Winship Green Center for Health & Rehab, LLC
51 Winship Street, Bath, ME 04530 · For profit - Limited Liability company · 72 certified beds · (207) 443-9772 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 number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 25% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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.
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 | 17.3% | 24.4% | 15.4% | worse |
| 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 | 1.0% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.5% | 2.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 19.6% | 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 | 2.6% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.7% | 25.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 39.2% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.8% | 29.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.6% | 20.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.0% | 74.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.5% | 20.8% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.3% | 16.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.48 | 1.45 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.36 | 2.01 | 1.80 | worse |
‡ 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.
55.1% 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 102 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.1% 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 52 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 55.1%CMS range 44.6–65.0 | 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 | 8.9%CMS range 6.2–13.4 | 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 | 48.1% | 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 | 44.2% | 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 | 44.2% | 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 | 99.0% | 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 | 86.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 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 | 5.8% | 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 | 5.6%CMS range 3.1–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 66.0 residents a day — about 92% occupied, or roughly 6 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 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 4.01 on weekdays — 10% thinner on weekends. RN hours go from 0.66 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Ecited before2026-03-23 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 have as needed medication readily available for resident use in a timely manner and failed to follow physician orders related to medication administration for 2 of 4 residents reviewed for medications (Resident #1 and #12).Findings:1. On 3/10/26 the Division of Licensing received a complaint regarding Resident #1 not having access to his/her respiratory medication (Acetylcysteine) in a timely manner. The complainant states Resident #1 had asked for this medication multiple days before he/she was able to receive it.Review of Resident #1 clinical record contained the following physician orders; Acetylcysteine Inhalation Solution 10% with instructions reading 200 milligram inhale orally every 6 hours as needed for PNA (pneumonia), ordered on 2/19/26 and discontinued on 2/25/26. A new order for Acetylcysteine Inhalation Solution 10% with instructions to inhale 10 ml orally every 6 hours as needed for PNA on 2/25/26. Ipatropium-Albuterol Solution 0.5-2.5 (3) MG/3ML with instructions to inhale 1 vial orally 4 times a day 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.
- Potential for harm · D2026-03-23 · 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 observations and interviews, the facility failed to ensure the confidentiality of protected health information for 10 of 67 residents during 1 of 1 day of survey (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11).Findings:1. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff members assignment sheet on it, face up. The assignment sheet contained personal medical information regarding Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11. It was visible and easily accessible to residents, visitors, and unauthorized personnel. Environmental Service staff and Certified Nursing Assistance were noted nearby.On 3/23/26 at 8:16 a.m., through surveyor intervention, the assignment sheet was properly taken care of by a Licensed Practical Nurse, who at this time confirmed the assignment sheet should not be left in the open and should have been in a secure location.2. On3/23/26 from 3:35 p.m. to 3:41p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with a staff members assignment…
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 · D2026-03-23 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — the official record, unedited, may be distressing
Based on record reviews and interviews, the facility failed to ensure written bed hold and transfer/discharge notices were provided to the resident or their legal representative for a facility-initiated transfer/discharge for 1 of 3 sampled residents who were transferred/discharged to an acute care facility (Residents #1). Findings:1. Review of Resident 1's clinical record indicated that he/she was transferred to an acute hospital on 3/8/26 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice and a transfer/discharge notice to the resident and/or legal representative. On 3/23/26 at 1:30 p.m., the above was confirmed with the Director of Nursing.
- Potential for harm · D2026-03-23 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to notify the physician of a significant change in condition for 1 of 3 residents reviewed for a significant change in condition. (Resident #1)Findings:A review of Resident #1's entire clinical record showed he/she was transferred to the emergency room on 3/8/26 and was subsequently admitted to the hospital for difficulty breathing. Further review of the clinical record lacked evidence that the physician was notified of Resident #1's transfer to the hospital.Review of the facilities Change of Condition Policy and Procedure states The facility must inform the resident, consult with the resident's healthcare provider, and if known, notify the resident's legal representative or family member when there is. A decision to transfer or discharge the resident from the facility Further review of the policy states Physician/family notification must be documented in the electronic health record.On 3/23/36 at 1:30 p.m., the Director of Nursing confirmed there is no documentation in the resident's electronic medical record that showed a…
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 · D2025-01-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 evidence that the Resident Representative was informed of a physician order for an antipsychotic medication, informed of the side effects of that medication and given the opportunity to agree or disagree with the use of medication for 1 of 3 sampled residents reviewed for unnecessary medications (#1). Finding: A review of the clinical record Resident #1 had been admitted to the facility on [DATE] from an acute care hospital. admission diagnoses included Urinary Tract Infection, Metabolic Encephalopathy, Delirium, Insulin Dependent Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, Obsessive Compulsive Disorder, Congestive Heart Failure, Aortic Stenosis, and a history of frequent falls. On 12/25/24, Resident #1 experienced agitation, increased confusion and became aggressive and combative to staff and other residents. Efforts to redirect were ineffective and Resident #1 was transferred to the Emergency Department via…
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 · E2024-07-11 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews, the facility failed to deliver resident mail in a timely manner to 2 out of 4 residents who receive mail in the facility. ( #48 and #63) Findings: Reviewed Policy titled: Therapeutic Recreation last revised 10/2023 that states Ensure that mail is delivered to the person unopened or postmarked (for outgoing mail) within 24 hours, including Saturday. On 7/11/24 at 10:45 a.m., in an interview with with Resident #48 and Resident #63, stated they are not receiving their mail for 2 or 3 days after it arrives at the facility. On 7/11/24 at 11:00 a.m., in an interview with the Activities Director, stated that Activities deliver the mail but they have to wait until the Business Office sorts it and that can take a few days. On 7/11/24 at 11:20 a.m., in an interview with the Business Office Manager, the staff confirmed that sometimes mail doesn't get delivered within 24 hours, especially Saturday's mail. They stated that getting the mail sorted and out to residents timely has been a known challenge because residents have complained.
- Potential for harm · E2024-07-11 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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/obtain residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 8 of 23 residents reviewed for advanced directives ( #10, #35, #46, #67, #37, #9, #63 and #23). Findings: 1. Resident #10 was admitted to the facility on [DATE]. Review of Resident #10's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 7/9/24 at 11:10 a.m., Resident #10's family member indicated he/she is legal guardian and has documentation but has never been asked to supply it. 2. Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's clinical record lacked evidence that the facility provided/obtained resident and/or resident's representative…
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 before2024-07-11 · 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 services necessary to maintain the facility in good repair and sanitary condition for the ceiling air vents and surrounding ceiling tiles, all unit shower rooms, and bathrooms in rooms [ROOM NUMBER] on the [NAME] Unit. Findings: 1. On 7/9/24 at 8:00 a.m., a surveyor observed that all the ceiling vents in all hallways and in the main dining room have a moderate to heavy buildup of black material on the vents and on the ceiling surrounding the vents for 3 of 3 Resident units. This was confirmed with the Administrator at that time. 2. On 7/10/24 at 10:00 a.m., during the facility tour with the Administrator and the Maintenance Manager, the following were observed: Passport Unit - The Shower room has a moderate to heavy buildup of black substance on shower grout. Pemaquid Unit - The Shower room has brown stain on shower room floor and buildup of black substance on shower grout. room [ROOM NUMBER], the bathroom contains…
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 · E2024-07-11 · 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 interviews and record review, and policy review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessments, for 6 of 6 residents whose care plans were reviewed (#16, #10, #13, #26, #23, #31). Findings: 1. A surveyor reviewed the clinical documentation of Resident #16, which included review of a comprehensive Quarterly MDS dated [DATE], 3/8/24 and 6/8/324. The surveyor could not locate evidence, after completion of the above 3 MDS assessments, that a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #16 and/or his/her representative to review and revise the care plan. On 7/10/24 at 9:46 a.m., during an interview with the Social Services Director (SW), she confirmed the above IDT meetings were not completed. 2. A surveyor reviewed the clinical documentation of Resident #10, which…
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 before2024-07-11 · 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, interviews, record review, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, failed to ensure foods were dated/ labeled and stored appropriately for 2 of 3 survey days (kitchen and Pemaquid dining room), failed to ensure that the freezers and refrigerator's temperatures were monitored appropriately. This has the potential to affect all residents that eat food prepared by kitchen staff. Findings: 1. On 7/8/24 between 6:04 p.m., and 6:21 p.m., a surveyor and the cook completed an initial tour of the kitchen which revealed the following: Observation of 3 door refrigerator noted the following: - Individual sliced yellow cheese wrapped in saran wrap, undated, unlabeled and available for use. -clear squeeze bottle of yellow substance, undated, unlabeled and available for use. -plastic container of chopped red chili peppers, undated, unlabeled and available for use. -Clear plastic container containing biscuits covered with saran wrap unlabeled, undated and available for use. -Gallon jar of ranch dressing…
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.
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- Potential for harm · D2024-07-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 24 sampled residents observed for 2 of 3 days of survey (#10). Findings: During medical record review, Resident #10 has diagnoses to include quadriplegia and is totally dependent on staff for all Activities of Daily Living. He/she is only able to rotate his/her head from left to right and uses a tap call bell by the right side of his/her head to ask for assistance. Review of Resident #10's care plan updated 4/4/24 states Ensure/provide .Call light in reach . On 7/09/24 at 9:53 a.m. Resident #10 was observed lying in bed, touch call bell observed on right side behind pillow and not in reach. On 7/10/24 at 7:38 a.m., Resident #10 was observed lying in bed, touch call bell observed on top of pillow to right side of resident's head and not in reach. During an interview, resident was asked to demonstrate how he/she would call for help if needed. Resident #10 moved his/her head in an attempt to use the bell but was unable to reach it. During an interview on 7/10/24 at 7:41 a.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.
- Potential for harm · Dcited before2024-07-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 update/implement goals and interventions in the area of depression for 1 of 4 residents reviewed ( #10), In addition facility failed to ensure care plan was updated/implemented on the areas of elopement, and diabetes for 1 of 4 care plans reviewed ( #13). Findings: 1. Resident #10 was originally admitted on [DATE] with diagnoses to include traumatic brain hemorrhage, quadriplegia, depression, bilateral extremity contractures and expressive aphasia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 has bilateral hand/arm contractures and is totally dependent on staff for all Activities of Daily Living and is dependent on G-tube [gastronomy tube] for all nutrition needs. Review of Resident #10's care plan, updated 4/4/24, states [Resident #10] has depression r/t physical limitations secondary to quadriplegia, TBI . Intervention: Monitor/document/report PRN any risk for harm to self: suicidal plan, risky actions (stockpiling…
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 · D2024-07-11 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, observations and interviews, the facility failed to provide residents with a continuous resident centered activities program for 1 of 1 resident reviewed for activity participation ( #10). Findings: Review of facility policy Participation Record dated 5/14 states An individual's level of involvement in recreation programming will be documented on the Recreation Participation Record . The current Participation Record will be maintained daily, organized, and easily accessible to all Recreation . Review of facility policy Individual Program Planning dated 10/23 states Regularly scheduled programming will be provided to all patients who are not able to tolerate or prefer not to participate in group or independent leisure opportunities and/or at risk of a lack of meaningful recreational and/or social engagement. An individualized program will: Include interactions and experiences that support the resident's patient's overall wellbeing . The patient's engagement in individual (one-to-one) programs will be recorded on the Resident Participation Record…
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 · D2024-07-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that the resident's safety when the residents wander guard was expired for 1 of 1 resident reviewed for elopement (#13). In addition, the facility failed to a blocked fire door on 1 of 3 units ([NAME] Unit), on 2 of 3 survey days. Findings: 1. Resident #13 was admitted on [DATE] and has diagnoses to include dementia, anxiety, and is legally blind. Review of significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status of 4 of 15 indicating he/she is not cognitively intact. Review of Resident #13's care plan updated [DATE] states [Resident #13] is at a High Risk for Elopement r/t wandering risk scale, wandering behavior pattern, attempts at opening doors to outside [Resident #13] demands to be brought to store at times with difficulty redirecting- Observations of Resident #13 between [DATE] at 7:49 p.m., [DATE] at 9:53 a.m., and [DATE] at 10:01 a.m., revealed Resident #13's self propelling…
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 · D2024-07-11 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 2 of 190 days reviewed for RN coverage. Findings: On 7/10/24 a surveyor reviewed the nursing working schedules from 1/1/24-7/8/24 and found that on Sunday 2/4/24 and Friday 7/5/24 the facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours. On 7/10/24 at 10:39 a.m. a surveyor met with the Administrator about the days listed above with no RN on duty.
- Potential for harm · Dcited before2024-07-11 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and facility policy, the facility failed to ensure an outdated vaccine was removed from the supply available for use in medication refrigerator in 1 of 1 medication storage rooms reviewed for 1 of 4 days of survey. Finding: On 7/10/24 at 8:49 a.m., a surveyor observed the medication refrigerator in the medication storage room with Registered Nurse (RN) #2. The Surveyor observed a Covid-19 vaccine with and expiration date of 6/28/24. The RN confirmed the vaccine was expired and disposed of the vaccine immediately. The facilities policy titled Medication Storage Regulation states, .Facility must have a system in place to regularly check the entire Medication Refrigerator for .expired medications which includes the removal of these medications from the regular stock PRIOR to the expiration date .
- Potential for harm · Dcited before2024-07-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that the resident's record contained accurate information (#13). Findings: During a medical record review of Resident #13's Treatment Administration Record (TAR) dated [DATE] revealed order with start date of [DATE] to Check [wanderguard] expiration date one time weekly every day shift every Friday for [wanderguard]. Further review of Resident #13's TAR revealed it was checked on [DATE] on 7a-3p shift. Review of Resident #13's care plan updated [DATE] states [Resident #13] is at a High Risk for Elopement r/t wandering risk scale, wandering behavior pattern, attempts at opening doors to outside (Resident #13) demands to be brought to store at times with difficulty redirecting- Wander guard to wheelchair EXP [DATE] 9000-0139I. On [DATE] at 10:01 a.m., a surveyor observed Resident #13's wander guard located under wheelchair to have expiration date of [DATE] 9000-01391. Review of Resident #13's Kardex revealed Wander guard to wheelchair…
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 · D2024-07-11 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews and observations, the facility failed to ensure a resident's wheelchair was clean on 2 of 3 survey days (#13). Findings: On 7/08/24 at 7:49 a.m., 7/9/24 at 9:54 a.m., and 7/10/24 at 9:53 a.m., Resident #13 was observed in the hall, sitting in his/her wheelchair. The wheelchair was observed to be soiled on each observation. During an interview on 7/10/24 at 11:21 a.m., Administrator confirmed Resident #13's wheelchair is soiled.
- Potential for harm · D2024-01-17 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
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 readmit 1 of 1 Resident (#1) back to the facility following a hospital emergency department/hospital visit. Finding: On 1/5/24 the Department of Licensing & Certification received an anonymous complaint indicating on 1/3/24 Resident #1 was transferred to an acute care hospital and the facility refused to take [him/her] back, indicating that it was unclear why the facility would not allow him/her to return to the facility. On 1/17/24 a review of Resident #1's clinical record indicated that Resident #1 was admitted to the facility on [DATE] for rehabilitation after a hospitalization for an ORIF (Open Reduction and Internal Fixation) revision of the left hip. Progress notes dated 1/3/24 9:41 p.m. indicate that Resident #1 requested to be sent to the hospital emergency department for pain in his/her left hip and lower leg. A review Bed Hold/Transfer and Discharge Notification/Authorization dated 1/3/24 signed by the resident and a facility representative…
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 before2023-04-05 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 2 of 3 units observed (Passport and [NAME]). Findings: 1. On 4/3/23 at 7:52 a.m., observation of the Passport treatment cart with a Licensed Practical Nurse #1, the surveyor noted an opened Lantus insulin pen not labeled with an open or discard date with manufacturer's directions to use within 28 days after initial use. 2. On 4/3/23 at 7:58 a.m., observation of the [NAME] treatment cart with a Licensed Practical Nurse #2, the surveyor noted an opened Novolog insulin vial labeled with an open date of 2/27/23 and manufacturer's directions of should be discard after 28 days after opening. On 4/5/23 at 12:21 p.m., the above concerns were discussed with the Director of Nursing.
- Potential for harm · Ecited before2023-04-05 · 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 that the kitchen was maintained in a clean and sanitary manner for 2 of 4 kitchen tours. In addition, the facility failed to ensure the main dining room refrigerator temperatures were maintained at 41 degrees for 1 of 4 days of survey. Findings: On 4/3/23 between 9:07 a.m. and 9:26 a.m., during the initial tour of the kitchen with the Head [NAME] and Dietary Aid, a surveyor observed the following: An air conditioner in the dish machine room that was dusty and dirty. A sign above the air conditioner states If you do not clean me, you will lose me. An air conditioner near the cook stove that was dusty and dirty. These findings were confirmed with the Head cook and Dietary Aid at 4/3/23 at 9:26 a.m. On 4/4/23 at 9:20 a.m., a second tour of the kitchen was completed with the Food Service Director (FSD). The findings from 4/3/23 were discussed and observed again. Review of the facility's Sanitary Dining Services Protocol - Policy Issued 4/2011, revised 4/2013; All refrigerator must be maintained at 41 degrees…
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 before2023-04-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview the facility failed to provided care in accordance with professional standards of practice, based on the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents reviewed for positioning (Resident #27). Findings: Resident #27 was admitted to the facility in September of 2018, with diagnoses to include spastic diplegic cerebral palsy (CP), scoliosis, dysphonia, osteoarthritis, rotator cuff tear or rupture of right shoulder, segmental and somatic dysfunction of cervical region, thoracic region, lumbar region and pelvic region. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status of 15 of 15, indicating he/she was cognitively intact. Further review revealed Resident #27 required extensive assist with Activities of Daily Living (ADL), including bed mobility. Review of the comprehensive care plan states, [Resident #27] has an ADL self-care performance deficit\ r/t CP,…
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 · D2023-04-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 record review and interviews, the facility failed to ensure that a Restorative Nursing Program (RNP) was provided in accordance with the Physical Therapist (PT) recommendations for 1 of 3 sampled residents reviewed for rehabilitation (#27). Finding: Review of resident #27's medical record contained a care plan, initiated on 3/4/23 and the Certified Nurses Aid (CNA) [NAME] for PASSIVE ROM (Range of Motion) PROGRAM: Provide slow, sustained stretching >30 seconds 2 x day; see plan in resident's chart. The Certified Nurses Aid (CNA) [NAME] stated, Review of the restorative Nursing program recommended by the Physical Therapist on 2/28/23 states a goal of, Patient will participate in daily PROM (passive range of motion) to facilitate increased ROM, decreased spasticity, decreased complaints of discomfort BLE (bilateral lower extremities) and to increase safety with transfers, increase out of bed tolerance with nursing interventions of, provide slow and sustained stretching> 30 sec 2x/day. Stabilize above and…
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 · D2023-04-05 · 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 — the official record, unedited, may be distressing
Based on observation, record review and interview, the facility failed to obtain physician orders for oxygen therapy for 1 of 5 residents reviewed for respiratory care (#161) . Findings: On 4/2/23 at 10:30 a.m., Resident #161 was observed wearing a nasal cannula and a nearby oxygen concentrator was set to provide oxygen at 2 liters. A review of the clinical record revealed Resident #161 had been admitted to the facility in March of 2023, from an acute hospital. Diagnoses included pneumonia and COPD (chronic obstructive pulmonary disease) with a history of oxygen use. The baseline care plan, initiated on 3/30/23, included the problem area: alteration in respiratory status with oxygen use as an intervention. A review of the physician's admission orders found no orders for the use of oxygen. On 4/3/23, in an interview with the surveyor, the Director of Nursing and the Regional Director of Operations reviewed Resident #161's physician orders and confirmed there were no orders for the use of oxygen.
- Potential for harm · Ecited before2021-06-03 · 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 in good repair and sanitary condition, for 2 of 2 environmental tours. Findings: 1. On 6/2/2021 between 1:30 p.m. and 2:00 p.m., two surveyors did an enviornmental tour of the Laundry Room with the Manager of Housekeeping, Director of Maintenance and Administrator. The following findings were confirmed at the time of the tour: -Multiple cracks and missing floor tile creating an uncleanable surface -Heavy and imbedded grime on the floor. -Floor drain missing grate creating a trip hazard. -Storage rack heavily coated with lint. -Rubber floor mat rusty and cracked, creating rust on the floor. 2. On 6/2/2021 between 2:07 p.m. and 2:30 p.m , a surveyor did an enviornmental tour with the Manager of Housekeeping. The following findings were confirmed at the time of the tour: -room [ROOM NUMBER]-B: Moderate dust on window blinds. -room [ROOM NUMBER]: Heater cover partially removed…
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 before2021-06-03 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 interventions outlined in the resident's care plan for 2 of 29 sampled residents. (#43, #203). Findings: 1. A review of Resident #43's care plan identified a focus area of Impaired Physical Mobility, initiated on 5/18/2021. The care plan lacked any interventions to address the resident's need. In addition, the facility identified an area of focus as the Resident has shortness of breath related to COPD (chronic obstructive pulmonary disease)/asthma, initiated on 5/18/2021. The care plan lacked any interventions to address the resident's need. On 6/2/2021 at 2:55 p.m., in a discussion with the Assistant Director of Nursing, the surveyor confirmed the comprehensive care plan did not include the necessary interventions to direct staff on how to provide care to meet Resident #43's needs. 2. Resident #203 clinical record revealed physician orders dated 5/21/21 for Quetiapine Fumarate 25 milligram (mg) (antipsychotic medication) twice daily, Trazadone HCL 100 mg at bedtime and Sertraline HCI 100 mg (antidepressants)…
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 before2021-06-03 · 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 and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 4 medication carts (Pemaquid) and failed to store medication according to manufacturer specifications for Acidophilous in 3 of 4 medication carts observed (Passport and Pemaquid). Findings: 1. On 6/1/2021 at 9:50 a.m., observation of the medication cart on Pemaquid unit contained an Epinephrine, Auto-Injector pen with an expiration date of April 21 and one opened multi-dose bottle of Acidophilus probiotic dietary supplement with the manufacturer specifications to refrigerate after opening. At this time, the surveyor confirmed the above findings with the Licensed Practical Nurse. 2. On 6/1/2021 at 10:03 a.m., observation of the Odd and Even room medication carts on Passport unit both containing an opened multi-dose bottle of Acidophilus dietary supplement with manufactures instructions to refrigerate after opening. At this time, the surveyor confirmed the above findings with the Certified Medication Technician. On 6/1/2021 at 10:10 a.m., 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 · Ecited before2021-06-03 · 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 — the official record, unedited, may be distressing
Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for (1) fan, two light switches and the dish wash room floor for 1 of 3 days of survey. Finding: On 6/2/2021 between 9:30 a.m. and 10:00 a.m., during the kitchen tour, a surveyor and the Director of Kitchen confirmed the following: - A/C Fan with moderate dust. - Moderate dirt on top of two wall light switches - Built up grime along the edging of the dish room floor.
- Potential for harm · Ecited before2021-06-03 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 interview, the facility failed to ensure that clinical records were complete and contained accurate documentation for 2 of 29 sampled residents (#5 and #32). Findings: 1. On 6/2/2021 at 1:20 p.m., a surveyor observed the Registered Nurse administer Resident #5's Daptomycin (antibiotic). The medication IV solution bag stated, Daptomycin 350 mg, Administer: 57 milliliter (ml) over 30 minutes daily intravenously. Review of Resident #5's medical record, indicated a Physician order dated 4/23/2021 for Daptomycin Solution Reconstituted 500 MG (milligram). Use 1 dose intravenously one time a day for L4-L5 discitis, last dose 6/10/2021. On 6/2/2021 at 1:38 p.m., the surveyor and the Director of Nursing (DON) observed Resident #5's Daptomycin 350mg IV infusing, surveyor showed the DON the physician order for Daptomycin 500 mg daily. DON stated that Resident #5 is receiving the correct dose as per the hospital discharge instructions. Both the surveyor and the DON reviewed the hospital discharge instructions dated 4/23/21 which stated, Daptomycin IV 350 mg daily 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.
- No harm found · B2023-04-05 · 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
Based on observation and interview, the facility failed to maintain the dignity of 1 of 3 residents (Resident #14) reviewed for dignity related to urinary collection bags during 2 of 4 days of survey (4/2/23 and 4/4/23). Findings: On 4/2/23 at 10:53 a.m., observation of Resident #14's uncovered urinary catheter drainage bag, with dark yellow/orange colored urine, visible from the hallway and attached to the bed frame. In an interview, Resident #14 stated that he/she would prefer the urinary bag to be covered, stating, it was a problem before, that's when they started to put the cover on. On 4/4/23 at 8:42 a.m., observation of Resident #14's uncovered urinary catheter drainage bag, with dark yellow colored urine, visible from the hallway and attached to the bed frame with the urinary drainage bag cover hanging next to it. In an additional interview, Resident #14 stated that he/she would prefer the urinary bag to be covered, stating, I would like to have it covered. On 4/4/22 at 8:46 a.m., the Registered Nurse confirmed that the resident's uncovered urinary catheter drainage bag 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.
“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 | 2 of 5 | 3.0 | -1.0 vs chain |
| Quality measures | 2 of 5 | 4.1 | -2.1 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 01/28/2013 |
| MARVIN OSTREICHER FAMILY TRUST 2012 | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 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; ADP OF THE SNF | 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; ADP OF THE SNF | since 01/28/2013 |
| OSTREICHER, SUSAN | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 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 |
| CHADWICK, CARL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/23/2025 |
| 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 |
| DAVID, ALBERT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 11/26/2025 |
| SHAYA-MOGRABY, MOSHE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 11/26/2025 |
| BARRY BOKOW 2012 FAMILY TRUST | Organization | ADP OF THE SNF | since 08/07/2020 |
| BPB VENTURES LLC | Organization | ADP OF THE SNF | since 08/07/2020 |
| CEDAR HILL NG TRUST | Organization | ADP OF THE SNF | since 05/14/2025 |
| IMPACT HEALTH PC | Organization | ADP OF THE SNF | since 06/01/2025 |
| JUNIPER NG TRUST | Organization | ADP OF THE SNF | since 05/14/2025 |
| NATIONAL HEALTH CARE ASSOCIATES INC | Organization | ADP OF THE SNF | since 01/28/2013 |
| OAK DRIVE NG TRUST | Organization | ADP OF THE SNF | since 05/14/2025 |
| 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 05/14/2025 |
| ALMEIDA, ELIZABETH | Individual | ADP OF THE SNF | since 01/28/2013 |
| BOKOW, MICHAEL | Individual | ADP OF THE SNF | since 09/30/2015 |
| LOPIANSKY, REBECCA | Individual | ADP OF THE SNF | since 05/14/2025 |
| STEG, SHAYNA | Individual | ADP OF THE SNF | since 05/14/2025 |
CMS files one row per role, so the 50 rows in the source record cover these 38 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.
16 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 $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 205078. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-11, 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 →
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