Below 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 Market Square Health Care Center, Llc during CMS and state inspections, most recent first.
A facility failed to develop and implement complete care plans for several residents with current therapy, behavior, and fall-monitoring needs. One resident with quadriplegia and adaptive drinking equipment had OT orders but no therapy goals or interventions in the care plan; another resident requiring 2 staff for all care had that need documented but not fully reflected in the care plan. A resident with repeated verbal and physical aggression toward others also lacked behavior interventions, two residents receiving PT/OT had no therapy-related care plan goals, and a resident on hourly rounding after a fall had multiple missed rounds documented.
Kitchen sanitation, food storage, and tray service deficiencies were identified when surveyors observed a food mixer with residue, dirty and damaged food prep surfaces, unlabeled and undated food items, open food in the walk-in freezer, and spilled residue in a dining room refrigerator. Required dish machine, temp, and sanitizer logs were also missing for multiple dates, and CNAs were seen carrying uncovered meal trays down the hall while a Dietary Aide confirmed food was not being fully covered before tray delivery.
Infection control practices were not consistently followed during resident care. Staff were observed failing to wear required gown and gloves for EBP care, not cleaning a glucometer after use, not removing gloves or sanitizing hands between tasks, and handling soiled linen in an unbagged manner. A resident with ESBL E. coli UTI had conflicting precaution status and lacked clear documentation for contact precautions or EBP, and the facility had not completed its annual IPCP review.
Failure to Investigate Injury of Unknown Origin: A resident was found with a bruise/discolored skin on the inner thigh during CNA care, and the resident could not explain how it occurred. Facility notes documented an unknown source of injury and no prior fall or incident, but the DON and Administrator confirmed no investigation was completed and no follow-up report was submitted to the state. A later note described the resident falling onto a recliner arm and landing on the thigh, but this was documented after the initial injury was identified.
The facility did not maintain required documentation and monitoring for its Legionella Water Management Program, omitting key appendices and failing to monitor specified equipment. Additionally, a CNA-M used reusable blood pressure cuffs and a stethoscope on a resident and did not sanitize the equipment before returning it to the medication cart, despite acknowledging the need for disinfection between uses.
Surveyors identified widespread deficiencies in housekeeping and maintenance, including soiled equipment, uncleanable surfaces, damaged privacy curtains, dirty caulking, and exposed heating elements. These issues were observed in multiple resident rooms and common areas, resulting in an environment that was not consistently safe, clean, or comfortable for residents.
The facility did not create or implement baseline care plans within 48 hours of admission for three residents, including two who were current smokers and one with a Stage 4 pressure ulcer. The care plans lacked necessary interventions for smoking and did not accurately reflect the use of positioning wedges for pressure ulcer management, as confirmed by staff interviews and record reviews.
Staff did not consistently sign the controlled substance logs at shift changes, resulting in missing incoming and outgoing signatures on multiple occasions. Despite receiving education on the importance of this process, staff admitted to not always ensuring proper documentation, and these findings were confirmed by the facility's quality improvement specialist.
Surveyors found that the kitchen and food storage areas were not maintained in a clean and sanitary manner, with dirty floors, soiled equipment, and expired or unlabeled food items present. The Food Service Director and an RN confirmed these findings, which were not in accordance with the facility's food storage policy.
Surveyors identified incomplete and inaccurate clinical documentation for two residents related to smoking status and contracts, as both initialed all options on their smoking agreements and had inconsistent or incomplete smoking assessments. Additionally, documentation for a resident with a wander guard device failed to specify its placement during multiple shifts, and medication records for another resident lacked clear rationale and evidence of required orders, including for oxygen use. These deficiencies were confirmed by staff interviews and record reviews.
A resident did not consistently receive scheduled showers according to their preferences, with staff substituting bed baths due to staffing issues and failing to document refusals or changes. The facility's records confirmed missed showers and lack of proper documentation.
A resident receiving both a diuretic and an anticoagulant for atrial fibrillation did not have updated goals or interventions in their care plan addressing the use of these medications. Review by surveyors and a Quality Improvement Specialist confirmed the omission, which was not in accordance with facility policy requiring person-centered care plans with measurable objectives.
A resident did not receive wound care in accordance with physician orders, as an LPN deviated from prescribed wound care procedures for multiple wound sites and performed a dressing change on a wound without a current order. The LPN confirmed not following the provider's instructions and the lack of an order for one wound site.
A resident with COPD had their nasal cannula tubing left unbagged and draped over an oxygen concentrator, with the prongs in direct contact with the device, instead of being stored in a plastic bag as required by physician orders and the care plan. Staff confirmed that the tubing should have been stored properly when not in use, but this was not followed.
Surveyors observed that a resident had multiple medications, including eye drops, nasal sprays, and a cup of Lactulose, left unsecured at the bedside and on furniture in their room. There were no physician orders or IDT assessments for these medications or for self-administration, and an LPN confirmed that medications should not be left at the bedside and was unaware of their presence.
A facility failed to update a resident's care plan to include goals and interventions for falls, despite multiple incidents. The facility's policy requires care plans to be updated with new interventions, but the resident's care plan lacked evidence of such updates. The Administrator and ADON confirmed the oversight during interviews.
The facility failed to maintain complete clinical records for two residents following falls. One resident's record lacked the Post Fall Observation Tool for several incidents and did not include required nursing notes for three shifts post-fall. Another resident's record also missed nursing notes after falls, despite a care plan addressing fall risks. The ADON confirmed these deficiencies during a review.
A facility failed to maintain an effective Infection Control Program for a resident. Observations revealed an unbagged bedpan on the bathroom floor, an unused catheter bag stored with food items, and a nebulizer improperly stored with personal items. The resident expressed distress over these unsanitary conditions, and a nurse confirmed the improper practices.
The facility failed to maintain adequate hot water temperatures for its laundry equipment, resulting in insufficient cleaning and disinfection of linens. Despite reports from staff and the laundry chemical supplier, the facility's hot water system remained set at 120°F, below the required levels for effective disinfection. This deficiency poses a potential risk of exposure to contaminants for residents and staff.
The facility failed to maintain a clean kitchen environment, with issues such as dusty air conditioning units, food debris, and a dirty dish air dry machine. Additionally, there were significant gaps in monitoring and documenting kitchen operations, including dish machine temperatures and sanitizer levels, as confirmed by the Administrator.
The facility failed to maintain the small and large steam tables in safe operating condition. The small steam table had a broken electrical plug and inconsistent heating, while the large steam table was missing its plug end. Both were still used to serve food. The RD/LD was unaware of these issues until informed by staff, confirming the equipment was not properly maintained.
Incomplete care plans for therapy, behavior management, and fall monitoring
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented to reflect the current needs of 5 residents reviewed for care planning. For Resident #38, who was admitted with quadriplegia and was observed sitting in a high-back wheelchair using a hands-free adaptive drinking system, the clinical record showed physician orders for occupational therapy services, including therapeutic exercise, self-care/home management training, neuro-reeducation, and wheelchair management. The resident’s comprehensive care plan did not include goals or interventions related to the occupational therapy services being provided or the resident’s use of adaptive devices. For Resident #17, the care plan stated that the resident had physical behavioral symptoms directed at others and that all care should be provided with 2 staff members. However, during observation, one CNA responded alone to the resident’s call light and assisted the resident with a bedpan after stating she had forgotten about the request. Another observation showed the Activities Director and Social Services Assistant responding together to the resident’s call light, and the Social Services Assistant stated that two staff were to be present for all interactions with the resident for safety. The care plan did not reflect goals and interventions for this two-staff requirement. Resident #61 had multiple documented incidents of verbal and physical aggression toward other residents, including yelling, cursing, kicking, and threatening behavior, as well as a reported incident in which the resident used a motorized wheelchair to push another resident and ran over the resident’s foot. The care plan lacked goals and interventions addressing these behaviors. Resident #85 had PT and OT orders for therapeutic exercise, therapeutic activities, gait training, neuro re-education, and wheelchair management, but the care plan lacked therapy-related goals and interventions. Resident #25 sustained an unwitnessed fall, and although the care plan included hourly rounding as an intervention, review of hourly rounding sheets showed 14 missing rounds over two days.
Kitchen sanitation, food storage, and tray service deficiencies
Penalty
Summary
The facility failed to maintain the kitchen and related food storage areas in a clean and sanitary manner. During an initial kitchen tour, surveyors observed a food mixer with dried food particles and dried liquid residue on the shroud, cage, and base, and the mix arm had chipped and missing paint creating an uncleanable surface. Surveyors also observed a large bin of cereal that was not dated or labeled, large bins of sugar and flour that were not dated, a ceiling over food preparation areas with dried food and liquid residue spattered on it, a hood system missing filters with a dusty and dirty exhaust area, and a dish room door and frame with rust and chipped or missing paint creating uncleanable surfaces. Additional observations showed food storage and sanitation issues in multiple areas. A bag of bread products on a cart by the coffee maker was not labeled and dated, and six bags of bread products on a cart labeled first-in first-out were also not labeled and dated. The food disposal had dried liquid residue on it, the walk-in refrigerator had a cement floor with worn off and missing paint that was not sealed, and the walk-in freezer contained a bag of carrots, a bag of French fries, and a box of chicken patties that were previously opened and left open to the air and not secured, along with a large bag of tater tots that was not labeled and dated. A refrigerator in the main dining room also had spilled liquid residue on the shelving. The facility also failed to document required kitchen monitoring records for dish machine temperatures, freezer and refrigerator temperatures, and sink/bucket sanitizer and 3-bay PPM checks for multiple dates across February, March, and April 2026. In addition, surveyors observed CNA staff carrying breakfast trays with uncovered food down the hall to resident rooms, and a Dietary Aide stated that all food items are supposed to be covered or packaged but confirmed he had not been covering all food on the resident meal trays. The DON was informed of the tray observations and confirmed the information.
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a sanitary environment and prevent the development and transmission of infection during resident care activities involving enhanced barrier precautions, glucometer cleaning, linen handling, hand hygiene, and transmission-based precautions. During observation of a resident room on enhanced barrier precautions, a CNA entered the room without the required gown, held a trash bag with an ungloved hand, and another CNA was observed at the bedside without gown or gloves placing soiled linen into a plastic bag by hand. The sign outside the room directed staff to clean hands before entering and leaving and to wear gloves and a gown for high-contact resident care activities, including dressing, bathing, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. The facility also failed to follow its own hand hygiene and equipment cleaning practices during resident care. An LPN was observed leaving a resident’s room with a glucometer, placing it in a treatment cart, and locking the drawer without cleaning it after use, despite stating that glucometers are cleaned after each use. In another observation, a CNA donned gloves, removed a resident’s fall mat, assisted with a transfer, and then began to lift the resident’s meal tray cover without removing gloves or sanitizing hands. The CNA stated that the resident was usually already in the wheelchair and that trays needed to be passed quickly, and only sanitized hands after the surveyor intervened. The facility also failed to handle soiled linen according to policy and did not apply transmission-based precautions consistently. A CNA transported a shower chair containing unbagged soiled linens and trash out of a resident room, rinsed the chair in the shower room, and then carried the unbagged linens against her body to the soiled utility room before discarding them. In another instance, a resident with ESBL E. coli UTI had a stop sign and PPE cart outside the room, but the clinical record lacked evidence that contact precautions or enhanced barrier precautions were ordered, and staff gave conflicting statements about the resident’s precaution status. The facility further failed to complete an annual review of its Infection Prevention and Control Program; the Administrator confirmed the program had last been reviewed at a QAPI meeting in January 2025 and had not yet been reviewed for 2026.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate a resident's injury of unknown origin for Resident #27. Facility policy required that designated personnel begin an investigation immediately, complete a root cause investigation and analysis, and evaluate injuries of unknown origin or suspicious injuries as soon as they are discovered. On 2/21/26, the State of Maine's Division of Licensing and Certification received a facility-reported incident stating that staff noticed a small bruise on the inside of Resident #27's left thigh while providing care, and the resident could not recall how the bruise occurred. The report also indicated that no follow-up report was received by the DLC. Review of the clinical record showed a nursing progress note dated 2/20/26 documenting that a CNA reported an unknown source of injury during rounds and evening care, with discolored skin noted to the resident's left inner thigh and the resident unable to explain what happened. The note also stated there were no reports from the previous shift of a fall or incident and that administration/on-call nursing staff were notified. A later nursing progress note dated 3/4/26 stated the resident fell back onto the arm of a recliner and landed on the left thigh, but during interviews on 5/12/26 and 5/13/26, the DON and Administrator confirmed the facility did not complete an investigation for the injury of unknown origin and did not submit a follow-up report to the DLC.
Infection Control Program Deficiencies: Legionella Management and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, specifically regarding the prevention and control of Legionella. The Legionella Water Management Program referenced control measures and monitoring procedures in Appendices A and C, but these appendices were missing from the program documentation. Additionally, the monitoring spreadsheet (Appendix B) did not include required monitoring or sampling for the ice machine and floor scrubbing machine, both of which were identified as equipment to be included in the preventative maintenance schedule. The Quality Improvement Specialist confirmed that the facility was not following its own Legionella Water Management policy, as there were no measures in place to control, assess, or monitor areas where Legionella and other waterborne pathogens could grow and spread, nor was there a diagram indicating where these measures should be applied. During direct observation, a CNA-M used reusable blood pressure cuffs and a stethoscope on a resident and then failed to sanitize the equipment before placing it back in the medication cart or hanging it on the cart. The CNA-M acknowledged that the equipment was for multi-patient use and admitted that it should have been sanitized before being stored or reused. These findings were discussed with the Regional Quality Improvement Specialist, confirming lapses in infection control practices related to equipment sanitation.
Failure to Maintain Sanitary and Comfortable Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies in housekeeping and maintenance services across all three units during an environmental tour with the Environmental Services Director and the Quality Improvement Specialist. Specific findings included an EZ sit-to-stand patient lift with food debris and dirt in the foot base area, resident rooms with chipped or missing paint, marred walls, and exposed heating elements due to missing heater covers. In one room, a grabber/reacher was coated with a thick brown substance, and another room was noted to be very cold and without heat due to a broken baseboard heater. Additional issues included a bedpan stored on a toilet and a foam pad left on a shower floor. Further observations revealed multiple rooms with entrance and bathroom doors that were gouged, marred, or had untreated putty, creating uncleanable surfaces. Several rooms had privacy curtains in disrepair, missing hooks, or hanging down, and caulking around toilets was dirty. Floors were soiled with dirt and debris, bathroom exhaust fans were dusty, and some bathroom walls were marked with black scuffs. In one instance, a urine hat was found on a bathroom floor. These findings were confirmed by the Environmental Services Director and the Quality Improvement Specialist during the tour.
Failure to Develop and Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by facility policy. For one resident who was a current smoker, the baseline care plan did not include any interventions or instructions related to smoking upon admission, despite documentation of the resident's smoking status. Another resident, also identified as a smoker and permitted to smoke unsupervised, did not have any smoking-related interventions or goals included in the care plan as of the time of review. These omissions were confirmed during interviews with the Quality Improvement Specialist. Additionally, a resident with a Stage 4 sacral pressure ulcer was observed being repositioned with multiple wedge pillows, as described by staff. However, the baseline care plan for this resident only referenced the use of bolstered pillows to the bilateral lower extremities and did not reflect the actual practice of using additional positioning wedges for turning and repositioning every two hours. Interviews with staff confirmed the use of more wedges than documented in the care plan. These findings indicate that the facility did not ensure baseline care plans were accurately developed and implemented within the required timeframe for these residents.
Failure to Document Controlled Substance Shift Counts
Penalty
Summary
The facility failed to ensure that two authorized staff members signed the Shift Count page to confirm the count of all controlled substances at each change of shift on both the East and [NAME] Units. Record reviews revealed multiple instances where either the outgoing or incoming signature, or both, were missing from the controlled substance logs on various dates and times. This included missing signatures on both the East Wing Med Cart and Treatment Cart, as well as the [NAME] Wing Controlled Substance Log. The absence of these signatures indicates that the required verification of controlled substances was not consistently performed at shift changes. Interviews with Certified Nursing Assistant-Medication Technicians and a Licensed Practical Nurse confirmed that staff had received education on the importance of signing the controlled substance log after each count and at every shift change. However, staff admitted to not always ensuring that both parties signed the log as required. The Quality Improvement Specialist also confirmed these findings during the survey.
Deficient Sanitation and Food Storage Practices in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain the kitchen and food storage areas in a clean and sanitary condition. During a kitchen tour, the kitchen floor was found dirty with food debris and trash, and similar debris was noted under equipment and shelving. The dish room food disposal unit had dried food and liquid residue, and a wall-mounted fan was heavily soiled with dust. A plunger with dried food and liquid residue was found on the dish room floor. In the dry storage room, several boxes of Apple Juice Blend base and containers of Med Plus 2.0 Nutritional Drink were found past their best if used by dates, and multiple bags of cornflakes were not labeled. The walk-in refrigerator and freezer floors were dirty, missing paint or sealant, and contained unlabeled and undated food items such as hot dogs and buns. The storage room floor was also dirty and missing paint or sealant. Additionally, in a kitchenette refrigerator, expired Apple Juice Blend base and Med Plus 2.0 Nutritional Drink were found, along with an unmarked and undated container of cereal on top of the refrigerator. These findings were confirmed by the Food Service Director and a registered nurse during interviews. The facility's own food storage policy requires all foods to be covered, labeled, dated, and discarded if past their use by dates, which was not followed in these instances.
Incomplete and Inaccurate Clinical Documentation for Smoking, Medication, and Safety Devices
Penalty
Summary
The facility failed to ensure that clinical records for several residents contained complete and accurate documentation, specifically regarding smoking status, smoking contracts, medication orders, and monitoring of safety devices. For two residents who smoked, their clinical records and smoking contracts were not completed accurately. Both residents had initialed all options on the smoking contract, rather than selecting the appropriate choice, and the smoking status assessments were either incomplete or inconsistent with the residents' actual smoking behaviors. These discrepancies were confirmed during interviews with the residents and facility staff. Additionally, for one resident with an order for a wander guard device, the clinical record lacked documentation specifying the placement of the device during multiple shifts over several days. Nursing staff documented the presence of the wander guard but did not indicate its location on the resident, as required. This omission was acknowledged by the DON and Assistant DON during interviews. The review of medication orders for another resident revealed incomplete documentation regarding the rationale for certain medications, such as constipation and sleep medications, and a lack of evidence that an order was obtained for oxygen use, despite active orders for oxygen tubing changes. These documentation gaps were confirmed by the facility's Quality Improvement Specialist during record reviews and interviews.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to accommodate a resident's preferences for bathing, as evidenced by the resident not consistently receiving scheduled showers on Sundays and Wednesdays. The resident reported that, due to staffing issues, showers were often replaced with bed baths without their preference being honored. Review of the bathing documentation for February 2025 confirmed that the resident did not receive showers on several scheduled dates, and there was no documentation indicating that the resident refused showers or that bed baths were provided as a substitute. The Quality Improvement Specialist verified the lack of documentation and the deviation from the resident's established bathing schedule.
Failure to Update Care Plan for Diuretic and Anticoagulant Use
Penalty
Summary
The facility failed to update and implement measurable goals and interventions in the care plan for a resident who was prescribed both a diuretic (Lasix) and an anticoagulant (Eliquis) for atrial fibrillation. Record review showed that the resident had active medication orders for these drugs, but the most recent care plan update did not include any goals or interventions related to their use. During a care plan review with the Quality Improvement Specialist and surveyors, it was confirmed that the care plan lacked the required documentation for managing these medications, despite facility policy requiring person-centered care plans with measurable objectives and timeframes for all identified needs.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care were followed for one resident. Clinical record review revealed specific physician orders for wound care on the right shoulder, anterior neck, and lateral neck, including detailed instructions for cleansing, application of skin prep, Kaltostat, Medihoney, and appropriate dressings. However, during direct observation, the LPN did not follow these orders as written. For the right shoulder, the LPN applied Medihoney before Kaltostat, then placed a saline-soaked gauze over the Kaltostat, which was not in accordance with the physician's instructions. For the anterior and lateral neck wounds, the LPN applied Medihoney to a Mepilix dressing and then applied it to the wound, which also deviated from the prescribed method. Additionally, there was no current physician order for wound management for the left shoulder wound, yet the LPN performed a dressing change on this site. During interview, the LPN confirmed the failure to follow the provider's orders for the right shoulder, anterior neck, and lateral neck wounds, as well as the absence of a wound order for the left shoulder. These actions resulted in the facility not providing treatment and care according to physician orders and the resident's care plan.
Failure to Maintain Sanitary Storage of Oxygen Tubing
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the development and transmission of infection related to respiratory care for a resident with chronic obstructive pulmonary disease (COPD). During observations on two separate occasions, the resident's nasal cannula tubing was found unbagged and draped over the oxygen concentrator, with the prongs in direct contact with the concentrator's surface. An empty plastic storage bag, intended for storing the tubing when not in use, was tied to the nightstand drawer handle instead of being used. The resident's clinical record included active orders to change the tubing weekly and to store unused oxygen tubing in a plastic bag, as well as a care plan reflecting these requirements. Interviews with a CNA and an LPN confirmed that the tubing should have been stored in the designated bag when not in use, but this was not done.
Failure to Secure and Document Medications at Bedside
Penalty
Summary
Surveyors found that the facility failed to properly store medications and treatments on two out of three days of the survey. Specifically, a resident was observed to have multiple medications, including thera tears lubricant eye drops, Top Care nasal spray (oxymetazoline hydrochloride), and fluticasone propionate nasal spray, at their bedside and on their over-the-bed table and TV stand. Additionally, a clear medication cup containing approximately 30ml of yellow liquid, identified as Lactulose, was also found on the resident's TV stand. These medications were not secured in locked compartments as required. Review of the resident's clinical record revealed there were no physician orders for the medications found at the bedside, nor was there an order for self-administration. The record also lacked evidence of an interdisciplinary team (IDT) assessment to determine if self-administration was safe, as required by facility policy. An LPN confirmed that medications should not be left at the bedside and was unaware that the resident had these medications in their room.
Failure to Update Care Plan for Falls
Penalty
Summary
The facility failed to update a resident's care plan to reflect current care needs in the area of falls. The facility's Falls Management Policy requires that residents' care plans be updated with all new interventions. However, a review of the clinical record for a resident revealed multiple falls on specific dates, yet the care plan, last updated on 11/12/24, did not include goals and interventions for falls. During interviews with surveyors, both the Administrator and the Assistant Director of Nursing confirmed that the care plan was not updated to include necessary interventions for falls, despite the expectation that it should be updated after each fall.
Incomplete Clinical Records for Residents After Falls
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For one resident, the clinical record revealed multiple falls on specific dates, but the Post Fall Observation Tool was not completed for several of these incidents. Additionally, the clinical record lacked evidence of a nurse's note for each shift for three shifts following these falls, as required by the facility's Falls Management Policy. Another resident's care plan indicated a history of falls related to impaired mobility and other factors, with specific interventions outlined to prevent further incidents. However, the clinical record for this resident also lacked evidence of nursing notes being completed for each shift for three shifts after falls occurred. The Assistant Director of Nursing confirmed these deficiencies during a review of the clinical records with surveyors.
Infection Control Program Deficiency
Penalty
Summary
The facility failed to maintain an effective Infection Control Program for one of the sampled residents. Observations in the resident's room revealed several issues: an unbagged bedpan was found on the bathroom floor, an unused catheter bag dated two days prior was placed in a cardboard box containing the resident's pudding cups, and a nebulizer was left disassembled on the bedside table. Additionally, the nebulizer tubing was improperly stored in a wash basin with personal items like headbands and a hairbrush with a significant amount of hair. The resident expressed distress over the unsanitary conditions, particularly the catheter bag being stored with food items. A registered nurse confirmed these findings, acknowledging that bedpans should be bagged, catheter bags should not be mixed with personal items, and nebulizer tubing should be bagged when not in use.
Inadequate Hot Water Supply for Laundry
Penalty
Summary
The facility failed to maintain its laundry equipment according to the manufacturer's instructions, resulting in inadequate cleaning and disinfecting of linens. On the day of the survey, the hot water temperatures in the washing machines were significantly below the required levels for effective cleaning and disinfection. The Laundry/Housekeeping Supervisor confirmed that the hot water temperatures were insufficient, and logs from August 2024 showed consistently low temperatures, ranging from 64°F to 123°F, which did not meet the necessary standards for healthcare settings. Interviews with maintenance workers revealed that the facility's hot water system was set at 120°F, which was insufficient for the laundry's needs. The system could not be adjusted higher due to the risk of scalding in resident areas. A hot water booster, which could have addressed the issue, had been removed years prior and was never replaced. The maintenance workers confirmed that the current setup could not provide the necessary hot water temperatures for proper linen disinfection. The Quality Improvement Specialist and other staff members had reported the issue to corporate employees and the facility's administration, but no effective solution had been implemented. Documentation from the Patriot Company, which provided laundry chemicals, consistently noted the low water temperatures in their monthly reports. Despite these warnings, the facility did not take action to ensure the washing machines received adequate hot water, leading to a potential risk of exposure to contaminants for both residents and staff.
Deficiencies in Kitchen Sanitation and Monitoring
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a survey. The surveyor noted several areas of concern, including dusty and dirty wall-mounted air conditioning units, food debris and trash on the kitchen floor, a dirty plunger in the dish room, and a dusty dish air dry machine. Additionally, the grease trap was found to be rusty and dirty, and the dry storage room had a heavily soiled floor, a dusty wall vent, and a ceiling light with a cracked lens filled with dust and debris. The walk-in freezer had a significant ice buildup and was littered with trash and dirt, with a bag of cut green beans frozen into the ice. These observations were confirmed with the cook during the survey. The facility also failed to adequately monitor and document critical kitchen operations. The Daily High-Temp Ware Wash Checklist showed temperatures below manufacturer recommendations on multiple occasions, and there were numerous missing entries for dish machine temperatures. Similarly, the Sink/Bucket Sanitizer checklist and the Refrigerator/Freezer Temperature Log had extensive gaps in monitoring and documentation. These deficiencies were confirmed with the Administrator, indicating a systemic failure to adhere to established protocols for maintaining kitchen sanitation and equipment monitoring.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the small and large steam tables, in good repair and safe operating condition. During a kitchen tour, a surveyor observed that the small steam table had a broken electrical plug and was still in use, while the large steam table was missing its electrical plug end entirely. Both pieces of equipment were reportedly used to serve food to residents despite their malfunctioning state. The dietary aide and cook confirmed that the small steam table had inconsistent heating issues and that maintenance was aware of the problem but had not yet fixed it. The large steam table had been broken for two to three months, and the facility was in the process of acquiring a replacement. The Registered Dietitian/Licensed Dietitian (RD/LD) was unaware of the issues with the steam tables until informed by the kitchen staff. She confirmed that both steam tables were being used to keep food hot, despite not being maintained in a safe and proper working condition. The RD/LD acknowledged that the equipment had not been properly maintained, which was corroborated by the observations and interviews conducted by the surveyor. The facility's failure to ensure the safe operation of essential kitchen equipment was evident in the continued use of the malfunctioning steam tables.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norway Center For Health & Rehabilitation, Llc | 1.6 mi | ★★★★★ | 0 | 0 |
| Maine Veterans Home - So Paris | 2.1 mi | ★★★★★ | 5 | 0 |
| Clover Health Care | 16.4 mi | ★★★★★ | 7 | 1 |
| Odd Fellows Health Care Center | 16.7 mi | ★★★★★ | 10 | 0 |
| Montello Manor | 17.4 mi | ★★★★★ | 2 | 0 |
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