Based on record review and interview, the facility failed to notify the physician of significant change in condition for 1 of 1 resident reviewed for Abuse [Resident #16 (R16)]. This failure delayed physician intervention that resulted in harm to R16 when R16 had requested to go to the hospital on 1/27/26 while experiencing respiratory distress which included needing increased supplemental oxygen above physician order, increased anxiety and restlessness which required frequent staff intervention and redirection. The Medical Provider was not notified of the change in condition until 1/29/26. …
F580 citations in Maine
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maine cites F580 more often than its own record predicts
1.14 times the share F580 takes of citations nationally.
Of every deficiency written in Maine in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maine surveyors wrote
F580 findings written in Maine, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review, interview, and facility policy, the facility failed to follow their policy to notify a physician that medication was unavailable for 1 of 3 residents reviewed during a complaint investigation (Resident #1). Finding:A review of the facility's physician standing orders, dated 1/6/26 states, New Admissions.May Use Discharge summary as active orders.May hold unavailable medication x 2 doses until medication arrives from pharmacy if pt [patient] vital signs stable and clinically asymptomatic.Resident #1 was admitted with diagnoses to include hypoosmolality (a low concentration of solutes, including sodium, in the blood plasma) and hyponatremia (low blood sodium levels).A review of Resident #1's clinical record revealed the following active physician orders:An order with… …
The short window
Recent years
| Year | Share of Maine citations | vs expected |
|---|---|---|
| 2023 | 0.63% | 0.44× |
| 2024 | 1.58% | 1.04× |
| 2025 | 1.70% | 1.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maine surveyors cite →
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