Inspection Reports for Magnolia Assisted Living – Tall Pines Building 2
34 MARTIN LN, ME, 04915-6080
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Monitoring
Census: 28
Capacity: 53
Deficiencies: 12
Aug 18, 2025
Visit Reason
Monitoring survey and case investigation to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs and Infection Prevention and Control, including verification of correction of previously cited deficiencies.
Findings
The facility was found to have multiple repeat deficiencies related to confidentiality procedures, resident consent documentation, medication administration and storage, staff training, incident reporting, resident care coordination, and employee records. These deficiencies represent failures to meet the conditions of the 05/7/2025 Directed Plan of Correction and Conditional License.
Severity Breakdown
Class II: 2
Class III: 4
Class IV: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to develop and implement a written procedure to ensure confidentiality of administrative and resident records. | — |
| Failed to have dated written consent to release information for 1 of 6 resident records reviewed (Resident #5) and failed to develop a written procedure related to written consent. | Class IV |
| Failed to implement procedures with pharmacist input for controlled substances and competency assessment of unlicensed assistive personnel regarding medications. | — |
| Failed to administer medication as ordered by licensed practitioner for Resident #4 (Morphine dose and schedule). | Class II |
| Failed to ensure unlicensed assistive personnel were trained by a registered nurse regarding diabetes management for 3 of 7 employee records reviewed. | Class III |
| Failed to keep physical separation and labeling for storage of residents' Schedule II medications in medication carts. | Class III |
| Failed to include corrective action column in documentation review of residents' Schedule II controlled substances records. | Class II |
| Failed to document required information in Medication Administration Records (MAR) and transcribed medication incorrectly for Resident #4. | Class III |
| Failed to ensure full signatures of medication administrators on MARs for 2 residents and failed to document medication administration or refusal for 1 resident. | Class III |
| Failed to provide mandatory training to staff and agency personnel regarding incident reporting. | — |
| Failed to draft and implement written procedure and documented review to ensure prompt coordination and assistance in accessing appropriate services for residents. | — |
| Failed to have job descriptions for 3 of 7 staff records reviewed and failed to implement a written policy including all required employee record items. | — |
Report Facts
Resident census: 28
Total capacity: 53
Employee records reviewed: 7
Resident records reviewed: 7
Repeat deficiencies: 12
Inspection Report
Monitoring
Census: 28
Capacity: 53
Deficiencies: 11
Aug 18, 2025
Visit Reason
Monitoring survey and case investigation to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs and Infection Prevention and Control.
Findings
The facility was found not in compliance with multiple regulatory requirements including confidentiality procedures, resident rights to confidentiality, medication administration and storage, employee training, incident reporting, and documentation. Several deficiencies were repeat findings from prior inspections and directed plans of correction.
Severity Breakdown
Class II: 3
Class III: 3
Class IV: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to develop and implement a written procedure to ensure confidentiality of administrative and resident records. | — |
| Failure to have dated written consent to release information for 1 of 6 resident records reviewed. | Class IV |
| Failure to implement procedures with pharmacist input for controlled substances and medication competency assessments for unlicensed personnel. | Class II |
| Failure to administer medication as ordered by licensed practitioner (Resident #4). | Classes II |
| Failure to ensure unlicensed assistive personnel were trained by a registered nurse regarding diabetes management for 3 of 7 employee records reviewed. | Class III |
| Failure to keep physical separation for storage of resident Schedule II medications. | Class III |
| Failure to document review and corrective action for residents' individual records of Schedule II controlled substances. | Class II |
| Failure to document specific required information and transcription accuracy in Medication Administration Records (MAR) for residents. | Class III |
| Failure to develop mandatory training for staff and agency personnel regarding incident reporting. | — |
| Failure to draft and implement a written procedure to coordinate and assist in accessing appropriate medical and health care services for residents. | — |
| Failure to maintain accurate employee records including job descriptions for 3 of 57 staff records reviewed. | — |
Report Facts
Census: 28
Total Capacity: 53
Employee records reviewed: 57
Employee records reviewed for diabetes training: 7
Resident records reviewed for consent: 6
Resident records reviewed for MAR transcription: 7
Inspection Report
Plan of Correction
Capacity: 53
Deficiencies: 0
Jun 30, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Magnolia Assisted Living – Tall Pines Building 2, related to licensing and certification compliance.
Findings
Magnolia Assisted Living – Tall Pines Building 2 is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Inspection Report
Plan of Correction
Capacity: 53
Deficiencies: 0
Jun 17, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Magnolia Assisted Living – Tall Pines Building 2, related to licensing and certification compliance.
Findings
Magnolia Assisted Living – Tall Pines Building 2 is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Inspection Report
Complaint Investigation
Census: 33
Capacity: 53
Deficiencies: 9
May 1, 2025
Visit Reason
A case investigation was conducted due to complaints regarding medication administration and resident care violations at Magnolia Assisted Living - Tall Pines Building 2.
Findings
The facility was found out of compliance with regulations governing assisted housing programs, with multiple deficiencies related to medication administration errors, failure to report rights violations, incomplete documentation, delayed medical care, and maintenance issues.
Complaint Details
The investigation was triggered by complaints regarding medication administration errors, including administration of a broken Fluoxetine capsule to Resident #3 causing burning sensations, failure to report the incident, and medication omissions for Resident #2 leading to adverse effects.
Severity Breakdown
Class II: 3
Class III: 2
Class IV: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to immediately report a known conduct of care violation to the Department of Health and Human Services and other entities. | Class IV |
| Unsafe medication administration procedures, including administering a broken medication capsule. | Class II |
| Failure to administer medications as ordered by duly authorized licensed practitioners. | Class II |
| Failure to have telephone orders signed by licensed practitioners within five working days. | Class III |
| Medication/treatment administration records (MAR) not properly documented, including incorrect documentation of medication administration and failure to document PRN medication details. | Class III |
| Failure to complete incident reports for medication errors and reactions. | Class II |
| Failure to promptly coordinate and assist in accessing appropriate health care services for residents. | — |
| Registered nurse failed to ensure completeness and accuracy of resident medication administration records. | — |
| Facility failed to maintain evidence of routine maintenance and housekeeping, including damaged walls and malfunctioning call bell systems. | — |
Report Facts
Deficiencies cited: 9
Resident census: 33
Total capacity: 53
Medication doses missed: 20
Days without Diazepam PRN medication: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michaelene Achorn | Acting Administrator | Named in relation to findings and interviews regarding medication administration and facility compliance. |
| Nicole Guenette | Assisted Housing Program Manager | Author of the report and contact for questions. |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 53
Deficiencies: 11
Mar 26, 2025
Visit Reason
The inspection was conducted based on complaint investigations related to medication administration incidents and compliance with regulations governing assisted housing programs and infection prevention and control.
Findings
The facility was found non-compliant with multiple regulations including failure to immediately report a conduct of care violation, unsafe medication administration procedures, incomplete medication administration records, failure to document medication errors, failure to promptly access appropriate medical services, and inadequate facility maintenance.
Complaint Details
The complaint investigation was triggered by a medication administration incident involving Resident #3 receiving a broken Fluoxetine capsule causing burning sensations. Additional complaints included medication omissions and documentation errors affecting Residents #1 and #2.
Severity Breakdown
Class IV: 1
Class III: 2
Class II: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to immediately report a known conduct of care violation to the Department of Health and Human Services and other entities. | Class IV |
| Unsafe administration of medication by giving a broken capsule of Fluoxetine to a resident. | Class II |
| Failure to administer medication as ordered by a duly authorized licensed practitioner, resulting in a resident being without Diazepam for 19 days. | Class II |
| Failure to have a telephone order signed by the duly authorized licensed practitioner within five working days. | Class III |
| Failure to document medication administration records accurately, including incorrect documentation of medication administration and failure to update MAR for oxygen treatment changes. | Class III |
| Failure to record medication error reports for unsafe medication administration and omission of medication. | Class II |
| Failure to document date, time, reason, and results for PRN medication administration on MAR. | — |
| Failure to complete incident reports for medication administration errors. | — |
| Failure to promptly access appropriate medical services for a resident. | — |
| Failure of registered nurse to ensure completeness and accuracy of resident medication administration records. | — |
| Failure to maintain routine maintenance and housekeeping, including damaged walls and malfunctioning call bell systems. | — |
Report Facts
Resident census: 33
Total capacity: 53
Medication omission days: 19
Medication doses missed: 20
Inspection date: Mar 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michaelene Achorn | Acting Administrator | Administrator interviewed and confirmed findings related to medication errors and reporting |
Loading inspection reports...
