Inspection Reports for
Forest Avenue Home
5 Forest Avenue, Ellsworth, ME 04605, ME, 04605
Back to Facility Profile24 Reports
Inspection Report — Mar 9, 2026
Annual Inspection
Date: Mar 9, 2026
Visit Reason
The survey was conducted as part of the annual Long Term Care Survey Process for Federal Recertification.
Findings
The facility was found not in compliance with several requirements including resident dignity during dining, proper assessment and monitoring of restraint use, and sanitary food preparation practices.
Deficiencies (3)
F0550: The facility failed to promote care to residents in a manner that maintains each resident's dignity during lunch dining services, as staff were observed assisting a resident while standing instead of sitting.
F0684: The facility failed to obtain a provider order, complete an assessment, and monitor the use of a seatbelt while in a motorized wheelchair for one resident.
F0812: The facility failed to prepare food under sanitary conditions, as frying pans were observed with baked/fried on substances and worn nonstick coatings.
Report Facts
: 1E3E27-H1
: 0305
Inspection Report — Mar 9, 2026
Plan of Correction
Date: Mar 9, 2026
Visit Reason
The document is a plan of correction for the survey completed on 03/11/2026 addressing deficiencies related to resident rights, quality of care, food safety, and sanitary conditions.
Findings
This document is the facility's plan of correction for the survey completed on 03/11/2026. It addresses deficiencies related to resident rights, quality of care, and food safety requirements.
Report Facts
: 40
Inspection Report — Jul 15, 2025
Plan of Correction
Date: Jul 15, 2025
Visit Reason
This document is the facility's plan of correction for the survey completed on 07/15/2025 addressing deficiencies related to respiratory/tracheostomy care and suctioning.
Findings
This is the facility's plan of correction for the survey of 07/15/2025, addressing deficiencies cited under rule F0695 regarding respiratory care and tracheostomy suctioning.
Report Facts
: MED0052163
Inspection Report — Apr 15, 2025
Annual Inspection
Date: Apr 15, 2025
Visit Reason
On 4/15/25, an on-site visit was conducted at Forest Hill Manor for the purpose of completing the revisit to the annual Survey Process for Federal Recertification dated 2/20/25.
Findings
Forest Hill Manor was determined to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, with no deficiencies cited.
Inspection Report — Feb 20, 2025
Annual Inspection
Date: Feb 20, 2025
Visit Reason
The survey was conducted for the purpose of completing the annual Survey Process for Federal Recertification.
Findings
Forest Hill Manor was found not in compliance with multiple federal requirements including notification of changes, safe environment, comprehensive care plans, quality of care, free of accident hazards, nutrition and hydration, respiratory care, sufficient nursing staff, labeling and storage of drugs, infection prevention and control, and influenza and pneumococcal immunizations.
Deficiencies (13)
F580: The facility failed to timely notify the Medical Provider of abnormal laboratory results for a resident, resulting in delayed follow-up and communication.
F584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including worn flooring, chipped paint, and dirt buildup in resident areas.
F656: The facility failed to develop and implement a comprehensive person-centered care plan for a resident with diabetes, lacking measurable goals and interventions.
F657: The facility failed to update and revise care plans for residents on Enhanced Barrier Precautions, lacking evidence of required precautions in care plans.
F684: The facility failed to ensure physician orders were followed for unnecessary medications, specifically sliding scale insulin coverage for a resident with diabetes.
F689: The facility failed to ensure hot water temperatures in resident rooms did not exceed 120 degrees Fahrenheit, creating a potential hazard.
F692: The facility failed to recognize and address significant weight loss in a resident, lacking appropriate nutritional interventions and documentation.
F695: The facility failed to maintain respiratory care equipment and ensure proper oxygen tubing management, including missing filters and untimely tubing changes.
F725: The facility failed to provide sufficient nursing staff with appropriate competencies and skills to meet resident needs and ensure safety.
F761: The facility failed to ensure proper labeling, storage, and monitoring of drugs and biologicals, including expired medications and unsecured storage areas.
F773: The facility failed to provide timely notification of abnormal laboratory results to the ordering physician and failed to follow policies for such notifications.
F880: The facility failed to establish and maintain an effective infection prevention and control program, including proper PPE usage, hand hygiene, and linen handling.
F883: The facility failed to develop and implement policies to ensure residents received influenza and pneumococcal immunizations or education regarding these vaccines.
Report Facts
: 9:06 a.m. and 9:23 a.m. on 1/21/25
: 14.6
: 4.0-10.0
: 158
: 136-145
: 5.3
: 3.5-5.1
: Array
: Array
: 3 lbs
: Array
: every 2 weeks
: Q4 2024 (July 1 - September 30)
Inspection Report — Feb 18, 2025
Annual Inspection
Date: Feb 18, 2025
Visit Reason
Annual Survey Process for Federal Recertification conducted from 2/18/25 through 2/20/25.
Findings
The facility was found not in compliance with multiple regulatory requirements including timely notification of abnormal lab results, maintenance of a safe and clean environment, development and implementation of comprehensive care plans, medication administration, infection control, and staffing adequacy.
Deficiencies (12)
F773: The facility failed to notify the medical provider timely of abnormal laboratory results for Resident #42, with a 28-hour delay in review by the Nurse Practitioner after results were available.
F584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, evidenced by worn and cracked flooring, chipped paint, broken sink trim, and soiled floor mats in multiple areas.
F656: The facility failed to develop a person-centered comprehensive care plan addressing Diabetes management for Resident #13.
F657: The facility failed to update care plans to include Enhanced Barrier Precautions for Residents #26 and #27.
F684: The facility failed to follow physician orders for sliding scale insulin administration for Resident #13, consistently administering less than the ordered dose.
F689: The facility failed to maintain hot water temperatures below 120°F in resident rooms and failed to repair loose floor tiles creating trip hazards.
F692: The facility failed to recognize and intervene for significant weight loss in Resident #30, lacking notification to medical providers and initiation of nutritional interventions.
F695: The facility failed to maintain respiratory equipment in a sanitary manner for Residents #11, #27, and #33, including soiled oxygen concentrator filters, missing filters, and tubing not changed per protocol.
F725: The facility failed to ensure sufficient nursing staff were scheduled and on duty to meet resident needs, particularly on weekends during the fourth quarter of 2024.
F761: The facility failed to remove expired drugs and biologicals from medication storage areas, including expired nasal gel and gastrointestinal cocktail.
F880: The facility failed to implement infection prevention measures, including failure to wear gowns and gloves during enhanced barrier precautions, improper medication administration without gloves, and incomplete water management monitoring.
F883: The facility failed to ensure Resident #34 was offered pneumococcal immunization or documented refusal or contraindication.
Report Facts
: 14.6
: 158
: 5.3
: 184
: 175
: 168
: 160
: 155
: 175
: 153
: 228
: 151
: 162
: 161
: 205
: 240
: 157
: 124.8
: 122.1
: 124.5
: 124.8
: 122.5
: 120.9
: 120.8
Inspection Report — Feb 18, 2025
Biennial Survey
Date: Feb 18, 2025
Visit Reason
Federal Recertification Survey conducted on 02/18/2025 at Forest Hill Manor, a long term care facility.
Findings
The facility failed to include a documented, facility-based and community-based risk assessment in the Emergency Preparedness Plan, did not maintain subsistence needs for staff and patients during emergencies, lacked documentation of roles under a waiver declared by the Secretary, failed to include required emergency officials contact information, and was not in substantial compliance with NFPA 101 Life Safety Code requirements regarding means of egress, exit signage, corridor widths, portable fire extinguishers, corridor doors, and fire damper inspections.
Deficiencies (9)
E 006: The facility failed to include a documented, facility-based and community-based risk assessment in the Emergency Preparedness Plan as required by 42 CFR 483.73(a).
E 015: The facility failed to maintain subsistence needs for staff and patients during emergencies, including food, water, medical and pharmaceutical supplies, and alternate energy sources, in accordance with 42 CFR 483.73(b)(1).
E 026: The facility failed to document the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act, as required by 42 CFR 483.73(b)(8).
E 031: The facility failed to include contact information for emergency preparedness officials, including the Office of the State Long-Term Care Ombudsman, as required by 42 CFR 483.73(c)(2).
K 211: The facility failed to maintain means of egress free of obstructions, including exit signage height and snow/ice clearance at exit discharge, in accordance with NFPA 101 Life Safety Code 2012 edition sections 18.2.1, 19.2.1, and 7.1.10.1.
K 232: The facility failed to maintain required corridor widths free of obstructions, including unsecured chairs reducing corridor width below required minimum, violating NFPA 101 Life Safety Code 2012 edition section 19.2.3.4(5).
K 355: The facility failed to properly install and inspect portable fire extinguishers, including obstruction of a Class K extinguisher in the kitchen, violating NFPA 10 Standard for Portable Fire Extinguishers and NFPA 101 Life Safety Code 2012 edition sections 19.3.5.12 and 9.7.4.1.
K 363: The facility failed to maintain corridor doors to resist passage of smoke, including gaps in resident room doors and doors rubbing floors preventing proper closure, violating NFPA 101 Life Safety Code 2012 edition section 19.3.6.3.
K 521: The facility failed to test and inspect fire, smoke, and combination fire and smoke dampers within one year of installation and every four years thereafter, violating NFPA Life Safety Code 2012 edition sections 9.2.1 and 19.5.2.1.
Report Facts
: Feb 25, 2025
: scheduled with third party inspector
Inspection Report — Feb 12, 2025
Complaint Investigation
Date: Feb 12, 2025
Visit Reason
The inspection was conducted following a complaint investigation triggered by video evidence of alleged physical abuse and neglect of a resident at Forest Avenue Home.
Complaint Details
The complaint was substantiated based on video evidence showing physical abuse and verbal mistreatment of Resident #1 by CRMA #1. The staff member was terminated on 10/20/2025. The incident was reported to State Adult Protective Services and local police, who completed their investigation.
Findings
The facility failed to ensure residents were free from physical abuse and was found to have staff verbally abusing and physically mistreating Resident #1, as evidenced by video footage and interviews. The staff member involved was terminated, and retraining was mandated for all agency staff.
Deficiencies (2)
Right to freedom from abuse, neglect or exploitation. Facility failed to ensure residents were free from physical abuse.
Right to privacy and consideration. Facility failed to ensure Resident #1 was treated with dignity and respect while receiving personal care.
Report Facts
Dates of retraining: Retraining conducted between 1/28/2025 and 2/5/2025
Termination date: Staff member terminated on 10/20/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Holdsworth | Administrator | Administrator of Forest Avenue Home, named on the report |
| Unnamed Adult Services Director | Adult Services Director | Completed investigation and confirmed findings |
| Unnamed HR Director | HR Director | Completed investigation and oversaw staff retraining |
Inspection Report — Oct 16, 2024
Follow-Up
Date: Oct 16, 2024
Visit Reason
Follow-up to the federal deficiency cited during the complaint investigation survey on 10/16/2024.
Findings
Forest Hill Manor was determined to be in substantial compliance with 42 CFR 483, subpart B-Requirements for Long Term Care Facilities.
Report Facts
: Oct 16, 2024
Inspection Report — Sep 4, 2024
Complaint Investigation
Date: Sep 4, 2024
Visit Reason
An unannounced on-site visit was conducted to investigate complaint #ME00048284 regarding care deficiencies.
Complaint Details
Complaint #ME00048284 triggered the investigation.
Findings
Forest Hill Manor failed to ensure that resident preferences for whirlpool baths were followed. Resident #1 did not receive whirlpool baths for 7 days in the past 31 days despite care plans indicating daily whirlpool baths in the evening.
Deficiencies (1)
483.24(a)(2): The facility failed to provide necessary bathing services to maintain good personal hygiene for Resident #1, who did not receive whirlpool baths as scheduled.
Report Facts
: ME00048284
: 7
: 1
Inspection Report — May 21, 2024
Follow-Up
Date: May 21, 2024
Visit Reason
This was a follow-up survey conducted offsite to review the facility's compliance after a complaint investigation survey on 4/23/24.
Findings
Forest Hill Manor was determined to be in substantial compliance with 42 CFR 483, subpart B-Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: Apr 23, 2024
Inspection Report — Apr 23, 2024
Follow-Up
Date: Apr 23, 2024
Visit Reason
Follow-up survey conducted to determine compliance with Medicare and Medicaid Federal Conditions of Participation requirements for nursing homes.
Findings
No regulatory deficiencies were identified as a result of the follow-up survey conducted on 4/23/24.
Inspection Report — Feb 27, 2024
Date: Feb 27, 2024
Visit Reason
Federal Recertification Survey for Forest Hill Manor.
Findings
Forest Hill Manor was found not in substantial compliance with NFPA 101 Life Safety Code 2012 due to failure to conduct fire door inspections as required.
Deficiencies (1)
K 761: The facility failed to complete the assessment of all fire doors and did not provide documentation that fire doors had been inspected since 7/26/2022 by qualified personnel. Individuals lacked documented training for fire door inspections.
Report Facts
: Feb 27, 2024
: 09:00-12:00
: Jul 26, 2022
Inspection Report — Feb 26, 2024
Annual Inspection
Date: Feb 26, 2024
Visit Reason
The survey was conducted to complete the annual Long Term Care Survey Process for Federal Recertification.
Findings
The facility was found not in compliance with several federal requirements including accuracy of assessments, preadmission screening, quality of care, nurse aide performance review, food safety, infection prevention and control, and immunizations.
Deficiencies (7)
F641: The facility failed to ensure the Admission Minimum Data Set (MDS) 3.0 was coded accurately for active diagnosis of anxiety for one resident.
F645: The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) was completed accurately and updated for one resident.
F684: The facility failed to follow fall policy and procedure for neurological checks for three residents who had a fall and sustained a head injury.
F730: The facility failed to complete annual performance evaluations for two of six sampled employees.
F812: The facility failed to maintain the kitchen in a clean and sanitary manner and failed to label and date food in a reach-in freezer.
F880: The facility failed to implement infection prevention measures for two of three days of survey, including lack of signage for personal protective equipment stations and improper storage of bed pans.
F883: The facility failed to ensure residents were offered and received influenza and pneumococcal immunizations according to CDC recommendations.
Report Facts
: Feb 27, 2024
: 2024-02-25 to 2024-02-27
: 2024-02-25 to 2024-02-26
Inspection Report — Feb 25, 2024
Annual Inspection
Date: Feb 25, 2024
Visit Reason
The survey was conducted as part of the annual Long Term Care Survey Process for Federal Recertification.
Findings
The facility was found not in compliance with multiple federal requirements including accuracy of assessments, PASRR screening, quality of care, nurse aide performance reviews, food safety, infection prevention, and immunizations.
Deficiencies (7)
§483.20(g): The facility failed to ensure that the Admission Minimum Data Set (MDS) 3.0 accurately reflected the resident's status for 1 of 1 sampled residents, omitting a diagnosis of anxiety despite hospital discharge paperwork and physician orders indicating the diagnosis.
§483.20(k): The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) was updated to include current diagnoses and resubmitted to the State-designated authority for 1 of 1 residents reviewed.
§483.25: The facility failed to follow their fall policy and procedure for completing neurological checks for 3 of 3 residents who had a fall and sustained a head injury, lacking evidence of neuro checks at required intervals.
§483.35(d)(7): The facility failed to complete annual performance evaluations for 2 of 6 sampled employees, including a Certified Nursing Assistant and a Unit Care Taker.
§483.60(i): The facility failed to maintain the kitchen in a clean and sanitary manner, including chipped paint, dust, corrosion, and unlabeled and undated food items in the reach-in freezer.
§483.80(a): The facility failed to implement infection prevention measures by not posting signage indicating necessary precautions at personal protective equipment stations outside resident rooms and failing to label and store bed pans properly to prevent infection spread.
§483.80(d): The facility failed to ensure 5 of 6 residents were reviewed and offered pneumococcal vaccinations (PCV20) in accordance with CDC recommendations.
Report Facts
: 1
: 3
: 1
: 1
: 1
: 1
: 1
: 1
Inspection Report — Jun 6, 2023
Biennial Survey
Date: Jun 6, 2023
Visit Reason
An on-site biennial survey inspection was conducted to assess compliance with regulations governing the licensing and functioning of Level III Residential Care Facilities.
Findings
Forest Avenue Home was found to be in substantial compliance with the applicable regulations for Level III Residential Care Facilities.
Document — 85YH H2 SOD
Date: 85YH H2 SOD
Inspection Report — P8TF11 POC
Date: P8TF11 POC
Findings
This document is a scanned CMS-2567 Plan of Correction form with no extractable text.
Inspection Report — 3OYV11 SOD
Date: 3OYV11 SOD
Visit Reason
Focused Infection Control/COVID-19 Survey conducted on 08/16/2023.
Findings
Forest Hill Manor was found to be in compliance with regulation 483.80(a)(1)(2)(4)(e)(f), also known as F880, within 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
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