Citations in Maine
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Maine.
Statistics for Maine (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Maine
A resident with a court-appointed public guardian had their Lithium dosage increased for worsening hallucinations and delusions without documented discussion with or consent from the guardian, despite a care plan requiring guardian involvement in decisions and informed consent for psychotropic medications. The social worker described a process in which nursing should obtain guardian approval for decisions, but the guardian later reported learning of the Lithium change only after it occurred and stated that voicemail or email notifications do not constitute consent, noting the resident cannot provide their own consent.
The facility failed to maintain safe, unobstructed egress routes when two of three ground-floor exits were blocked by significant snow accumulation, leaving only an employee entrance cleared. Surveyors observed deep snow on the front walkways and ramps, while 25 residents would have needed to be moved either through locked doors and narrow corridors to the side employee entrance or through the snow-obstructed front exits. Two maintenance staff were seen performing other tasks, and the Administrator reported that she had instructed maintenance to clear the egresses, but this had not yet been done.
The facility failed to maintain a documented, routine program for inspecting bed frames, mattresses, and bed rails for safety and entrapment risks. Although a resident’s bed and four other beds with air mattresses and side rails were observed by the DON and found to have proper mattress fit and no unsafe gaps, the Maintenance Supervisor stated that while he measures and assesses beds for proper fit and entrapment hazards when placing new mattresses, he does not document these assessments and does not perform regular, scheduled safety checks of all beds.
Surveyors identified widespread environmental and housekeeping deficiencies across three units, the therapy room, a common area, and the laundry room. Cooking dishes were stored under a therapy room sink near the drainpipe. Multiple resident rooms had privacy curtains in disrepair, rusty and chipped baseboard heaters, damaged bathroom doors with exposed unsealed wood, and a rusty toilet water line escutcheon. Hallways on two units had numerous chipped and broken floor tiles, and a whirlpool room had damaged walls, ripped and missing linoleum, rusty ceiling components, and a dirty, stained, and cracked whirlpool tub with soiled jets and intake screen. Additional findings included a damaged bathroom ceiling tile around a sprinkler head, cracked floor tiles and chipped paint in a shower room, stained ceiling near a nurse’s station, a broken ramp handrail, and laundry equipment and carts held together with Velcro and duct tape. These conditions were confirmed by the DON, Maintenance Director, and Director of Environmental Services.
Two residents were transferred multiple times to acute care hospitals, including ED visits and an admission for an intestinal blockage, without documented written transfer/discharge notices or bed-hold notices, including cost of care, being provided to their legal representatives. Clinical records and nursing notes confirmed the transfers and hospital admissions, but lacked evidence of the required written notifications. The LSW later acknowledged that there was no documentation of these notices and indicated that one ED transfer was viewed as a scheduled appointment, and thus she believed notices were not required.
A resident with multiple antihypertensive medications (Carvedilol, Diltiazem, Enalapril, and Spironolactone) had physician orders requiring SBP and pulse checks with hold parameters (SBP <110 or HR <60) prior to administration. Over a multi-day period, staff documented these medications as given on the MAR without recording required vital signs on the MAR, and on numerous occasions when the vital signs record showed SBP values below the ordered threshold or lacked SBP documentation within the ordered administration windows. Some doses were also associated with blood pressure readings taken outside the prescribed time frames, yet still recorded as administered according to the MAR.
The facility did not follow its Abuse, Neglect and Exploitation policy by allowing several new employees to begin work without required pre-employment screening and by delaying required reporting of an allegation of resident-to-resident sexual contact. Employee file review showed that multiple CNAs began work without a current Maine background check completed by the facility, with some checks done weeks after hire, and a therapist was hired without documented reference checks. Separately, documentation showed that a wheelchair-bound resident reported being touched in a sexually inappropriate manner by another wheelchair-bound resident, but the DON was not informed until two days after the event, and state agencies were not notified until that time, contrary to the policy’s requirement for timely reporting.
The facility failed to timely report a resident-to-resident sexual altercation to the State Agency as required by its abuse reporting policies. A cognitively impaired, wheelchair-dependent resident was inappropriately sexually touched by another cognitively impaired, wheelchair-dependent male resident. Although the incident was documented in the nurse’s notes, the DON and Social Worker were not informed until two days later, and the State Agency was only notified after the DON became aware, exceeding the policy requirement to notify appropriate agencies immediately and within 24 hours of discovery.
A resident who experienced a fall with major injury and was transferred to the hospital for evaluation and treatment did not receive the required written bed-hold notice at the time of transfer. Review of the clinical record showed no documentation that the resident or representative was given a bed-hold notice for that hospitalization, and a social worker confirmed during interview that, although other bed-hold notices existed in the record, none corresponded to the date of this specific transfer.
A resident with dementia and a history of falls had an unwitnessed fall in their room, after which initial assessment noted no injuries and indicated neuro checks were completed and passed, but the medical record contained no documentation of ongoing neuro checks following the event. A later, witnessed fall in a hallway was documented with normal ROM and vital signs and no head impact. During interview, the DON stated that neuro checks are required for every unwitnessed fall and produced a neuro check sheet dated for a different day, which she believed corresponded to the unwitnessed fall, yet no neuro check documentation for that unwitnessed fall was present in the medical record, resulting in the cited deficiency.
Failure to Obtain Guardian Consent for Psychotropic Medication Change
Penalty
Summary
The facility failed to ensure that a court-appointed public guardian was notified and able to exercise decision-making rights regarding a resident’s medication change. A resident with a court order dated 10/31/18 appointing the Department of Health and Human Services as full public guardian and conservator had an increase in Lithium, a mood stabilizer and antimanic agent, from 300 mg twice daily to 450 mg twice daily for increased hallucinations and delusions. The resident’s care plan, last revised 9/11/25, documented that the state guardian would be involved in decisions and that informed consent would be provided to the resident or healthcare decision maker for psychotherapeutic medications. Despite these documented interventions, the clinical record lacked evidence that the Lithium dose increase was discussed with or consent obtained from the guardian. In interviews, the facility’s social worker stated that for any change in condition or need to send a resident out, nursing is to call and get approval from the guardian for anything requiring a decision. However, the resident’s Public Guardian Representative reported that the primary provider increased the Lithium dose without obtaining the guardian’s consent. Email correspondence between the facility and the guardian showed the guardian later raised concerns that the facility failed to obtain consent for treatment and medication changes, clarifying that a phone call with voicemail or an email notification of what is going to be done does not constitute consent. The guardian specifically stated they learned after the fact that the Lithium had been changed and emphasized that the resident was unable to provide their own consent, which was the reason for the state guardianship.
Snow-Blocked Egresses Limit Safe Exit Routes
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards when two of three ground-floor egresses used by residents were blocked by snow and not easily passable. On the morning of 1/27/26 at 9:00 a.m., surveyors observed that the walkways to the two front entrance/egress doors were hindered by snow measuring approximately 15 inches at the street and approximately 4 to 6 inches on the walkways and ramps leading to these doors. The only walkway and door that had been shoveled free of snow was the employee entrance located at the left side of the building. To exit through the only unobstructed egress, the 25 current residents would have to be taken through one of two locked doors and navigated through narrow corridors to reach the side employee entrance, or alternatively attempt to exit through the front egresses that remained hindered by snow. During this time, two maintenance staff were observed inside the building performing other tasks. In an interview shortly after 9:00 a.m., the Administrator stated that she had asked the maintenance staff to clear the egresses of snow, but they had not yet done so.
Lack of Documented and Ongoing Bed Safety Inspections
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document regular inspections of all bed frames and mattresses as part of a maintenance program to ensure mattress–bed frame compatibility and identify areas of entrapment. During an observation of one resident’s bed with the DON, the mattress was found to fit the bed frame appropriately, and no unsafe gaps were noted around the quarter bedrails; additional observations of four other residents’ beds with air mattresses and side rails also revealed no entrapment or safety issues. In an interview, the Maintenance Supervisor reported that he measures bed mattresses and frames to ensure proper fit and assesses the mattress, frame, and bed rails for gaps or entrapment hazards when placing a new mattress. However, he acknowledged that he does not document these assessments and does not have a regular, ongoing maintenance program for checking beds for safety, leading to the cited deficiency.
Environmental and Housekeeping Deficiencies Across Multiple Units and Service Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, and comfortable environment across multiple units and service areas. Surveyors observed multiple cooking dishes stored under the therapy room sink next to and below the drainpipe; this was confirmed by a COTA and the DON. During an environmental tour, surveyors, accompanied by the Maintenance Director and Director of Environmental Services, identified resident rooms on Cortland and Northern Spy units with privacy curtains missing hooks, hanging down, and in disrepair. In one Cortland resident room, the bathroom baseboard heater and room baseboard heater had chipped/missing paint and rust, creating uncleanable surfaces; the bathroom door’s protective surface was pulled away on both sides, and the bottom of the door was chipped/gouged with exposed unsealed wood. The same bathroom contained a wash basin on the floor under the sink and a toilet water fill line with a rusty escutcheon. Additional environmental issues were found throughout the facility. On Cortland, the hallway floor had seven chipped/broken tiles, and the whirlpool room had walls with chipped/missing paint and damaged sheetrock, ripped/missing linoleum at the wall corner and sink cabinet, ripped/missing flooring around the floor drain, split seams in the middle of the floor, a rusty ceiling light and ceiling grid, and a whirlpool tub that was dirty, yellow-stained, cracked, with soiled and stained water intake screen and jets. On Northern Spy, one resident room had a bathroom ceiling tile around a sprinkler head that was bubbled and bent, and the hallway floor had 32 chipped/broken tiles. On the [NAME] unit, six cracked/broken floor tiles and a shower room with chipped and missing paint on the walls were observed. In common areas, the ceiling near the nurse’s station had large brown stains, and a ramp handrail going downstairs was broken. In the laundry room, the left clothes dryer had Velcro tape holding the bottom lint door and tape on the door glass, and a three-shelf laundry cart had ripped and hanging duct tape on the bottom shelf. The Maintenance Director and Director of Environmental Services confirmed these findings.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge and bed-hold notices, including cost of care information, to residents and/or their legal representatives when residents were transferred to an acute care hospital. For one resident admitted in January 2024, the clinical record showed that the resident was transported to an acute care hospital on a specified date, but there was no documentation that the resident or the resident’s representative received a written transfer/discharge notice or a written bed-hold notice for that transfer. For another resident admitted in October 2022, the clinical record showed multiple transfers to an acute care hospital on several dates, including an Emergency Department visit followed by an admission for an intestinal blockage. Nursing progress notes documented communication with a gastroenterologist, the decision by the team to send the resident to an alternate ED, and the subsequent hospital admission. Additional record review showed another hospital transfer and admission on a later date. However, the record lacked evidence that the resident’s representative received written transfer/discharge notices and written bed-hold notices for any of these transfers. During an interview, the LSW confirmed there was no evidence of such notices for the identified transfers and stated that one ED transfer was considered a scheduled appointment, and therefore she believed notices were not required.
Failure to Follow Antihypertensive Hold Parameters and Vital Sign Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for multiple antihypertensive medications for one resident, specifically by not checking and documenting required vital signs and by administering medications outside of ordered blood pressure parameters and time frames. For Carvedilol, ordered twice daily with instructions to hold the dose if systolic blood pressure (SBP) was less than 110 or heart rate was less than 60, the record review for 12/10/25–12/23/25 showed that blood pressure and pulse were not documented on the MAR. During this period, the vital signs record showed multiple SBP readings below 110 (including 90, 95, 98, 105, 103, 104, 86, and 85) at times corresponding to medication administration, yet the MAR indicated the medication was given. On several dates there was no documented SBP in the ordered administration windows, but the MAR still showed that Carvedilol was administered. For Diltiazem, ordered once daily between 7 a.m. and 12 p.m. with instructions to hold if SBP was less than 110 or heart rate less than 60, the facility again did not document blood pressure and pulse on the MAR between 12/18/25–12/23/25. The vital signs record showed SBP values of 105, 103, and 86 during this period, all below the ordered SBP hold parameter of 110, yet the MAR documented that Diltiazem was given on those days. On other days within the same period, there was no documented SBP in the ordered administration window, but the MAR still reflected that the medication was administered. For Enalapril, ordered once daily between 4 p.m. and 7 p.m. with the same hold parameters (SBP less than 110 or heart rate less than 60), the MAR from 12/10/25–12/23/25 lacked blood pressure and pulse documentation. The vital signs record showed SBP readings below 110 (including 90, 95, 109, 90, 104, and 85) at or near the relevant times, yet the MAR indicated the medication was given. Some SBP readings were documented outside the ordered time window, and on several days there was no SBP documented in the 4 p.m.–7 p.m. window, but the MAR still showed administration. Similarly, for Spironolactone, ordered once daily between 7 a.m. and 12 p.m. with the same hold parameters, there was no blood pressure or pulse documented on the MAR between 12/18/25–12/23/25. During this time, the vital signs record showed SBP readings of 105, 103, and 86, all below the ordered threshold, or no SBP documented in the ordered time window, yet the MAR consistently indicated that Spironolactone was administered.
Failure to Follow Abuse Policy for Staff Screening and Timely Reporting of Resident-to-Resident Sexual Incident
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy regarding pre-employment screening for multiple staff. The policy, revised 11/1/25, required that potential employees, contracted staff, students, volunteers, and consultants be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credential checks, with documentation maintained as proof. Review of employee files on 1/6/26 with the Assistant DON showed that one CNA hired on 3/4/24 had no Maine background check completed by the facility prior to hire; the only background check present was from a staffing agency dated more than a year before hire. Two CNAs hired on 10/9/24 had Maine background checks completed 21 days after their hire dates, rather than before they began working. A therapist hired on 10/28/25 had no evidence in the file that references were checked, contrary to the facility’s policy requirements. The facility also failed to implement its Abuse, Neglect and Exploitation policy regarding timely reporting of an allegation of resident-to-resident inappropriate sexual contact. A nurse’s note dated 1/3/26 documented that a resident had been touched in a sexually inappropriate manner by a male resident; both residents involved were wheelchair-bound. Another nurse’s note dated 1/5/26 indicated that the affected resident’s guardian was notified of the incident. In an interview on 1/8/26, the DON confirmed that the incident occurred on 1/3/26, but she was not informed until 1/5/26, at which time she notified the state agencies (Licensing and Certification and Adult Protective Services). The DON acknowledged that the state agencies were not notified in a timely manner, as required by the facility’s abuse, neglect, and exploitation policy.
Failure to Timely Report Resident-to-Resident Sexual Altercation to State Agency
Penalty
Summary
The facility failed to timely notify the State Agency of a resident-to-resident sexual altercation involving a cognitively impaired, wheelchair-dependent resident (R28). Record review showed that on a Saturday afternoon, R28 was inappropriately sexually touched by a cognitively impaired, wheelchair-dependent male resident. Nursing notes documented the incident in the clinical record, but the Director of Nursing (DON) and Social Worker were not notified until the following Monday. Facility policies in the Abuse-Risk Management Folder and the Compliance with Reporting Allegations of Abuse/Neglect/Exploitation procedure require that appropriate agencies, including the State Agency and Adult Protective Agency, be notified immediately and no later than 24 hours after discovery of an allegation of abuse. In an interview, the DON confirmed that the incident occurred on Saturday and acknowledged it should have been reported to Licensing and Certification at that time, but the State Agency was not notified until she became aware of the incident on Monday.
Failure to Provide Required Bed-Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notice to a resident who was transferred to the hospital for medical evaluation and treatment following a fall with major injury. Record review on 1/7/26 showed that the resident was transferred on 2/24/25, but the clinical record contained no evidence that the resident or the resident’s representative received the required written bed-hold notice at the time of transfer. During an interview on 1/8/26 at 9:45 a.m., the Licensed Social Worker reported that she had reviewed the entire record and found several bed-hold notices, but none corresponding to the date of the hospital transfer in question, confirming that the notice was not provided for that hospitalization. This deficiency is based solely on the absence of documentation of a bed-hold notice for the specific transfer date and the Licensed Social Worker’s confirmation during the surveyor interview that no such notice was given for that event.
Failure to Document Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure neurological checks were completed according to orders and facility practice for a resident reviewed for falls. The resident, who had dementia and a history of falls, experienced an unwitnessed fall in their room on 12/12/25 at 6:30 a.m., where they were found lying on their right side on the floor and reported having gotten up and slid on the floor. The incident report documented that the resident was assessed with no injuries and that initial neuro checks were completed and passed, but the medical record contained no evidence that ongoing neuro checks were performed after this unwitnessed fall. A subsequent, witnessed fall in the hallway on 12/16/25 was documented with no head impact, no injuries, normal ROM and vital signs, and transfer back to a chair near the nurses’ station for close monitoring. During an interview, the DON stated that neuro checks are done for every unwitnessed fall and provided a neuro check sheet dated 12/16/25, which she believed was intended for the 12/12/25 fall, but at the time of review there was no documentation of neurological checks in the medical record for the 12/12/25 unwitnessed fall, confirming the deficiency.
Some of the Latest Corrective Actions taken by Facilities in Maine
- The Skilled Nurse Manager re-educated the C.N.A.-M on the medication administration policy and procedure. Copies of the policy, along with sign sheets, were placed at nurse's stations. All medication technicians and nurses were mandated to review the policy and sign the review sheet. Audits were completed to ensure all residents' Medication Administration Records (MARs) had a photo, and ongoing audits are conducted to ensure new residents have photos attached to their MAR. (G - F0760 - ME)
Medication Administration Error Leads to Hospital Transfer
Penalty
Summary
The facility failed to protect a resident from receiving another resident's medications, resulting in the resident being transferred to the Acute Care Emergency Department for evaluation and monitoring. During a morning medication pass, a Certified Nurse Assistant-Medication (C.N.A.-M) mistakenly administered medications intended for another resident to Resident #1 (R1). The medications included Aspirin, Cholestyramine, Clopidogrel Bisulfate, Isosorbide, Psyllium Husk Powder, Metoprolol Tartrate, and Tylenol. R1 was not allergic to these medications, but the error led to low blood pressure and a mild drop in hemoglobin and hematocrit levels. The error occurred because the C.N.A.-M misread the name in the computer system, confusing R1's name with that of Resident #2 (R2). The C.N.A.-M, who had recently returned to work after a two-month absence, did not recognize R1 and mistakenly thought R1 was R2. The C.N.A.-M asked R1 if their name was R2's last name, and R1, who was mildly cognitively impaired, confirmed. This led to the administration of the wrong medications. Upon realizing the mistake, the C.N.A.-M immediately notified a nurse, and R1 was assessed and sent to the Emergency Department. R1's clinical records indicated a history of hypertension, with a prescribed medication of Metoprolol Tartrate. The resident's Minimum Data Set showed a Brief Interview for Mental Status score indicating mild cognitive impairment. After receiving the wrong medications, R1 experienced low blood pressure and lightheadedness, prompting an emergency transfer to the hospital. The facility's Medication Administration Policy requires verification of the resident's identity, including checking photographs and medication labels, which was not adequately followed in this incident.
Removal Plan
- The Skilled Nurse Manager re-educated C.N.A.-M on the medication administration policy and procedure.
- Copies of the Medication Administration policy and procedure along with sign sheets were placed at the nurse's stations.
- All medication technicians and nurses that administer medications were mandated to review the policy and procedure and sign the sheet that they did the review.
- Audits of all the residents' MARs were completed to ensure they all had a picture.
- On-going audits are being done by the Director of Nursing and/or the Skilled Nurse Manager to ensure new residents have a picture taken and attached to their MAR.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. A Certified Nursing Assistant (C.N.A.1) was reported to have held a resident's arms down during care, resulting in bruising on the resident's arms and causing the resident to become angry. The resident, diagnosed with dementia, anxiety, severe agitation, and psychosis, resides in a secured memory care unit. On the day of the incident, the resident was observed with new bruises on the left upper and lower forearm and the upper right arm. The resident accused C.N.A.1 of throwing them around, which was corroborated by another C.N.A. (C.N.A.2) who observed the bruises and reported the incident to the Registered Nurse-Nurse Manager (RN-NM). C.N.A.1 admitted to holding the resident's arm down on the toilet's safety rail during care to prevent the resident from hitting him. Interviews with other staff members, including C.N.A.2, the day Charge Nurse, and C.N.A.3, confirmed that the bruises were not present the day before the incident. C.N.A.3 also reported that the resident claimed C.N.A.1 had grabbed them. The facility's Abuse Policy defines physical abuse as actions that may cause pain, inability to move limbs, burns, cuts, internal injuries, marks, or bruises. The incident was identified as a failure to adhere to this policy, resulting in physical abuse of the resident by C.N.A.1.
Removal Plan
- The RN-NM terminated C.N.A.1.
- The Staff Development Coordinator and the Assistant Director of Nursing provided all direct care staff and licensed nurses on all the facility's Units on Resident Abuse, Neglect and Exploitation.
- Staff were in-serviced on 'Burn Out'.
Failure to Follow Hoyer Lift Policy Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a resident's safety during a Hoyer lift transfer, resulting in harm to the resident. On 4/9/24, a Certified Nursing Assistant (CNA) attempted to transfer a resident alone using a Hoyer lift, contrary to the facility's policy requiring two CNAs for such transfers. During the transfer, the resident became restless and slipped out of the Hoyer pad, falling to the floor and hitting their head. The resident sustained a closed head injury and was diagnosed with swelling at the back of the head. The resident's care plan, dated 3/2/24, indicated the need for extensive assistance with transfers using a mechanical lift and two people, which was not followed in this instance. The facility's internal investigation and the Incident Report confirmed that the CNA was aware of the policy but proceeded without assistance due to the unavailability of another CNA. The Root Cause Analysis identified the failure to follow the lift policy as a contributing factor. Interviews with the CNA and the facility administrator corroborated these findings, highlighting the lapse in adhering to established safety protocols during the transfer process.
Removal Plan
- One on One training with CNA #1 on the Lifting Machine policy and procedure that indicates At least two nursing assistants are needed to safely move a resident with a mechanical lift.
- Mandatory re-education on Hoyer Safety with all nursing staff.
- Newly hired CNAs will demonstrate competency with Hoyer lift transfers.
Explore Popular Searches
