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Stillwater Health Care

335 Stillwater Ave, Bangor, ME 04401 · For profit - Individual · 63 certified beds · (207) 947-1111 Medicare & Medicaid certified

Call the home — (207) 947-1111 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 20232 actual-harm citations$11,190 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $11,190 in federal fines (most recent 2025-01-16)
  • its payroll-based staffing score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
498 Essex St · (207) 947-0558 · Call to confirm hours
Pharmacy
711 Broadway · (207) 922-3849 · Call to confirm hours
Grocery
Broadway Shopping Ct, 653 Broadway St. · (207) 947-8338 · Call to confirm hours
Park
Watchmaker Ave. · (207) 745-5301 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 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 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.9%24.4%15.4%better
Long-stay residents who lose too much weight12.8%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.1%0.9%better
Long-stay residents with a urinary tract infection5.0%2.2%2.0%worse
Long-stay residents with depressive symptoms2.1%11.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.9%4.1%3.3%better
Long-stay residents whose ability to walk worsened10.5%25.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.9%17.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.5%95.3%typical
Long-stay residents with pressure ulcers2.8%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control24.4%29.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.2%20.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%74.5%79.4%better
Short-stay residents rehospitalized after admission12.0%20.8%22.6%better
Short-stay residents with an outpatient ER visit11.8%16.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.041.451.67worse
Long-stay outpatient ER visits per 1,000 resident days1.592.011.80better

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.

53.1% 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 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.1%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
58.1%U.S. median 56.6%
Met the expected recovery
0.11U.S. median 0.31
Therapy hours / resident / day
0.01hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy

Met the expected recovery: 58.1% 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 43 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 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 41% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.1%CMS range 41.5–62.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 6.7–15.110.7%Oct 2022–Sep 2024no 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 discharge58.1%56.6%Oct 2024–Sep 2025CMS 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 discharge46.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge46.5%50.0%Oct 2024–Sep 2025CMS 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 identified98.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 discharge96.4%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.3%CMS range 5.0–14.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS 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

1.12
RN hours/ resident / day
0.11
LPN hours/ resident / day
2.88
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.75
RN hoursweekends
31.9%
Total nursing turnover
13.3%
RN turnover

How full it usually is: this home is certified for 63 beds and averages 58.5 residents a day — about 93% 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 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.12 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.88 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 3.60 hrs/resident/day on weekends vs 4.31 on weekdays — 17% thinner on weekends. RN hours go from 1.27 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% 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

9
deficiencies at the latest standard inspection (2026-02-27)
10
at the previous standard inspection (2025-01-16)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2025-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide interventions outlined in the resident's care plan to ensure that two-person assist was provided during activities of daily living (ADL) for 1 of 2 sampled residents (Resident #12 [R12]), reviewed for falls. The failure to have supervision (two-person assist) as directed by the care plan resulted in an avoidable accident; R12 falling out of bed during evening ADL care, requiring transfer to the emergency room [ER] with admission to the hospital, sustaining a laceration to the head, and rib fractures with increased pain. In addition, based on record review, and interview, the facility failed to adequately supervise a fall risk resident for 1 of 2 sampled residents (R30), reviewed for falls. Findings: R12 was admitted on [DATE] with diagnosis to include diabetes mellitus, peripheral vascular disease with history of right above-the knee amputation, most recently a left toe amputation, and history of deep vein thrombosis on Coumadin (a blood…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-08-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, review of the facility reportable incident form, and review of the medical record, the facility failed remove a bed pan timely from 1 of residents reviewed. This resulted in harm when a resident was left on a bed pan for approximately 45 minutes and sustained a Stage 2 pressure ulcer (Resident 1). Finding: A Nursing Facility Reportable Incident form was faxed to Division of Licensing and Certification office indicating on 7/25/23 at approximately 4:00 a.m., a Certified Nurse Aide (CNA) placed a resident on a bed pan, left resident on bedpan and failed to monitor the resident per policy. At approximately 4:45 a.m., when resident asked to be taken off the bedpan while removing the bed pan, the resident had 2 open areas on left buttock creating a Stage II injury. A review of Resident #1's medical record stated, in a nursing note, on 7/25/23, Certified Nursing Assistant (CNA) #1 at approximately 4:00 a.m., placed a bed pan under [Resident #1] for toileting. At approximately 4:45 a.m. CNA #2 answered Resident #1's call bell. Upon removing the bedpan, skin came off…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 2 of 3 Medication Storage Areas reviewed (A Wing Treatment Cart and B Wing Treatment Cart).Findings:On 2/25/26 at 3:16 p.m., a surveyor and the Director of Nursing Services (DON) observed and confirmed the following were in the A Wing treatment cart and available for use:-1 box of 12 rectal Acetaminophen Suppositories 650 milligrams (mg) with an expiration date of 01/2026-1 multi-use vial containing 10 milliliter (ml) of Insulin glargine 100 units (u)/10ml, open but unlabeled with an open date or an expiration date. The DON stated insulin is good for 28 days after opening, and was unable to determine when the vial would expire.-2 open vials, 10mL insulin lispro 100u/ml, with an open date of 1/14/26. The insulin expired on 2/11/26 and was available for use 14 days past expiration.On 2/25/26 at 3:35 p.m., a surveyor and the DON observed and confirmed the following were in the B Wing treatment cart and available for use:-1 open vial, 10mL insulin…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 manner on 2 of 3 days of survey (2/24/26 and 2/25/26), the facility failed to ensure that dented cans were removed from use and the facility failed to discard expired products in the reach-in refrigerator and the walk in refrigerator located in the kitchen that were available for use on 1 of 3 days of survey (2/24/26), Findings: On 2/24/26 at 10:45 a.m., during the initial tour of the kitchen a surveyor observed a built-in air conditioner that was heavily covered in dirt and grime, also observed were dust webs from the top corners right and left of the air conditioner to the ceiling. In the dry food storage room on the shelves and in the can rack the surveyor and Food Service Director observed the following dented cans2 cans of crushed pineapples in juice, 6 pounds, 12-ounce cans that were dented near the bottom seal. 4 cans of mushrooms, pieces and stems 3-pound, 14-ounce cans that were dented near the bottom and top seals. In the reach-in refrigerator there was a carton of half…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-27 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 reviews and interviews, the facility failed to ensure that clinical record(s) contained complete and accurate information for 6 of 10 sampled residents reviewed on survey (Resident #7 [R7], R8, R51, R2, R36, and R17).Findings: 1. On 2/25/26, R7's clinical record was reviewed. R7's Order Summary indicated, Check monthly weights every day shift every 1 month(s) starting on the 1st for 7 day(s) for Monitoring with a start date of 8/1/25, Check monthly vital signs every day shift every 1 month(s) starting on the 1st for 7 day(s) for Monitoring with a start date of 8/1/25, and Weekly [blood pressure (B/P)] and [heart rate (HR)] checks. every day shift every [Sunday] for [Monitoring] B/P meds with a start date of 8/17/25. The Treatment Administration Record [TAR] indicated R7's vital signs (weight, blood pressure, temperature, pulse, respiratory rate, and oxygen saturation rate) were identical on 2/1/26, 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26 and 2/7/26, 7 days. 2. On 2/25/26, R8's clinical record was reviewed. R8's Order Summary Report indicated an order, start dated…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-27 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, record review, and interviews, the facility failed to ensure allegations of abuse and neglect was investigated for 1 of 4 complaints reviewed.Findings:A review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program effective: 6/2016, revised 03/2025 states, 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.A review of a facility-provided written statement that the Director of Nursing (DON) received from a staff member dated 9/25/25 states, .a handful of residents are scared. and . has neglected some residents care., referring to another staff member.A review of a facility-provided written statement that the DON received, not signed, or dated states, resident looked so scared.(he's/she's) so rough and mean to me, referring to another staff member.On 2/25/26 at 4:47 p. m. in an interview with the DON, a surveyor confirmed that during the facility's recertification survey and this investigation, the facility was not able to provide evidence…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews, the facility failed to ensure that a physician ordered medication was available for use to meet the needs for 1 of 4 residents observed during medication administration pass (Resident #64 [R64]).Finding:On 2/26/26 at 7:56 a.m., a surveyor observed Registered Nurse #1 (RN1) complete a medication administration pass for R64. RN1 stated she could not administer Testosterone Gel (a medication used to treat low testosterone levels not due to normal aging) to R64 because the facility did not have any.On 2/26/26, R64's clinical record review indicated an order, dated 2/20/26, for Testosterone Transdermal Gel 20.25 [milligram (MG)] per (/) Actuation (ACT)] (1.62%) (Testosterone) Apply 1 pump [applied to the skin (transdermally)] one time a day for [HYPOGONADISM (a condition in which the body doesn't make enough of the hormone testosterone)] APPLY TO UPPER ARM. Review of the Medication Administration Record indicated that R64's Testosterone Gel was not available and R64 had not received Testosterone Gel as physician ordered, from 2/20/26…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of the facility Infection Control Program (ICP) and interview, the facility failed to complete an annual review of the ICP and update/revise the program if needed for 1 of 1 ICP.Finding: On 2/25/26 at 9:00 a.m., in an interview with the Infection Preventionist (IP), she stated she did not know if the ICP had been annually reviewed. A review of the ICP was completed and there was no evidence that an annual review of the ICP had been completed.On 2/25/26 at 9:53 a.m., in an interview with the surveyor, the Administrator, confirmed that the facility has not completed an annual review of the ICP.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-27 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on employee record reviews and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on dementia management by failing to ensure that 1 of 5 Certified Nursing Assistant (CNA) staff employed completed their required training (CNA3).Finding:On 2/26/26 the following employee record was reviewed:CNA3 was hired on 7/3/23. There was no documented training on dementia in over 12 months.On 2/26/26 at 8:00 a.m., in an interview with a surveyor, the Administrator stated that she was unable to find any documented trainings listed above, and a surveyor confirmed that CNA3 lacked evidence that mandatory training on dementia was completed within the past 12 months.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 maintain a comfortable air temperature for 3 of 4 days of survey. Findings: On 1/13/25, during an initial tour of A-Wing and B-Wing, the air temperature was observed to be chilly. On 1/13/25, between 11:15 a.m. and 12:00 p.m., in an interview with the surveyor, Resident #5 (R5), R10, R11, R17 and R36 stated they feel cold and at night, it is colder. On 1/14/25, the facility air temperature was observed to be chilly on A-Wing. On 1/15/25 at 12:30 p.m., the air temperature was observed to be chilly on A-Wing. The thermostats on A and B-Wing and in the main dining room were observed to be set at 70 degrees Fahrenheit (F). On 1/15/25 at 1:00 p.m., the air temperature was taken in front of the nurse's station on A-Wing and registered at 69.9 Degrees F; in front of room [ROOM NUMBER] the air temperature was 70.1 degrees F, in front of room [ROOM NUMBER] the air temperature was 70.1 degrees F, and in front of room [ROOM NUMBER] the air temperature was 70.1…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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

    Based on record review, review of the facility's 'Fall Policy and Procedure' and interview, the facility failed to re-evaluate fall interventions and the relevance of the current fall interventions for 1 of 2 sampled residents (Resident #30 [R30]) reviewed for 7 falls within 8 months timeframe. Finding: On 1/15/25, a review of R30's clinical record was completed. R30 is diagnosed with Alzheimer's Disease/Dementia. Nurse's notes indicated that from 6/3/24 through 1/3/25, R30 has had several unwitnessed falls, mostly in the late afternoon and evening time, in his/her bedroom. On 6/12/24 at 12:23 p.m., R30 was found on their bedroom floor and had sustained a fracture of the right femur. On 8/19/24, R30 found in bedroom and apparently had slid from their wheelchair onto their bedroom floor. On 9/14/24, R30 fell to the bedroom floor. When found, R30 told staff they were reaching for the TV remote. On 10/25/24, R30 found on floor next to the bed. On 11/13/24, R30 found on bedroom floor, slid to the floor from his/her bed while staff in room. On 12/11/24, R30 found on bedroom floor after…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 to maintain oxygen filled tanks while in use, failed to maintain a physician ordered oxygen setting on an air concentrator, and failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 residents reviewed for respiratory care (Resident #10 [R10], R15 and R1). Findings: 1. On 1/13/25 at 12:10 p.m., the surveyor observed Resident #10 (R10) in his/her wheelchair that held a portable oxygen tank on the back of the wheelchair. R10 was using a nasal cannula to receive the extra oxygen. Upon observation of the oxygen tank, it registered empty. After the observation, the surveyor reviewed R10's clinical record under the physician order section. R10 had a physician order for continuous oxygen to be kept at a range between 2-5 liters per minute (LPM) to maintain an oxygen saturation of 90%. At 12:25 p.m., RN1 was observed changing…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · E2025-01-16 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings: Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the fourth quarter of 2024 (July 1 - September 30). On 1/14/25 at 2:35 p.m., in an interview with a surveyor and review of weekend staffing for July 1, 2024, through September 30, 2024, the Administrator confirmed the facility did not have enough staff to meet resident needs on the weekends.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the proper storage and labeling of foods in the walk-in refrigerator located in the kitchen, failed to ensure a vegetable sink had the proper air gap and failed to ensure kitchen staff properly wore hairnets by leaving hair uncovered and unrestrained for 2 of 4 days of survey (1/13/25, 1/15/25). Findings: 1. On 1/13/25 at 10:30 a.m., during the initial kitchen tour, a surveyor observed the Food Service Director (FSD) with a hairnet that did not contain all her hair. In the walk-in refrigerator there was a large cup of [NAME] Donuts beverage that was not labeled with a name or date, and a 1-pound (lb.) brick of Gold'N'Sweet butter that was noted to have a torn cover exposing the butter and showing marks of scrapes and punctures along the edges and on the top of the butter brick. The vegetable sink was observed with an improper air gap on the drainpipe. The 10-114 State of Maine Rules Chapter 226, definition Section A, defines an Air-Gap…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the observations, facility policy reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and during two medication administration observations and for a Resident on Enhanced Barrier Precautions (Resident #25 [R25] on 2 of 4 days of survey (1/14/25 and 1/15/25). Findings: The facility's policy, Administering Oral Medications, revised 2/2022, noted that for tablets or capsules from a bottle - do not touch the medication with your hands. 1. On 1/14/25 at 6:50 a.m., a surveyor observed Certified Nursing Assistant - Medications #1 (CNA-M1) preparing medications. There were already 2 pills in the plastic cup when the surveyor started the observation. CNA-M1 popped a pill from the medication card into her hands and placed the pill in the plastic cup. The surveyor confirmed during this observation with CNA-M1 that she had touched the medication with her hand at this time. 2. On 1/15/25 at 6:50 a.m., during a medication pass observation with CNA-M1 for…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-16 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on employee record reviews and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, and on dementia management by failing to ensure that 5 of 5 Certified Nursing Assistant (CNA) staff employed completed their required training (CNA1, CNA2, CNA4, CNA5, and CNA6). Findings: On 1/16/25 the following employee records were reviewed: 1. CNA1 was hired on 5/17/23. There was no documented training in over 12 months. 2. CNA2 was hired on 9/25/23. There was no documented training in over 12 months. 3. CNA4 was hired 2/28/24. There was no documented orientation, or training on dementia, and there is no documented reorientation as outline in a performance correction notice dated 6/11/24. 5. CNA5 was rehired on 9/26/24. There was no documented training on dementia. 6. CNA6 was hired on 5/8/23. There was no documented training on dementia. On 1/16/25 at 11:27 a.m., in an interview with a surveyor, the Administrator stated that she was unable to find any documented trainings listed above, and 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and facility policy review, the facility failed to ensure an alleged violation involving fall with major injury was thoroughly investigated for 1 of 2 facility reported incidents reviewed (Resident #1 (R1). Finding: On 4/10/24, the Division of Licensing and Certification received from the facility a Reportable Incident Form which indicated an allegation of fall with major injury of R1. A review of the closed clinical record for R1 revealed an admission date of 4/4/24 from private residence. Diagnoses included a history of heart disease and Alzheimer's disease and was admitted with hospice services. R1 sustained a fracture and was discharged to acute care hospital on 4/10/24. The facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation - Reporting and Investigating, revised 2/23, indicated that, Investigating Allegations. 1. All allegations are throughly investigated. There is no evidence that staff were interviewed. On 5/7/24 at 12:02 p.m., in an interview with a surveyor, a hospice registered nurse stated that R1 stated he/she fell, and when…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-07 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents reviewed for fall with major injury (Resident #1 (R1)). Finding: A review of the closed clinical record for R1 revealed an admission date of 4/4/24 from private residence. Diagnoses included a history of heart disease and Alzheimer's disease was admitted with hospice services. R1 sustained a fracture and was discharged to acute care hospital on 4/10/24. A review of the clinical record failed to locate evidence that a baseline care plan was developed and implemented within 48 hours of R1's admission. On 5/7/24 at 12:52 p.m., in an interview with a surveyor, the Director of Nursing confirmed that no care plan had been developed.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-26 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 interview, the facility failed to ensure that clinical records were complete and contained accurate information for 22 of 31 treatment opportunities for Resident #1's treatment for Nitroglycerin ointment application. Findings: On 3/26/24, R1's clinical record included a physician order for Nitroglycerin ointment, dated 3/1/24, to be applied to the necrotic (dead tissue) area on the left 3rd finger three times a day, at 9:00 a.m., 2:00 p.m., and 7:30 p.m. with parameters to hold if systolic blood pressure is below 100. The Treatment Administration Record (TAR) was reviewed and contained the following: 3/1/24 at 2:00 p.m., the treatment was administered but the clinical record lacked evidence of a blood pressure prior to the application of the Nitroglycerin. 3/2/24 at 2:00 p.m. and 7:30 p.m., the treatment was administered but the clinical record lacked evidence of a blood pressure prior to the application of the Nitroglycerin. 3/3/24 at 2:00 p.m. and 7:30 p.m., the treatment was administered but the clinical record lacked evidence of a blood pressure prior…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 ensure physician ordered medications with parameters to hold were followed for 1 of 1 residents reviewed with medication parameters (Resident [R]1). Findings; 1. On 3/26/24, R1's clinical record was reviewed and included a physician order, dated 2/28/24, for scheduled Acetaminophen, 325 milligrams (mg) tablets x 3 tablets (975 mg) to be administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The clinical record also included an as needed (PRN) order for Acetaminophen, dated 2/27/24, 500 mg every 4 hours as needed for pain/fever, with parameters not to exceed 3 grams (3000 milligrams) in a 24 hour period. A review of the Medication Administration Record indicated at on 3/10/24 at 10:00 p.m., R1 received 975 mg of Acetaminophen; on 3/11/24, R1 received 975 mg of Acetaminophen at 6:00 a.m. and 2:00 p.m. and 500 mg at 8:43 a.m. for fever and 4:41 p.m. for pain. The total Acetaminophen documented as being administered in a 24 hour period was 3925 milligrams, exceeding 3000 milligrams in a 24 hour period. On 3/26/24 at 12:55 p.m.,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of the electronic Medication Administration Record (eMAR) and interviews, the facility failed to ensure physician orders were followed for 2 of 5 sampled residents for unnecessary medications (Resident #152 (R152) and R11)). Findings: 1. R152 was admitted on [DATE]. During a review of R152's admission orders, dated 11/15/23, he/she had an order for Quetiapine to take 0.5 tablet to equal 12.5 milligram (mg) by mouth twice daily. Review of the eMAR for November 2023 indicates that R152 had an order, dated 11/15/23, for Quetiapine Fumarate 50 milligram dose: 0.5 tablet/25 mg by mouth two times a day. R152 received the following doses at 25 mg instead of the ordered 12.5 mg on 11/15/23 at 6:30 p.m., 11/16/23 at 8:30 a.m., 11/16/23 at 6:30 p.m., 11/17/23 at 8:30 a.m. and on 11/17/23 at 6:30 p.m. (Total of 5 doses). On 11/29/23 at 1:21 p.m., during an interview with the Director of Nursing, the surveyor confirmed that R152 received 5 incorrect doses of his/her Quetiapine…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, facility policy review, and interview, the facility failed to follow their own policy in obtaining a resident's Pneumococcal vaccination status and providing a vaccination if needed, for 1 of 5 residents reviewed for immunizations Resident #18 (R 18). Finding: The facility's policy, Pneumococcal Vaccine, revised 6/2022, indicated: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of Pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. On 11/29/23, R18's clinical record was reviewed which indicated the resident was admitted to the facility on [DATE], from another facility. The surveyor reviewed the electronic charting and found that 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2026-02-27 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 notify (at least monthly) the Ombudsman office of transfer/discharges for 1 of 1 resident reviewed for discharge (Resident #63 [R63]), and the facility failed to issue a written transfer/bed hold notice to a resident and their legal representative for a facility-initiated transfer/discharge for 1 of 1 resident reviewed for hospitalization (R61). Findings:1. On 2/26/26, a review of R63's clinical record was completed. Documentation indicated R63 was transferred home with services on 12/29/25. On 2/26/26 at 8:42 a.m., in an interview with the surveyor, the Licensed Social Worker stated she has not been sending notifications to the Ombudsman's office for any transfers or discharges. 2. On 2/26/26, a review of R61's clinical record was completed. Documentation indicated R61 was transferred to the hospital on [DATE] for respiratory distress. There was no evidence that the resident or resident representative had been provided a written copy of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-02-27 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to provide resident/resident representative's with a summary of their baseline care plan for 3 of 4 residents reviewed for baseline care plans (Resident #3 [R3], R5, R61). Findings: 1. On 2/25/26, a review of R3's clinical record was completed. A baseline care plan was completed within 48 hours of R3's admission. There was no evidence that a summary of the baseline care plan was provided to the resident or the resident representative. On 2/25/2026 at 12:35 p.m., in an interview with the surveyor, the Director of Nursing [DON] stated that they do not provide a copy of the baseline care plan to the resident or the resident representative. The surveyor confirmed at this time that the resident/resident representative did not receive a summary of the baseline care plan. 2. On 2/25/26, a review of R5s clinical record was completed. A baseline care plan was completed within 48 hours of R5's admission. There was no evidence that a summary of the baseline care plan was provided to the resident or the resident representative. On…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-01-16 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview, the facility failed to post the nurse staffing information in an area visible to residents for 4 of 4 days of survey (1/13/25, 1/14/25, 1/15/25, and 1/16/25). Finding: On 1/14/25 through 1/16/25, a surveyor observed that the nurse staffing information was not posted in an area visible to residents. On 1/16/25 at 11:27 a.m., in an interview with a surveyor, the Administrator and Director of Nursing stated the nurse staff information was posted outside of the main entrance door to the facility, and the surveyor confirmed that it was not posted in an area that residents had visible access too.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-01-16 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that a resident's record contained the Power of Attorney paperwork, 2 months after admission, for 1 of 2 residents reviewed for Advance Directives (Resident #55 [R55]). Finding: On 1/14/25, R55's clinical record was reviewed and noted that R55 was admitted to the facility on [DATE] and that a family member was the Power of Attorney. The Acknowledgement of Important Information and Policies document uploaded in R55's electronic clinical record indicated that R55 has an Advanced Directive and have provided the facility with a copy of the document but the surveyor could not find this document. On 1/15/25 at 11:58 a.m., during an interview with a surveyor, the Licensed Social Worker (LSW) stated that she did not have a copy of an Advance Directive or the Power of Attorney (POA) paperwork. On 1/15/25 at 1:15 p.m., LSW handed the surveyor a copy of the Power of Attorney paperwork that she just received from the hospital. The surveyor confirmed that…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-11-29 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for a nurse aide at least every 12 months, for 4 of 5 sampled Certified Nursing Assistants (CNA) employed greater than 1 year (CNA1, CNA2, CNA3, CNA4). Findings: On 11/29/23, a surveyor reviewed the following employee files: 1. CNA1 was hired on 10/17/22. There was no annual evaluation completed by October 2023. On 11/29/23 at 11:05 a.m., during an interview with a surveyor, the Business Office Manager (BOM) stated she was unable to find where the annual evaluation due last month was completed and she also checked with the Director of Nursing to see if CNA1's annual evaluation might be with him but he had no evaluations in his office either. 2. CNA2 was hired 9/24/19. The last annual evaluation was completed 9/24/22 and there was not one that had been completed by September 2023. On 11/29/23 at 1:01 p.m., during an interview with a surveyor, the Administrative Assistant/Scheduler stated she was unable to find one for 2023. 3. CNA3 was hired 1/10/14. The employee…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-11-29 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview, the facility failed to post the nurse staffing information in an area visible to residents and visitors for 3 of 3 days of survey. Finding: On 11/27/23 through 11/29/23, the surveyor observed that the nurse staffing information was not posted in an area visible to residents and visitors. On 11/29/23 at 8:48 a.m., in an interview with the surveyor, the Director of Nursing stated the nurse staff information was behind the nurse's station and confirmed that it was not posted in an area that residents and visitors had visible access too.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$11,190 in federal fines across 1 penalty.

  • $11,190 — penalty dated 2025-01-16

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to FIRST ATLANTIC HEALTHCARE — 10 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 →

RatingThis homeChain avg
Overall 4 of 53.4+0.6 vs chain
Health inspection 3 of 53.0≈ chain avg
Staffing 5 of 54.4+0.6 vs chain
Quality measures 4 of 52.8+1.2 vs chain
The other 9 homes this chain runs (chain average 3.4★, per CMS)

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 / managerTypeRoleSince
FORUM MANAGEMENT LLCOrganizationDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTERESTsince 06/11/2010
BERNARD, KIMBERLYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
OTIS-HIGGINS, ANDREAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/11/2015
PELKEY, WANDAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
RIENDEAU, CHRISTINEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/07/2018
FIRST ATLANTIC HEALTHCARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/04/2025
FRIDMAN, FREDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/11/2024
YOUNG, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/11/2023
EASTERN MAINE MEDICAL CENTEROrganizationADP OF THE SNFsince 10/01/2018
FIRST ATLANTIC CORPORATIONOrganizationADP OF THE SNFsince 06/30/2010
MAINE MEDICAL CONSULTANTS PCOrganizationADP OF THE SNFsince 07/11/2024
BOWDEN, KENNETHIndividualADP OF THE SNFsince 06/30/2010
COFFIN, CRAIGIndividualADP OF THE SNFsince 06/30/2019

CMS files one row per role, so the 25 rows in the source record cover these 13 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.

5 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.

$7.0M
Net patient revenuemost recent cost report
-4.7%
Operating marginrevenue minus expenses
$238K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 8%Other / private 11%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $238K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$399per resident / day
operating cost
$12,135per month
≈ monthly operating cost
$381per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Maine
$13,976/mo
Nursing home (semi-private)
$14,904/mo
Nursing home (private)
$8,205/mo
Assisted living

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 205116. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, 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.

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