Over the past three years, Maine inspectors have gone to Maine’s 107 nursing homes a total of 380 times, during which they documented 1,462 violations, according to data from ProPublica, a watchdog journalism group that provides a searchable database of nursing home deficiencies.

But most of those problems, recorded in a document called a statement of deficiencies, are minor.

Inspectors categorize the deficiencies to give the public some idea of their severity level. The vast majority of violations are not considered to be serious — that is, they don’t show an isolated incidence or a pattern that jeopardizes the immediate health or well-being of residents.

There are 12 categories of severity.

Just a handful of nursing homes — six in Maine — have been guilty of the three most serious categories, according to the inspectors, a team of state-employed nurses, licensed social workers and health facility specialists trained to inspect long term care homes on behalf of both the state and federal governments.

But, in each of those serious cases, the implications have been frightening.


The worst category of all is for severities which demonstrate a widespread, immediate threat to health or safety. Two nursing homes, — Horizons Living and Rehab Center in Brunswick, and Bridgton Health Care Center in Bridgton — have been cited under that category.

Federal investigators documented three such deficiencies at Horizons, a 65-bed for-profit nursing home, during an April 2012 inspection. The home’s administrators didn’t properly investigate and report to the state an incident in which a resident choked to death on a banana. Because the response was not sufficient, the state surveyors found that other residents at Horizons were at risk of death by choking over a period of months.

Horizons was also cited for not taking measures to prevent residents from burning themselves on the metal and glass exterior surfaces of gas fireplaces, which reached temperatures of up to 250 degrees.

Horizons was fined $5,200 in connection with the inspection.

In Bridgton, just before lunchtime on Sept. 12, 2012, when the door of the kitchen refrigerator was opened at Bridgton Health Care Center, a 43-bed for-profit nursing home, a state inspector noticed warm air coming from inside.

According to the refrigerator’s temperature gauge, any reading above 40 degrees is in the danger zone. The thermometer gave a reading of 50 degrees. The inspector noted the presence of mayonnaise, eggs, rigatoni and turkey sandwiches, then closed the door and waited several minutes to see whether the temperature would go down. Eleven minutes after the first reading, the thermometer registered the temperature at 55 degrees.


The inspector prevented the cook and the dietary aide from serving food to residents from the refrigerator. A subsequent investigation showed that the nursing home failed to monitor and document the refrigerator temperatures on a daily basis, as required by facility policy.

“This failure to monitor food temperatures resulted in elevated temperatures of food meant for residents’ consumption jeopardizing the health of all residents by creating the potential for food borne illnesses,” according to the report.

The home was fined $5,200 and has been subject to a payment suspension, according to Medicare reports.

Rumford Community Homes, a 32-bed nonprofit nursing home was cited in 2011 for the second-most serious category of deficiency, cases where the immediate threat to resident health or safety is part of a pattern.

A resident there was found on the floor next to the bed, badly injured, with a collection of blood on the surface of the brain, and fractures of bones surrounding the left eye and the left upper jaw.

It is possible that the injuries that contributed to the bleak prognosis could have been prevented, according to the state inspector’s report, which found that the home had failed to take measures to prevent the accident from happening. That resident had fallen several times in recent months, sometimes sustaining lesser injuries. Other residents with a high risk of falls were also not being properly protected, according to the state inspectors.


As a result of violations found during that inspection, the nursing home was fined $4,550.

Facilities in Rockland and Jackman were cited for the third-most serious deficiency, having isolated deficiencies that posed an immediate jeopardy to resident health or safety.

At Knox Center for Long Term Care in Rockland, an 84-bed nonprofit nursing home, a microwaved heating pack was placed on a resident when it was too hot. The resident removed the pack, but not before it had burned a small hole in the blanket and scorched the sheet beneath, creating what the resident’s roommate described as a horrible stench.

Knox Center was fined $3,900 for the violation.

At Jackman Regional Health Center, an 18-bed nonprofit nursing home, a resident wearing slippers and a sweatsuit left the facility at 6:15 a.m. on a frosty morning, went down some concrete steps in the dark without his or her usual walker, crossed uneven ground covered in wet grass and walked onto a road that was heavily traveled by large commercial pulp wood trucks.

A few minutes after leaving the facility, the resident was seen through the windows by staff, who ran outside and retrieved the resident, who suffered no injuries other than to complain, in French, of being cold.


Staff should have been more watchful, the state surveyor said, in part because he had a history of trying to leave the facility.

Jackman Regional Health Center was fined $3,900 for the violation.

After their inspections, each home submitted a plan of correction and was cleared, meaning it had made changes and was in full compliance, according to Tammy Steuber, a paralegal with the Division of Licensing and Regulatory Services.

— Matt Hongoltz-Hetling

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