Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbor Hill Center during CMS and state inspections, most recent first.
The facility failed to complete annual performance evaluations for 5 of 5 sampled CNAs. During the survey, the last two performance evaluations were requested, and the Administrator stated that the CNAs had not had a performance evaluation for the past two years.
A facility failed to maintain resident privacy and confidentiality when two video monitors at the nurses station were visible to staff, family, visitors, and other residents. Surveyors observed two residents on the monitors, including one resident exposed in bed with an incontinent brief and another resident lying in bed, and found no physician order or resident/resident representative consent for the video camera/monitor use.
Housekeeping and linen handling deficiencies were observed when a resident room had heavily soiled walls, bedside furniture with dried fluid residues and food debris, and a wedge pillow with torn covering and exposed foam. In the laundry area, an LST was seen placing a face cloth from the floor into the clean linen pile, and a ceiling tile had an unidentified red stain.
Infection control failed when staff did not follow EBP/PPE requirements and hand hygiene practices. A Charge Nurse handled a bag with a soiled incontinence pad and did not wash her hands after leaving the soiled utility room, and CNAs entered a resident's room for repositioning without PPE despite posted EBP signage and a precaution cart outside the room. The resident had open areas to the ear, buttocks, and bilateral heels, with ordered treatments for pressure ulcers on the coccyx and both heels.
Failure to maintain resident dignity and respect when several residents reported that an LPN was rude, mean, and made them cry when they asked for help. Residents said the LPN covered for staff who did not provide care such as whirlpools, washing up, and toileting, falsely reported that they refused care, and denied bathroom assistance by saying she did not have time.
A resident was unable to access personal funds after office hours or on weekends because the money was kept locked in the office and only available when the office was open. The SW confirmed that resident accounts were managed by the receptionist and that the facility did not have a petty fund for evening or weekend access.
A resident’s code status was not accurately documented in the clinical record. Physician orders listed the resident as Full Code, while the care plan identified the resident as DNR/DNI. Admission social services documentation noted the resident did not want to address advance directives, and the hospital discharge summary stated the resident wished to remain Full Code. Social Services later confirmed the code status was inaccurate.
Failure to Resubmit PASRR Screens for Extended Convalescent Care Stays: The facility failed to resubmit PASRR Level I screens for two residents admitted under convalescent care when their stays extended beyond the approved 30 days. Both residents had PASRRs indicating convalescent care categorical status, and the records showed no evidence that a new screen request was sent to Maximus within the required timeframe before approval expiration. The Administrator and SW confirmed the requests were not resubmitted.
A resident’s Baseline Care Plan was not developed and implemented within 48 hours of admission and did not include key provider orders or care needs. The plan failed to address HOB elevation to avoid SOB while lying flat, PT, OT, dietary orders, or ADL care, and the ADON confirmed the care plan lacked ADL information during record review.
Care plans were not updated for a resident requiring EBP due to open wounds and for another resident with a new Type 2 DM diagnosis. Surveyors found an EBP sign posted outside one resident’s room, but the care plan did not address EBP use. For the other resident, the clinical record showed a new Type 2 DM diagnosis, yet there were no associated notes and the care plan was not revised to include problems, goals, or interventions.
Failure to provide scheduled bathing and hygiene assistance: A resident who was dependent on staff for ADLs was observed with greasy, unwashed hair and later remained in pajamas from the night before. The resident stated staff had not assisted with bathing, hair washing, or dressing, and the bathing schedule binder was outdated and did not list the resident. The CNA said staff could not update the schedule, the Charge Nurse was unsure who maintained it, and the ADON confirmed the record lacked evidence that the resident received the scheduled whirlpool bath or had their hair washed since admission.
Delayed Bowel Regimen Initiation: A resident with constipation and significant pain had ordered bowel meds that were not started on time. Record review showed the bowel protocol was initiated later than ordered after 72 hours without a BM, and on a later episode no bowel protocol was started at all; the ADON/IP confirmed the protocol was not followed as ordered.
A resident receiving quetiapine had no documented AIMS despite a pharmacy consultant recommendation and the facility’s policy for antipsychotic monitoring. In a separate event, another resident received doxycycline three times in one day because overlapping doxycycline orders were active, resulting in more doses than ordered.
Food Storage and Ice Machine Plumbing Deficiencies: Emergency food supplies were observed without expiration dates, and the Dietary Account Manager stated the parcels were labeled only with the month and day received while the original boxes with expiration dates were discarded. An ice machine outside the kitchen was also observed without a 1 air gap, with wet flooring around the drain and multiple drain tubes present, including one actively draining water.
Survey results were not posted in a readily accessible location for residents, family members, and legal representatives. A surveyor observed the Survey Results bin in the entrance foyer empty, and the Administrator later confirmed the binder was kept in the DON's office instead of being available in the foyer.
A resident was transferred to the hospital for an infection and returned four days later, but the facility did not provide a written bed-hold notice to the resident or the resident’s representative. The Administrator confirmed the omission and stated the facility does not notify the State Ombudsman Program when residents are transferred to the hospital.
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 Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees, identified as CNA1 through CNA5. During the survey, the last two performance evaluations were requested for these five CNAs, and the Administrator stated that the requested CNAs had not had a performance evaluation for the past two years.
Resident Video Monitors Visible at Nurses Station Without Orders or Consent
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential by displaying video camera monitors at the nurses station where staff, family, visitors, and other residents could view them. During an initial tour of the Long Term Care unit, surveyors observed two video monitors on the nurses station desk showing residents in their beds. One monitor showed R8 lying on his/her right side with his/her face away from the camera and his/her bare left shoulder and back exposed, and another monitor later showed R2 in bed. A Registered Nurse Charge Nurse confirmed at the time of observation that R8 and R2's privacy and confidentiality were not maintained. Further observation showed that R8 was lying on his/her side uncovered, wearing an incontinent brief, with the body exposed, and a video camera was seen on the bedside table pointed toward the resident. Review of R8's clinical record found no physician's order for the video camera and no consent from the resident or resident representative for use of the video monitor. Review of R2's clinical record also found no consent from the resident or resident representative for use of the video monitor. During interview, the Marketing Clinical Advisor and the Administrator confirmed that the video monitors were visible at the nurses station and that R8 did not have a physician order and neither resident had consent for the video monitor.
Housekeeping and Linen Handling Deficiencies
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. During observations in a resident room, the wall at the head of bed 1 and the bedside cabinet were heavily soiled with dried fluid residues, and both bedside tables were heavily soiled with food debris before lunch service. In another room, a wedge pillow used in bed 2 had a torn plastic covering with exposed internal foam, and a ceiling tile just inside the door to Fort Point had an unidentified red stain. During a laundry department observation, a Laundry Staff member was seen folding clean linens when a face cloth was found on the floor below the basket. The staff member picked up the face cloth, folded it, placed it on the clean linens pile, and continued folding laundry. When asked where the face cloth went, the staff member stated, "I folded it," and the surveyor confirmed the soiled linen had been placed in the clean linen pile. The same room conditions were later observed again with the heavily soiled wall and bedside cabinet, and an ADON and Lighthouse Keeper 3 confirmed the observations.
Infection Control Program Failure with PPE and Hand Hygiene Lapses
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection when staff did not use proper PPE in an Enhanced Barrier Precaution room and did not wash hands after handling soiled linens and touching multiple surfaces. The report states that on 1/13/26, a Charge Nurse exited a resident room holding a clear plastic bag containing a soiled incontinence pad, took the bag to the soiled utility room, stopped at the door, returned to the nurse's station to obtain a key, went back and opened the soiled utility room door, threw the bag into a bin from the doorway, and then returned the key to the nurse station; the surveyor confirmed the Charge Nurse did not wash her hands after returning from the soiled utility room. The report also describes observations involving a resident with open areas to the right ear, buttocks, and bilateral heels. A review of the resident's clinical record showed treatments ordered for open wounds on the coccyx and both heels, identified as pressure ulcers. On 1/13/26, a CNA entered the resident's room to assist with repositioning without donning PPE and stated she was not aware PPE was required despite the sign outside the room; after the sign was brought to her attention, she and another staff member donned PPE. On 1/14/26, another CNA entered the room to assist with repositioning and again stated she was not aware that full PPE had to be worn when providing care, even though the precaution cart was outside the room and the EBP sign was posted.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to promote care for residents in a manner that maintained dignity and respect when several residents reported that an LPN was rude, mean, and made them cry when they asked for assistance. During interviews, residents stated they were afraid of retaliation from this nurse and requested to remain anonymous. They reported that the LPN would cover for favored staff when care was not provided, including whirlpools, daily washing up, and toileting, and would tell oncoming staff that residents refused care even though the residents said they did not refuse showers because they did not receive them consistently. Residents also stated that on several occasions when they asked to use the bathroom, the LPN told them no and said she did not have time to help them. The Administrator stated that the LPN had not worked that week, that residents did not have to interact with her during that time, and that the LPN was placed on administrative leave pending investigation.
Lack of Access to Resident Personal Funds After Hours
Penalty
Summary
The facility failed to provide residents with access to personal funds after business hours during evenings and weekends for Resident #16, who was reviewed for personal funds. During an interview, the resident stated that money was kept in the office and could only be obtained when the office was open, requiring the resident to wait until Monday if money was needed after hours or on weekends. A later interview with the Social Worker confirmed that money after hours or on weekends was not available, that the receptionist kept resident funds locked in the office and managed resident accounts, and that the facility did not have a petty fund available for residents during evening and weekend hours. The surveyor confirmed this lack of access to resident funds outside office hours.
Inaccurate Code Status in Resident Record
Penalty
Summary
The facility failed to ensure that one resident’s advance directive/code status was accurately reflected in the clinical record. During record review, Resident #6 was found to be listed as Full Code on physician orders, while the care plan identified the resident as Do Not Resuscitate/Do Not Intubate (DNR/DNI). The social services assessment completed at admission documented that the resident did not want to address advance directives, and the hospital discharge summary stated that the resident wished to remain Full Code. During an interview, Social Services confirmed that the resident’s code status was not accurate in the record.
Failure to Resubmit PASRR Screens for Extended Convalescent Care Stays
Penalty
Summary
The facility failed to resubmit PASRR Level I screens when two residents admitted under convalescent care remained in the nursing home beyond the allotted 30 days. For Resident #6, the record showed a PASRR Level I Screen completed on 11/21/25 before admission, and the screen indicated the resident met criteria for convalescent care categorical. The PASRR instructions stated that if the resident needed to stay longer than the approved number of days, the nursing facility had to submit a new PASRR screen request to Maximus 7 to 10 days before the approval expired, but there was no evidence in the clinical record or Social Service office that a timely request was resubmitted. For Resident #16, the record showed a PASRR Level I Screen completed on 11/5/25 before admission, and it also indicated the resident met criteria for convalescent care categorical. The same PASRR instructions required a new screen request to Maximus 7 to 10 days before approval expiration if the stay extended beyond the approved days, but there was no evidence in the clinical record or Social Service office that a timely request was resubmitted. The Administrator confirmed that a new PASRR screen was not resubmitted or requested before the approval expired, and the Administrator and Social Worker confirmed the same for Resident #16.
Baseline Care Plan Missing Required Resident Care Information
Penalty
Summary
The facility failed to ensure a Baseline Care Plan was developed and implemented within 48 hours of admission for Resident #46, and the plan did not include the instructions needed to provide minimum healthcare information necessary to properly care for the resident. On 1/13/26, the resident’s record was reviewed and the Baseline Care Plan was found not to address provider orders for head of bed elevation to avoid shortness of breath while lying flat on day and night shift, physical therapy, occupational therapy, dietary orders, or the resident’s needs regarding ADL care. During an interview on 1/13/26 at 2:00 p.m., the surveyor reviewed the clinical record with the ADON, and the ADON confirmed that the Baseline Care Plan did not contain information regarding ADL care for the resident.
Care plans not updated for EBP and new diabetes diagnosis
Penalty
Summary
The facility failed to update and revise care plans for Enhanced Barrier Precautions (EBP) for a resident with open wounds on the coccyx and both heels. On 1/13/25, a surveyor observed an EBP sign posted outside the resident’s room. Record review showed the resident had open wounds on the coccyx and on the right and left heels, but the care plan lacked evidence of addressing the need for EBP while providing care. During an interview and record review with the Unit Manager, the surveyor confirmed the care plan did not include the use of EBP. The facility also failed to revise and implement a care plan for a resident with a new diagnosis of Type 2 Diabetes. Record review and interview with the ADON showed the resident’s provider progress note on 6/6/25 did not include a diagnosis of Type 2 Diabetes, the resident had a normal Hemoglobin A1c on 8/5/25, and the clinical record later indicated a new diagnosis of Type 2 Diabetes on 9/30/25 with no notes associated with that diagnosis. The resident’s care plan was not revised to address the new diagnosis. The ADON stated the resident was diagnosed with Type 2 Diabetes, that the Hemoglobin A1c confirmed the condition was diet controlled, and that the resident was monitored annually, but the care plan still did not include problems, goals, or interventions for the diagnosis.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to provide the necessary services for a resident who was dependent on staff for activities of daily living and personal hygiene. A surveyor observed the resident’s hair appeared greasy and the hair around the temple area was standing on end. During an interview, the resident stated they had not had a shower or bath and had not had their hair washed since admission. On a later observation, the resident was still in pajamas from the night before and stated they were not dressed yet. The resident reported that staff had only helped with set-up for washing up that morning, but did not assist with bathing, washing the hair, or getting dressed. Review of the bathing schedule binder showed an outdated October 2025 list with several names crossed out, and the resident was not listed. The CNA stated staff were not allowed to update the schedule, and the Charge Nurse stated the resident should have been on the Wednesday schedule but was unsure who updated the binder. The ADON later reviewed the clinical record and stated the resident was scheduled for a whirlpool bath on Thursdays, but the record lacked evidence that the resident received the whirlpool bath on the scheduled day or that the hair had been washed since admission.
Delayed Bowel Regimen Initiation
Penalty
Summary
The facility failed to initiate a resident's bowel regimen protocol in a timely manner for Resident #2, who was experiencing significant constipation and pain. During an OT evaluation on 12/30/25, the resident was documented as having 9/10 pain due to constipation and was unable to complete ADL and functional mobility assessment because of the pain, though the resident was agreeable to the evaluation write-up. The resident's active bowel orders included MiraLax if no bowel movement in 72 hours, Milk of Magnesia if no bowel movement in 3 days, Dulcolax suppository if no result from MOM and/or MiraLax by the next shift, and mineral oil enema as needed. Record review showed large bowel movements on 12/26/25, then no bowel movements on 12/27/25, 12/28/25, and 12/29/25, but the bowel protocol was not started until 12/30/25 at 12:07 p.m. with MiraLax, instead of beginning on 12/29/25 at 2:34 p.m. with MOM after 72 hours without a bowel movement. The record also showed a medium bowel movement on 1/2/26, followed by no bowel movements on 1/3/26, 1/4/26, and 1/5/26, when the bowel protocol should have started on 1/5/26 at 11:24 p.m., but no bowel protocol was initiated. In interview, the ADON/IP confirmed the bowel protocol was not followed as ordered and that the facility was starting the protocol on the 4th day without a bowel movement instead of after 72 hours.
Unnecessary Medication Monitoring and Dosing Errors
Penalty
Summary
The facility failed to adequately monitor a resident who was receiving quetiapine for an antipsychotic indication. A pharmacy consultant reviewed the resident’s record and recommended that an Abnormal Involuntary Movement Scale (AIMS) be completed within 30 days of admission or start of the antipsychotic and then every 6 months. The resident’s record showed orders for quetiapine 0.5 mg by mouth daily at 9 a.m. and 25 mg by mouth daily at 6 p.m., but there was no evidence that an AIMS had been completed in the clinical record. The facility’s policy stated that the AIMS should be completed per nursing schedule for patients receiving antipsychotic medications, and the consulting Administrator confirmed that the AIMS was not completed for the resident. The facility also failed to ensure that another resident’s drug regimen was free from unnecessary medications when doxycycline was administered more times than ordered. The resident had an order for doxycycline hyclate 100 mg by mouth twice daily starting on 12/18/25 at 9:00 p.m., and the medication was given at approximately 9:00 a.m. on 12/19/25. A second order for doxycycline mono 100 mg by mouth twice daily began on 12/19/25 at 10:00 a.m., and that dose was also given at approximately 10:00 a.m. on 12/19/25. The first doxycycline order was not discontinued until 2:40 p.m. that day, and the resident received a third doxycycline dose in the evening, resulting in three doses on 12/19/25 instead of the ordered two doses.
Food Storage and Ice Machine Plumbing Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not ensuring emergency food supplies were labeled with expiration dates and by not ensuring plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code. During observation and interview on 1/13/26 at 10:44 a.m., the emergency food supply was found and confirmed to be unlabeled with expiration dates. The Dietary Account Manager stated the food parcels were labeled with the month and day they were received but not the year, and that the expiration dates were on the boxes the food parcels came in, but the boxes were discarded to save space. Later that day at 11:04 a.m., the ice machine outside the kitchen was observed and confirmed to not have a 1 air gap. The floor around the drain was wet, three drain type tubes were observed behind the ice machine, a black tube and a clear tube were resting on the floor, the clear tube was actively draining water, and an orange tube was descending into the drain beyond sight.
Survey Results Not Posted in Accessible Area
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. During observation on 1/12/26 at 10:45 a.m., a surveyor found the bin labeled Survey Results in the entrance foyer empty. On 1/13/26 at 1:45 p.m., the surveyor and the Administrator again observed that the Survey Results bin in the entrance foyer was empty, and at 1:47 p.m. the Administrator stated that the survey results binder was in the DON's office.
Failure to Provide Bed-Hold Notice and Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to issue a written bed-hold notice to Resident #37 or the resident’s legal representative after the resident was transferred to the hospital for an infection and returned four days later. Record review showed no evidence that the resident or the representative/POA/brother received a written copy of the bed-hold notice. During interview, the Administrator confirmed that the written bed-hold notice was not provided. The Administrator also stated that the facility notifies the State Ombudsman Program monthly of residents discharged from the facility, but does not notify the Ombudsman Program of residents who are transferred or discharged to the hospital.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belfast
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windward Gardens | 16 mi | — | 26 | 0 |
| Breakwater Commons | 23 mi | ★★★★★ | 22 | 0 |
| Brewer Center For Health & Rehabilitation, Llc | 27 mi | ★★★★★ | 7 | 0 |
| Bangor Nursing & Rehabilitation Center | 27.6 mi | ★★★★★ | 24 | 0 |
| Westgate Center For Rehab & Alzheimers Care | 28 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.