Harbor Hill Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Belfast, Maine.
- Location
- 2 Footbridge Rd, Belfast, Maine 04915
- CMS Provider Number
- 205122
- Inspections on file
- 22
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Harbor Hill Center during CMS and state inspections, most recent first.
A resident was transferred using a sit-to-stand lift, contrary to recent therapy recommendations for a full mechanical lift due to instability and inability to bear weight. During the transfer, the resident's foot slipped, resulting in a fall and a femur fracture that required hospitalization and surgery. The care plan contained conflicting transfer instructions, and there was no evidence that nursing staff were notified of the updated transfer status.
The facility did not maintain complete and accurate clinical records for several residents, including missing documentation of bathing preferences, meal intake, oral hygiene, and toileting assistance. For example, a resident's care plan required showers to be offered, but only bed baths were documented, and there was no record of showers being offered or refused. Other residents had incomplete records for meal intake and oral hygiene, despite specific care plan requirements. Staff interviews indicated a lack of awareness of care preferences and delayed documentation practices.
A resident was repeatedly observed without access to a call bell, as it was left out of reach on top of a refrigerator despite staff entering the room multiple times. The care plan required the call light to be within reach, but staff failed to ensure this, and no alternative communication device was provided or documented. The deficiency was confirmed through observation and staff interviews.
A resident with anoxic brain damage and identified as a fall risk was observed with a fall mat in use, but the care plan did not include this intervention. The care plan only addressed placing the call light and personal items within reach, and was not updated to reflect the use of the fall mat as required by facility policy.
A side rail on a resident's bed was found to be improperly attached, causing it to extend outward when used for support. Despite a previous work order for repair, the issue persisted, and both a RN and the Clinical Marketing Director confirmed the problem during separate observations. The resident reported using the side rail for support when getting out of bed.
A resident's room was found to have a torn fall mat that could not be properly cleaned and an unwrapped bed pan stored next to the toilet, both of which did not meet infection control standards. Staff confirmed the bed pan should have been wrapped.
The facility failed to maintain a sanitary and homelike environment, with deficiencies observed in both Fort Point and Harbor House units. Issues included scuffed walls, cracked safety mats, soiled curtains, and dirty caulking around toilets. The kitchenette and dining areas had split floor seams and marked cabinets, while patient lifts and the laundry room showed signs of neglect.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan did not address diabetes management or insulin use, despite having a diagnosis of Type 2 Diabetes and an insulin order. Another resident's care plan lacked focus, goals, and interventions for wandering or elopement, despite having a physician order for a Wander Guard due to poor safety awareness. These deficiencies were confirmed in interviews with the facility's clinical advisors.
The facility failed to maintain respiratory equipment in a sanitary manner for two residents, one of whom had acute and chronic respiratory failure. Observations revealed that oxygen concentrators were heavily soiled with dust and debris, and a nebulizer was improperly stored. The DON confirmed these findings, noting that maintenance was responsible for cleaning the equipment.
The facility failed to prevent accident hazards by improperly storing Micro-Kill Bleach Germicidal Bleach Wipes at wheelchair height in a hallway accessible to residents and visitors. A RN confirmed the wipes should not be accessible, as residents could ambulate and use wheelchairs in the area. This was discussed with the DON.
The facility failed to correct previously identified deficiencies related to maintaining a safe, clean, and homelike environment. Despite a plan of correction, issues such as a soiled shower chair, urine odor, and unfinished handrails persisted. The Administrator cited a lack of matching paint as a reason for incomplete corrections.
The facility did not hold a required quarterly QAPI meeting for one of the four quarters. Meetings were documented on three occasions, but there was no evidence of a meeting in the fourth quarter. The Marketing Clinical Advisor confirmed the absence of a meeting during an interview.
A facility failed to accommodate a resident's bathing preferences, resulting in a deficiency. The resident's MDS indicated the importance of choosing their bathing options, but CNA documentation showed showers were only given on two occasions, with no evidence of showers during two separate weeks. The Market Clinical Advisor confirmed the facility's policy of providing at least one bath or shower per week was not followed.
The facility did not provide a SNFABN to a resident whose Medicare Part A services were discontinued, preventing the resident from making an informed decision about continuing services and assuming financial responsibility. The MDS Coordinator confirmed the oversight during an interview.
Failure to Implement Consistent Transfer Instructions Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure safe transfer practices and implement clear, consistent transfer instructions for a resident reviewed for falls. Staff attempted to transfer the resident using a sit-to-stand lift, despite recent therapy recommendations indicating the need for a full mechanical lift (Hoyer) due to the resident's instability and inability to safely bear weight. During the transfer, the resident's foot slipped from the lift platform, and staff were unable to safely reposition the foot, resulting in the resident being lowered to the floor. The transfer was then completed using a full mechanical lift. The resident subsequently complained of pain, and an assessment revealed swelling and a femur fracture, requiring hospitalization and surgical intervention. Review of the resident's care plan revealed conflicting transfer instructions, with both sit-to-stand and full mechanical lift interventions listed simultaneously. The clinical record did not contain evidence that nursing staff were notified of the change in transfer status prior to the incident. The resident's functional assessment indicated a need for substantial to total assistance with transfers, and the care plan had not been appropriately updated to reflect the therapy recommendations. The administrator confirmed that the care plan continued to list both transfer methods and had not been edited to reflect the change.
Incomplete and Inaccurate Clinical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for several residents, as evidenced by missing or incomplete documentation in multiple areas. For one resident, the care plan specified a preference for showers on certain days, but documentation showed only bed baths were provided over a three-week period, and there was no evidence that showers were offered or refused as required. Additionally, meal intake records for this resident were incomplete, with several meals lacking documentation despite the resident being at nutritional risk and under hospice care. A CNA reported not being aware of the resident's bathing preferences due to lack of information on the task sheet and not knowing how to access this information in the electronic medical record. Another resident with dental issues and a recent hip fracture had a care plan requiring oral hygiene to be offered twice daily, but records lacked evidence that this was done or refused on multiple days. For a resident with Parkinson's and anxiety disorder receiving end-of-life care, documentation of meal offerings was missing for several meals. Furthermore, for a resident requiring two-person assistance for toileting due to a hip fracture and confusion, there was no documented evidence of appropriate toileting assistance during admission. Staff interviews revealed that documentation was often completed at the end of shifts rather than in real time, despite in-service training on timely ADL documentation.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a call bell was accessible to a resident as required by policy. During multiple observations, the call bell was found attached to the wall behind the bed and draped over a box of popcorn and two photo frames on top of the resident's refrigerator, making it out of reach for the resident while lying in bed. When asked how assistance would be summoned, the resident attempted to reach for the call bell with both arms but was unsuccessful. The resident's care plan specified that the call light and desired personal items should be placed within reach when the resident was in bed or a bedside chair. Certified Nursing Assistant (CNA) staff entered and exited the resident's room several times without ensuring the call bell was accessible, leaving it in the same inaccessible position. When a Registered Nurse (RN) was present, the call bell was finally placed within reach by tying it to the bed. The RN was unaware of any alternative accommodations for the resident to use the call system, despite the facility's policy requiring evaluation for special needs and documentation in the care plan. The deficiency was identified through direct observation and interviews, confirming that the resident did not have consistent access to the call bell as required.
Care Plan Not Updated to Reflect Fall Prevention Interventions
Penalty
Summary
The facility failed to update and implement a care plan addressing communication needs for a resident identified as a fall risk with a diagnosis of anoxic brain damage. The resident was observed in bed with a fall mat placed on the floor, but the care plan, last updated on 2/5/25, did not include the use of a fall mat as an intervention. The care plan only specified placing the call light and personal items within reach when the resident was in bed or a bedside chair. There was no evidence that the care plan was revised to reflect the use of the fall mat, as required by facility policy, which states that care plans must be customized, communicated, and updated to reflect changing needs and responses to care.
Improperly Attached Bed Side Rail Creates Accident Hazard
Penalty
Summary
A deficiency was identified when a side rail on the left side of bed 107-B was found to be improperly attached, causing it to extend outward when used for support. The issue was first noted in a previous work order indicating the need for repair, but during subsequent observations, the side rail remained inadequately secured. The resident currently occupying the bed reported using the side rail for support when getting out of bed, and demonstrated that the rail extended outward when grabbed. A registered nurse confirmed the improper attachment and was unable to reattach the rail during the observation. The findings were further confirmed by the Clinical Marketing Director during a later observation. The deficiency centers on the facility's failure to maintain the resident environment as free from accident hazards as possible, specifically regarding the unresolved issue with the bed side rail used by a resident for mobility support.
Failure to Maintain Sanitary Equipment and Proper Bed Pan Storage
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to professional standards of infection prevention and control. During observations, a fall mat with two tears was found on the floor next to a resident's bed, creating a surface that could not be properly cleaned. Additionally, an unwrapped bed pan was observed leaning against the wall next to the toilet in the resident's bathroom, making it available for use in an unsanitary condition. These deficiencies were confirmed through interviews and direct observation, with staff acknowledging that the bed pan should have been wrapped.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment, as evidenced by multiple deficiencies observed during environmental tours of the Fort Point and Harbor House units. In Fort Point, several rooms had issues such as gauged and scuffed bathroom walls, cracked and torn safety fall mats, soiled and stained room divider curtains, and missing paint on walls. The dining room and kitchenette areas also showed signs of neglect, with scuffed and gouged wooden thresholds and marred cabinets. In Harbor House, the kitchenette and dining areas had split and unsealed floor seams filled with dirt and debris, and cabinets were marked with black marks. The hallway ceiling tiles had large brown stains, and the whirlpool room had chipped paint. Patient lifts had chipped paint, and several rooms had dirty caulking around toilets, split floor seams, and missing privacy curtain hooks. The laundry room had chipped paint on the floor and stained ceiling tiles, with a heavily soiled ceiling vent. These observations indicate a lack of adequate housekeeping and maintenance services necessary to maintain the building in a sanitary condition.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the physical needs of two residents. One resident was admitted with a diagnosis of Type 2 Diabetes and had an order for 15 units of Insulin Glargine to be administered subcutaneously at bedtime. However, the care plan did not include management strategies for diabetes or the use of insulin. This was confirmed during an interview with the Marketing Clinical Advisor. Another resident had a physician order for a Wander Guard/Wander Elopement Device due to poor safety awareness, but the care plan lacked focus, goals, and interventions for wandering or elopement. This omission was also confirmed in an interview with the Market Clinical Advisor.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner, which was observed during a survey. Two residents, one with acute and chronic respiratory failure and dependence on supplemental oxygen, were affected. The surveyor noted that the oxygen concentrators for both residents were heavily soiled with dust and debris. Additionally, one resident's nebulizer was left exposed to the environment, contrary to the facility's procedure that requires nebulizers to be stored in a labeled treatment bag after use. The Director of Nursing confirmed these findings and stated that the maintenance department was responsible for cleaning the concentrator equipment.
Improper Storage of Bleach Wipes Poses Hazard
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to improper storage of chemicals. During a survey, a container of Micro-Kill Bleach Germicidal Bleach Wipes was observed stored at wheelchair height in a hallway storage area containing personal protective equipment and oxygen concentrators. The Safety Data Sheet for the bleach wipes indicated potential hazards, including the need for emergency medical attention if ingested. A Registered Nurse confirmed that the bleach wipes should not be accessible to residents and visitors, as there were residents capable of ambulating and using wheelchairs in the hallway. This finding was discussed with the Director of Nursing.
Recurrent Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility's quality assurance committee failed to ensure the effectiveness of the plan of correction for deficiencies identified during a Recertification Survey. Specifically, the deficiency F584, which pertains to maintaining a safe, clean, comfortable, and homelike environment, was identified again during a Re-visit Survey. The initial survey found issues with housekeeping and maintenance services, resulting in unsanitary and disorderly conditions in two units. The facility's plan of correction included auditing and repairing various aspects of the environment, such as flooring, walls, and caulking, with a completion date set for mid-January. During the Re-visit Survey, the same deficiency was re-cited, indicating that the facility did not follow through with their plan of correction. Observations included a soiled shower chair in the hallway, a strong smell of urine on one unit, unfinished handrails, and scuff marks on walls. An interview with the Administrator revealed that the corrections had not been completed due to a lack of matching paint, confirming the surveyor's findings.
Failure to Hold Quarterly QAPI Meeting
Penalty
Summary
The facility failed to hold a required quarterly Quality Assessment and Assurance (QAPI) meeting for one of the four quarters. A review of the facility's QAPI Committee meeting attendance sheets revealed that meetings were held on 9/27/24, 6/18/24, and 3/5/24. However, there was no evidence of a meeting being held in December 2023 or January 2023 for the fourth quarter. During an interview with the surveyor, the Marketing Clinical Advisor confirmed that the facility did not conduct a quarterly QAPI meeting in the specified time frame, and the last documented meeting was dated 10/24/23.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing preferences of a resident, leading to a deficiency in care. The resident, who was admitted and later discharged within a specified period, had indicated in their admission minimum data set (MDS) that choosing their bathing options was very important. However, the facility's Certified Nurse's Assistant (CNA) bathing documentation showed that the resident only received showers on two specific dates and lacked evidence of showers during two separate weeks. An interview with the Market Clinical Advisor confirmed that the facility's policy required residents to receive at least one bath or shower per week, which was not adhered to in this case.
Failure to Provide SNFABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident whose Medicare Part A services were discontinued. The review of the resident's Skilled Beneficiary Notification form, completed by the Minimum Data Set (MDS) Coordinator, indicated that the resident's Medicare Part A services ended on 10/30/24. However, there was no evidence that the required SNFABN was issued to the resident, which would have allowed them to make an informed decision about continuing skilled services that may not be covered by Medicare and assuming financial responsibility. During an interview with the surveyor on 12/3/24, the MDS Coordinator confirmed that the SNFABN was not provided to the resident, highlighting a lapse in the facility's process for notifying residents of their Medicare coverage status and potential financial liabilities.
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.
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