Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Hill Manor during CMS and state inspections, most recent first.
Failure to maintain resident dignity during meal assistance was observed during lunch dining service. An RN was seen standing while helping a resident eat and stated she knew she should be sitting but was covering briefly for another staff member. The DON was also observed standing while assisting the resident before later pulling up a chair, and the findings were confirmed by the surveyor and DON.
A resident with cerebral palsy was observed wearing a seatbelt while seated in a motorized wheelchair, but the clinical record lacked a provider order, documented assessment, and monitoring for the seatbelt use. The care plan noted the seatbelt was used to prevent falls or slipping out of the wheelchair, and the DON stated the resident could release the seatbelt and had been assessed, but the assessment was not documented.
Food Preparation Equipment Not Maintained in Sanitary Condition: A surveyor observed multiple frying pans and a skillet encrusted with baked/fried-on residue, and the pans had worn nonstick coating with bare metal exposed on the cooking surface. The cook and dietary aide stated the pans had been non-stick at one time, but the Teflon wore off from cooking and cleaning, and the finding was confirmed by the FSD.
A resident with orders for supplemental oxygen and CPAP/BIPAP treatments experienced multiple episodes of low oxygen saturation, but there was no documentation that the provider was notified as required. Additionally, provider orders lacked clarity regarding when and how CPAP/BIPAP and supplemental oxygen should be used, and the DON confirmed these gaps in documentation and order clarity.
The facility did not ensure adequate staffing levels on weekends, as identified in a review of the Payroll Based Journal staffing report for the fourth quarter of 2024. The Administrator confirmed that the facility lacked sufficient staff to meet resident needs, particularly affecting those requiring assistance with ADLs.
The facility failed to maintain a safe and clean environment, with observations of discolored and cracked flooring, dirt buildup, chipped paint, and broken trim in resident areas. A resident's wheelchair was also found with dirt and debris, indicating inadequate cleaning and maintenance.
The facility did not update care plans to include Enhanced Barrier Precautions (EBP) for two residents. One resident with heel wounds requiring daily dressing changes had an EBP sign, but the care plan did not address EBP needs. Another resident with VRE in the urine had orders for precautions, but the care plan lacked continuous EBP documentation. These deficiencies were confirmed by staff interviews.
The facility failed to maintain safe hot water temperatures in resident rooms, with several instances exceeding 120 degrees Fahrenheit due to a faulty mixing valve. Additionally, blue floor tiles in the Skilled Unit hallway were lifting, creating a potential trip hazard. The Administrator acknowledged both issues, with plans to address the flooring hazard.
The facility failed to maintain respiratory equipment in a sanitary manner for three residents, with issues such as soiled oxygen concentrator filters, missing filters, and outdated oxygen tubing. These deficiencies were confirmed through observations and interviews with the DON.
The facility failed to implement proper infection prevention measures, with staff not adhering to Enhanced Barrier Precautions (EBP) during care activities. Instances included staff not wearing protective gowns or gloves when required. Additionally, the facility did not fully implement a water management program to prevent Legionella and other pathogens, as necessary monitoring activities were not conducted.
A facility failed to promptly notify the Medical Provider and Resident Representative of abnormal lab results for a resident. The resident's blood work showed high white blood cell count, sodium, and potassium levels, but these results were not reviewed by the NP until 28 hours later. The RR requested an update on the results but was told to wait until the next day. The DON acknowledged that both the Medical Provider and RR should have been informed immediately.
A facility failed to develop a comprehensive care plan for a resident with Diabetes, as the care plan lacked goals and interventions for managing the condition and the use of insulin. This was confirmed during a review with the Residential Care Coordinator.
A facility failed to follow physician orders for sliding scale insulin for a resident. The resident's blood sugar levels were checked four times daily, but the Medication Administration Record (MAR) showed incorrect dosages of Novolin R insulin were administered on multiple occasions. Despite blood sugar levels indicating the need for 2 or 4 units, only 1 unit was given, as confirmed by the Resident Care Coordinator.
A facility failed to recognize and address significant weight loss in a resident, whose care plan required a daily nutritional supplement to maintain a target weight. Despite a decline from 184 lbs to 155 lbs over several months, the order for the supplement was dropped, and there was no evidence of notification to the medical provider or dietitian, nor were additional nutritional interventions initiated.
The facility failed to remove expired medications from its storage units. A surveyor found an expired box of Ayr Saline Nasal Gel in the skilled nursing unit and an expired bottle of GI Cocktail in the LTC unit's refrigerator, which was still available for a resident with a current order for its use. These findings were confirmed with the CNA responsible for medications, and the expired items were removed for destruction.
A facility failed to promptly notify a medical provider of abnormal lab results for a resident. Blood work ordered on a resident showed high white blood cell count, sodium, and potassium levels, but these results were not reviewed by a Nurse Practitioner until 28 hours later. The facility's protocol required checking the computer for results unless they were critical, in which case the lab would call. The DON stated the provider should have been informed by phone when the results were available.
A facility failed to offer a pneumococcal immunization to a resident, as required by their policy. The policy mandates offering the vaccine unless contraindicated, but a review of the resident's clinical record showed no evidence of an offer, declination, or receipt of the vaccine. The Infection Preventionist confirmed the absence of documentation, and the resident's representative consented to the immunization only after the surveyor's inquiry.
A resident with multiple cognitive impairments was sexually abused by a staff member, the Transporter, Activities staff, who was found with his hands under the resident's shirt. The incident was witnessed by a CNA who reported it immediately. The resident was unable to consent due to their medical condition, and the staff member admitted to the inappropriate contact. The facility's policy on preventing sexual abuse was violated, and the incident was reported to the relevant authorities.
The facility failed to ensure that two unlicensed staff members completed mandatory training on abuse, neglect, exploitation, and misappropriation of resident property. A transporter and a handyman did not receive the required training within the past year, as confirmed by the DON during a surveyor interview.
A resident's preference for daily evening whirlpool baths was not followed, as they did not receive the baths for 7 days in the past month. The facility's documentation practices failed to specify the type of bath received, leading to a lack of evidence that the resident's care plan was adhered to.
The facility failed to follow physician orders to obtain a urine sample for a resident who had a change in mental status. Despite a provider order, the sample was not obtained, and there was no record of any attempt or completion.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote care to residents in a manner that maintains each resident's dignity during 1 of 2 lunch dining services observed. On 3/9/26 at 11:35 a.m., a surveyor observed RN1 standing while assisting R23 to eat, and RN1 confirmed at the time of the observation that she knew she should be sitting but was only assisting for a couple of minutes to cover for another staff member who had stepped away. On 3/9/26 at 11:37 a.m., the surveyor observed the DON assisting R23 to eat while standing. At 11:40 a.m., the surveyor observed the DON pull up a chair to assist R23 to eat. On 3/11/26 at 8:00 a.m., the surveyor and the DON confirmed the findings.
Missing Order, Assessment, and Monitoring for Wheelchair Seatbelt Use
Penalty
Summary
The facility failed to obtain a provider order, complete an assessment, and monitor the use of a seatbelt while a resident with cerebral palsy was seated in a motorized wheelchair. The resident’s care plan stated that a seatbelt was used on the new motorized wheelchair to prevent falls or slipping out of the wheelchair due to body habitus, and a surveyor observed the resident wearing a seatbelt while in a wheelchair. Review of the clinical record found no evidence of a provider order for the seatbelt, no documented assessment for its use, and no monitoring documentation while the resident used the seatbelt. The Licensed Social Worker stated the resident received the new wheelchair on 2/23/26, and the DON stated the resident was able to release the seatbelt and had been assessed for the wheelchair and seatbelt, but that the assessment was not documented.
Food Preparation Equipment Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to prepare food under sanitary conditions for 1 of 3 days of survey. During an observation on 3/9/26 at approximately 11:45 a.m., a surveyor saw the cook take a small skillet from a shelf and observed that it was encrusted with a baked/fried-on substance. On the same shelf, two additional small frying pans and one medium frying pan were also observed to be encrusted with a baked/fried-on substance. The cooking surfaces of the frying pans were observed to have Teflon nonstick coating remaining only on the outer borders, with bare metal visible on the bottom and middle of the cooking surface. During the observation and interviews with the cook and dietary aide, it was stated that the pans had been non-stick at one time, but the Teflon wore off from cooking and cleaning the pans. This was confirmed by the surveyor with the cook, dietary aide, and later with the Food Service Director.
Failure to Follow Physician Orders for Respiratory Care and Inadequate Documentation
Penalty
Summary
The facility failed to follow physician orders for respiratory care for one resident requiring supplemental oxygen and CPAP/BIPAP treatments. The resident's clinical record included a provider order to check oxygen saturation (SpO2) four times per shift and to notify the covering provider if SpO2 dropped below 90% while awake or below 88% when sleeping. Multiple nursing narrative notes documented SpO2 readings below these thresholds on several occasions, but there was no evidence in the clinical record that the covering provider was notified as required by the order. Additionally, the resident had orders for CPAP use at bedtime, but observations and interviews revealed unclear documentation regarding whether the resident should use CPAP or BIPAP at times other than bedtime, and whether supplemental oxygen should be attached to the CPAP/BIPAP machine during use. The Director of Nursing confirmed that the provider orders were not clear regarding the timing and method of CPAP/BIPAP use and that the required notifications to the provider were not documented when low SpO2 readings occurred.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed low weekend staffing during the fourth quarter of 2024. During an interview with a surveyor, the Administrator confirmed that the facility did not have enough staff on duty to meet resident needs on weekends, affecting residents requiring assistance with Activities of Daily Living (ADLs).
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment for residents. Observations revealed discolored and cracked flooring in resident rooms, dining areas, common areas, and hallways, creating uncleanable surfaces. Dirt buildup was noted along the thresholds between hallways and resident rooms. Additionally, chipped paint and broken trim were observed in a resident's room, along with a soiled floor mat. Furthermore, a resident's wheelchair was found to have dirt and dried debris on both arms and wheels, indicating a lack of proper cleaning and maintenance.
Failure to Update Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to update and revise care plans to include Enhanced Barrier Precautions (EBP) for two residents. For one resident, an EBP sign was observed on the door, and the resident had wounds on both heels requiring daily dressing changes. However, the care plan did not address the need for EBP during care. This was confirmed during an interview with the Residential Care Coordinator. For another resident, an EBP sign was also observed, and the resident had orders for precautions due to Vancomycin-resistant Enterococci (VRE) in the urine. The care plan lacked evidence of the need for continuous EBP for this diagnosis, as confirmed by the Resident Care Coordinator.
Hot Water Temperature and Flooring Hazards
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms, with several instances of temperatures exceeding the maximum allowable limit of 120 degrees Fahrenheit. On the first day of the survey, multiple rooms were found with hot water temperatures ranging from 120.4 to 124.8 degrees. Despite adjustments made by the facility after the initial findings, subsequent checks still revealed temperatures above the acceptable limit. The issue was attributed to a faulty mixing valve, which was identified and replaced on the second day of the survey. Additionally, the facility did not ensure that the flooring in the Skilled Unit hallway was free from hazards. Surveyors observed that blue floor tiles were lifting and becoming unglued, creating a potential trip hazard. The Administrator acknowledged the issue and mentioned that the tiles were located downstairs and that there were plans to replace them. These deficiencies indicate lapses in maintaining a safe environment for residents, as required by regulatory standards.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for three residents, leading to potential risks of disease and infection transmission. For one resident, the oxygen tubing was observed resting on the floor, and the oxygen concentrator filters were heavily soiled with dust and debris. The tubing had not been changed according to the facility's protocol, which requires a change every two weeks. The Director of Nursing (DON) confirmed these observations and acknowledged the failure to maintain the equipment properly. Another resident's oxygen concentrator was missing both side filters, and the oxygen tubing had not been changed since the beginning of January, despite the resident using oxygen every night. The manual for the oxygen concentrator specified that it should not be operated without the filters. A third resident also had oxygen tubing with a nasal cannula resting on the floor, and the tubing had not been changed in a timely manner per protocol. These deficiencies were confirmed through observations and interviews with the DON.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention measures during the survey period. On multiple occasions, staff did not adhere to Enhanced Barrier Precautions (EBP) when providing care to residents. For instance, a Unit Caretaker was observed changing linens for a resident on EBP without wearing a protective gown. Similarly, a Certified Nursing Assistant - Medications (CNA-M) administered eye drops to a resident without wearing gloves, contrary to the guidelines outlined in the Lippincott Nursing Procedures. Additionally, two CNAs assisted a resident with repositioning in bed without wearing the required protective gown and gloves, and a Registered Nurse (RN) assisted a resident with toileting hygiene without wearing a gown, despite the resident being on EBP for Vancomycin-Resistant Enterococcus (VRE). The facility also failed to fully develop and implement a water management program to prevent the growth and spread of Legionella and other water-borne pathogens. The Water Management Program required monitoring activities such as checking hot water temperatures at faucets and cleaning showerheads, but these were not being conducted. The Forest Hill Maintenance Specialist only checked the water temperatures in the boiler room and did not perform other necessary monitoring tasks. The Administrator confirmed that the facility was not monitoring the action items identified in the Water Management Policy, except for the ice machine and boiler room checks.
Failure to Timely Notify Medical Provider and Resident Representative of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the Medical Provider in a timely manner regarding abnormal laboratory results for a resident who was reviewed for hospitalization. The resident had blood work done, including a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), which showed abnormal results. These results were available on the morning of January 21, 2025, but were not reviewed by the Nurse Practitioner until 28 hours later. The Director of Nursing acknowledged that the Medical Provider should have been informed of the abnormal results immediately by telephone. Additionally, the facility did not promptly inform the Resident Representative (RR) about the abnormal lab results when requested. The RR asked for an update on the blood work results on the evening of January 21, 2025, but was told that the results would be reviewed by the doctor the following day, and the RR would be informed afterward. The Director of Nursing admitted that the RR should have been given the information at the time of the request, as the RR could have decided to transfer the resident to the hospital for further evaluation.
Failure to Develop Comprehensive Diabetes Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with Diabetes. The resident was admitted to the facility and had a current physician order for Novolin R insulin sliding scale. However, upon review of the resident's care plan, it was found that there was no evidence of goals and interventions related to the management of Diabetes and the use of insulin. This deficiency was confirmed during a review of the care plan with the Residential Care Coordinator, indicating that the treatment of the resident's Diabetes was not addressed in the care plan.
Failure to Administer Correct Insulin Dosage
Penalty
Summary
The facility failed to ensure that physician orders for sliding scale insulin were followed for a resident. The clinical record review revealed that the resident's blood sugar levels were checked four times a day, and the sliding scale insulin coverage was to be administered according to specific blood sugar ranges. However, on multiple occasions, the resident received an incorrect dosage of Novolin R insulin, as documented in the Medication Administration Record (MAR). For instance, when the resident's blood sugar levels indicated the need for 2 or 4 units of insulin, the MAR showed that only 1 unit was administered. The discrepancies in insulin administration occurred on several dates, with the resident consistently receiving less insulin than prescribed. The surveyor confirmed these findings during an interview with the Resident Care Coordinator, who reviewed the MAR and acknowledged the incorrect dosages. This failure to administer the correct insulin dosage as per the physician's orders constitutes a deficiency in the facility's care for the resident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to recognize and address a significant weight loss in one resident, who was part of a sample reviewed for nutrition. The resident's care plan, revised in late November, indicated a need for a nutritional supplement once a day to address weight loss, with a goal to maintain a body weight within 3 lbs of 179 lbs. However, the resident's weight continued to decline from 184 lbs in early September to 155 lbs by mid-February. During an interview, the Director of Nursing acknowledged that the dietician had ordered a supplement, but the order had been dropped. The clinical record lacked evidence that the nursing staff had notified the medical provider or registered dietitian, nor had they initiated additional nutritional interventions to address the ongoing weight loss.
Expired Medications Found in Storage Units
Penalty
Summary
The facility failed to ensure the removal of expired drugs and biologicals from its medication storage units. During an inspection of the medication storage room on the skilled nursing unit, a surveyor found a box of Ayr Saline Nasal Gel that had expired on July 24. Additionally, in the medication storage refrigerator on the long-term care unit, a surveyor discovered a bottle of GI Cocktail, labeled with a discard date of February 2, which was still available for use. This bottle was associated with a resident who had a current physician's order for the GI Cocktail to be administered twice daily as needed for dyspepsia. These findings were confirmed with the Certified Nursing Assistant responsible for medications, and the expired items were immediately removed for destruction.
Failure to Timely Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the medical provider of abnormal laboratory results in a timely manner for a resident who was reviewed for hospitalization. On January 21, 2025, the resident had blood work and a chest x-ray ordered by the doctor. The blood work, which included a Comprehensive Metabolic Panel (CMP) and Complete Blood Count (CBC), was completed and the results were available by 9:23 a.m. the same day. The results showed abnormal values, including a high white blood cell count, sodium level, and potassium level. However, the facility's documentation indicated that these results were not reviewed by a Nurse Practitioner until 28 hours later, on January 22, 2025, at 1:44 p.m. During interviews, the Registered Nurse stated that results must be checked on the computer unless they are critical values, which would prompt a call from the laboratory. The Director of Nursing acknowledged that the medical provider should have been informed of the abnormal results by telephone when they were available.
Failure to Offer Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that a resident was offered a pneumococcal immunization, as required by their policy. The policy, last revised in February 2012, mandates that all patients be offered the vaccine unless contraindicated due to health history, with administration following a standing order. During a review of the clinical record for one resident, the surveyor found no evidence that the resident was offered, declined, or received the pneumococcal immunization. An interview with the Infection Preventionist confirmed the absence of any record of offering, history of receiving, or declination of the vaccine in the resident's clinical record. The resident's representative consented to the immunization only after the surveyor inquired about the vaccination status.
Resident Sexual Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving a staff member, the Transporter, Activities staff, who was found with his hands under the resident's shirt, touching the resident's breasts. This incident was reported by a Certified Nursing Assistant (CNA1) who entered the resident's room and witnessed the inappropriate contact. The resident involved had multiple diagnoses, including generalized anxiety disorder, major depressive disorder, PTSD, agitation, dementia, major neurocognitive disorder, Alzheimer's disease, and vascular dementia, and was incapable of consenting to sexual activity. The facility's investigation revealed that the Transporter, Activities staff admitted to the inappropriate contact and acknowledged that the resident was not in a normal state of mind and could not consent. The resident did not exhibit outward signs of emotional distress following the incident, but the situation was a clear violation of the resident's dignity and the facility's policy that residents will be free from sexual abuse. The incident was reported to the Maine Department of Health and Human Services, Division of Licensing and Certification, and was identified as Immediate Jeopardy at past non-compliance.
Deficiency in Staff Training on Abuse and Neglect
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, specifically regarding mandatory education on abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during a review of facility staff education records, which revealed that two unlicensed staff members, a transporter in activities and a handyman in housekeeping and engineer services, did not complete the required training within the past year. The transporter was hired on March 28, 2016, and the handyman was hired on January 5, 2023. The Director of Nursing confirmed during an interview with a surveyor that the mandatory training had not been completed for these staff members within the required timeframe.
Failure to Follow Resident's Bathing Preferences
Penalty
Summary
The facility failed to adhere to a resident's care plan preference for daily evening whirlpool baths. The resident, identified as R1, reported to a surveyor that they were supposed to receive whirlpool baths every evening as per their care plan but did not receive them for 7 days in the past 31 days. The resident only refused the whirlpool bath twice, once due to illness and once due to returning late from an outing. The resident's care plan, last evaluated on 8/27/24, confirmed the request for a daily evening whirlpool bath, with the option to decline if necessary. The facility's documentation practices were found to be inadequate in reflecting the type of bathing the resident received. The facility's decision to document bathing according to Section GG of the MDS 3.0 did not specify the type of bath, leading to a lack of evidence that the resident received any whirlpool baths in the past 31 days. Interviews with the Registered Nurse and the Administrator confirmed the absence of documentation for whirlpool baths, highlighting a deficiency in following the resident's care plan and preferences.
Failure to Follow Physician Orders for Urine Sample
Penalty
Summary
The facility failed to follow physician orders to obtain a urine sample for a resident who was being reviewed for resident-to-resident abuse. The medical record showed a provider order dated 4/18/24 to obtain a urinalysis due to a change in the resident's mental status. However, as confirmed by the Administrator during an interview on 4/23/24, the urine sample was not obtained five days after the order was given, and there was no record of any attempt or completion of the urine sample.
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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.
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Nursing homes near Fort Kent
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| High View Rehabilitation And Living Center | 14.4 mi | — | 0 | 0 |
| Mercy Home | 15.8 mi | — | 0 | 0 |
| Borderview Rehab & Living Ctr | 31.6 mi | — | 0 | 0 |
| Caribou Rehab And Nursing Center | 38.5 mi | — | 1 | 0 |
| Maine Veterans Home - Caribou | 39.6 mi | — | 5 | 0 |
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