Harbor Hill Center

Inspectors wroteBased on interview, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1] CNA2, CNA3, CNA4, CNA5).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the privacy and confidentiality of residents by displaying video camera/monitors at the nurses station that staff, family, visitors and other residents could view and failed to obtain an order for use of a video camera/monitors, or consent from residents and/or resident representatives prior to use of a video camera/monitor for 2 of 2 residents reviewed (Resident #8 [R8] and R2).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment for 3 of 3 days of survey (1/12/26, 1/13/26, and 1/14/26).

Inspectors wroteBased on observations, facility policy reviews, and interviews, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for 2 of 3 days of survey by failing to ensure staff utilize proper personal protective equipment (PPE) in an Enhanced Barrier Precaution (EBP) room and failing to ensure staff washed their hands after handling soiled linens and touching multiple surfaces (1/13/26 and 1/14/26).

Inspectors wroteBased on interviews, the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff were perceived by several residents as being rude, mean and who denied toileting needs for 4 of 4 residents interviewed.

Inspectors wroteBased on interviews and observation, the facility failed to provide residents with access to personal funds after business hours during the evenings and on weekends for 1 of 1 resident reviewed for personal funds (Resident #16 [R16])

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's right to formulate an advanced directive regarding code status (cardiopulmonary resuscitation [CPR]) was accurate in the clinical record for 1 of 5 residents reviewed for Advanced Directives (Resident #6 [R6]).

Inspectors wroteBased on record reviews and interviews, the facility failed to resubmit a Preadmission screening and resident review (PASRR) Level 1 screen when the nursing home stay of residents who were admitted under convalescent care exceeded the allotted 30 days for 2 of 2 residents whose PASRR's were reviewed (Resident #6 [R6] and R16).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Baseline Care Plan was developed and implemented within 48 hours, that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents (Resident #46 [R46]) reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to update/revise care plans for the use of Enhanced Barrier Precautions (EBP) for 1 of 2 resident reviewed (Resident #8 [R8]). In addition, the facility failed to ensure a care plan was updated and implemented for 1 of 1 resident reviewed with a new diagnosis (R39).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide the necessary services for a resident to maintain personal hygiene for 1 of 2 residents reviewed for activities of daily living and who were dependent on staff for their care [Resident #46 (R46)].

Inspectors wroteBased on clinical record review and interviews, the facility failed to initiate a resident's bowel regime protocol timely for 1 of 5 residents reviewed for unnecessary medications (Resident #2 [R2]).

Inspectors wroteBased on record review, pharmacy consultant monthly review, and interview, the facility failed to adequately monitor a resident who was on an antipsychotic medication for tardive dyskinesia and/or other movement disorders for 1 of 5 residents reviewed for unnecessary medications (Resident #3 [R3]) and failed to ensure that a resident's drug regimen was free from unnecessary medications by administering an excessive dose of an antibiotic in less than 12 hours for 1 of 5 residents reviewed for unnecessary medications (R2).

Inspectors wroteBased on observations and interviews, 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 not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 3 days of survey (1/13/26). This has the potential to effect all residents.

Inspectors wroteBased on observations and interview, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives, the results of the most recent survey of the facility in the survey folder (located in the entrance foyer) for 2 of 3 days of survey (1/12/26 and 1/13/26). On 1/12/26 at 10:45 a.m., a surveyor observed a bin labeled Survey Results, located in the entrance foyer, was empty. On 1/13/26 at 1:45 p.m., during an interview with a surveyor and the Administrator, the bin labeled Survey Results, located in the entrance foyer, was observed and confirmed to be empty. At 1:47 p.m., the Administrator stated the survey results binder was in the Director of Nursing's office.

Inspectors wroteBased on record review and interview, the facility failed to issue a written bed-hold notice to the resident and/or legal representative for 1 of 1 sampled resident's reviewed for re-hospitalization/transfer to an acute care facility (Residents #37 [R37]). In addition, the State Ombudsman Program was not notified of residents that were transferred to an acute care facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure safe transfer practices implement clear, consistent transfer instructions for 1 of 2 residents reviewed for falls. The failure resulted in Resident #5 being transferred with an inappropriate device, inconsistent with therapy recommendations, which contributed to a fall-related injury requiring hospitalization and surgical intervention.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 3 of 4 sampled residents reviewed during a complaint investigation (Resident [R] 1, R3 and R4).1. Review of R1's care plan updated 2/5/25 states It is important for me to be offered a shower Mon Wed Fri but can choose an alternate form of bathing at any time. Review of R1's tub/shower schedule: Monday 7-3 and Wednesday 7-3 and Friday 7-3. Review of R1's GG Bathing task revealed R1 has only received bed baths from 7/1/25 through 7/22/25. During a follow up interview on 7/22/25 at 10:13 a.m., Certified Nursing Assistant (CNA)1 states she was not aware R1 preferred showers because it's not on her task sheet and always gives him/her bed baths because [he's/she's] unable to stand on [his/her] own. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a call bell was accessible for 1 of 3 residents reviewed during a complaint investigation (Resident [R]1). Review of policy Call Lights dated 7/15/25 states Patients will have a call light or alternative communication device at each personas bedside, toilet and bathing room to allow patients to call for assistance when attended. Staff will respond to call lights and communication devices promptly. Each patient will be evaluated for unique needs and preferences to determine any special accommodation's that may be needed in order for the patient to use the call system. Special accommodations will be identified on the patients person-centered care plan of care and provided accordingly (examples include touch pads, larger buttons, bright colors etc.). [...]

Inspectors wroteBased on record review and interviews, the facility failed to update/implement a care plan in the area of communication for 1 of 1 resident reviewed for falls (Resident [R]1). Review of policy Person-Centered Care plan dated 10/24/22 states .The care plan must be customized to each individual patient's preferences and needs. Care plans will be: communicated to appropriate staff, patient, patient representative, family; Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment's, and as needed to reflect the response to care and changing needs and goals. Resident [R]1was admitted with diagnoses to include anoxic brain damage (brain damage caused by lack of oxygen) and is considered a fall risk. During an observation of Resident [R1] on 7/22/25 at 8:35 a.m. R1 was observed lying in bed. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards, as is possible, related to side rail use for 1 of 3 complaint investigations (Resident [R]5). The Department of Licensing received a complaint indicating bed 107-B side rail was broken during the previous residents' stay from 7/2/25 through 7/15/25. Review of Tels work order #8718 dated 7/2/25 states Left grab rail needs to be fixed to lick Comments Checked both beds and they are locking. Observation of room [ROOM NUMBER]-B, currently occupied by R5 revealed side rail on left of bed is not attached appropriately to bed causing it to extend outward when grabbed. The resident currently occupying the bed states he/she gets out of the bed on the left side. At this time a surveyor asked R5 how he/she would use the bed rail to assist him/her. [...]

Inspectors wroteBased on observations and interviews and record review the facility failed to follow professional standards of practice to provide a sanitary environment to help prevent the development and transmission of disease and infection related to bed pan storage, and failed to maintain equipment in a sanitary manner related to a ripped floor mat (Resident [R]1).1. During an observation of Resident [R1] on 7/22/25 at 8:35 a.m., a fall mat was observed on the floor of R1's left side with two tears in it, making it an uncleanable surface.2. Observations of R1's bathroom r on 7/22/25 at 8:35 a.m., 10:17 a.m., revealed an unwrapped bed pan leaning on side of wall next to toilet available for use. During an observation of R1 10:17 a.m., with Registered Nurse (RN)1 observed the unbagged bed pan and stated it should be wrapped. At this time RN1 put the bed pan in a bag and stored it. [...]

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary condition for 2 of 2 environmental tours, both on 12/3/24, on 2 of 2 units[Harbor Hill and Fort Point].

Inspectors wroteBased on record reviews and interview, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 2 of 4 sampled residents (Resident #26 [R26] and [R29]).

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 4 residents reviewed for respiratory care (Resident #4 [R4] and [R26]).

Inspectors wroteBased on interview and record review, the facility failed to ensure accommodations were made for a resident, to include the facility's bathing schedule and resident preferences for 1 of 1 resident reviewed for bathing (Resident #295).

Inspectors wroteBased on observation, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 1 of 3 days of survey (12/2/24).

Inspectors wroteBased on observations, review of the plan of correction, and interview, the facility's quality assurance committee failed to ensure that the plan of correction for identified deficiencies from the Recertification Survey, dated 12/4/24, were effective. The deficiency F584 (Safe/ clean/ comfortable/ homelike Environment) was again identified during the 1/28/25 Re-visit Survey.

Inspectors wroteBased on review of the facility's Quality Performance Improvement (QAPI) Committee meeting attendance sheets and interview, the facility failed to provide evidence that a quarterly meeting was held for 1 of 4 quarters.

Inspectors wroteBased on interview and Beneficiary form review, the facility failed to ensure that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was provided to 1 of 3 residents whose Medicare Part A services were discontinued (Residents #22 [R22]).

Inspectors wroteBased on observations, interview and review of facility Safety Data Sheets, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the 2 of 2 units(Harbor House and Fort Point), a common area and the laundry room for 1 of 1 facility tours (10/19/23).

Inspectors wrote4. On 10/18/23, the facility Falls Management policy and procedure was reviewed. Under Section 5-#5.3-any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neurological check, per policy. R16's clinical record was reviewed for neurological checks post the 4/21/23 unwitnessed fall. There was no evidence that neurological checks were completed per facility post fall management policy and procedure. On 10/18/23 at 1:30 p.m., in an interview, the RCL confirmed that the facility was unable to locate any neurological checks post the resident's unwitnessed fall on 4/21/23.

Inspectors wroteBased on performance evaluations and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled Certified Nursing Assistants (CNA1, CNA2, and CNA3).

Inspectors wroteBased on observations, the facility failed to ensure that proper hand sanitizing and proper food handling during lunch service was followed for 1 of 2 lunch observations (10/16/23) on the Fort Point Unit. The facility also failed to ensure the kitchen was maintained in a clean, sanitary and safe manner for a food slicer, ceiling vents, the dish machine, the food disposal unit and wiring, the walk-in freezer, and a kitchenette refrigerator; and failed to ensure that chemicals were not stored openly in a multipurpose storage room with food for 1 of 1 kitchen tour (10/16/23).

Inspectors wroteBased on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 trash dumpster and the surrounding grounds for 2 of 4 days of survey. (10/16/23, and 10/19/23)

Inspectors wroteBased on interview, the facility failed to ensure that the facility Infection Preventionist (IP) had completed specialized training prior to starting the IP position.

Inspectors wroteBased on interviews, and record reviews the facility failed to meet the requirements for a facility-initiated discharge for 1 of 1 resident reviewed for facility-initiated discharge (Resident 35 [R35]).

Inspectors wroteBased on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #34 [R34]).

Inspectors wroteBased on review of the facility's Infection Prevention and Control Program (IPCP) and interview, the facility failed to ensure that the IPCP was reviewed annually.