Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 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 maintain resident dignity during personal care and dressing: one cognitively intact resident was observed sitting on the bed in only a brief while being assisted to get up and dressed with the door open and no privacy curtain drawn, and another resident with dementia and severe cognitive impairment was observed exposed in a hospital gown and later shirtless with the door and privacy curtain open while staff passed by. The observations were confirmed by the Administrator, DNS, and VP of Clinical Services.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. A surveyor observed dirty and stained floors, rust, chipped or missing paint, stained ceiling tiles, damaged privacy curtains, cracked and stained sink and toilet areas, exposed sheetrock, and untreated or broken surfaces in resident rooms and the laundry area; the ES Director and Housekeeping/Laundry Supervisor confirmed the findings.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices: The facility did not provide written transfer/discharge notices or bed hold notices, including cost of care and appeal rights, for multiple residents transferred to the hospital. Records for several residents lacked evidence that the resident or resident representative received the required written notice, and the DON confirmed the missing documentation.
Crash carts on two units were not properly checked or stocked for emergency use. Surveyors found missing ambu bags, empty or unusable O2 equipment, and missing suction supplies on the East Wing and Tuttle Unit carts, and staff could not identify when checks were last completed. The AED was not located where listed, was found on another unit, and staff and the DON confirmed AED checks were not being performed.
A facility failed to keep the environment free of accident hazards when a patient lift had a broken safety clip and a bottle of Clorox Urine Remover was left unsecured in a resident room. The facility also failed to complete required motorized wheelchair safety screens for a resident with a history of unsafe power chair use, including an incident where the resident pushed another resident and ran over that resident’s foot.
A resident receiving supplemental O2 had the nasal cannula in place while the tubing connector repeatedly remained on the floor and disconnected from the concentrator during multiple observations. CNAs and an LPN observed the resident in this condition, and the resident’s O2 sat was checked at 89% during the event. The resident had an order for O2 to keep sats above 90%, and the care plan called for O2 sat monitoring every shift and PRN when O2 was in use.
Missing Controlled Substance Shift Count Signatures: The facility failed to ensure that two authorized medication administrators signed the shift count page to verify controlled substance counts at shift change on two units. Review of controlled substance logs showed multiple missing incoming and outgoing signatures on the med carts for both units, and the findings were reviewed and confirmed with the Facility Administrator.
A resident had an unknown white powder left in a medicine cup on the over-bed table, and an LPN confirmed the resident had an active Nystatin order but was giving the treatment to CNAs and documenting it as administered before it was actually provided. The facility also had repeated out-of-range temperatures in three medication refrigerators storing insulin and vaccines, with staff stating they would call maintenance and document the issue.
Surveyors found unresolved sanitation issues in the laundry room and kitchen areas. The laundry room had a worn, uncleanable cement floor, multiple cracked or missing floor tiles, and missing cove base, while the walk-in refrigerator/freezer floor was unsealed with worn paint and the dish room door and frame had chipped paint and rotted, rusted areas. The Maintenance Director confirmed several items had not been completed as stated in the POC.
Incomplete Staff Orientation and Emergency Preparedness Training: The facility’s orientation records and staff interviews showed that new hires, including a CNA, two RNs, and an LPN, did not receive complete orientation on emergency procedures, fire safety, evacuation routes, alarm locations, or related communication systems. Staff reported being placed on the floor after only signing abuse, neglect, and misappropriation paperwork, and several stated they did not know what to do in a fire or emergency.
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.
Call Bells Not Within Reach for Two Residents: Two residents had call bells out of reach during observations. One resident with a history of falls and balance issues had the call light hanging behind the bed and down to the floor despite a care plan directing it be in reach at all times. Another resident with a fall history had the call light cord tucked between the mattress and wall, and the call bell itself could not be located during one observation.
A resident's personal medical information was left displayed on an unattended treatment cart with an open computer screen, making it visible and easily accessible to residents, visitors, and unauthorized personnel. Surveyors observed the issue and the unit manager closed the screen after intervention.
A resident’s quarterly MDS was inaccurately coded for therapy services. The record showed an active OT order for 12 weeks, but Section O0390 was marked as “None of the above” even though the resident was receiving OT at the time of the assessment. The MDS Coordinator confirmed the coding error during survey review.
A resident admitted with foot and leg fractures had a baseline care plan that did not include the problem, goals, or interventions for the fractures and incorrectly included opioid therapy even though the resident declined it. The President of Clinical Services confirmed the care plan should have addressed the fractures and should not have listed opioid therapy.
A resident receiving PT/OT had unsigned PT orders in the clinical record, while another resident with a left lower leg fracture, NWB status, chronic pain, urinary incontinence, and constipation risk had missing bladder and bowel ADL documentation across multiple shifts. The record also showed a gap of over 40 hours between bladder entries.
The facility failed to ensure that a CNA completed the required 12 hours of annual in-service education. CNA #1 was hired in February 2025, and the employee in-service/attendance record lacked evidence of the required continuing education for the 2/2025 to 2/2026 period. The Facility Administrator confirmed the missing training documentation during interview.
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 Maintain Resident Dignity During Personal Care and Dressing
Penalty
Summary
The facility failed to promote care for residents in a manner that maintained dignity for 2 sampled residents. Resident #41 had a Quarterly MDS showing a BIMS score of 14 of 15, indicating cognitive intactness. On 5/11/26 at 9:23 a.m., a surveyor observed CNA #8 assisting Resident #41 to get up and dressed for breakfast while the resident was sitting on the edge of the bed in only a brief. The bedroom door was open, the privacy curtain was not drawn, and residents and staff were passing by the room. The Administrator confirmed the observation at the time. Resident #51 had diagnoses including dementia and a Quarterly MDS completed 4/3/26 showing a BIMS score of 0, indicating severe cognitive impairment. On 5/11/26 at 9:03 a.m., a surveyor observed Resident #51 wearing a hospital gown with the open part in the front, exposing the resident's bare abdomen and parts of the bare chest while the roommate was seated on the bed. CNA #2 stated the resident usually wore a hospital gown to bed and could sometimes dress self, but was mainly dependent on staff assistance, and that the resident sometimes removed clothing and did not put it back on properly. On 5/12/26 at 2:32 p.m., a repeat observation found Resident #51 seated on the bed shirtless with the door and privacy curtain open while staff walked by in the hall. The DNS and VP of Clinical Services confirmed the finding.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the [NAME] East, [NAME], and Tuttle units, as well as in the laundry room. During an environmental tour on 5/14/26 with the Environmental Services Director and the Housekeeping/Laundry Supervisor, the surveyor observed multiple areas of dirt, staining, rust, chipped or missing paint, and other damaged surfaces that created uncleanable conditions. On [NAME] East Unit, the spa room floor and whirlpool base had dirty/stained caulking and rust, and resident rooms had dirty or stained floors and chipped or missing paint on a baseboard heater. On [NAME] Unit, an unlabeled urinal was left on a shared sink, a bathroom wall was scuffed and missing paint, a wheelchair footrest was on the bathroom floor, and ceiling tiles were stained above a toilet and near a bed. On Tuttle Unit, several resident rooms had privacy curtains missing hooks and hanging in disrepair, ripped wheelchair armrests, chipped or missing paint on baseboard heaters, cracked and stained sink basins, black marks on walls and closet doors, dirty toilets and caulking, gouged walls with exposed sheetrock, and bathroom doors and frames with chipped or missing paint. In the laundry room, the wooden shelf and exposed wooden wall by the washing machines were untreated, the cement floor surface was worn off and untreated, 15 floor tiles were cracked, broken, or missing, and the cove base was coming off the wall by the left dryer. At 9:25 a.m., the Environmental Services Director and the Housekeeping/Laundry Supervisor confirmed the observed findings.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed hold notices, including the cost of care and appeal rights, for 4 of 4 residents reviewed for discharge: Resident #1, Resident #9, Resident #38, and Resident #77. The record for Resident #1 showed transfers to an acute care hospital and subsequent admission, but there was no evidence that the resident, who was responsible for himself/herself, received written bed hold notices for the transfers. During interview, the DON confirmed that written bed hold notices were not provided for the two hospital transfers. Resident #77’s record showed a transfer to an acute care hospital, but there was no evidence that the resident and/or resident representative received a written transfer/discharge notice or bed hold notice. Resident #38’s record showed transfers to an acute care hospital and subsequent admission, including another transfer on 2/18/26, but the facility had no evidence of written transfer/discharge and bed hold notices for those dates. Resident #9’s record showed a hospital transfer, and although an email referenced bed hold information and payment, it lacked evidence of a written notice with appeal rights, ombudsman name and contact information, and transfer notice; the DON confirmed the findings.
Crash Carts and AED Not Properly Checked or Restocked
Penalty
Summary
The facility failed to ensure lifesaving emergency equipment was restocked and readily available for use in an emergency on two crash carts, the East Wing crash cart and the Tuttle Unit crash cart. The facility’s Emergency Equipment Checklist policy required emergency equipment and supplies to be checked every night on third shift, including oxygen and oxygen equipment, a cardiac board, suction machine and suction equipment, an ambu bag, and PPE. On the East Wing crash cart, surveyors observed that the cart did not have an ambu bag, the O2 tank was empty, and there was no yankauer or suction tubing for the suction machine. The East Daily Code/Crash Cart Equipment Check for 4/2025 was blank, and there was no evidence that the equipment check had been completed in 2026. The East Unit Manager stated second shift was supposed to complete and sign the crash cart checks and was unable to find when the last check had been completed or what was supposed to be in the cart. On the Tuttle Unit crash cart, surveyors observed there was no O2 regulator, making the O2 tank unavailable for use in an emergency. The Tuttle Daily Code Cart Equipment Check showed entries signed off on multiple dates, but the unit manager stated she believed the night nurse was responsible for reviewing and restocking the crash cart and that she did not check whether it was done. Surveyors also found that the AED listed as being in the Tuttle nurses station could not be located there, and staff on the unit did not know where it was. The AED was later found on the East Unit, and the AED Inspection Record sticker showed it had last been inspected on a prior date. RN1 confirmed staff do not perform checks on the AED, and the DON confirmed the facility was not performing checks on the AED.
Accident hazards and missing motorized wheelchair safety screening
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards when a patient lift observed in the hallway by a resident room had a broken safety clip on the sling arm that would not safely secure a sling strap during resident transfers. The Administrator observed the lift and confirmed the broken safety clip during the surveyor interview. The facility also failed to ensure that chemicals were properly secured when a 32 fluid ounce bottle of Clorox Urine Remover for Stains and Odors was observed on a bureau next to the door in a resident room, and an LPN confirmed the finding and removed the bottle. The facility’s SDS for the product listed first aid measures for eye contact, skin contact, inhalation, and ingestion. In addition, the facility failed to complete required motorized wheelchair safety screens for a resident who had a documented history of unsafe wheelchair use, including an incident in which the resident used the motorized wheelchair to push another resident out of the way and ran over that resident’s foot. The resident’s record contained a safety screen dated 3/13/24, but no evidence of any later screens, including before the reported incident.
Oxygen Tubing Left on Floor and Disconnected While Resident Used Nasal Cannula
Penalty
Summary
The facility failed to provide a sanitary environment to ensure that respiratory equipment was clean for a resident receiving oxygen therapy. Resident #11 had an order for supplemental oxygen 1-2 L via nasal cannula as needed to keep oxygen saturation greater than 90 percent, and the care plan directed staff to monitor oxygen saturation every shift and as needed when oxygen was in use. During multiple observations, the resident was seen lying in bed with the nasal cannula in place, but the oxygen tubing connector was lying on the floor in front of the oxygen concentrator and visible from the doorway. The same condition was observed repeatedly by surveyors and staff throughout the morning, including when CNAs were present in the doorway, when breakfast was brought to the resident, and when the head of bed was elevated. At one point, an LPN was asked to check the resident’s oxygen saturation and obtained a reading of 89% after placing the pulse oximeter on the resident’s finger. The LPN then stated he would try another finger, and the surveyor pointed out that the tubing end was not connected to the concentrator, confirming the oxygen tubing remained on the floor and disconnected while the nasal cannula stayed in the resident’s nose.
Missing Controlled Substance Shift Count Signatures
Penalty
Summary
The facility failed to ensure that two people authorized to administer medications signed the Shift Count page to document that all controlled substances were counted at the change of shift for 2 of 3 units reviewed for medication storage, Tuttle and Andrew's Went Unit's. Review of Tuttle's Med Cart Controlled Substance Log showed multiple missing outgoing signatures, including entries on 5/25/25 at 0630, 5/28/25 at 0700, 6/12/25 at 2100, 8/13/25 at 0700, 9/10/25 at 0700, 9/19/25 at 1535, 10/6/25 at 2300, 11/28/25 at 0700, and 12/10/25 at 0700, as well as missing incoming signatures on 9/19/25 at 1900 and 11/27/25 at 2035. Review of Andrew's Med Cart Controlled Substance Log showed multiple missing outgoing signatures on 3/2/26 at 1900, 3/4/26 at 1500, 2/19/26 at 1500, 3/25/26 at 1500, 3/25/26 at 2300, 3/26/26 at 1900, 4/18/26 at 1900, 4/21/26 at 1500, and 4/30/26 at 1930, along with missing incoming signatures on 1/23/26 at 2300, 3/3/26 at an unknown time, 3/4/26 at 0700, 2/19/26 at 0700, 3/25/26 at 1500, and 4/10/26 at 0715. This information was reviewed and confirmed with the Facility Administrator.
Improper medication storage and treatment handling
Penalty
Summary
The facility failed to ensure medications and treatments were stored and handled appropriately. During observations of Resident #17's room on 5/11/26 and 5/12/26, a medicine cup containing an unknown white powder was found on the resident's over-the-bed table. Resident #17 stated the powder was for a rash. On 5/12/26, an LPN confirmed the resident had an active physician order for Nystatin twice daily and stated she gave the medication to CNAs to provide the treatment to residents. The LPN also confirmed she documented the medication as administered before it was actually given, and stated that if the CNA said they provided the treatment, they usually got it done. The DON stated the medication should not be left at the bedside and that the nurse should be providing the treatments, not CNAs. The facility also failed to adequately maintain medication refrigerator temperatures. Facility policy required refrigerated medications to be kept between 36 degrees Fahrenheit and 46 degrees Fahrenheit. Observations of three medication refrigerators showed insulin, tuberculin purified protein, Ativan, Shingrix, Spikevax, and Prevnar stored in them. Review of temperature logs showed repeated out-of-range readings in all three refrigerators across multiple months, including 9 out-of-range readings in one unit for March and 5 for April, 1 out-of-range reading in another unit for April, and 23 out-of-range readings in February and 16 in March in a third unit. Nursing staff stated they would call maintenance and document the issue, and the DON confirmed that was the expectation, while Maintenance Assistant #1 stated there had not been recent maintenance slips regarding refrigerator temperatures being out of range.
Unresolved environmental sanitation deficiencies in laundry and kitchen areas
Penalty
Summary
F584, Safe/clean/comfortable/homelike environment, was recited after surveyors observed the laundry room with a worn cement floor surface that was untreated and therefore uncleanable, 15 cracked, broken, or missing floor tiles, and missing cove base along the bottom of the wall to the left of the dryers. The facility’s plan of correction for the earlier annual recertification survey stated that the cement floor had been repainted, the cracked tiles had been replaced, and the cove base had been secured to the wall, but during the follow-up survey the Maintenance Director stated he knew the concerns needed to be completed and that the cove base was in house, but it had not yet been replaced. F812, Food Procurement, Store/Prepare/Serve-Sanitary, was recited after surveyors observed that the walk-in refrigerator/freezer floor had worn off and missing paint and was not sealed, and that the back of the dish room door had chipped and missing paint with a significantly rusted or rotted area at the bottom of the frame, creating uncleanable surfaces. The facility’s plan of correction stated that the dish room door and frame were painted and the walk-in freezer floor was sealed or painted, but during the follow-up survey the Maintenance Director confirmed he had not painted the back of the dish room door, stated the bottom of the frame was rotted and needed replacement, and confirmed he did not paint the floor.
Incomplete Staff Orientation and Emergency Preparedness Training
Penalty
Summary
The facility failed to maintain an effective training program for new staff members. Review of the facility’s Orientation Program policy stated that all new staff were to receive a comprehensive orientation and that no employee was to begin working in the assigned position until required portions of the program were completed. However, review of employee files showed that CNA #11, hired on 11/7/25, lacked evidence of formal orientation, including what to do in an emergency. During interview, CNA #11 stated she had not received any education regarding emergency procedures and described a fire the prior week as chaotic because she did not know where to go or what to do and just stood there. Review of RN #1’s and RN #2’s orientation records lacked evidence of education on fire extinguisher and alarm pull box locations, building maps and room evacuation tags, and use of the telephone system, emergency paging, and transferring calls. RN #1 stated she had only signed a packet on abuse, neglect, and misappropriation, had been put right on the floor, and had not received other formal education; she also stated she did not know where the crash carts were, what supplies belonged on them, or what to do in a fire. RN #2 stated she had only signed abuse, neglect, and misappropriation documents on her first day and had not received further orientation, and she did not know what to do in an emergency. LPN #1 also stated he was unable to locate fire extinguishers and fire alarms and was unsure how to evacuate residents safely if there were a fire. The Business Office Manager stated new staff received a brief orientation covering abuse, neglect, and misappropriation and were then put on the floor, with a formal orientation including fire safety occurring within 30 days.
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.
Call Bells Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for 2 sampled residents, Residents #5 and #51. Resident #5 was observed asleep in bed with the call bell hanging between the top of the mattress and the headboard and extending to the floor, out of reach, and on a repeat observation the call light was again hanging behind the bed and down to the floor. Resident #5's care plan identified a high fall risk related to balance issues and a history of falls and directed that the call bell be in reach at all times. Resident #51 was observed sitting on the side of the bed with the call light cord tucked between the mattress and the wall, and the surveyor could not locate the call bell itself; on a repeat observation, the call bell cord was still tucked between the mattress and the wall. Resident #51's care plan identified a fall history and directed that the call light be within reach and that the resident be instructed to ring for assistance. The surveyor confirmed the findings with the Unit Manager and later discussed them with the Administrator.
Failure to Protect Resident PHI
Penalty
Summary
The facility failed to ensure the confidentiality of protected health information for 1 of 70 residents. On 5/12/26, two surveyors observed an open computer screen on an unattended treatment cart on the Tuttle Unit displaying Resident #38's personal medical information. The information was visible and easily accessible to residents, visitors, and unauthorized personnel. The Tuttle Unit Manager closed the computer screen after surveyor intervention, and the Facility Administrator later confirmed the observation.
Inaccurate MDS Coding for Therapy Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Version 3.0 assessment was accurately coded for therapy services for Resident #38. Review of the resident’s clinical record showed a physician order starting 2/9/26 for occupational therapy for 12 weeks. However, the resident’s quarterly MDS assessment dated 2/24/26, Section O0390 Therapy Services, was coded as “None of the above” despite the resident receiving OT services at the time of the assessment. On 5/14/26 at 12:32 p.m., a surveyor reviewed the record with the MDS Coordinator, who confirmed that Resident #38 was receiving OT services when the quarterly assessment was completed and that the assessment was not accurately coded.
Baseline Care Plan Not Accurate for Fractures and Declined Opioid Therapy
Penalty
Summary
The facility failed to ensure that Resident #77’s baseline care plan was developed and accurate for the resident’s most immediate needs related to quality of care and opioid therapy. Resident #77 was admitted in April 2026 with diagnoses including a displaced trimalleolar fracture of the right lower leg, fracture of unspecified metatarsal bone(s) of the left foot, and encounter for other orthopedic aftercare. The nurse-to-nurse report from the hospital to the facility listed these admitting diagnoses, and the resident signed an Informed Acknowledgement and Agreement for Opioid Therapy form declining opioid therapy. Review of the baseline care plan showed it lacked evidence of the problem, goals, and interventions for the resident’s foot and leg fractures/breaks, and it also included opioid therapy even though the resident had refused it. During interview, the President of Clinical Services confirmed that the baseline care plan should have addressed the fractures/breaks and should not have included opioid therapy because the resident declined it.
Incomplete Therapy Orders and ADL Documentation
Penalty
Summary
The facility failed to ensure the clinical record was accurate and complete for a resident receiving therapy services. Resident #85 was admitted for skilled care services and had active PT orders for therapeutic exercise, therapeutic activities, gait training, neuro-reeducation, and wheelchair management, as well as a PT evaluate-and-treat order. During record review, both PT orders were found unsigned by a provider. The Occupational Therapist confirmed the resident had been receiving PT and OT services 5 days per week with restorative aide support on weekends and acknowledged that the orders were not signed in the clinical record. The facility also failed to maintain complete ADL documentation for another resident with a left lower leg fracture, non-weightbearing status, chronic pain, urinary incontinence, and risk for constipation. Resident #17’s care plan directed staff to assist with toileting, check for incontinence, and document bowel movements, but the ADL record lacked bladder documentation on multiple day, evening, and night shifts and lacked bowel documentation on multiple shifts across several dates. A nursing progress note showed the resident returned from an orthopedic appointment on 4/21/26, and bladder documentation showed continence and bedpan use on 4/20/26, but there was no further bladder entry until 4/22/26, over 40 hours later.
Missing Annual CNA In-Service Training
Penalty
Summary
The facility failed to monitor and ensure that CNA #1 completed the required 12 hours of annual in-service education training for 1 of 5 randomly selected CNAs employed greater than 1 year. CNA #1 was hired in February 2025, and review of the employee in-service/attendance records showed no evidence of the required 12 hours of continuing education from 2/2025 to 2/2026. During an interview on 5/14/26 at 2:36 p.m., the Facility Administrator confirmed the missing training documentation.
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
All 10 risk areas, ranked with evidence
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 101 citations issued within 25 miles in the last 12 months — including the 1 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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 | ★★★★★ | 4 | 0 |
| Odd Fellows Health Care Center | 16.7 mi | ★★★★★ | 10 | 0 |
| Montello Manor | 17.4 mi | ★★★★★ | 29 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Market Square Health Care Center, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.