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
A resident with a wound vac had an MD order for dressing changes every 48 hours, but the facility did not complete the scheduled changes on time. The hospital SW reported the facility lacked wound vac supplies and that dressing changes had not been done, and the TAR showed the first documented change was not until several days later, with the expected changes not coded as completed.
A resident with Parkinson’s disease and obesity, documented as a 2-assist for bed mobility and dependent for personal hygiene/oral care, was being washed by one CNA alone when the resident began sliding off the bed. The CNA could not stop the descent, called for help, and the resident was lowered to the floor; later ED documentation showed bilateral comminuted femur fractures. Interviews confirmed the resident required two staff for care and that the care was not provided as documented.
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 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.
Failure to Complete Ordered Wound Vac Dressing Changes
Penalty
Summary
The facility failed to follow a physician’s order for wound vac dressing changes every 48 hours for one resident. The resident had been admitted with a wound vac, and the hospital discharge summary documented the order for dressing changes every 48 hours. A hospital Social Worker stated the facility called on 5/4/26 requesting wound vac supplies because none were available and that the wound vac dressing changes had not been completed as of that date. The Social Worker also stated the last wound vac dressing change had been completed on 4/29/26. Review of the resident’s TAR showed the first dressing change at the facility was not documented until 5/5/26, and the scheduled changes that would have been due on 5/1/26 and 5/3/26 were not coded as completed. The Administrator confirmed that the ordered wound vac dressing changes did not occur on those scheduled dates.
Failure to Provide Required Two-Person Assistance During Bed Care
Penalty
Summary
The facility failed to ensure that a resident was free from accidents and hazards during personal care when one CNA attempted to provide care alone despite the resident being documented as a 2-person assist for bed mobility. The CNA entered the room alone, helped the resident roll onto her side to begin washing her, and the resident then began sliding off the side of the bed. The CNA was unable to stop the resident’s descent because of the resident’s size and called for help; an LPN and another staff member responded and lowered the resident to the floor. The resident had persistent pain after the incident. The resident had Parkinson’s disease and obesity and was dependent for personal hygiene and oral care. The facility’s investigation stated that the resident’s care plan and Kardex reflected the 2-assist requirement, but staff did not follow that direction during the incident. Emergency department documentation later showed bilateral femur fractures that were comminuted and extensive. Interviews with the ADON and an LPN confirmed that the resident required two staff for care and that staff did not perform care alone for this resident.
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 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.
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Compliance trends in Maine
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
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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