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
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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