The appointment was scheduled for November 4, 2024, but when federal inspectors arrived nearly a year later, the facility's own staff couldn't piece together what happened.
Licensed Vocational Nurse 1 told inspectors on October 3 that she "could not recall why Resident 1 missed a scheduled urology appointment" because "there was no documentation available to explain the absence." She had received the appointment order from a hospital, entered it into the facility's system, and passed a copy to Social Services. That's where her involvement ended.
Social Services Designee 1 was responsible for arranging transportation. She had the appointment order on file but "did not know why the resident missed the appointment." No notes. No documentation indicating whether the resident attended or why transportation failed to occur.
Her assistant was supposed to contact the transportation provider but was "also unaware of what happened."
The Social Services Assistant admitted she had texted the transportation company using her personal phone about the appointment. She had no notes or records to verify the contact. No documentation at all.
Registered Nurse Supervisor 1 was working the day of the missed appointment. She didn't know why the resident missed it either. Staff had reviewed the resident's chart and "were unable to locate any documentation explaining the missed appointment."
The Director of Nursing interviewed everyone involved in coordinating appointments, including the entire social services team. Nobody could explain what happened.
"The DON stated she felt bad over Resident 1's missed appointment," inspectors wrote.
The facility's own policy, dating to December 2016, states that residents have the right to be notified of their condition and any changes in their condition. Missing medical appointments without explanation violates that fundamental right.
What emerged from the interviews was a system where critical information moved through multiple hands with no accountability. The nurse entered the order. Social Services was supposed to arrange transportation. An assistant was supposed to call the company. A supervisor was working that day. A director oversaw the process.
None of them documented what they did. None could explain what went wrong.
The Social Services Designee acknowledged "the lack of documentation" and said the facility implemented a tracking system to log all residents scheduled for outside appointments. The Social Services Assistant reported the facility implemented "a new process for documenting and communicating all resident appointments to ensure accountability."
The Registered Nurse Supervisor said the facility implemented "three separate tracking systems to monitor resident appointments." The Director of Nursing conducted "multiple in-service training courses and revised the facility's appointment coordination process."
But those changes came nearly a year after the missed appointment, and only after inspectors started asking questions nobody could answer.
The inspection report doesn't explain why the resident needed urology care or what medical consequences resulted from the missed appointment. It doesn't identify whether the appointment was rescheduled or if the resident received the needed care elsewhere.
What it documents is a breakdown in basic care coordination that left a resident without scheduled medical treatment and staff scrambling to explain a failure they couldn't even document.
Five staff members. Multiple departments. One missed appointment. Zero records of what happened.
The facility received a citation for minimal harm with potential for actual harm, affecting few residents. But for the resident who needed urology care on November 4, 2024, the harm was specific and immediate: medical treatment that simply didn't happen, in a facility where nobody could explain why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harbor Post Acute Care Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
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