Orchard Park Rehab & Living Center
Orchard Park Rehab & Living Center in Farmington, ME — inspection on August 26, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
to ensure that 1 of 1 resident reviewed for dignity was provided care in a manner that maintained and
facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.
Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot.
The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards, with the ties positioned in the back and secured in a double knot to deter Resident #1 from accessing his/her brief because he was unable to locate a belt. CNA #6 further explained that Resident #1 was noted to shred and remove her brief. CNA #6 confirmed these interventions were not included in Resident 1's plan of care and acknowledged that he had previously received training on abuse, neglect, restraints and resident rights. CNA #6 further stated he did not recognize his actions of applying the johnny pants backwards with the ties positioned in the back in a double knot and secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief.
The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent.
The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief.
All of which constituted resident abuse. CNA #6's contract was terminated immediately.
The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint.
The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
205168 08/26/2025
Orchard Park Rehab & Living Center 107 Orchard Street Farmington, ME 04938
residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot
immediately.
The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity
above findings were discussed, including concerns related to dignity, respect, abuse and restraint.
The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.
205168 08/26/2025
Orchard Park Rehab & Living Center 107 Orchard Street Farmington, ME 04938
treatment.
failed to ensure that 1 of 1 resident was free from the use of restraints. (Resident #1 The Division of
mistreatment on 8/4/25.
Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot.
The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot.
The facilities restraint use policy indicates: The facility must ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the residents' medical symptoms. II.
Procedure Examples of facility practices and meeting the definition of a physical restraint include but are not limited to: C.
Tucking in a sheet tightly so the resident cannot get out of bed or fastening fabric or clothing, so a resident's freedom of movement is restricted. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards, with the ties positioned in the back and secured in a double knot to deter Resident #1 from accessing his/her brief because he was unable to locate a belt.
CNA #6 further explained that Resident #1 was noted to shred and remove her brief. CNA #6 confirmed these interventions were not included in Resident 1's plan of care and acknowledged that he had previously received training on abuse, neglect, restraints and resident rights. CNA #6 further stated he did not recognize his actions of applying the johnny pants backwards with the ties positioned in the back in a double knot and secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief.
The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent.
The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief.
All of which constituted resident abuse. CNA #6's contract was terminated immediately.
The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint.
The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.