Forest Hill Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Kent, Maine.
- Location
- 25 Bolduc Ave, Fort Kent, Maine 04743
- CMS Provider Number
- 205176
- Inspections on file
- 22
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Forest Hill Manor during CMS and state inspections, most recent first.
Failure to maintain resident dignity during meal assistance was observed during lunch dining service. An RN was seen standing while helping a resident eat and stated she knew she should be sitting but was covering briefly for another staff member. The DON was also observed standing while assisting the resident before later pulling up a chair, and the findings were confirmed by the surveyor and DON.
A resident with cerebral palsy was observed wearing a seatbelt while seated in a motorized wheelchair, but the clinical record lacked a provider order, documented assessment, and monitoring for the seatbelt use. The care plan noted the seatbelt was used to prevent falls or slipping out of the wheelchair, and the DON stated the resident could release the seatbelt and had been assessed, but the assessment was not documented.
Food Preparation Equipment Not Maintained in Sanitary Condition: A surveyor observed multiple frying pans and a skillet encrusted with baked/fried-on residue, and the pans had worn nonstick coating with bare metal exposed on the cooking surface. The cook and dietary aide stated the pans had been non-stick at one time, but the Teflon wore off from cooking and cleaning, and the finding was confirmed by the FSD.
A resident with orders for supplemental oxygen and CPAP/BIPAP treatments experienced multiple episodes of low oxygen saturation, but there was no documentation that the provider was notified as required. Additionally, provider orders lacked clarity regarding when and how CPAP/BIPAP and supplemental oxygen should be used, and the DON confirmed these gaps in documentation and order clarity.
The facility did not ensure adequate staffing levels on weekends, as identified in a review of the Payroll Based Journal staffing report for the fourth quarter of 2024. The Administrator confirmed that the facility lacked sufficient staff to meet resident needs, particularly affecting those requiring assistance with ADLs.
The facility failed to maintain a safe and clean environment, with observations of discolored and cracked flooring, dirt buildup, chipped paint, and broken trim in resident areas. A resident's wheelchair was also found with dirt and debris, indicating inadequate cleaning and maintenance.
The facility did not update care plans to include Enhanced Barrier Precautions (EBP) for two residents. One resident with heel wounds requiring daily dressing changes had an EBP sign, but the care plan did not address EBP needs. Another resident with VRE in the urine had orders for precautions, but the care plan lacked continuous EBP documentation. These deficiencies were confirmed by staff interviews.
The facility failed to maintain safe hot water temperatures in resident rooms, with several instances exceeding 120 degrees Fahrenheit due to a faulty mixing valve. Additionally, blue floor tiles in the Skilled Unit hallway were lifting, creating a potential trip hazard. The Administrator acknowledged both issues, with plans to address the flooring hazard.
The facility failed to maintain respiratory equipment in a sanitary manner for three residents, with issues such as soiled oxygen concentrator filters, missing filters, and outdated oxygen tubing. These deficiencies were confirmed through observations and interviews with the DON.
The facility failed to implement proper infection prevention measures, with staff not adhering to Enhanced Barrier Precautions (EBP) during care activities. Instances included staff not wearing protective gowns or gloves when required. Additionally, the facility did not fully implement a water management program to prevent Legionella and other pathogens, as necessary monitoring activities were not conducted.
A facility failed to promptly notify the Medical Provider and Resident Representative of abnormal lab results for a resident. The resident's blood work showed high white blood cell count, sodium, and potassium levels, but these results were not reviewed by the NP until 28 hours later. The RR requested an update on the results but was told to wait until the next day. The DON acknowledged that both the Medical Provider and RR should have been informed immediately.
A facility failed to develop a comprehensive care plan for a resident with Diabetes, as the care plan lacked goals and interventions for managing the condition and the use of insulin. This was confirmed during a review with the Residential Care Coordinator.
A facility failed to follow physician orders for sliding scale insulin for a resident. The resident's blood sugar levels were checked four times daily, but the Medication Administration Record (MAR) showed incorrect dosages of Novolin R insulin were administered on multiple occasions. Despite blood sugar levels indicating the need for 2 or 4 units, only 1 unit was given, as confirmed by the Resident Care Coordinator.
A facility failed to recognize and address significant weight loss in a resident, whose care plan required a daily nutritional supplement to maintain a target weight. Despite a decline from 184 lbs to 155 lbs over several months, the order for the supplement was dropped, and there was no evidence of notification to the medical provider or dietitian, nor were additional nutritional interventions initiated.
The facility failed to remove expired medications from its storage units. A surveyor found an expired box of Ayr Saline Nasal Gel in the skilled nursing unit and an expired bottle of GI Cocktail in the LTC unit's refrigerator, which was still available for a resident with a current order for its use. These findings were confirmed with the CNA responsible for medications, and the expired items were removed for destruction.
A facility failed to promptly notify a medical provider of abnormal lab results for a resident. Blood work ordered on a resident showed high white blood cell count, sodium, and potassium levels, but these results were not reviewed by a Nurse Practitioner until 28 hours later. The facility's protocol required checking the computer for results unless they were critical, in which case the lab would call. The DON stated the provider should have been informed by phone when the results were available.
A facility failed to offer a pneumococcal immunization to a resident, as required by their policy. The policy mandates offering the vaccine unless contraindicated, but a review of the resident's clinical record showed no evidence of an offer, declination, or receipt of the vaccine. The Infection Preventionist confirmed the absence of documentation, and the resident's representative consented to the immunization only after the surveyor's inquiry.
A resident with multiple cognitive impairments was sexually abused by a staff member, the Transporter, Activities staff, who was found with his hands under the resident's shirt. The incident was witnessed by a CNA who reported it immediately. The resident was unable to consent due to their medical condition, and the staff member admitted to the inappropriate contact. The facility's policy on preventing sexual abuse was violated, and the incident was reported to the relevant authorities.
The facility failed to ensure that two unlicensed staff members completed mandatory training on abuse, neglect, exploitation, and misappropriation of resident property. A transporter and a handyman did not receive the required training within the past year, as confirmed by the DON during a surveyor interview.
A resident's preference for daily evening whirlpool baths was not followed, as they did not receive the baths for 7 days in the past month. The facility's documentation practices failed to specify the type of bath received, leading to a lack of evidence that the resident's care plan was adhered to.
The facility failed to follow physician orders to obtain a urine sample for a resident who had a change in mental status. Despite a provider order, the sample was not obtained, and there was no record of any attempt or completion.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote care to residents in a manner that maintains each resident's dignity during 1 of 2 lunch dining services observed. On 3/9/26 at 11:35 a.m., a surveyor observed RN1 standing while assisting R23 to eat, and RN1 confirmed at the time of the observation that she knew she should be sitting but was only assisting for a couple of minutes to cover for another staff member who had stepped away. On 3/9/26 at 11:37 a.m., the surveyor observed the DON assisting R23 to eat while standing. At 11:40 a.m., the surveyor observed the DON pull up a chair to assist R23 to eat. On 3/11/26 at 8:00 a.m., the surveyor and the DON confirmed the findings.
Missing Order, Assessment, and Monitoring for Wheelchair Seatbelt Use
Penalty
Summary
The facility failed to obtain a provider order, complete an assessment, and monitor the use of a seatbelt while a resident with cerebral palsy was seated in a motorized wheelchair. The resident’s care plan stated that a seatbelt was used on the new motorized wheelchair to prevent falls or slipping out of the wheelchair due to body habitus, and a surveyor observed the resident wearing a seatbelt while in a wheelchair. Review of the clinical record found no evidence of a provider order for the seatbelt, no documented assessment for its use, and no monitoring documentation while the resident used the seatbelt. The Licensed Social Worker stated the resident received the new wheelchair on 2/23/26, and the DON stated the resident was able to release the seatbelt and had been assessed for the wheelchair and seatbelt, but that the assessment was not documented.
Food Preparation Equipment Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to prepare food under sanitary conditions for 1 of 3 days of survey. During an observation on 3/9/26 at approximately 11:45 a.m., a surveyor saw the cook take a small skillet from a shelf and observed that it was encrusted with a baked/fried-on substance. On the same shelf, two additional small frying pans and one medium frying pan were also observed to be encrusted with a baked/fried-on substance. The cooking surfaces of the frying pans were observed to have Teflon nonstick coating remaining only on the outer borders, with bare metal visible on the bottom and middle of the cooking surface. During the observation and interviews with the cook and dietary aide, it was stated that the pans had been non-stick at one time, but the Teflon wore off from cooking and cleaning the pans. This was confirmed by the surveyor with the cook, dietary aide, and later with the Food Service Director.
Failure to Follow Physician Orders for Respiratory Care and Inadequate Documentation
Penalty
Summary
The facility failed to follow physician orders for respiratory care for one resident requiring supplemental oxygen and CPAP/BIPAP treatments. The resident's clinical record included a provider order to check oxygen saturation (SpO2) four times per shift and to notify the covering provider if SpO2 dropped below 90% while awake or below 88% when sleeping. Multiple nursing narrative notes documented SpO2 readings below these thresholds on several occasions, but there was no evidence in the clinical record that the covering provider was notified as required by the order. Additionally, the resident had orders for CPAP use at bedtime, but observations and interviews revealed unclear documentation regarding whether the resident should use CPAP or BIPAP at times other than bedtime, and whether supplemental oxygen should be attached to the CPAP/BIPAP machine during use. The Director of Nursing confirmed that the provider orders were not clear regarding the timing and method of CPAP/BIPAP use and that the required notifications to the provider were not documented when low SpO2 readings occurred.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed low weekend staffing during the fourth quarter of 2024. During an interview with a surveyor, the Administrator confirmed that the facility did not have enough staff on duty to meet resident needs on weekends, affecting residents requiring assistance with Activities of Daily Living (ADLs).
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment for residents. Observations revealed discolored and cracked flooring in resident rooms, dining areas, common areas, and hallways, creating uncleanable surfaces. Dirt buildup was noted along the thresholds between hallways and resident rooms. Additionally, chipped paint and broken trim were observed in a resident's room, along with a soiled floor mat. Furthermore, a resident's wheelchair was found to have dirt and dried debris on both arms and wheels, indicating a lack of proper cleaning and maintenance.
Failure to Update Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to update and revise care plans to include Enhanced Barrier Precautions (EBP) for two residents. For one resident, an EBP sign was observed on the door, and the resident had wounds on both heels requiring daily dressing changes. However, the care plan did not address the need for EBP during care. This was confirmed during an interview with the Residential Care Coordinator. For another resident, an EBP sign was also observed, and the resident had orders for precautions due to Vancomycin-resistant Enterococci (VRE) in the urine. The care plan lacked evidence of the need for continuous EBP for this diagnosis, as confirmed by the Resident Care Coordinator.
Hot Water Temperature and Flooring Hazards
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms, with several instances of temperatures exceeding the maximum allowable limit of 120 degrees Fahrenheit. On the first day of the survey, multiple rooms were found with hot water temperatures ranging from 120.4 to 124.8 degrees. Despite adjustments made by the facility after the initial findings, subsequent checks still revealed temperatures above the acceptable limit. The issue was attributed to a faulty mixing valve, which was identified and replaced on the second day of the survey. Additionally, the facility did not ensure that the flooring in the Skilled Unit hallway was free from hazards. Surveyors observed that blue floor tiles were lifting and becoming unglued, creating a potential trip hazard. The Administrator acknowledged the issue and mentioned that the tiles were located downstairs and that there were plans to replace them. These deficiencies indicate lapses in maintaining a safe environment for residents, as required by regulatory standards.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for three residents, leading to potential risks of disease and infection transmission. For one resident, the oxygen tubing was observed resting on the floor, and the oxygen concentrator filters were heavily soiled with dust and debris. The tubing had not been changed according to the facility's protocol, which requires a change every two weeks. The Director of Nursing (DON) confirmed these observations and acknowledged the failure to maintain the equipment properly. Another resident's oxygen concentrator was missing both side filters, and the oxygen tubing had not been changed since the beginning of January, despite the resident using oxygen every night. The manual for the oxygen concentrator specified that it should not be operated without the filters. A third resident also had oxygen tubing with a nasal cannula resting on the floor, and the tubing had not been changed in a timely manner per protocol. These deficiencies were confirmed through observations and interviews with the DON.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention measures during the survey period. On multiple occasions, staff did not adhere to Enhanced Barrier Precautions (EBP) when providing care to residents. For instance, a Unit Caretaker was observed changing linens for a resident on EBP without wearing a protective gown. Similarly, a Certified Nursing Assistant - Medications (CNA-M) administered eye drops to a resident without wearing gloves, contrary to the guidelines outlined in the Lippincott Nursing Procedures. Additionally, two CNAs assisted a resident with repositioning in bed without wearing the required protective gown and gloves, and a Registered Nurse (RN) assisted a resident with toileting hygiene without wearing a gown, despite the resident being on EBP for Vancomycin-Resistant Enterococcus (VRE). The facility also failed to fully develop and implement a water management program to prevent the growth and spread of Legionella and other water-borne pathogens. The Water Management Program required monitoring activities such as checking hot water temperatures at faucets and cleaning showerheads, but these were not being conducted. The Forest Hill Maintenance Specialist only checked the water temperatures in the boiler room and did not perform other necessary monitoring tasks. The Administrator confirmed that the facility was not monitoring the action items identified in the Water Management Policy, except for the ice machine and boiler room checks.
Failure to Timely Notify Medical Provider and Resident Representative of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the Medical Provider in a timely manner regarding abnormal laboratory results for a resident who was reviewed for hospitalization. The resident had blood work done, including a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), which showed abnormal results. These results were available on the morning of January 21, 2025, but were not reviewed by the Nurse Practitioner until 28 hours later. The Director of Nursing acknowledged that the Medical Provider should have been informed of the abnormal results immediately by telephone. Additionally, the facility did not promptly inform the Resident Representative (RR) about the abnormal lab results when requested. The RR asked for an update on the blood work results on the evening of January 21, 2025, but was told that the results would be reviewed by the doctor the following day, and the RR would be informed afterward. The Director of Nursing admitted that the RR should have been given the information at the time of the request, as the RR could have decided to transfer the resident to the hospital for further evaluation.
Failure to Develop Comprehensive Diabetes Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with Diabetes. The resident was admitted to the facility and had a current physician order for Novolin R insulin sliding scale. However, upon review of the resident's care plan, it was found that there was no evidence of goals and interventions related to the management of Diabetes and the use of insulin. This deficiency was confirmed during a review of the care plan with the Residential Care Coordinator, indicating that the treatment of the resident's Diabetes was not addressed in the care plan.
Failure to Administer Correct Insulin Dosage
Penalty
Summary
The facility failed to ensure that physician orders for sliding scale insulin were followed for a resident. The clinical record review revealed that the resident's blood sugar levels were checked four times a day, and the sliding scale insulin coverage was to be administered according to specific blood sugar ranges. However, on multiple occasions, the resident received an incorrect dosage of Novolin R insulin, as documented in the Medication Administration Record (MAR). For instance, when the resident's blood sugar levels indicated the need for 2 or 4 units of insulin, the MAR showed that only 1 unit was administered. The discrepancies in insulin administration occurred on several dates, with the resident consistently receiving less insulin than prescribed. The surveyor confirmed these findings during an interview with the Resident Care Coordinator, who reviewed the MAR and acknowledged the incorrect dosages. This failure to administer the correct insulin dosage as per the physician's orders constitutes a deficiency in the facility's care for the resident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to recognize and address a significant weight loss in one resident, who was part of a sample reviewed for nutrition. The resident's care plan, revised in late November, indicated a need for a nutritional supplement once a day to address weight loss, with a goal to maintain a body weight within 3 lbs of 179 lbs. However, the resident's weight continued to decline from 184 lbs in early September to 155 lbs by mid-February. During an interview, the Director of Nursing acknowledged that the dietician had ordered a supplement, but the order had been dropped. The clinical record lacked evidence that the nursing staff had notified the medical provider or registered dietitian, nor had they initiated additional nutritional interventions to address the ongoing weight loss.
Expired Medications Found in Storage Units
Penalty
Summary
The facility failed to ensure the removal of expired drugs and biologicals from its medication storage units. During an inspection of the medication storage room on the skilled nursing unit, a surveyor found a box of Ayr Saline Nasal Gel that had expired on July 24. Additionally, in the medication storage refrigerator on the long-term care unit, a surveyor discovered a bottle of GI Cocktail, labeled with a discard date of February 2, which was still available for use. This bottle was associated with a resident who had a current physician's order for the GI Cocktail to be administered twice daily as needed for dyspepsia. These findings were confirmed with the Certified Nursing Assistant responsible for medications, and the expired items were immediately removed for destruction.
Failure to Timely Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the medical provider of abnormal laboratory results in a timely manner for a resident who was reviewed for hospitalization. On January 21, 2025, the resident had blood work and a chest x-ray ordered by the doctor. The blood work, which included a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), was completed and the results were available by 9:23 a.m. the same day. The results showed abnormal values, including a high white blood cell count, sodium level, and potassium level. However, the facility's documentation indicated that these results were not reviewed by a Nurse Practitioner until 28 hours later, on January 22, 2025, at 1:44 p.m. During interviews, the Registered Nurse stated that results must be checked on the computer unless they are critical values, which would prompt a call from the laboratory. The Director of Nursing acknowledged that the medical provider should have been informed of the abnormal results by telephone when they were available.
Failure to Offer Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that a resident was offered a pneumococcal immunization, as required by their policy. The policy, last revised in February 2012, mandates that all patients be offered the vaccine unless contraindicated due to health history, with administration following a standing order. During a review of the clinical record for one resident, the surveyor found no evidence that the resident was offered, declined, or received the pneumococcal immunization. An interview with the Infection Preventionist confirmed the absence of any record of offering, history of receiving, or declination of the vaccine in the resident's clinical record. The resident's representative consented to the immunization only after the surveyor inquired about the vaccination status.
Resident Sexual Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving a staff member, the Transporter, Activities staff, who was found with his hands under the resident's shirt, touching the resident's breasts. This incident was reported by a Certified Nursing Assistant (CNA1) who entered the resident's room and witnessed the inappropriate contact. The resident involved had multiple diagnoses, including generalized anxiety disorder, major depressive disorder, PTSD, agitation, dementia, major neurocognitive disorder, Alzheimer's disease, and vascular dementia, and was incapable of consenting to sexual activity. The facility's investigation revealed that the Transporter, Activities staff admitted to the inappropriate contact and acknowledged that the resident was not in a normal state of mind and could not consent. The resident did not exhibit outward signs of emotional distress following the incident, but the situation was a clear violation of the resident's dignity and the facility's policy that residents will be free from sexual abuse. The incident was reported to the Maine Department of Health and Human Services, Division of Licensing and Certification, and was identified as Immediate Jeopardy at past non-compliance.
Deficiency in Staff Training on Abuse and Neglect
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, specifically regarding mandatory education on abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during a review of facility staff education records, which revealed that two unlicensed staff members, a transporter in activities and a handyman in housekeeping and engineer services, did not complete the required training within the past year. The transporter was hired on March 28, 2016, and the handyman was hired on January 5, 2023. The Director of Nursing confirmed during an interview with a surveyor that the mandatory training had not been completed for these staff members within the required timeframe.
Failure to Follow Resident's Bathing Preferences
Penalty
Summary
The facility failed to adhere to a resident's care plan preference for daily evening whirlpool baths. The resident, identified as R1, reported to a surveyor that they were supposed to receive whirlpool baths every evening as per their care plan but did not receive them for 7 days in the past 31 days. The resident only refused the whirlpool bath twice, once due to illness and once due to returning late from an outing. The resident's care plan, last evaluated on 8/27/24, confirmed the request for a daily evening whirlpool bath, with the option to decline if necessary. The facility's documentation practices were found to be inadequate in reflecting the type of bathing the resident received. The facility's decision to document bathing according to Section GG of the MDS 3.0 did not specify the type of bath, leading to a lack of evidence that the resident received any whirlpool baths in the past 31 days. Interviews with the Registered Nurse and the Administrator confirmed the absence of documentation for whirlpool baths, highlighting a deficiency in following the resident's care plan and preferences.
Failure to Follow Physician Orders for Urine Sample
Penalty
Summary
The facility failed to follow physician orders to obtain a urine sample for a resident who was being reviewed for resident-to-resident abuse. The medical record showed a provider order dated 4/18/24 to obtain a urinalysis due to a change in the resident's mental status. However, as confirmed by the Administrator during an interview on 4/23/24, the urine sample was not obtained five days after the order was given, and there was no record of any attempt or completion of the urine sample.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
