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)
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.
Latest Citations in Maine
Surveyors found that the facility did not provide or document required information about advanced directives for the majority of sampled residents. Both electronic and paper records lacked evidence that residents or their representatives were offered or reviewed information on their right to formulate an advanced directive, as confirmed by facility leadership.
Surveyors identified widespread deficiencies in housekeeping and maintenance, including dirty and stained bathroom floors, disrepair of privacy curtains, untreated wooden laundry carts, chipped paint, broken heater parts, and uncleanable surfaces in several resident rooms and common areas. These issues were confirmed by staff interviews and affected the overall cleanliness and comfort of the facility.
Surveyors found unsecured cleaning chemicals, medical and wound care supplies, and a sharp object accessible to residents in multiple units. Environmental hazards included a loose toilet and a headphone cord taped across a walkway with lifting tape, creating a tripping risk. These deficiencies were confirmed through staff interviews and direct observation, indicating a failure to ensure a safe environment and adequate supervision to prevent accidents.
The facility did not have a functioning Antibiotic Stewardship Program, as infection tracking logs were incomplete and lacked essential information such as organism identification, culture results, and antibiotic appropriateness. Key data fields were left blank, and there was no evidence of monitoring infection trends or antibiotic use. Leadership confirmed that infection tracking was not fully implemented, and a recent staff change in the Infection Preventionist role contributed to the deficiency.
A resident who had indicated a desire to receive the pneumococcal vaccine did not have documentation in their clinical or immunization records showing that the vaccine was reviewed or administered, as confirmed by the Administrator during a surveyor interview.
A resident who had indicated a desire to receive the COVID-19 vaccine did not have documentation in their immunization records showing that the vaccine was reviewed or administered. This was confirmed by the Administrator during a surveyor interview.
A CNA did not complete the required annual dementia training, as confirmed by a review of employee education records and verification with the Facility Administrator.
The facility did not complete required annual performance evaluations for three CNAs, as there was no evidence of evaluations for the current year for staff hired in various years. This was confirmed through review and interviews with facility leadership.
A medication cart was found to contain an expired punch card of Codeine Sulfate 30mg, which remained available for use. The expired medication was discovered during a medication pass and confirmed by the DON.
Surveyors found unsanitary kitchen conditions, improper food labeling and dating, expired food items in use, and significant gaps in required temperature monitoring and documentation for dish machines and refrigerators/freezers. Staff and administrator interviews confirmed these deficiencies, which were observed across multiple areas and units.
Failure to Document and Provide Advanced Directive Information
Penalty
Summary
The facility failed to ensure that documentation regarding residents' advanced directives was accurate and present in the clinical records for 20 out of 24 sampled residents. Record reviews revealed that both electronic and paper medical records for these residents lacked evidence that the facility had offered, reviewed, or provided written information about the right to formulate an advanced directive to the residents or their representatives. This deficiency was identified through a comprehensive review of multiple residents' records, which consistently showed missing documentation related to advanced directives. The absence of such documentation was noted across a significant number of residents, indicating a widespread issue rather than isolated incidents. The findings were confirmed during interviews with facility leadership, including the Director of Nursing and the Administrator, who acknowledged the lack of proper documentation. No information was provided in the report regarding the specific medical histories or conditions of the affected residents at the time of the deficiency. The focus of the findings was solely on the facility's failure to provide and document the required information about advanced directives as mandated by policy and regulation.
Failure to Maintain Sanitary and Comfortable Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's housekeeping and maintenance services across three of four units and the laundry room during two separate facility tours. Specific findings included dirty and stained floors around the base of toilets in several resident rooms, a pink wash bucket left on the bathroom floor, and privacy curtains in disrepair. Additional issues were noted such as untreated wooden bases on laundry carts, peeling laminate and missing finish on bathroom doors, chipped and missing paint on baseboard heaters, broken heater parts on the floor, rusty sinks, stained transition strips, and dusty wall fans. The walls behind residents' beds were also marred with black marks and chipped paint exposing sheetrock. These conditions were confirmed by interviews with facility staff, including a Registered Nurse, the Administrator, and the Director of Nursing. The observations indicated that the facility failed to maintain a sanitary, orderly, and comfortable environment as required, impacting the safety and comfort of residents in multiple areas of the building.
Unsecured Chemicals, Medical Supplies, and Environmental Hazards Create Accident Risks
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision across several units in the facility. Unsecured cleaning chemicals, including a container of Sani-Cloth Plus Germicidal Disposable Cloth and a spray bottle of Virex TB Ready-To-Use Disinfectant Cleaner, were found accessible to residents in their rooms and common areas. Additionally, wound care and medication supplies, as well as a sharp object (scissors), were left unattended and accessible to residents on the Geriatric Psychiatric Kennebec Unit. A toilet in one resident's room was observed to be loose and not secured to the floor, and a resident was found with a headphone cord taped across the walkway, with the tape lifting and creating a tripping hazard. Oxygen tanks were also not stored securely on one of the days observed. These deficiencies were confirmed through direct observation and interviews with facility staff, including the Unit Manager, Housekeeping Team Lead, Quality Improvement Manager, Registered Nurse, and Administrator. The presence of unsecured chemicals, medical supplies, sharp objects, and environmental hazards such as a loose toilet and tripping hazards demonstrated a failure to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required. Record reviews showed that the Infection Preventionist's monthly antibiotic log for the period from 1/1/25 through 3/11/25 listed 13 resident infections, but the documentation was incomplete. Several columns intended to capture critical information such as bacteria type, infection site, and other relevant data were left blank. The log also lacked evidence of follow-through on antibiotic use, analysis of infection trends, identification of organisms, detection of infection clusters, and tracking of antibiotic types used. During an interview, the Administrator and DON acknowledged that infection tracking was incomplete, missing information on whether cultures were performed, culture results, organism identification, and appropriateness of antibiotic selection. The facility had a recent change in Infection Preventionist staff, with the previous person leaving abruptly and a new employee starting on the day of the interview, further contributing to the lack of an implemented ASP.
Failure to Administer Pneumococcal Vaccine as Requested
Penalty
Summary
A deficiency was identified when a resident's clinical and immunization records were reviewed and found to lack evidence that a pneumococcal vaccine had been reviewed or administered. The resident had previously indicated on a vaccine consent form a desire to receive the pneumonia vaccine. During an interview, the Administrator confirmed that there was no documentation of the vaccine being reviewed or given to the resident.
Failure to Review and Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to review and/or offer the COVID-19 vaccine to one of five residents reviewed for immunizations. Specifically, the clinical record for this resident included a form indicating that the resident understood the information provided and wished to receive the COVID-19 vaccine. However, the resident's immunization records did not contain evidence that the COVID-19 vaccine was reviewed or administered. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the COVID-19 vaccine had not been reviewed or given to the resident.
Failure to Ensure Mandatory Dementia Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) attended the mandatory yearly dementia training. Review of the CNA's employee in-service and attendance record showed no evidence that the required dementia training was completed for the year 2024. This deficiency was identified during a review of employee files and was confirmed by the Facility Administrator.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of five sampled certified nursing assistants (CNAs), as required. Specifically, there was no evidence of completed annual performance evaluations for the year 2024 for CNAs who were hired in July 2001, July 2023, and March 1990. This deficiency was identified through performance evaluation reviews and staff interviews, and the absence of documentation was confirmed with the Facility Administrator.
Expired Medication Found in Medication Cart
Penalty
Summary
Surveyors observed that a medication cart on the [NAME] Unit contained a medication punch card of Codeine Sulfate 30mg that had expired in January 2025. This expired medication was still available for use in the cart at the time of observation. The issue was identified during a morning medication pass and brought to the attention of the Certified Nursing Assistant responsible for administering medications from the cart, as well as the Registered Nurse present. The Director of Nursing confirmed the presence of the expired medication in the cart later that morning. The deficiency was related to the facility's failure to ensure that expired medications were removed from the supply available for use, as required by regulations for the storage and labeling of drugs and biologicals.
Deficiencies in Kitchen Sanitation, Food Storage, and Temperature Monitoring
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including unsanitary conditions and improper food handling practices. During an initial kitchen tour, observations included a broken ceiling light lens, rusty and dirty dish machine table legs, missing floor tiles exposing untreated cement, and food debris and dirt on the kitchen and dry storage floors. Additionally, a chemical hose was found hanging into a sink, a bus bucket was collecting drain water under a vegetable sink, and a standing floor mixer had dried residue. Dishes and cups were found wet stacked and stained, and several food items in dry storage, the walk-in refrigerator, and the walk-in freezer were not properly labeled or dated. Further deficiencies were noted with expired food items, as a container of thickened orange juice was found on a unit service cart ten days past its best use by date. Staff interviews confirmed the presence and use of these expired and improperly stored items. The facility's policies require proper dating, labeling, and storage of food, as well as regular monitoring and documentation of dish machine and refrigerator/freezer temperatures to ensure food safety, but these procedures were not consistently followed. A review of temperature monitoring logs revealed significant gaps in documentation for both dish machine and refrigerator/freezer temperatures across multiple units and months. No documentation was provided for certain months, and numerous dates were missing for others. The administrator confirmed the lack of monitoring and documentation, as well as the other observed deficiencies in food storage, cleanliness, and equipment maintenance.
Explore Popular Searches
