Augusta Center For Health & Rehabilitation, LLC
188 Eastern Ave, Augusta, ME 04330 · For profit - Corporation · 72 certified beds · (207) 622-3121 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-04 to 2026-06, this home’s CMS overall rating improved from 1 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.5% | 24.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.2% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.6% | 2.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 20.3% | 11.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.9% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.2% | 25.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.4% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.4% | 29.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.3% | 20.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.1% | 74.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.0% | 20.8% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 27.3% | 16.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.91 | 1.45 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.92 | 2.01 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.9%CMS range 46.4–61.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.5–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 57.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 70.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.3–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 72 beds and averages 67.5 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.75 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.66 hrs/resident/day on weekends vs 4.13 on weekdays — 12% thinner on weekends. RN hours go from 1.19 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure that a resident was free of accidents/hazards for a resident who had rolled out of bed during personal care resulting in a fracture for 1 of 3 residents reviewed for falls. (Resident #1).Findings:On 4/19/26 Division of Licensing and Certification received an incident report indicating the following: On Thursday 4/15, staff member (Certified Nursing Assistant CNA #1) was giving care to [Resident #1]. [Resident #1] began to fall out of bed. The [CNA#1] called out for help. Two other staff arrived and helped lower [Resident #1] to the floor. [Resident #1] had persistent pain. X-ray results today show bilateral fractures above the knee. Facility investigation, dated 4/21/26, indicated the following: [CNA #1] attempted to provide care to [Resident#1] alone with bed in the high position. Kardex and care plan reflect that resident is a 2-assist for bed mobility. CNA#1 entered the room alone and helped resident roll onto her side so that she could begin washing her up for the day. After rolling resident onto her side,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 3 of 3 units ([NAME], Penobscot and Kennebec Units) and a common area for 1 of 1 environmental tour (2/5/26).Findings: On 2/5/26 from 8:55 a.m. to 9:25 a.m., a surveyor conducted an Environmental Tour with the Maintenance Director and the Administrator in which the following findings were discussed and observed: Common Area:- A hallway ceiling tile, by the main entrance door, had a large brown stain on it. Penobscot Unit:- Resident room [ROOM NUMBER] - There was a full cup of liquid, with a straw in it, on floor next to bed B. There was an unbagged bed pan on the bathroom floor.- Resident room [ROOM NUMBER] - There was a medium size bottle of powder lying on floor behind the head of bed A. The oxygen concentrator, located between the beds, had dirt/debris and dried liquid residue on it.- Resident room [ROOM NUMBER] -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-05 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 7 residents reviewed for care planning (Residents #3, #6, #7, #9, and #24).Findings:1. Review of Resident #3's clinical record revealed an MDS Quarterly Assessment was completed on 11/27/25. Further review of Resident #3's clinical record revealed that an IDT meeting was held 12/10/25 (13 days after assessment) and lacked evidence that an IDT meeting was held within 7 days following the assessment.Additional review of Resident #3's clinical record indicated that he/she sustained an unwitnessed fall at the facility on 12/17/25 and was subsequently admitted to an acute care hospital on [DATE], was diagnosed with a left hip fracture, and underwent left hip surgery on 12/18/25. Resident #3 returned to the facility on 1/3/26. The clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-05 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to ensure medications, including treatments, were stored properly by failing to obtain physician orders for medications located at a resident's bedside for 2 of 20 sampled residents (Residents #64, #9). In addition, the facility lacked evidence of consistent monitoring of medication storage room refrigerator temperatures to ensure proper medication and vaccine storage temperatures for 5 of 7 months reviewed. Findings: 1. On 2/1/26 at 9:45 a.m., during an observation of Resident #64's room, a 43 g bottle of miconazole topical 2% powder with a pharmacy label for Resident #64 and a medicine cup containing an unknown white substance was located on the counter next to the shared sink. During an interview at this time, Resident #64 stated that he/she cannot apply the medications himself/herself because he/she is disabled and that staff apply his/her medications. 2. On 2/1/26 at 10:24 a.m., during an observation of Resident #9's room, a 6 fluid ounce bottle of Calamine lotion with a pharmacy label for Resident #9 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-05 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the confidentiality of protected health information when resident identifiable assignment sheets and a monthly weight documentation sheet were left unattended in the solarium, an area accessible to residents and visitors, on 1 of 4 days of survey. Finding:On 2/1/26 at 11:00 a.m., a surveyor observed copies of multiple resident care assignment sheets and a document titled December Monthly Weights left unattended on a table in the solarium, an area accessible to residents and visitors. At the time of the observation, two residents and one visitor were present in the solarium. The assignment sheets contained resident identifiable information including resident names, room numbers, diagnosis, continence status, required assistance with activities of daily living (ADL's), transfer needs (including Hoyer use), fall risk status and other personal care instructions. The monthly weight sheet contained resident names and recorded weights. The documents were left unattended in a publicly accessible area without safeguards to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of nutrition and wound care for 2 of 20 sampled residents (Residents #6, #9).Findings:1. Resident #6 was admitted in May 2023 with diagnoses to include Parkinson's Disease and dysphagia.On 2/5/26 at 8:05 a.m., a surveyor observed Resident #6 in bed with his/her over-the-bed table set up with his/her breakfast meal, including a spoon in the bowl of oatmeal and a fork by the entree plate. No staff were in the room at the time of the observation.On 2/5/26 at 9:45 a.m. during an interview, the Director of Nursing (DON) stated that there have been concerns with aspiration and an overall functional decline and that staff have been assisting Resident #6 more with feeding recently. A review of Resident #6's clinical record revealed an active physician order with a start date of 5/14/25 for Full supervision with all meals.Further review of Resident #6's clinical record revealed a quarterly nutrition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-05 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to provide adaptive utensils for 1 of 3 residents reviewed for nutrition (Resident #6).Finding:Resident #6 was admitted in May 2023 with diagnoses to include Parkinson's Disease and dysphagia.On 2/5/26 at 8:05 a.m., a surveyor observed Resident #6's breakfast meal set up on his/her over-the-bed table. A standard spoon was resting in the bowl of oatmeal and a standard fork was set up next to Resident #6's entree, served on a lip plate. There were no adaptive utensils or cups.Review of Resident #6's care plan revealed the following: .ADL [Activities of Daily Living] self-care performance deficit.Lip plate with meals.L [left] and R [right] angled spoons.adaptive dining equipment: lip plate at meals. Blue insulated mug. Left and right angled spoon.On 2/5/26 at 12:53 p.m., during a repeat observation, Resident #6 received his/her lunch tray in his/her room. The meal ticket indicated .Blue insulated mug Left and right-angled spoon . There were no adaptive utensils or specialized mug. During an interview at this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-05 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall and the floor; failed to ensure foods were labeled and dated in a reach-in freezer; and failed to ensure kitchen staff with facial hair wore facial protection for 1 of 1 kitchen tour for 1 of 1 day of survey (2/1/26). Findings: On 2/1/26 from 9:05 a.m. to 9:35 a.m., a surveyor conducted an Initial Kitchen Tour in which the following findings were observed: - Two male kitchen workers with facial hair (beards and moustaches) were not wearing facial hair protection. - The wall behind the toaster had chipped/missing paint creating an uncleanable surface. - The kitchen floor had food debris and trash throughout the kitchen, under equipment and under shelving. - The Reach-in freezer, nearest the walk-in refrigerator, had a previously opened package of strips/tenders that was not labeled and dated. On 2/1/26 at 9:38 a.m., in an interview, a surveyor discussed the findings with the Dietary Aide. On 2/1/26 at 11:25 a.m., in an interview, a surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to transporting soiled linens and disinfecting a soiled surface during a wound dressing observation for 1 of 3 residents reviewed for wounds (Resident #9). Findings: On 2/1/26 from 12:14 to 12:43 PM, during an observation of Resident #9's left leg wound dressing change, Registered Nurse (RN) #1 sanitized her hands and donned (put on) Personal Protective Equipment (PPE) per the Contact precautions sign hanging outside Resident #9's door. RN #1 then placed Resident #9's left leg on a towel located on top of his/her bed and proceeded to remove Resident #9's existing dressing, provide wound care, and apply a new dressing. Resident #9's open wounds were in direct contact with the towel during the wound care and dressing change. After the dressing change, RN #1 discarded the soiled dressing and then removed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-05 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure that the resident's medical record included documentation that indicated that the resident or resident representative accepted a COVID-19 vaccine that the resident received for 1 of 5 residents reviewed for immunizations (Resident #24).Finding:Review of Resident #24's clinical record revealed a signed Immunization Consent Form dated 6/6/25, indicating Resident #24 declined the COVID-19 vaccine. Further review of the clinical record revealed that Resident #24 received the COVID-19 immunization on 11/5/25. On 2/5/26 at 1:08 p.m. during an interview, the Director of Nursing and the Administrator stated that they were looking for evidence that Resident #24 had consented to receive the COVID-19 vaccine administered on 11/5/25. At this time, the Regional Director of Clinical Operations stated that Resident #24 had refused the 2024-2025 COVID-19 vaccine but consented to receiving the 2025-2026 vaccine.The facility failed to provide evidence that Resident #24 consented to receiving the vaccine by the end of the survey.
- Potential for harm · Ecited before2024-11-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 3 units ([NAME] Unit, and Kennebec Unit) for 1 of 1 environmental tour (11/19/24). Findings: On 11/19/24, from 10:05 a.m. to 10:30 a.m., an environmental tour was conducted with the Administrator and the Maintenance Director in which the following findings were observed: [NAME] Unit: > 3 hallway ceiling vents by resident rooms [ROOM NUMBER] were rusty and had dust on them. > Resident room [ROOM NUMBER] - The toilet surface and behind the seat were dirty with dried liquid residue. The bathroom exhaust vent was dusty/dirty. The caulking on floor around the bathroom door frame was dirty and stained. There was a urine collection cup on the floor by the toilet. > Resident room [ROOM NUMBER] - The bathroom floor was dirty. There was a yellow/brown stain on a ceiling tile near the vent above the toilet. The caulking at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Ecited before2024-11-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap, a baseboard heater register and the floor. Additionally, the facility failed to ensure foods were sealed, labeled and dated in a reach-in freezer and in a walk-in refrigerator for 1 of 1 kitchen tour for 1 of 1 day of survey (11/17/24). Findings: On 11/17/24 from 11:30 a.m. to 11:58 a.m., two surveyors conducted a kitchen tour in which the following findings were observed: > The grease trap exterior had rust on the lid and the base. Additionally, the caulking around the base was dirty and stained with a black substance. > The baseboard heater register, located between the grease trap and a sink, was dusty/dirty and had dried liquid residue and food splatter on it. > The floor, under the sink across from the steam table, was heavily soiled with food debris and dried liquid residue. > The reach-in freezer had a 10.2 ounce box of cinnamon donuts and an 18 ounce box of waffles that were not sealed and open to the air. > The walk-in refrigerator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure residents were treated in a dignified manner when staff failed to respond and attend to a resident's request for incontinence care during meal service. (Resident #40 [R40] and R41) Finding: On 11/17/24 at 1:10 p.m. during resident interviews with R40 and R41 they stated they make me wait. I get very anxious, and I get a bad headache, and that they are not changing him/her as frequently as he/she should be. R41 stated they just don't have enough staff, and they tell me I have to wait to use my urinal, and I don't want to wet my brief, and they make me wait. I want to use my urinal. I want to keep it going so I don't wet myself. On 11/18/24, during a record review a Health Status Note for Behavior dated 11/12/24, was documented in R40's clinical record stating It's policy that staff does not interrupt passing trays until they are all passed during mealtime. R40 has been informed of this policy many times. The nurse documented that R40 was informed again of the above policy, yet he/she continues to ring and holler out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to complete neurological assessments for 1 of 1 resident reviewed for fall with major injury (Resident #27 [R27]). Finding: The facility's paper form for a neurological (neuro) assessment indicated the following: Vital signs/Neuros to be done initially then every (q) 15 minutes x 2, q 30 minutes x 4, q 2 (hrs) x 4, then q shift x 3 (24 hours). The columns on the form to be completed included nurse's initials, date, time, vital signs (temperature, pulse, respirations, blood pressure) and neurological check (pupils, level of consciousness, motor function, speech, and facility symmetry). On 11/20/24, R27's clinical record was reviewed. On 9/10/24 at 4:06 a.m., a health status note was documented that indicated at approximately 3:30 a.m., a staff member went into R27's room to find the resident face down on the floor with a puddle of blood under his/her face. Emergency Medical Services (EMS) was called and when EMS got resident into the stretcher for transport, R27 had visible facial swelling, a laceration to the forehead,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interviews, the facility failed to provide the proper adaptive equipment to a resident during a meal service for 1 of 6 observed meals for Resident #35 [R35] who was involved in an incident on 11/6/24. Finding: On 11/7/24, the Division of Licensing and Certification received from the facility a reportable incident form which indicated that on 11/6/24 R35 had spilled hot chocolate on his/her lap which caused burns which later in the day developed into blistered areas on both his/her thighs. On 11/18/24, during resident observations it was noted that R35 was sitting in the dining room with a Kennedy cup (spillproof cup). During interviews it was noted that R35 was evaluated by Occupational Therapy (OT) on 11/12/24 with recommendation for use of covered mug for hot liquids secondary to decreased fine motor coordination. On 11/20/24 at 8:30 a.m., R35 was observed in the dining room for breakfast, he/she had a plate of pureed food and a bowl of oatmeal in front of him/her on the table. R35 was observed by the surveyor drinking using a regular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide respiratory care according to physician orders for 1 of 1 sampled residents (Resident #7 [R7]). Findings: Resident R7 was admitted on [DATE] and has diagnoses to include chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and congestive heart failure (CHF). A review of R7's active orders revealed a physician order, dated 5/30/24, for Oxygen therapy 1-2Lpm [liters per minute] titration to keep O2 sat (oxygen saturation) at 90-92%. every shift for SOB (shortness of breath)/cough. During an observation of R7 in the [NAME] unit dayroom, on 11/20/24 at 10:48 a.m., R7 was seated in a wheelchair at a table, working on a puzzle. R7 was wearing a nasal cannula, and the oxygen tubing was connected to a portable oxygen tank that was secured on the back of the wheelchair. The oxygen flow rate was set to 3Lpm, and the needle on the oxygen tank gauge was observed in the red area of the gauge marked, empty.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to adequately date open medications and properly dispose of expired medications, according to manufacturer specifications for two inhalers in 2 of 3 medication carts ([NAME] Unit, and Penobscot Unit) observed. Findings: On 11/19/24 at 8:50 a.m., two surveyors and Certified Nurse Med Tech (CNA-M) 1 observed, in the medication cart on the [NAME] unit, a Trelegy Ellipta Inhalation Aerosol device, labeled for Resident (R) 314, with a pharmacy label stating, came in on 10/4/24. The manufacturer box states, Discard 6 weeks after opening or when the counter reads '0'. The box and the device itself were not labeled with a date indicating when the device was opened. On 11/19/24 at 8:55 a.m., during an interview with CNA-M1, two surveyors confirmed that the Trelegy Ellipta device was not labeled with an opened date to ensure use and disposal according to manufacturer specifications. On 11/19/24 at 9:43 a.m., two surveyors and CNA-M2 observed, in the medication cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-20 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure a clinical record contained complete and accurate information for 1 of 1 residents reviewed for falls (Resident #27 [R27]). Finding: On 11/20/24, R27's clinical record was reviewed and the surveyor requested to review the facility's fall report for R27 that occurred on 9/29/24. Documentation on the fall report, completed 9/29/24 at 2:48 p.m. by Registered Nurse #2 (RN2) indicated that R27 was transferring self, fell forward towards the wall, and a staff member was able to grab R27 and sit back down on the bed. R27 sustained a nosebleed. The fall report indicated that the physician (Third Eye) was notified at 2:57 p.m. Review of the Third Eye health note documented in R27's progress notes, completed by Third Eye, on 9/29/24 at 10:44 p.m., indicated that on 9/29/24 at 1:53 p.m. (central time) which is 2:53 p.m. (eastern time), it was reported by RN2 that R27 had an unwitnessed fall, likely slid onto floor in bedroom, found on buttocks, with no head strike or trauma reported. On 11/20/24 at 2:07 p.m., during an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-30 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff spoke and acted rudely to residents in their care for 2 of 2 residents reviewed (Resident #43 and Resident #33). Findings: 1. On 5/28/24 at 1:49 p.m., during an interview with Resident #43 he/she stated that there is one Certified Nursing Assistant (CNA) who is rude and on his/her case all the time. Resident #43 stated that this CNA does things just to get Resident #43 upset, the examples were that when the resident requests their door be closed due to the noise level this CNA (CNA #4) comes in the room and opens the window shades and turns on the roommates television. Resident #43 also stated that when he/she knows CNA #4 is on, they are in for it. Resident #43 told the surveyor to ask CNA #3 who this person was because she knows that they just don't get along. Resident #43 also stated there are other staff who know that CNA is rude and disrespectful.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-30 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the 3 of 3 units ( Penobscot, [NAME] and Kennebec) and a nurse's station for 1 of 1 facility tours (5/30/24). Findings: 1. On 5/30/24 from 1:30 p.m. to 2:00 p.m., during a tour of the facility, a surveyor and the Maintenance Director, the Regional Housekeeping Manager, the [NAME] Health Services Laundry Manager, the Housekeeping/Laundry Manager, the Lead Maintenance Director/National the Administrator observed the following findings: > The nurse's station had ripped/torn duct tape around the entire front edge of counter top creating an uncleanable surface. Penobscot Unit > Resident room [ROOM NUMBER] - The caulking around the base of the toilet was dirty and stained. > Resident room [ROOM NUMBER] - The room entrance floor had 8 broken/cracked floor tiles and a buildup of dirt at the door entrance edges. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-30 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that 2 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #33 and Resident #35). Finding: 1. Resident #31 was admitted to the facility on [DATE] with diagnosis of Panic Disorder, Major Depressive Disorder recurrent with Severe Psychotic Symptoms and Nightmare Disorder. Resident #31's clinical record contained a PASRR Level I determination letter dated 10/10/23 that stated further PASRR evaluation was not required due to Resident #31 met the criteria for a short-term convalescence admission. Resident #31 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-30 · tag F0676 — failed to keep up residents' daily-living abilities — patternEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide services to maintain and/or improve residents highest level of ambulation and Active Range of Motion (AROM), the facility failed to provide Restorative services as outlined in the resident's restorative therapy program care planned for 2 of 2 sampled residents (Resident #43 and Resident #21,). Findings: 1. On 5/28/24 at 1:38 p.m. during an interview with Resident #43 he/she stated I think they should take extra care; I need the exercises and they don't have time to walk meand that makes me weaker. They do not walk with me every day. Resident #43's care plan documents interventions as follows: Nursing Maintenance/Restorative: Ambulation - distance 50 feet or as resident tolerates with a 2 wheeled walker (ww), 2 assist (A) and wheelchair (w/c) to follow. Resident #43's [NAME] (identifies resident needs for care) documents a restorative plan for Nursing Maintenance/Restorative: Ambulation - distance 50 feet or as resident tolerates with 2 ww, 2A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed provide respiratory care consistent with professional standards of practice by failing to ensure that respiratory equipment was clean, failed to follow physician orders, and failed to date and label oxygen tubing for 5 of 5 sampled residents. (Resident #43, Resident #23, Resident #10, Resident #19, and Resident #160) Findings: 1.On 5/28/24 at 1:46 p.m. ,during a resident observation and interview Resident #43's nasal mask for his/her Continue positive airway pressure (CPAP) nasal mask was on the floor. During the interview Resident #43 stated that they do not wear their CPAP mask because staff do not clean the nasal mask before attempting to put the nasal mask on him/her. On 5/29/24, several observations were made of Resident #43's nasal mask for the CPAP remains on the floor in his/her room. On 5/30/24 at 10:20 a.m., Resident #43's nasal mask for their CPAP remains on the floor in the same spot as it was on 5/28. At this time the surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a ceiling vent, a food disposal unit, the dish machine, and a food mixer; failed to ensure facial hair protection was worn; and failed to ensure glasses were not wet stacked for 1 of 1 kitchen tour. Findings: On 5/28/24 from 11:15 a.m. to 11:35 a.m., an initial kitchen tour was conducted with a Food Service Director in which the following findings were observed: > The ceiling vent in the dish room was heavily soiled with dust. > The food disposal unit had dried food particles and dried liquid residue on it. > There was a large amount of chemical residue buildup on top of the dish machine. > The large standing food mixer had dried food particles on the bowl, the protective cage and the base. > A male kitchen worker had a mustache and beard and did not have facial hair protector over his mustache. > There were 20 clear tumblers that were wet stacked on a tray after washing. On 5/28/24 at 11:35 a.m., in an interview, a Food Service Director confirmed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to notify the resident and/or resident representative in writing for the reason of a transfer/discharge from the facility, for 1 of 2 hospital transfers (2/22/24) for Resident #36. In addition, the facility failed to notify the Ombudsman of the February transfer/discharge for Resident #36. Finding: On 5/28/24, Resident #36's clinical record was reviewed and indicated that Resident #36 was transferred to the hospital on 2/22/24 and admitted . The clinical record lacked evidence of a written transfer/discharge notice being provided to the resident/resident representative. On 5/30/24 at 12:07 p.m., during an interview with a surveyor, the Administrator stated she was unable to find evidence that a written transfer/discharge notice had been given to the resident and/or representative. During this interview, the Administrator stated that the Director of Social Services is responsible for notifying the Ombudsman. On 5/30/24 at 12:16 p.m., the Administrator stated that the Ombudsman had not been notified of Resident #36's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a bed hold notice after a transfer/admission to an acute care hospital, for 1 of 2 hospital transfers (2/22/24) for Resident #36. Finding: On 5/28/24, Resident #36's clinical record was reviewed and indicated that Resident #36 was transferred to the hospital on 2/22/24 and admitted . The clinical record lacked evidence of a written bed hold notice being provided to the resident/resident representative. On 5/30/24 at 12:07 p.m., during an interview with a surveyor, the Administrator stated she was unable to find evidence that a written bed hold had been given to the resident and/or representative.
- Potential for harm · Dcited before2024-05-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure physician orders for sliding scale insulin were followed for 1 of 4 residents reviewed (Resident #155). Finding: On 5/30/24, Resident #155's clinical record was reviewed and included a physician order for sliding scale insulin to administer Humalog 12 units but hold if not eating or blood sugar less than 150. On 10/22/23 Resident #155's morning blood sugar was documented as 109 and the treatment administration record for October 2023 indicated that insulin was given in the abdomen. On 5/30/24 at 8:09 a.m., a surveyor and the Regional Director of Clinical Operations reviewed Resident #155's documentation; the surveyor confirmed that the insulin was given even though the documented blood sugar was less than 150.
- Potential for harm · D2024-05-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews, observations, and interviews, the facility failed to ensure nutrition and hydration parameters were met to maintain sufficient hydration and health for 2 of 2 residents reviewed for nutrition and hydration (Resident #11 and Resident #18). Findings: 1. On 05/28/24 at 12:11 p.m., a surveyor observed a lunch tray delivered to Resident #11's bed table, which was positioned over the resident's lap, then left the room. The lunch was observed to be spaghetti and sauce with garlic bread. After several minutes two staff returned and attempted to rouse Resident #11 for the meal, when Resident #11 did not wake, they removed the tray. On 5/29/24 the clinical record indicated Resident #11's diagnosis included severe dementia and unspecified convulsions. The provider orders indicate Resident #11 needs a mechanical soft diet for dysphagia (difficulty swallowing). The care plan identified Resident #11's self-care performance deficit related to occasional syncope, seizures, and cognitive impairment. The intervention stated: Eating: The resident requires extensive assist of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interviews, the facility failed to ensure that physician's orders were followed for 1 of 5 sampled residents (Resident #2). Finding: Resident #2's Physician Order Summary sheet, dated 12/15/23, indicated the resident was to be weighed weekly for Congestive Heart Failure. There was no evidence in the resident's clinical record to indicate the resident was weighed on 1/26/24, 2/2/24 and 2/23/24. The surveyor confirmed this finding in an interview with the Administrator on 3/18/24 at 2:30 p.m.
- Potential for harm · Dcited before2024-03-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to transport soiled linens in a sanitary manner on 1 of 3 units. ([NAME] unit) Finding: On 3/18/24 at 10:15 a.m., a surveyor observed a Certified Nursing Assistant #1 (CNA) carry unbagged bed linens against her body in the [NAME] unit corridor. During an interview with a surveyor, CNA #1 confirmed the bed linens were soiled and acknowledged that she was holding soiled bed linens close to her body. The facilities Handling Soiled Linen Policy & Procedure dated 1/2020 instructs staff to place soiled linen directly into a soiled linen hamper or a plain plastic bag. On 3/18/24 at 11:19 a.m., the surveyor confirmed the above finding in an interview with the Director of Nursing.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to NATIONAL HEALTH CARE ASSOCIATES — 42 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 4.1 | -1.1 vs chain |
The other 41 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 41; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| VK HEALTH FACILITIES LLC | Organization | DIRECT OWNERSHIP INTEREST | since 01/15/2013 |
| MARVIN OSTREICHER FAMILY TRUST 2012 | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| MERIDIAN CAPITAL FOUNDATION | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| MSO ASSOCIATES LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| SUSAN OSTREICHER FAMILY TRUST 2012 | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| VENTAS NHV FUND | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| BOKOW, BARRY | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/28/2013 |
| GEFFNER, IRA | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| GLUCK, ROBERT | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| LOBELL, JONAH | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| LOWINGER, BEN | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| LOWINGER, JOSEPH | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| OSTREICHER, DAVID | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/28/2013 |
| OSTREICHER, MARC | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/28/2013 |
| OSTREICHER, MARVIN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/28/2013 |
| OSTREICHER, SUSAN | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| SCHOOR, KALMAN | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| STEG, YITZCHOK | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| WEINSTOCK, ABRAHAM | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| GILMARTIN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2016 |
| VENTURA, JOSE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2025 |
| BOKOW, MICHAEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 11/21/2025 |
| BARRY BOKOW 2012 FAMILY TRUST | Organization | ADP OF THE SNF | since 01/28/2013 |
| BERRY DUNN MCNEIL & PARKER LLC | Organization | ADP OF THE SNF | since 01/28/2013 |
| BPB VENTURES LLC | Organization | ADP OF THE SNF | since 01/28/2013 |
| CEDAR HILL NG TRUST | Organization | ADP OF THE SNF | since 01/28/2013 |
| IMPACT HEALTH PC | Organization | ADP OF THE SNF | since 06/01/2025 |
| JUNIPER NG TRUST | Organization | ADP OF THE SNF | since 01/28/2013 |
| NATIONAL HEALTH CARE ASSOCIATES INC | Organization | ADP OF THE SNF | since 01/28/2013 |
| OAK DRIVE NG TRUST | Organization | ADP OF THE SNF | since 01/28/2013 |
| PREFERRED PROFESSIONAL SERVICES LLC | Organization | ADP OF THE SNF | since 01/28/2013 |
| PREFERRED THERAPY SOLUTIONS LLC | Organization | ADP OF THE SNF | since 01/28/2013 |
| ROLLING HILL NG TRUST | Organization | ADP OF THE SNF | since 01/28/2013 |
| ALMEIDA, ELIZABETH | Individual | ADP OF THE SNF | since 01/28/2013 |
| LOPIANSKY, REBECCA | Individual | ADP OF THE SNF | since 01/28/2013 |
| NICHOLS, ASHLEY | Individual | ADP OF THE SNF | since 06/26/2025 |
| STEG, SHAYNA | Individual | ADP OF THE SNF | since 01/28/2013 |
CMS files one row per role, so the 44 rows in the source record cover these 37 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
17 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in ME
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maine Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205077. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.