Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Maefair Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with hemiparesis and dementia, requiring maximal assistance and frequent incontinence care, did not receive timely morning ADL and incontinent care. Documentation and staff interviews confirmed that care was delayed until the afternoon, regular two-hour checks were not performed, and care was provided by a single aide instead of the required two staff members. Other staff did not intervene or assist, and facility leadership acknowledged that care was not provided according to policy.
A resident with hemiparesis, vascular dementia, and moderately impaired cognition, who required maximal assistance and two staff for care, did not receive care according to the established plan. On one occasion, a nurse aide provided incontinence care alone, despite the care plan specifying two staff were needed, and there were extended periods without care checks. Facility leadership confirmed the care plan was not followed.
A resident with hemiparesis and vascular dementia, requiring maximal assistance and frequent incontinent care, did not have complete or accurate documentation of care provided. Although a nurse aide reported giving care around midday, there was no record of this in the clinical documentation, and facility leadership could not provide evidence of the care. Facility policy required documentation to be completed by the end of the shift, but this was not done.
A resident with a signed DNR order in their paper chart was incorrectly listed as full code in the EMR. The care plan and interventions conflicted with the resident's documented wishes, and the discrepancy was confirmed by the DON, who acknowledged that staff rely on the EMR for code status. The facility's policy requiring a physician's DNR order in the EMR was not followed.
Two residents experienced deficiencies in their living environment, including improper storage of personal care equipment and persistent urine odors in their rooms. Staff interviews and observations revealed confusion about storage procedures and unclear responsibilities for addressing odors, resulting in a failure to maintain a clean, comfortable, and homelike setting.
A resident with multiple chronic conditions did not receive prescribed medications and a blood sugar check as ordered, with no documentation of refusal or rationale for omission in the MAR or nurse's notes. Facility policy requires administration and documentation of all medications, but this was not followed, resulting in a deficiency.
A resident with significant mobility deficits was transferred using a mechanical lift without the base being opened as required by facility policy and manufacturer guidelines. Two nurse aides involved in the transfer were unaware of the need to open the base for stability, despite having received orientation on lift use. This failure to follow established safety protocols resulted in a deficiency related to accident prevention and resident safety.
A resident with multiple complex medical conditions, including a stage 4 pressure ulcer and risk for malnutrition, did not have weekly weights and re-weights obtained and documented as ordered by the physician. Despite care plan interventions and facility policy requiring regular weight monitoring and verification of significant weight changes, staff failed to consistently record weights or perform timely re-weighs, resulting in missed documentation of significant weight loss.
Surveyors found expired IV fluids and penicillin tablets in a medication room, with no documented checks or timely removal as required by facility policy. Additionally, a resident with dementia and other conditions was left with medication at the bedside for self-administration, contrary to policy requiring staff to observe medication ingestion. Staff interviews revealed confusion about responsibility for both expired medication checks and proper medication administration.
A resident with multiple medical and psychiatric diagnoses was found to have a lesion on the lower lip during a dental visit, with a recommendation for evaluation by an oral surgeon. The facility did not arrange or follow up on this referral, despite the resident later verbalizing dental pain and the facility's policy requiring provision of necessary dental services.
A resident with dementia and a history of wandering was not properly accounted for after a door alarm was triggered. Staff failed to check all possible exit routes, specifically missing a second, unalarmed door leading to a stairwell. The resident was later found injured at the bottom of the stairs with fractures and was hospitalized as a result.
A resident with severe cognitive impairment and a known risk for elopement was able to leave the facility unsupervised after a recreation event. Despite having a wanderguard bracelet and a care plan in place, the resident accessed an elevator with visitors, triggered an alarm that was deactivated by a social worker, and was not properly monitored upon return to the recreation area. The resident exited through a door that was left ajar and not alarmed, and was later found in the parking lot by another resident.
Failure to Provide Timely ADL and Incontinent Care
Penalty
Summary
A resident with hemiparesis and vascular dementia, who required maximal assistance with activities of daily living (ADLs) and was frequently incontinent, did not receive timely personal and incontinent care as required by their care plan. Documentation and staff interviews revealed that the resident was not provided morning care until the afternoon, despite having their call light on for an extended period and requesting assistance. The nurse aide assigned to the resident failed to perform regular two-hour checks and did not provide morning ADL care, only attending to the resident after a supervisor intervened. The aide also provided care alone, despite the resident's care plan specifying the need for two staff members due to left-sided weakness. Further review showed that the last documented incontinent care was provided early in the morning, with no evidence of care between 7 AM and 3 PM. The nurse aide admitted to not providing morning care and to being unfamiliar with the assignment, which she found heavy. Other staff, including an LPN, entered the resident's room for medication administration but did not check for incontinence or provide personal care. Facility leadership confirmed that required two-hour rounds and morning care were not conducted as per policy, resulting in the resident not receiving necessary care in a timely manner.
Failure to Follow Care Plan Requiring Two Staff for Dependent Resident
Penalty
Summary
A deficiency occurred when care was not provided in accordance with the resident's plan of care for a resident diagnosed with hemiparesis and vascular dementia, who had moderately impaired cognition and required maximal assistance with ADLs. The resident's care plan specified that two staff members were required to provide care due to left-sided weakness and behavioral concerns, and to assist with incontinence. On the day in question, the resident alleged that the call light was on for 45 minutes and that ADL care was not provided in the morning. Documentation and staff interviews confirmed that care was provided by only one nurse aide, despite the care plan's requirement for two staff members to be present during care. Further review revealed that the nurse aide checked the resident for incontinence early in the morning but did not check again for approximately three and a half hours, at which point the resident was found incontinent and care was provided by the aide alone. The aide admitted to providing care without a second staff member, citing experience and unavailability of other aides, and acknowledged that this was not in accordance with the care plan. Interviews with facility leadership confirmed that the resident required two staff for care and that the care plan was not followed during the incident.
Incomplete Documentation of Incontinent Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the medical record for a resident with hemiparesis and vascular dementia was complete and accurate regarding incontinent care provided. The resident, who had moderately impaired cognition and required maximal assistance with ADLs, was frequently incontinent of bowel and bladder. The care plan directed staff to provide incontinent care, and facility documentation indicated that the resident alleged not receiving ADL care from the morning and having the call light on for 45 minutes without response. An incident summary confirmed that the nurse aide assigned to the resident did not provide any morning care/ADL care and only checked on the resident at the start of the shift and gave incontinent care before lunch, but this was not documented in the clinical record. Review of the nurse aide documentation showed the last recorded incontinent care was at 6:59 AM, with no further documentation of care between 7 AM and 3 PM. The nurse aide later stated she provided care around midday but did not document it, citing lack of time before her shift ended. Interviews with facility leadership confirmed they could not provide documentation of the care, and facility policy required documentation to be completed at the time of service or by the end of the shift. This failure resulted in an incomplete and inaccurate medical record for the resident.
Failure to Accurately Reflect Resident's Advanced Directive in EMR
Penalty
Summary
A deficiency occurred when a resident with diagnoses including atherosclerotic heart disease, congestive heart failure, and anxiety had a signed Do Not Resuscitate (DNR) order in their paper chart, but the Electronic Medical Record (EMR) incorrectly listed the resident as full code. The resident's care plan acknowledged an established advanced directive, but interventions were documented to support the resident's wish to receive CPR, which conflicted with the signed DNR. The quarterly assessment indicated the resident was moderately cognitively impaired and required moderate assistance with daily activities. During observation, surveyors found the EMR did not match the resident's signed advanced directive. The Director of Nursing Services (DNS) confirmed that nursing staff rely on the EMR for code status and was unsure why the records did not match. The DNS stated that the EMR should be updated as soon as an advanced directive is signed and that it is the responsibility of the nursing team, including herself and physicians, to ensure this is done. The facility's policy requires a physician's order for DNR to be placed in the EMR, but this was not done prior to the surveyor's inquiry.
Failure to Maintain Homelike Environment Due to Improper Storage and Persistent Odors
Penalty
Summary
The facility failed to provide a homelike environment for two residents by not ensuring proper storage of personal care equipment and not maintaining a room free from persistent odors. For one resident with a pelvic fracture and dementia, observations revealed a grey bedpan wedged between the wall and a grab-bar next to the toilet, and two clear graduated containers placed upside down on the toilet tank. The resident's denture cup, toothpaste, and toothbrush were also stored on a shelf over the sink rather than in the bedside dresser as indicated by staff. Interviews with nursing staff and aides confirmed that these items were not stored according to facility expectations, and there was confusion about ownership and proper storage procedures. The facility was unable to provide a policy for the storage and dating of bedpans and containers used for urinary catheter care. For another resident with hypertension, diabetes, and PTSD, the facility did not ensure the resident's room was free from urine odors. Multiple observations over several days identified a persistent urine-like odor in the room. Staff interviews indicated that the odor may have been due to soiled sheets or urine seeping into the tiles, and that the responsibility for addressing the odor was not clearly defined among nursing and housekeeping staff. Despite the beds being made without visible soil, the odor persisted, and staff acknowledged awareness of the issue prior to the surveyor's observations. These deficiencies were identified through clinical reviews, direct observations, and staff interviews, which demonstrated lapses in maintaining a clean, comfortable, and homelike environment for residents. The lack of clear policies and inconsistent practices regarding the storage of personal care equipment and the management of persistent odors contributed to the failure to honor residents' rights to a safe and homelike living space.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including GERD, type 2 diabetes mellitus, and bipolar disorder did not receive medications as ordered by the physician. The resident's care plan identified risks for constipation and the use of psychotropic medications, with interventions including medication administration as ordered and monitoring of bowel movements and orthostatic blood pressure. On review of the Medication Administration Record (MAR), it was observed that doses of Pantoprazole Sodium, Linaclotide, and a scheduled blood sugar check were missed. There was no documentation in the nurse's notes to indicate that the resident refused the medications or to provide a rationale for why the MAR was not signed or the medications were not given. Physician's orders specified the administration of Pantoprazole Sodium and Linaclotide once daily and blood sugar checks twice daily. Facility policy requires that all medications be administered safely and timely per physician's orders, with refusals documented in the Electronic Medical Record and progress notes. An interview with the Director of Nursing Services confirmed that all MARs and Treatment Administration Records should be signed and that the nursing team is responsible for ensuring this. The failure to administer medications as ordered and to document refusals or reasons for omission led to the identified deficiency.
Failure to Follow Mechanical Lift Safety Protocols During Resident Transfer
Penalty
Summary
Staff failed to ensure a safe transfer for a resident with morbid obesity, intellectual disabilities, and osteoarthritis by not following manufacturer specifications for the use of a mechanical lift. The resident's care plan required the use of a mechanical lift for transfers, and the facility's policy, as well as the manufacturer's guidelines, directed that the base legs of the lift be locked in the maximum open position for stability and safety. During an observed transfer, two nurse aides did not open the base of the mechanical lift before moving the resident out of bed. Interviews with the nurse aides revealed that they were unaware of the importance of opening the base of the lift prior to use, and one aide stated she was not taught to do so. The Director of Staff Development indicated that all staff receive in-service training on the use of the mechanical lift upon hire, and both aides had been oriented to its use. Facility documentation confirmed the policy requirement for the base to be open during transfers, and the manufacturer's guidelines emphasized the need for the base to be in the maximum open position to prevent tipping and ensure resident safety.
Failure to Obtain and Document Weekly Weights and Re-Weights as Ordered
Penalty
Summary
Staff failed to obtain and document weekly weights and re-weights as ordered by the physician for a resident with multiple complex medical conditions, including sepsis, chronic osteomyelitis, a stage 4 pressure ulcer, and a urinary tract infection. The physician's order specified that weights should be obtained on admission and then weekly for four weeks, but documentation showed that after the initial admission weights, subsequent weekly weights were missing for several weeks. The Medication Administration Record indicated that weights were signed off as completed, but no actual weight values were recorded for some dates, and there were significant gaps in the weight documentation. The resident's care plan identified a risk for malnutrition due to variable intake, obesity, and a pressure wound, with interventions including monitoring and evaluating weight and weight changes. Despite this, there were multiple instances where significant weight loss occurred, including a 10.1-pound loss between admission and the next recorded weight, and a 10.2-pound loss over six days, without timely re-weighs to confirm accuracy. The facility's policy required re-weighs to verify significant weight changes, but these were not consistently performed or documented. Interviews with staff, including the dietician, RN, and DON, confirmed that weights were missing and that the process for obtaining and verifying weights was not consistently followed. The lack of timely and accurate weight monitoring and re-weighs as ordered by the physician and required by facility policy contributed to the deficiency in ensuring adequate nutrition and hydration monitoring for the resident.
Expired Medications and Improper Medication Administration Practices Identified
Penalty
Summary
Expired intravenous (IV) fluids and penicillin tablets were found in the third-floor medication room during an observation with the Infection Preventionist and nursing supervisor. The IV fluids had an expiration date of March 2025, and the penicillin tablets expired on April 26, 2025. Staff interviews revealed that the night supervisor was responsible for checking the IV cart for expired medications, and the emergency stock box was typically reviewed by unit nurses or supervisors. However, there was no record of these checks, and the Director of Nursing Services (DNS) could not explain why the expired medications were not discarded, despite a facility policy requiring removal of medications by the expiration date. A resident with dementia, heart failure, and peripheral vascular disease was observed with a medication cup containing two white pills at the bedside. The resident stated that staff usually left the medication for self-administration, and that the last three doses had been taken independently. The resident had not taken the current dose because the pills were not split as needed. Staff interviews revealed uncertainty about who left the medication at the bedside, and the LPN who administered medications that morning denied leaving any pills for the resident. Facility policy requires staff to observe residents swallowing all administered medications and prohibits leaving medications at the bedside.
Failure to Follow Up on Dental Referral for Resident with Oral Lesion
Penalty
Summary
The facility failed to follow up on a physician's recommendation for dental care for a resident with multiple diagnoses, including pulmonary embolism, dementia with behavioral disturbance, schizophrenia, anxiety disorder, and depression. The physician's order called for dental care as needed, and during a dental vendor visit, a lump or lesion was identified on the resident's lower right lip. The dentist recommended that the lesion be evaluated by an oral surgeon, but there was no evidence that this consultation was arranged or followed up on by the facility. The resident was observed verbalizing tooth pain while sitting in a wheelchair, and a staff member communicated this concern to the nurse. Interviews with nursing staff revealed that the last documented dental visit in the resident's chart was from the previous year, and the Director of Nursing Services confirmed that no oral surgeon consultation had been set up for the lesion. The facility's dental services policy requires providing both routine and emergency dental services, including outside resources as needed, but this was not done in this case.
Resident Unaccounted for After Door Alarm, Found Injured in Stairwell
Penalty
Summary
A deficiency occurred when a resident with dementia, anxiety, and depression, who had a history of wandering and was dependent on staff for transfers, was not properly accounted for after an alarmed door was triggered. The resident, who self-propelled in a wheelchair and was identified as at risk for falls and wandering, was last seen in the hallway before a door alarm sounded. Staff responded to the alarm by checking three doors on the third floor, but failed to check a second, unalarmed door leading to a stairwell in the 3-2 hallway. Staff assumed the resident was at a recreational activity on another floor and did not confirm the resident's location. The resident was later found on the floor of the 3-2 stairwell, lying on the right side with the wheelchair overturned nearby. The resident was awake and alert but unable to explain the incident. Emergency services were called, and the resident was transferred to the hospital, where they were diagnosed with fractures to the clavicle and pubic ramus, as well as acute cystitis. The incident was reported after a family member alerted staff that the resident was missing, prompting a facility-wide search. Interviews and facility documentation revealed that the staff did not fully investigate all possible exit routes after the alarm was triggered, specifically neglecting to check the second door to the stairwell. The facility's alarm and door system on the third floor included keypads and alarms, but the second door in the 3-2 hallway, per fire code, was not alarmed or locked, allowing the resident to access the stairwell. Staff communication and resident accountability procedures were insufficient, leading to the resident being unaccounted for and sustaining injuries.
Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder, who was identified as being at risk for wandering and elopement, was able to exit the facility unsupervised. The resident had a history of severely impaired cognition and was independent with ambulation. The care plan included interventions such as a wanderguard bracelet and staff monitoring, but these measures were not effectively implemented during the incident. On the day of the event, the resident attended a group recreation activity and was initially escorted back to their room by recreation staff. However, the resident later managed to access the elevator with visitors, using a code provided to visitors by the receptionist, and returned to the main floor. The wanderguard alarm was triggered, and a social worker deactivated the alarm and redirected the resident to the recreation area. The social worker did not inform recreation staff of the resident's return to the area. Subsequently, the resident exited through a recreation room door that was ajar and not fully latched. This door was equipped only with a keycode pad and did not have an alarm. Staff did not witness the resident leaving, and the resident was later found unsupervised in the parking lot by another resident. The facility's investigation determined that the door had been left ajar by family members prior to the incident, and the lack of supervision and communication among staff contributed to the resident's elopement.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Trumbull
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Civita Care Northbridge | 2.5 mi | ★★★★★ | 22 | 0 |
| Mozaic Senior Life | 2.6 mi | ★★★★★ | 34 | 0 |
| Ludlowe Center For Health & Rehabilitation | 2.7 mi | ★★★★★ | 11 | 0 |
| Springs At 3030 Park, The | 2.9 mi | ★★★★★ | 3 | 0 |
| St Joseph's Center | 3.2 mi | — | 0 | 0 |
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