14 Reports
Inspection Report — Dec 9, 2025
Plan of Correction
Date: Dec 9, 2025
Visit Reason
Recertification survey conducted on December 9, 2025, due to facility not being in substantial compliance with certain Medicare and Medicaid certification requirements.
Findings
This document is the facility's plan of correction for the recertification survey completed on 2025-12-09. The plan addresses deficiencies related to pressure ulcer prevention and treatment, resident-identifiable information, infection prevention and control, and enhanced barrier precautions.
Report Facts
: Jan 20, 2026
: Dec 9, 2025
Inspection Report — Jun 24, 2025
Complaint Investigation
Date: Jun 24, 2025
Visit Reason
An unannounced on-site visit was conducted to investigate a facility reported incident #ME00051990.
Findings
Orono Commons was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: ME00051990
Inspection Report — May 6, 2025
Annual Inspection
Date: May 6, 2025
Visit Reason
Annual federal Recertification Survey conducted on 05/06/2025 to assess compliance with Medicare and Medicaid requirements and Life Safety Code.
Findings
The facility was found not in substantial compliance with NFPA 101 Life Safety Code, 2012 edition, due to unprotected wood framing in a two-story building and unsealed penetrations in smoke barriers. Maintenance staff will be trained and inspections will be conducted monthly to ensure compliance.
Deficiencies (2)
K 161: The building construction type does not meet the minimum requirements of NFPA 101, Life Safety Code, 2012 edition, for a two-story health care facility due to unprotected wood framing and lack of rated separation between levels.
K 371: Smoke barriers required by NFPA 101, Life Safety Code, 2012 edition, were not continuous due to a penetration with a 3-inch sprinkler pipe that was not fire stopped, compromising the smoke compartment integrity.
Report Facts
: 205031
: 1910
: OOU221
Inspection Report — May 4, 2025
Annual Inspection
Date: May 4, 2025
Visit Reason
Unannounced on-site visits were conducted to complete the annual Long Term Care Survey Process for Federal Recertification and to investigate multiple complaints.
Findings
The facility was found not in substantial compliance with federal regulations governing long term care. Deficiencies were identified in residents' rights to formulate advance directives, abuse reporting, PASARR coordination, baseline care planning, quality of care, pain management, staffing, and food safety.
Deficiencies (10)
F578: The facility failed to ensure a resident's right to formulate an accurate advance directive regarding code status, as evidenced by conflicting information in the clinical record and interviews.
F609: The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Agencies timely, as required by policy and state law.
F644: The facility failed to ensure the State mental health authority for Pre-Admission Screening and Resident Review (PASARR) was notified after a resident was newly diagnosed with bipolar disorder and symptoms related to a mental disorder or trauma.
F655: The facility failed to develop and implement baseline care plans within 48 hours of admission for 5 of 10 sampled residents, lacking necessary instructions for proper care.
F684: The facility failed to follow physician orders for 4 of 20 residents reviewed, including medication administration and monitoring.
F695: The facility failed to provide respiratory care as ordered for 1 of 3 residents using oxygen, lacking documentation of respiratory rate, skin color, and breath sounds evaluation.
F697: The facility failed to provide timely pain management for 2 of 2 residents reviewed, resulting in unrelieved pain and delays in receiving prescribed medications.
F725: The facility failed to maintain sufficient nursing staff with appropriate competencies to meet resident needs, as evidenced by low weekend staffing.
F804: The facility failed to serve hot foods at safe and appetizing temperatures and failed to maintain food storage areas in a sanitary manner.
F812: The facility failed to properly store, prepare, and serve food in accordance with professional standards, including failure to date food items and maintain dishwasher sanitation.
Report Facts
: Array
: Array
: Array
Inspection Report — May 21, 2024
Plan of Correction
Date: May 21, 2024
Visit Reason
Federal Recertification Survey for Orono Commons.
Findings
This document is the facility's plan of correction for the Federal Recertification Survey completed on 05/21/2024. It addresses deficiencies related to fire safety and building rehabilitation, including self-closing doors, sprinkler system maintenance, and smoke barrier penetrations.
Report Facts
: EVV021
: 1910
: May 21, 2024
: Array
Inspection Report — May 19, 2024
Plan of Correction
Date: May 19, 2024
Visit Reason
This document is the facility's plan of correction for the survey completed on 05/22/2024. It addresses deficiencies related to resident rights, self-determination, safe environment, notice requirements before transfer/discharge, bed hold policy, baseline care planning, trauma-informed care, physician visits, sufficient nursing staff, nurse staffing information, labeling and storage of drugs and biologicals, food procurement and safety, and other care and safety issues.
Findings
This document is the facility's plan of correction for the survey completed on 05/22/2024. It outlines corrective actions for deficiencies cited in the areas of resident rights, self-determination, safe environment, transfer/discharge notices, bed hold policies, care planning, trauma-informed care, physician visits, staffing, medication management, food safety, and other regulatory requirements.
Report Facts
: Array
: 15.1 lbs in 2 months
: Array
: 5 units Novolog SQ if glucose > 300
: oxygen tubing replaced every 7 days
: Minimum of Days 1:5, Evenings 1:10, Nights 1:15
: Array
Inspection Report — Apr 17, 2024
Complaint Investigation
Date: Apr 17, 2024
Visit Reason
An unannounced visit was conducted to complete the investigation for complaint #ME00047066.
Findings
Orono Commons was determined to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: ME00047066
Inspection Report — Dec 12, 2023
Complaint Investigation
Date: Dec 12, 2023
Visit Reason
An unannounced visit was conducted to investigate complaint #ME00045712.
Findings
Orono Commons was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: ME00045712
Document — 1E25B0 H1 SOD
Date: 1E25B0 H1 SOD
Inspection Report — EVV021 SOD
Date: EVV021 SOD
Visit Reason
Federal Recertification Survey
Findings
The facility is not in substantial compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition, as evidenced by multiple deficiencies related to building rehabilitation, sprinkler system maintenance, and corridor wall construction.
Deficiencies (4)
K111: The facility failed to meet the requirements for building rehabilitation under NFPA 101, including fire resistance ratings for walls and self-closing fire doors. Observations included two wall penetrations in a two-hour fire barrier wall and missing escutcheon plates on a sprinkler head.
K223: The facility failed to ensure that all doors with self-closing devices were properly latching as required by NFPA 101. The linen storage room door did not latch properly but was immediately corrected during the survey.
K353: The sprinkler system was not inspected, tested, and maintained in accordance with NFPA 25 standards. Required information such as date of last sprinkler system check and water supply source was missing.
K362: The facility failed to meet NFPA 101 requirements for corridor wall construction and smoke barrier integrity. Observations included penetrations in smoke barrier walls that compromised smoke tightness.
Report Facts
: May 21, 2024
: 09:00
: 11:30
Report
Report
Report
Report
8 CMS Surveys
Inspection Report — Dec 9, 2025
Date: Dec 9, 2025
Visit Reason
Federal nursing home survey documenting deficiencies in pressure ulcer care, clinical record accuracy, and infection prevention.
Findings
The facility failed to timely treat a new pressure ulcer, maintain accurate clinical records for eating assistance, and implement infection prevention protocols including enhanced barrier precautions and proper linen handling.
Deficiencies (3)
F0686: The facility failed to follow its own policy for pressure ulcer care by delaying treatment and monitoring of a new pressure ulcer on Resident #1's right big toe for 8 days.
F0842: The facility failed to ensure accurate and complete clinical record documentation of eating assistance for Resident #1, with 14 of 24 meals inaccurately documented.
F0880: The facility failed to maintain an infection prevention and control program, including inadequate use of enhanced barrier precautions and improper handling of soiled linen.
Report Facts
: 14
: 24
: 8
Inspection Report — May 6, 2025
Biennial Survey
Date: May 6, 2025
Visit Reason
The survey was conducted to assess compliance with health and safety regulations, including resident care, medication administration, staffing, and food service.
Findings
The facility failed to ensure timely and appropriate care in multiple areas including resident rights, abuse reporting, PASRR referrals, baseline care plans, medication administration, respiratory care, pain management, staffing levels, and food safety. Several residents experienced delayed or missed medications and pain management. Food temperatures were not maintained safely and food storage practices were inadequate.
Deficiencies (10)
F0578: The facility failed to ensure a resident's right to formulate an accurate advance directive regarding code status, resulting in conflicting information in the clinical record.
F0609: The facility failed to timely report a suspected abuse incident to the State Agencies as required by policy.
F0644: The facility failed to notify the State mental health authority for PASRR after a resident was newly diagnosed with bipolar disorder, delaying appropriate level of service determination.
F0655: The facility failed to develop and implement baseline care plans within 48 hours of admission for 5 of 10 sampled residents.
F0684: The facility failed to follow physician orders for medications, resulting in residents not receiving ordered medications including Aspirin, Quetiapine, Morphine, and insulin as prescribed.
F0695: The facility failed to provide respiratory care as ordered for a resident using oxygen, lacking documentation of required evaluations every shift.
F0697: The facility failed to provide timely and effective pain management for residents, resulting in unrelieved pain and one resident discharging against medical advice.
F0725: The facility failed to ensure sufficient nursing staff were scheduled and on duty to meet resident needs on weekends during the first quarter of 2025.
F0804: The facility failed to serve hot foods at safe and appetizing temperatures, with tested lunch trays served at temperatures below safe levels.
F0812: The facility failed to store, prepare, and serve food in accordance with professional standards, including improper hair restraints, inadequate dishwasher sanitation, improper plumbing air gap, unsafe food storage and thawing practices, and failure to remove or date beverages properly.
Report Facts
: 7
: 7
: 8
: 94
Inspection Report — May 6, 2025
Annual Inspection
Date: May 6, 2025
Visit Reason
The survey was conducted to assess compliance with regulations governing nursing home operations, including timely reporting of abuse, care planning, medication administration, pain management, and food service.
Findings
The facility failed to timely report an allegation of abuse, develop baseline care plans within 48 hours for multiple residents, follow physician medication orders, provide timely pain management resulting in actual harm, and serve hot foods at safe temperatures.
Deficiencies (5)
F0609: The facility failed to timely notify State Agencies and Adult Protective Services of an allegation of abuse for one of three reported incidents.
F0655: The facility failed to develop and implement baseline care plans within 48 hours of admission for five of ten sampled residents.
F0684: The facility failed to provide appropriate treatment and care according to physician orders for four of twenty residents, including failure to administer ordered medications available as stock or in the emergency kit.
F0697: The facility failed to provide safe and appropriate pain management for two residents, resulting in actual harm including one resident discharging against medical advice due to uncontrolled pain.
F0804: The facility failed to serve hot foods at an appetizing and safe temperature during lunch service, as confirmed by resident reports and temperature testing.
Report Facts
: 5
: 4
: 2
: 1
: 96.4
: 94.3
: 96.6
Inspection Report — May 19, 2024
Biennial Survey
Date: May 19, 2024
Visit Reason
The survey was conducted to assess compliance with health and safety regulations, including resident care, staffing, and facility conditions.
Findings
The facility demonstrated multiple deficiencies including delayed response to call bells, inadequate bathing assistance, poor environmental maintenance, failure to notify residents and representatives of transfers, incomplete care plans, medication errors, insufficient staffing, and food service issues including late meals and improper food storage.
Deficiencies (20)
F0550: The facility failed to respond to residents' call bells in a timely manner, resulting in delays of up to fifty minutes for assistance with toileting and bathing.
F0561: The facility failed to ensure a resident's preference for a second serving of the main meal choice was available, contributing to significant weight loss.
F0584: The facility failed to maintain a safe, clean, and homelike environment, including persistent strong urine odors, uncleanable surfaces, torn wheelchair armrests, and damaged furniture.
F0623: The facility failed to provide timely written notification of transfer/discharge to residents, representatives, and the Ombudsman.
F0625: The facility failed to notify residents or representatives in writing of bed hold policies after hospital transfers for multiple residents.
F0655: The facility failed to provide residents and representatives with a summary of baseline care plans within 48 hours of admission for multiple residents.
F0656: The facility failed to develop a care plan addressing Post-Traumatic Stress Disorder for a resident diagnosed with PTSD.
F0684: The facility failed to complete neurological assessments as ordered, failed to follow medication administration orders, delayed urgent diagnostic testing, and administered insulin doses not indicated by orders for multiple residents.
F0686: The facility failed to ensure appropriate pressure ulcer care, including missing weekly wound assessments, failure to obtain wound clinic referrals, and failure to provide prescribed pressure redistribution cushions.
F0695: The facility failed to follow its oxygen therapy policy, including failure to label oxygen tubing with dates, failure to clean equipment, and failure to document humidification orders.
F0699: The facility failed to assess and plan for trauma-informed care for a resident with PTSD, lacking identification of triggers and trauma interventions.
F0711: The facility failed to ensure timely physician review and signature of orders for a resident, with a delay of 29 days past the required review date.
F0725: The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed assistance with toileting and bathing, and residents waiting up to two hours for help.
F0730: The facility failed to complete annual performance evaluations for nurse aides employed more than one year.
F0732: The facility failed to post nurse staffing information in a prominent, accessible location for residents on multiple days of the survey.
F0761: The facility failed to ensure medications were properly labeled and stored, including unlabeled opened insulin and expired medications in storage rooms.
F0802: The facility failed to provide adequate dietary staffing, resulting in late meal service, insufficient food portions, and inability to meet resident dietary needs timely.
F0804: The facility failed to serve food at safe and appetizing temperatures, with hot foods served lukewarm and cold foods served too warm.
F0812: The facility failed to monitor food temperatures consistently, failed to store and label food properly, and failed to maintain proper air gap separation on plumbing fixtures, risking foodborne illness and cross-contamination.
F0947: The facility failed to provide abuse prevention training for a newly hired Certified Nursing Assistant.
Report Facts
: 15.1
: 117.2
: 102.1
: 3300
: 3
: 30
: 50
: 60
: 90
Inspection Report — May 19, 2024
Biennial Survey
Date: May 19, 2024
Visit Reason
The survey was conducted to assess compliance with regulations governing nursing home care, including resident dignity, treatment, staffing, and food service.
Findings
The facility failed to respond timely to call bells, provide morning baths, complete neurological assessments, follow physician orders, ensure sufficient staffing, and maintain proper food safety and storage practices. Multiple residents experienced delays in care and unmet needs, and food service was often late and improperly handled.
Deficiencies (7)
F0550: The facility failed to honor residents' rights to dignity and timely assistance, evidenced by delayed response to call bells for multiple residents and failure to provide morning bathing care.
F0684: The facility failed to provide appropriate treatment and care by not completing neurological assessments, not following physician orders for vital signs and referrals, and administering medications incorrectly for multiple residents.
F0686: The facility failed to provide appropriate pressure ulcer care by not completing weekly assessments, not following wound clinic referral orders, and not following care plans for residents with pressure ulcers.
F0725: The facility failed to provide enough nursing staff daily to meet the needs of residents, resulting in delayed assistance with toileting, missed baths, and unmet care needs.
F0802: The facility failed to provide sufficient dietary staff to safely and effectively carry out food and nutrition services, causing late meal delivery and insufficient food availability.
F0804: The facility failed to ensure food and drink were served at safe and appetizing temperatures, with hot foods served inadequately hot and cold foods inadequately cold.
F0812: The facility failed to procure food from approved sources and store, prepare, and serve food according to professional standards, including failure to monitor food temperatures, improper food storage, undated and open food packages, and improper plumbing preventing backflow.
Report Facts
: 650
: 1000
: 650
: 1000
: 30
: 105
: 116.9
: 66.8
Inspection Report — Mar 28, 2024
Date: Mar 28, 2024
Inspection Report — Feb 26, 2023
Biennial Survey
Date: Feb 26, 2023
Visit Reason
The survey was conducted as a biennial recertification and complaint survey to assess compliance with regulations governing nursing home operations and resident care.
Findings
The facility was found to have multiple deficiencies including failure to serve residents meals simultaneously, inadequate beverage choices, poor housekeeping and maintenance, incomplete care plans for resident behaviors, failure to follow physician's medication orders, insufficient nursing staff, lack of snacks for residents, and incomplete clinical records.
Deficiencies (8)
F0550: The facility failed to promote care that maintains each resident's dignity and respect by not serving all residents seated at the same table at the same time for 2 of 6 meals observed.
F0561: The facility failed to ensure residents were allowed to choose their beverage preferences throughout the day, limiting coffee to breakfast only and not offering soda.
F0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment by serving meals on trays instead of in a homelike manner and by inadequate housekeeping and maintenance including cracked ceilings, stained curtains, chipped railings, and stained ceiling tiles.
F0656: The facility failed to update and implement a complete care plan addressing behaviors of a resident who wandered into rooms and pushed other residents without consent.
F0684: The facility failed to follow a physician's order to check heart rate prior to administering Metoprolol to a resident, administering the medication without verifying heart rate.
F0725: The facility failed to provide enough nursing staff on the overnight shift to meet resident needs, resulting in neglect of care such as incomplete incontinence care and inadequate supervision of wandering residents.
F0809: The facility failed to offer snacks to all residents on the Homestead unit, with observations of no snacks available and staff reporting ongoing shortages.
F0842: The facility failed to maintain complete and accurate clinical records, evidenced by a nutritional supplement (magic cup) found in the refrigerator after the scheduled administration date but documented as consumed.
Report Facts
: 17
: 5
: 6
: 40
: 36
: 76
Inspection Report — Feb 26, 2023
Date: Feb 26, 2023
Visit Reason
The document does not specify a visit type in the first three header lines; it is a nursing home CMS-2567 form.
Findings
The facility failed to update and implement care plans addressing behaviors of Resident #27 and failed to ensure sufficient nursing staff to meet resident needs, resulting in potential harm.
Deficiencies (2)
F0656: The facility failed to update and implement a complete care plan for Resident #27 addressing behaviors such as wandering and pushing other residents without consent.
F0725: The facility failed to provide enough nursing staff every day to meet the needs of every resident, including having a licensed nurse in charge on each shift.
Report Facts
: 17
: 5
: 6
: 40
: 36
: 76
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