Citations in Maine
Statistics, citations 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
Hazardous bedside storage and lack of smoking safety assessments: Surveyors observed aerosol products and a cigarette lighter stored at a resident’s bedside, with the same items still present later. Two residents who smoked had histories of stroke with left-sided hemiplegia and BIMS scores of 15, but the record lacked evidence of a completed safe smoking assessment for either resident. One resident had burn holes on a wheelchair cushion, cigarettes and a lighter kept in a nightstand drawer that was not used, and the other had cigarettes observed on a desk and nightstand with no smoking-related interventions in the care plan.
A resident’s urinary catheter was repeatedly observed hanging from the bedframe and visible from the doorway. The resident said it bothered him/her that the Foley could be seen, and an LPN noted the catheter was not covered. The charge nurse stated it was likely a hospital Foley that had remained in place since the resident returned and should have been changed out or at least covered.
A resident with L hemiplegia from stroke, nicotine dependence, and COPD had a care plan that addressed smoking but did not include interventions for smoking safety related to the resident’s abilities and deficits. The resident was cognitively intact, required substantial to maximum assistance with transfers, was dependent for ADLs, used a wheelchair, and confirmed that someone brought cigarettes into the facility. Leadership was informed that the care plan did not address smoking safety.
Unclean Resident Rooms and Cluttered Surfaces: Surveyors found a strong urine odor, debris, spilled powder, open food, soiled bedding, and piles of clothing in a resident room, with an LPN confirming the conditions. In another room, an extinguished cigarette butt was found on a keyboard, and a resident’s wheelchair armrest was worn and torn, exposing foam padding and creating an uncleanable surface.
Incomplete ADL Documentation for a Dependent Resident: A resident who was dependent on staff for toileting transfers, hygiene, and mobility had multiple missing CNA ADL entries across day, evening, and night shifts. Facility policy required CNA documentation each shift, and both a CNA and the DON stated ADL care should be documented before the end of the shift, but the record lacked evidence of toileting and hygiene assistance on numerous occasions.
Incomplete Investigation of Resident-to-Resident Altercations: The facility failed to fully investigate two resident-to-resident altercations and did not provide complete follow-up documentation to the survey team. One incident involved a resident slapping another resident and hitting the resident with a slipper, and the other involved a resident threatening another resident and being struck on the arm. The DON and unit manager acknowledged missing investigation pieces, including witness interviews and other follow-up details.
Hazardous bedside storage and lack of smoking safety assessments
Penalty
Summary
The facility failed to keep a resident room free of accident hazards when surveyors observed multiple aerosol products and a cigarette lighter stored at the bedside of one resident’s room. On the first observation, the nightstand for bed 2 contained 2 cans of Wizard Double Action 2 in 1 Air Freshener and 4 cans of Power Stick body spray, and a cigarette lighter was in the center of the bed. A CNA and an LPN were present during the observation, and the CNA wiped the mattress with disinfectant wipes. When the unit was toured again later the same day, the same items remained on the nightstand, along with the canister of wipes. The SDS for the air freshener identified inhalation, skin contact, ingestion, and eye contact precautions, and the product information for the body spray stated it was flammable and not to be used near open flames or while smoking. The facility also failed to complete a safety assessment for two residents who smoked and did not document their abilities and deficits related to safe smoking. One resident had a history of stroke with left-sided hemiplegia, a BIMS score of 15, and a care plan that noted smoking education and observation for cigarette burns, but the record lacked evidence of an assessment of the resident’s ability to smoke safely. The nurse manager stated that the resident went outside to smoke, had been offered smoking cessation products, had fallen outside, and that a safe smoking assessment had not been completed because the campus was smoke-free. During interview, the resident stated cigarettes and a lighter were kept in a locked nightstand drawer that was not actually used, and burn holes were observed on the wheelchair cushion. The second resident also had a history of stroke with left-sided hemiplegia and a BIMS score of 15. Section GG showed the resident required substantial to maximum assistance with transfers. Surveyors observed cigarettes on a nearby desk and on the nightstand, and the resident stated the cigarettes were stored in the nightstand but it was not locked. The care plan did not include interventions related to safe smoking, and the record lacked evidence of an assessment of the resident’s ability to smoke safely. During the interview with the Administrator, DON, Clinical Coordinator, and unit nurse manager, the concerns about hazardous chemicals at the bedside, the lighter on the bed, the improperly stored cigarettes, and the burn holes on the wheelchair cushion were discussed, along with the facility’s smoke-free policy and the lack of a completed safety assessment.
Visible Foley Catheter Not Covered
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when a urinary catheter was observed hanging from the bedframe and visible from the doorway on multiple observations. During interviews, the resident stated it bothered him/her that the Foley could be seen from the door. An LPN observed that the Foley was visible and not covered, and stated the facility’s Foley catheters normally have a cover attached and are usually changed on admission. The charge nurse stated it had likely been that way for a while because it was a hospital Foley rather than the facility’s, and that the resident had been back since the prior weekend but the catheter should have been changed out or at least covered.
Failure to Include Smoking Safety in Care Plan
Penalty
Summary
The facility failed to develop and implement a resident care plan addressing smoking safety for 1 of 2 residents reviewed for smoking. The resident was admitted in September 2024 and had diagnoses including left-sided hemiplegia due to stroke and nicotine dependence. The MDS 3.0 quarterly assessment with an ARD of 5/3/26 showed the resident was cognitively intact with a BIMS score of 15, but also required substantial to maximum assistance with transfers, was dependent on staff for dressing, bathing, and personal hygiene, and used a wheelchair for mobility. The care plan, last revised 5/3/26, included a focus area of COPD related to smoking, but it did not include interventions addressing the resident’s capabilities or deficits affecting the ability to smoke safely. During interview, the resident confirmed smoking and stated that someone brings cigarettes into the facility for him/her. The Administrator, DON, Clinical Coordinator, and Unit Nurse Manager were later informed that the care plan had not been developed to include smoking safety.
Unclean Resident Rooms and Cluttered Surfaces
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in 2 of 22 resident rooms, including rooms 321 and 322 on one unit. In one room, a surveyor noted a strong odor of urine. Bed 1 was unmade but the bedding was clean, the nightstand was free of clutter, and a fall mat was on the floor next to the bed. No personal items were observed in that area. In the same room, the area around bed 2 had debris on the floor, including a white powder spilled onto the nightstand and floor. The nightstand was covered with cans of air freshener, body spray, creams, and food items, and the drawer was left open. The overbed table had packages of open food, the bed was unmade, and the sheet on the mattress was soiled with a black substance. Unfolded clothing was piled on the floor, bed, and chair near the window, and a red laundry bag was on the floor. A CNA was present during the observation, and an LPN confirmed the findings and stated the resident was now allowing staff to wash his/her clothes, which were placed in the red bag. In another observation, a surveyor found an extinguished cigarette butt on top of a computer keyboard on a nearby desk, and a resident's wheelchair armrest was worn and torn, exposing foam padding and creating an uncleanable surface.
Incomplete ADL Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed during a complaint investigation. Facility policy stated that CNA documentation should be completed accurately and efficiently each shift, and the CNA daily flow sheet should be completed each shift by the CNA assigned to the resident. Resident #1’s admission MDS showed the resident was dependent on facility staff for toileting transfers, hygiene, and mobility. Review of ADL charting from 4/14/26 through 5/30/36 showed multiple missing entries documenting toileting and hygiene assistance across day, evening, and night shifts. The record lacked evidence of toileting/hygiene assistance on numerous dates, and several shifts had no documentation of care provided. During interviews, a CNA stated staff are expected to document care for each resident in their assignment every day before the end of the shift and that refusals should also be documented in the EMR. The DON stated CNA staff should be documenting ADL care before the end of their shift.
Incomplete Investigation of Resident-to-Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident altercation involving Resident #39 and Resident #35, and failed to complete and submit the investigation to the State Agency within 5 business days for one of the reported incidents. The facility policy stated that reports of potential abuse from any source would be investigated, that the reporter, witnesses, alleged abuser, and resident would be interviewed, and that a written report would be submitted to the division of licensing and certification within 5 working days. For the incident reported on 2/13/26, Resident #39 was documented as slapping Resident #35 with an open hand and then hitting the resident in the face with a slipper. The record also contained nursing notes describing Resident #39 wandering into another resident’s room earlier that day and a separate note referencing the resident striking Resident #35 in the face, but the facility did not present follow-up investigation documentation, including witness interviews, to the survey team. The facility also failed to complete the investigation for a second resident-to-resident altercation involving Resident #186 and Resident #59. For the incident reported on 1/28/26, Resident #186 entered Resident #59’s room, Resident #186 was overheard threatening to cut Resident #59’s throat, and Resident #59 was seen striking Resident #186 on the right arm with no injury noted. When surveyors requested the follow-up investigation, the facility provided only the initial Facility Reported Incident and did not produce documentation of witness interviews, possible causes, or interventions implemented to maintain resident safety. The DON and 3 East Unit Manager acknowledged that additional investigation documentation should exist, but no further records were provided by the end of the survey.
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Compliance trends in Maine
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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