Harbor Hill Center
Inspection Findings
F-Tag F0689
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Level of Harm - Actual harm Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings:Review of an incident report dated 11/15/25 indicated that at approximately 6:30 a.m. staff attempted to transfer Resident #5 with a sit-to-stand lift. During the transfer, the resident's foot slipped from the lift platform, and staff were unable to safely reposition the foot. The resident was lowered to the floor. A full mechanical lift (Hoyer) was then used to complete the transfer. While being repositioned, the resident cried out and stated his/her knee had popped.A nursing assessment completed on 11/15/25 identified swelling and continued complaints of pain to the residents' left leg. The physician was notified and ordered an X-ray for further evaluation. The X-ray revealed a left femur fracture, and the resident was transferred to the hospital for surgical intervention.Resident #5's physical therapy documentation, dated 11/11/25, indicated the therapist assessed the resident as requiring a full mechanical lift (Hoyer) for all transfers due to instability and inability to safely bear weight. The therapist documented that nursing staff were notified of the change in transfer status and the care plan was updated. Additionally, the clinical record lacks evidence that nursing staff were notified of the change in transfer status prior to the incident. Review of Resident #5's comprehensive care plan under Activities of Daily Living (ADL) revealed that two transfer interventions were listed simultaneously. One intervention, initiated on 10/22/24, instructed staff to use a sit-to-stand lift for all transfers. A separate intervention dated 11/11/25, instructs staff to utilize a total lift for all transfers, and bed pan for toileting, until further notice while therapy continues to assess L ankle ROM and transfer options.
Resulting in conflicting transfer instructions. Review of the Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] Section GG: Functional Abilities, revealed the resident required substantial to total assistance with mobility and transfers. Chair/Bed-to-Chair Transfer (GG0170E) was assessed as 01-Dependent indicating staff provided all assistance and the resident did not perform any portion of the transfer independently.
Sit-to-stand (GG0170D) and Toilet Transfer (GG0170F) were assessed as 02- Substantial/Maximal Assistance indicating the resident was unable to safely come to standing position. without extensive physical assistance. During an interview on 12/30/25 at 2:55 p.m., the Administrator confirmed that Resident #5 required use of a full mechanical lift (Hoyer) for all transfers. The residents' care plan further confirmed that the residents care plan continued to list both sit-to-stand and full mechanical lift (Hoyer) for all transfers and had not been appropriately edited or updated to reflect the change in transfer status.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
HARBOR HILL CENTER in BELFAST, ME inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BELFAST, ME, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HARBOR HILL CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.