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 was transferred using a sit-to-stand lift, contrary to recent therapy recommendations for a full mechanical lift due to instability and inability to bear weight. During the transfer, the resident's foot slipped, resulting in a fall and a femur fracture that required hospitalization and surgery. The care plan contained conflicting transfer instructions, and there was no evidence that nursing staff were notified of the updated transfer status.
Surveyors and facility leadership observed standing water in two basement areas, one beneath the kitchen and another below resident rooms. The Maintenance Director explained that the water originated from leaks at the loading dock and windows, as well as landscaping that directed runoff toward the building.
Surveyors and the Food Service Director confirmed that food was not stored, prepared, or served according to professional standards, as food debris was found on kitchen floors, utensils were partially buried in debris, and various food items were stored directly on the floor in both dry and cold storage areas.
Surveyors found that garbage and refuse were not properly disposed of, with trash bags left on the ground next to dumpsters, a dumpster lid with broken hinges, and uncovered trash barrels containing debris and frozen items near the loading dock. These conditions were confirmed by the Regional Director of Clinical Operations.
Surveyors found that slings used for resident transport were improperly stored on the floor and on wall hooks where they touched the floor and a lint-filled garbage can. Additionally, there was a buildup of lint behind the dryer and the laundry room floor was covered with dirt and debris, all of which were confirmed by the Regional Director of Clinical Operations.
A resident with dementia, visual loss, and a history of falls was not provided with hip protectors as required by their care plan and physician orders. Staff interviews revealed a lack of awareness and follow-through regarding this intervention, and it was confirmed during the survey that the resident was not wearing hip protectors, despite being at high risk for falls.
A resident with chronic leg ulcers was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy, despite ongoing wound care orders and a care plan indicating EBP should be followed. Staff interviews revealed confusion about the resident's precaution status, and no EBP signage was posted outside the room.
A resident who returned from surgery with a drain in place had the drain removed by nursing staff one day after arrival, despite orders for it to remain until a follow-up visit. Documentation did not include a written or verbal order from the medical provider authorizing the removal, and this omission was confirmed by the DON.
A CNA failed to wear a gown while providing care to a resident on Enhanced Barrier Precautions (EBP) due to open wounds and an ileostomy, despite facility policy and posted signage requiring gown and glove use for high-contact care activities.
A resident with dysphagia and a physician order for a minced and moist diet was given a roll, which is not permitted under IDDSI Level 5 guidelines. After attempting to eat the roll, the resident experienced vomiting and difficulty swallowing, resulting in another ED visit. Facility staff confirmed the dietary order was not followed.
Failure to Implement Consistent Transfer Instructions Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure safe transfer practices and implement clear, consistent transfer instructions for a resident reviewed for falls. Staff attempted to transfer the resident using a sit-to-stand lift, despite recent therapy recommendations indicating the need for a full mechanical lift (Hoyer) due to the resident's instability and inability to safely bear weight. During the transfer, the resident's foot slipped from the lift platform, and staff were unable to safely reposition the foot, resulting in the resident being lowered to the floor. The transfer was then completed using a full mechanical lift. The resident subsequently complained of pain, and an assessment revealed swelling and a femur fracture, requiring hospitalization and surgical intervention. Review of the resident's care plan revealed conflicting transfer instructions, with both sit-to-stand and full mechanical lift interventions listed simultaneously. The clinical record did not contain evidence that nursing staff were notified of the change in transfer status prior to the incident. The resident's functional assessment indicated a need for substantial to total assistance with transfers, and the care plan had not been appropriately updated to reflect the therapy recommendations. The administrator confirmed that the care plan continued to list both transfer methods and had not been edited to reflect the change.
Standing Water Observed in Basement Areas Due to Leaks
Penalty
Summary
Surveyors observed and confirmed the presence of standing water in two separate basement areas of the facility during an environmental tour. One area of standing water was located in a basement storage room beneath the kitchen, which the Maintenance Director attributed to water leaking in from the loading dock and traveling through the wall. Another area of standing water was found in the basement space below resident rooms, which the Maintenance Director stated was due to leaking windows and landscaping that directed snow melt and runoff water toward the building. These conditions were directly observed and confirmed by surveyors and the Regional Director of Clinical Operations during the survey. No specific residents or staff were identified as being directly affected at the time of the deficiency, and no additional medical history or resident conditions were mentioned in the report.
Failure to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and kitchen sanitation during a tour of the facility's kitchen and food storage areas. Food debris was found on the floor under kitchen surfaces and shelves in the meal preparation area, not related to the current meal service. Behind the stove, a large pile of food debris was present against the wall, with cooking utensils partially buried in it. In the dry food storage area, loose fries and a biscuit were found on the floor. The walk-in freezer contained food debris, including a fish filet and loose fries on the floor, and an open box of green beans stored directly on the floor, along with boxes of hamburger patties, chicken breasts, and creamer stacked and stored on the floor. In the walk-in refrigerator, a large mesh bag of onions was also stored on the floor. These observations were confirmed by both the surveyor and the Food Service Director, indicating that food was not stored, prepared, or served in accordance with professional standards for food service safety.
Improper Disposal of Garbage and Refuse Observed
Penalty
Summary
Surveyors observed several deficiencies in the disposal of garbage and refuse at the facility. On the survey day, multiple bags of trash were found stored on the ground next to the facility dumpsters, rather than inside them. The hinges on the lid of one dumpster were broken, preventing the lid from covering the refuse. Additionally, in the outside area by the loading dock, a used food container was seen frozen in the snow on top of a snow-covered cooler, and a round trash barrel without a lid was found containing trash and debris, with a milk crate frozen in place and ice accumulating over the edges of the barrel. These findings were confirmed during an interview with the Regional Director of Clinical Operations.
Infection Control Deficiency in Laundry Room Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control practices in the laundry room. Specifically, there was a buildup of lint behind the dryer, and the floor was covered with dirt and debris. Slings used for resident transport were found piled on the floor between a door and a wall, and additional slings were hanging on wall hooks near the dryer in such a way that parts of the slings were touching the floor and the inside of a lint-filled garbage can. These observations were confirmed during a tour and interview with the Regional Director of Clinical Operations, who acknowledged the improper storage of slings on the floor and on hooks where they touched the floor.
Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to provide care in accordance with a resident's comprehensive care plan for fall prevention. The resident, who has diagnoses including dementia, visual loss, and a history of falls, was identified as high risk for falls due to factors such as poor balance, unsteady gait, blindness, and dementia. The care plan and physician orders specified that the resident should have hip protectors in place at all times unless being laundered. However, during the survey, it was observed that the resident was not wearing hip protectors as required. Interviews with staff revealed a lack of awareness and follow-through regarding the use of hip protectors for this resident. A CNA stated she was only aware of fall mats and a low bed as interventions, and upon inspection, confirmed the absence of hip protectors. An RN acknowledged that the resident was supposed to have hip protectors but had not had them since transferring to the current unit several months prior. The LTC manager also confirmed the resident should have had hip protectors in place but was unsure why they were not being used.
Failure to Follow Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to maintain its Infection Control Program by not following its own Enhanced Barrier Precautions (EBP) policy for a resident with chronic wounds. According to the facility's policy, EBPs are required for residents with wounds, and these precautions should remain in place for the duration of the wound or the resident's stay. The policy also requires staff training and the posting of signage outside the resident's room indicating the type of precautions and required PPE. During the survey, it was observed that there was no EBP sign posted outside the room of a resident with chronic right leg ulcers, and a Certified Nursing Assistant confirmed that the resident was not on any type of precautions, despite the care plan indicating the need to follow EBP. Further review of the resident's medical records showed ongoing physician orders for wound care and documentation of wound treatments provided by a Registered Nurse. Interviews with staff revealed confusion regarding the resident's EBP status, with the nurse stating that the resident was previously on EBP but was removed when the wounds improved, and the Infection Preventionist indicating that EBP was not needed if the wound was not draining. These actions and inactions resulted in the facility not adhering to its own infection control policy for residents with wounds, as required.
Incomplete Clinical Record for Surgical Drain Removal
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident who returned from surgery with a surgical drain in place. Upon review, it was found that there was a physician's order for daily dressing changes and for the drain output to be recorded every 12 hours, with instructions for the drain to remain in place until the resident's follow-up clinic visit in approximately one week. However, documentation showed that the drain was removed at the facility just one day after the resident's return, following a phone call to the surgical center nurse, but without any written or verbal order from the medical provider or surgical team authorizing the removal. The clinical record lacked evidence of such an order, and this was confirmed during interviews with the charge nurses and the Director of Nursing.
Failure to Follow Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when staff failed to implement required infection control practices for a resident with open wounds and an ileostomy who was on Enhanced Barrier Precautions (EBP). Facility policy required staff to wear gowns and gloves when providing high-contact care to residents on EBP, including those with chronic wounds or indwelling catheters. During an observation, a Certified Nursing Assistant (CNA) entered the resident's room to empty a catheter bag without donning a gown, despite a sign posted outside the room indicating EBP precautions were in place. The CNA acknowledged forgetting the need to wear a gown for this resident, and the surveyor confirmed the lapse at the time of the observation.
Failure to Provide Physician-Ordered Minced and Moist Diet
Penalty
Summary
A resident with a history of dysphagia and recent emergency room visits for increased cough, congestion, and concerns for aspiration pneumonia was placed on a physician-ordered minced and moist diet with thin liquids. The order, based on the IDDSI Level 5 guidelines, specifically excluded regular, dry bread, sandwiches, or toast. Despite this, the resident was provided a roll for lunch while on the modified diet. Following the consumption attempt, the resident was unable to swallow secretions and vomited upon swallowing food or drink, which led to another emergency department visit. Interviews with facility staff, including the Rehab Director and Director of Nursing, confirmed that the dietary order was not followed and that bread is not permitted on the minced and moist diet per IDDSI standards.
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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