing. Additionally, the facility did not maintain a sanitary environment for another resident with Alzheimer's Disease and on long-term anticoagulant therapy. The resident was observed with blood-stained sheets due to frequent removal of bandages, which led to skin tears. The Infection Preventionist acknowledged that the sheets should have been changed, and the Director of Nursing confirmed that a barrier should have been used to protect the dressing until the sheets could be changed. This failure to maintain a sanitary environment was contrary to the facility's infection prevention and control program, which aims to provide a safe and sanitary environment.
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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 Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Leisure Chateau Rehabilitation | 1.1 mi | ★★★★★ | 15 | 0 |
| Complete Care At Green Acres | 1.7 mi | ★★★★★ | 0 | 0 |
| Shore Gardens Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 2 | 0 |
| Fountainview Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Atlantic Coast Rehab & Health | 2.1 mi | ★★★★★ | 2 | 1 |
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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.