Based on record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to ensure a resident was free from an avoidable accident and environmental hazards. Specifically, Resident #1 [R1] exited their assigned unit onto an exterior courtyard/patio area without staff knowledge. The resident remained outdoors, inadequately dressed for the weather, for approximately 30 minutes before being discovered face down on the snow-covered ground. This failure created an immediate jeopardy situation.Findings: The Department of Licensing and Certification [State Agency] received an anonymous complaint which stated R1 was found outside on the ground in wet/snowy conditions in the early morning hours of March 21, 2026. …
F689 citations in Maine
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maine cites F689 less often than its own record predicts
0.97 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maine in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maine surveyors wrote
F689 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 clinical record review, and interviews, the facility failed to ensure a resident's safety during care resulting in the resident rolling out of bed to the floor and sustaining a fractured left humerus (long bone in upper arm) for 1 of 1 resident reviewed for fall and fracture.Finding: On 7/22/26, a review of R1's clinical record was completed. Documentation in a nursing note, dated 4/25/26, a statement made by Certified Nurse Assistant #1 (C.N.A.1), indicated that while C.N.A.1 was changing R1's bed sheets, R1 rolled out of bed onto the floor. On 4/25/26, documentation made at the Emergency Department (ED) indicated the resident was seen due to a fall out of bed. …
Based on observations and interviews, the facility failed to maintain a safe environment free from physical hazards in 2 of 6 rooms on Wing A. Findings: 1. On 8/19/26 at 11:15 a.m., during an observation of room [ROOM NUMBER], a surveyor observed a double paned window with a larger center window with a window that cranked out to open on each side. The center window was cracked on the interior lower section of the window, and a surveyor was able to rest a fingernail on the interior crack. 2. On 8/19/26 at 11:16 a.m., during an observation of room [ROOM NUMBER], a surveyor observed the same style window and noticed the upper interior part of the center window had clear tape on it. …
The short window
Recent years
| Year | Share of Maine citations | vs expected |
|---|---|---|
| 2023 | 5.05% | 1.02× |
| 2024 | 3.55% | 0.66× |
| 2025 | 5.35% | 0.97× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maine surveyors cite →
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