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
Surveyors identified that clinical records for several residents were incomplete or inaccurate, including missing documentation of ROM exercises, bathing, vital signs, and follow-up on physician orders. Staff confirmed that required entries were not made, and legal documents such as POA and Advance Directives were not present in the records despite being referenced in care plans.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
A resident admitted with a specialized mental health diagnosis was not screened for PASRR Level I, and no evidence was found that the required documentation was submitted to the state authority prior to admission. This lapse was confirmed by facility leadership during surveyor interviews.
The facility did not ensure that care plans were reviewed and revised by the IDT within the required timeframe after each MDS assessment for several residents. In some cases, IDT meetings were delayed, held before the assessment was completed, or lacked evidence of timely review. Additionally, care plans were not updated to address current diagnoses and care needs, such as chronic pain, atrial fibrillation, genital herpes, and MRSA.
The facility did not complete required neurological assessments or post-fall observations for three cognitively impaired residents after unwitnessed falls, as mandated by facility policy. In several cases, neurological checks were either missing or incomplete, and documentation of post-fall monitoring was lacking, despite residents reporting head injuries or having low BIMS scores. Facility leadership confirmed these lapses in assessment and documentation.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight by the facility.
A resident exhibiting exit-seeking and agitated behavior was placed in their room by an RN, who then held the door shut, preventing the resident from leaving. Multiple staff witnessed the incident, which involved the resident kicking and yelling to get out. This action violated facility policy prohibiting seclusion.
A deficiency was identified when an RN physically restrained a resident by holding their arms and hands down to prevent movement during an altercation, contrary to facility policy. Staff statements confirmed the RN used body contact to limit the resident's actions after the resident attempted to leave, became agitated, and tried to strike staff.
After staff reported concerns about an RN's escalating and potentially abusive behavior toward a resident, including physical and verbal actions, the DON did not immediately remove the RN from resident care or promptly initiate a thorough investigation. The RN continued to provide care to the resident throughout the weekend, and written statements detailing the incident were not collected until two days later.
Staff failed to promptly notify the State Agency about an alleged abuse incident involving a resident and an RN, where the RN escalated the resident's behavior, resulting in physical altercations and concerning staff conduct. The DON received multiple reports and concerns from CNAs about the RN's actions, but the facility delayed both the investigation and required notification.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for multiple residents. For several residents, documentation was missing or inaccurate regarding range of motion (ROM) exercises and bathing, with no evidence that these activities were completed or refused on numerous dates. Interviews with facility management confirmed the absence of required documentation in the residents' records. In other cases, clinical records lacked documentation of significant clinical events and follow-up. One resident experienced low blood pressure and dizziness, but the initial low blood pressure reading, the re-check, and physician notification were not documented, despite staff confirming these actions occurred. Another resident had a physician order for a urinalysis due to suspected infection, but the record did not show that the sample was collected, sent, or refused, nor that the provider was notified of the inability to obtain the sample, as required. Additional deficiencies included the absence of required legal documentation, such as Power of Attorney (POA) and Advance Directives, despite care plans and meeting notes indicating their existence. There were also inconsistencies in documenting the timing and assessment of a resident's fall, with vital signs and neurologic checks not accurately recorded in relation to the incident. Facility staff acknowledged these documentation gaps during interviews.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Complete PASRR Screening for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis was referred to the appropriate state-designated authority for a Pre-admission Screening & Resident Review (PASRR) evaluation and determination. Record review showed that the resident was admitted from a hospital with a mental health diagnosis, but there was no evidence in the clinical record that a PASRR Level I screening was completed or submitted to the state authority prior to admission. This deficiency was confirmed during an interview with the Social Services Director and the Administrator, who acknowledged the absence of required PASRR documentation in the resident's record.
Failure to Timely Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by an interdisciplinary team (IDT), including participation of the resident and/or their representative, within 7 days following each Minimum Data Set (MDS) assessment for multiple residents. Specifically, for several residents, there was either a delay in holding the IDT meeting after the MDS assessment, the meeting was held before the assessment was completed, or there was no evidence that the meeting occurred within the required timeframe. For example, one resident's IDT meeting was held 17 days after the MDS assessment, another's was held 19 days after, and in some cases, the IDT meeting was held prior to the completion of the MDS. Interviews with facility staff confirmed that the scheduling of IDT meetings was based on the Assessment Reference Date (ARD), and not always aligned with the completion of the MDS as required. Additionally, the care plans for some residents were not updated to reflect current diagnoses and care needs. One resident's care plan did not specify the cause or location of chronic pain and failed to address the monitoring and management of atrial fibrillation, a history of genital herpes, and MRSA, despite these being active or relevant diagnoses. The Director of Nursing acknowledged that certain diagnoses had not been included or updated in the care plan, and there was no documentation explaining the omissions.
Failure to Complete Required Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to properly assess and monitor residents following unwitnessed falls, and did not adhere to its own Fall Management and Neurological Assessment policies. According to the facility's policies, a neurological assessment is required after any unwitnessed fall for residents with a Brief Interview for Mental Status (BIMS) score of 12 or lower, or when a head injury is suspected. However, documentation revealed that for three residents with cognitive impairment, these assessments were either not completed or only partially completed after unwitnessed falls. One resident with a BIMS score of 5 experienced two unwitnessed falls. After the first fall, there was no evidence of a post-fall observation or neurological assessment. Following the second fall, where the resident reported hitting their forehead, only 5 out of the required 15 neurological checks were documented. Another resident with a BIMS score of 11 had an unwitnessed fall and only 3 of the 15 required neurological assessments were completed, despite the policy requirements. The Director of Nursing confirmed that staff did not follow the facility's policy in this case. A third resident, with severe cognitive impairment (BIMS score of 3), had multiple unwitnessed falls in a short period. Documentation showed that after one fall, the resident was sent to the emergency department, but for another fall, there was no evidence of post-fall evaluation or neurological assessments. Neurological assessments were only started after a subsequent fall and were not completed for all required intervals. Facility leadership confirmed the lack of appropriate monitoring and documentation for these incidents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Resident Subjected to Involuntary Seclusion by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) involuntarily secluded a resident by placing the resident in their room and holding the door shut, preventing the resident from leaving. The incident was witnessed by multiple staff members, who provided written and verbal statements confirming that the RN held the door closed while the resident, who was exhibiting exit-seeking behavior and escalating agitation, attempted to get out by kicking and yelling. The facility's policy, revised in March 2025, explicitly prohibits seclusion, defined as placing a resident alone in a room, and this action was in direct violation of that policy. The resident involved was described as being angry, yelling, and attempting to leave the facility, with staff unsuccessfully attempting to redirect the behavior prior to the seclusion. Staff accounts consistently indicated that the RN moved the resident to their room and physically held the door closed for a period of time, during which the resident was observed kicking the door from inside. The duration of the seclusion was not precisely determined, but staff confirmed the resident was confined against their will. The incident was reported to the Division of Licensing and Certification, and the RN was placed on leave pending investigation.
Use of Physical Restraint by RN on Resident
Penalty
Summary
A deficiency occurred when a Registered Nurse (RN) used physical restraint on a resident by holding the resident's arms and hands down to limit voluntary movement. The incident took place after the resident attempted to leave the facility, banged on a door, and threw a cup of coffee at the RN. Multiple staff statements and interviews confirmed that the RN held the resident's arms down from behind the wheelchair, and at one point, placed her arms around the resident's upper chest while wheeling the resident away from the door. The RN and the resident were engaged in a verbal altercation, and the RN was observed to be frustrated during the incident. The facility's policy, revised in March 2025, defines physical restraints as any manual method or device that restricts freedom of movement and cannot be easily removed by the individual. The RN's actions were documented in a Performance Correction Notice and corroborated by written statements and interviews from Certified Nursing Assistants (CNAs) who witnessed the event. The resident was actively resisting and attempting to hit staff, leading the RN to physically restrain the resident, which was not in accordance with the facility's restraint policy.
Failure to Protect Resident After Staff Reported Alleged Abuse by RN
Penalty
Summary
Staff reported concerns regarding the behavior of a Registered Nurse (RN) towards a resident who was agitated. On the day of the incident, multiple staff members notified the Director of Nursing (DON) via text messages that the RN was engaging in escalating behavior with the resident, including flapping her arms at the resident and verbally provoking the resident to hit her. Written statements later indicated that the RN physically put her hands on the resident, placed the resident in their room, closed the door, and held it shut. Despite these reports, the DON's initial response was to instruct the RN to complete an incident report and follow up with Work Health, without immediately removing the RN from resident care or initiating a thorough investigation at that time. The RN continued to provide care to the resident throughout the weekend following the incident, as confirmed by timecard records and staff interviews. The DON did not begin collecting written statements from involved staff until two days after the incident, delaying the facility's investigation. The resident was sent to the hospital following the incident, and upon return, care was reassigned, but the RN insisted on continuing to care for the resident. The facility failed to protect the resident after being notified of staff concerns about the RN's behavior, allowing the RN to remain in direct care of the resident despite allegations of abuse.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to notify the State Agency (Division of Licensing and Certification) in a timely manner regarding an allegation of abuse involving a resident and a registered nurse. On the date of the incident, staff reported to the Director of Nursing (DON) that a resident was agitated and that a registered nurse escalated the situation, resulting in the resident biting the nurse. Additional information was reported to the DON, including that the nurse placed the resident in their room, closed the door, and held it shut for several seconds up to one minute during the resident's escalating behaviors. Text messages from certified nursing assistants to the DON expressed concerns about the nurse's behavior, including the nurse flapping her arms at the resident and encouraging the resident to hit her. Despite these reports and concerns, the facility did not initiate an investigation or notify the State Agency until two days after the incident occurred.
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.
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