Southridge Rehab & Living Ctr
10 May Street, Biddeford, ME 04005 · Non profit - Other · 62 certified beds · (207) 282-4138 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,179 in federal fines (most recent 2025-06-02)
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (1/5)
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 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
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 2 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 | 38.5% | 24.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.4% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 2.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 9.7% | 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 | 6.0% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 39.8% | 25.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.1% | 17.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 93.8% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 32.8% | 29.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.4% | 20.2% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.4% | 74.5% | 79.4% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.2% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 55.2%CMS range 38.4–71.2 | 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 | 11.2%CMS range 7.6–18.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 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 62 beds and averages 53.5 residents a day — about 86% occupied, or roughly 8 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 4.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.02 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.99 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 4.20 hrs/resident/day on weekends vs 4.53 on weekdays — 7% thinner on weekends. RN hours go from 1.10 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-03-05 · 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 interviews, observations and record reviews, the facility failed to provide supervision to a resident after staff found resident in closet in another resident room, with an open window. Resident was previously identified as an elopement risk and had previous exit seeking attempts for 1 of 2 residents identified for elopement risk. Shortly after, the resident was found outside in a snowbank with a second story window open. This failure created an immediate jeopardy situation. (Resident #1) Findings: On 2/17/25 the Department of Licensing and Certification received a facility reported incident indicating [Resident #1] fell into snow from second floor on 2/17/24. [Resident #1] found in snowbank at approximately 1:00 a.m. Medical record indicated that on 2/12/25, Resident #1 was transferred from the facility residential care unit to a secured long term care unit(B1 Unit). The transfer was related to safety due to increased dementia behaviors including exit seeking and recent elopements from the residential…
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.
- Immediate jeopardy · Lcited before2023-03-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
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 interview, observation, and record review, the facility failed to ensure resident's exhibiting symptoms of gastroenteritis were on contact precautions; failed to ensure Personal Protective Equipment (PPE) supplies were available for use (gowns); failed to disinfect resident rooms and common areas with the appropriate (Environmental Protection Agency) EPA cleaner; and failed to educate and reeducate staff on contact precautions and appropriate disinfection resulting in spread of gastroenteritis creating an immediate jeopardy situation to 9 out of 34 Resident's, as of 3/6/2023, on the B2 Unit. (Resident #41, #29, #28, #32, #13, #27, #26, #35, #4). In addition to the immediate jeopardy, the facility failed to have a risk assessment and have water management policies and procedures in place to reduce the risk of growth and spread of Legionella and other opportunistic waterborne pathogens in the facility water system resulting in potential harm that is not immediate jeopardy to 52 residents in the facility.…
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.
- Actual harm · Gcited before2025-07-07 · 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 clinical record review, review of the facility's transport policy and interviews, a facility Transportation Aid failed to follow the transport a resident to an appointment safely by not attaching the shoulder harness strap and seat belt resulting in resident sliding from wheelchair during a transport and sustaining a fracture of the left femur for 1 of 3 residents reviewed for facility transports. (#1)Resident #1 was admitted to the facility in March of 2025 following a fall, for rehabilitation and treatment of a fracture of the resident's left distal femur, right proximal humerus, Type 2 Diabetes Mellitus, Atrial Fibrillation, and depression. The fracture of the left distal femur was not healing well, and the resident had an appointment with the Orthopedic Surgeon.During a review of the facility investigation, on 6/26/25, at approximately 8:30 a.m. the facility Transportation Aid (TA) loaded the resident into the van and secured the wheelchair. The Transportation Aid did not fasten the shoulder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation, and interviews, the facility failed to ensure that care plans were developed in the area of comfort care for 1 of 2 reviewed for hospice care (Resident #22), in the area of wandering for 1 of 1 reviewed for elopement (Resident #4), in the area of dialysis for 1 of 1 reviewed for dialysis needs (Resident #6), and in the area of pain for 1 of 1 resident reviewed for pain management (Resident #25). Findings: 1.Review of Resident #22's medical record stated they were admitted to the facility in November of 2021. A review of a hospice follow-up noted dated 12/29/25 states, Problem 1Hospice care Z51.5, Continue comfort-focused hospice management, Respect patient preference for minimal intervention. On 4/29/26 at 12:50 p.m., a surveyor reviewed resident #22's current care plan which lacked identification of comfort care with interventions. On 4/29/26 at 12:55 p.m RN #1 confirmed with surveyor that the resident does not have Hospice (comfort measures) listed on their care plan. 2.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-30 · tag F0947 — failed to train nurse aides adequately — patternEnsure 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 interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property by failing to ensure that 2 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training completed the required training (#1 , #2 & #3). Findings: On 4/29/26 during a review of facility staff education records the following were noted: CNA #1 was hired on 6/20/25. Review of the employee record lacked evidence CNA #1 completed mandatory abuse neglect and dementia training upon hire. CNA #2 was hired on 10/14/25. Review of the employee record lacked evidence CNA #2 completed mandatory dementia training upon hire. CNA #3 was hired on 10/16/24. The last abuse neglect and dementia training received by CNA #3 was completed in 2024. The employee record lacks evidence of mandatory abuse & neglect and dementia training in 2025. On 4/30/26 at 1:05 p.m., the surveyor confirmed the above finding with the Senior [NAME] President of Development and Operations.
- Potential for harm · D2026-04-30 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy, the facility failed to ensure current provider orders reflected a resident's self-administration of respiratory medication, and failed to complete an assessment of a resident's ability to safely self-administer medication for 1 of 1 residents reviewed for tracheostomy care (R3).Findings: Review of the clinical record for R3 noted diagnoses which included: Chronic Obstructive Respiratory Disease (COPD), Chronic respiratory failure, and Tracheostomy. Review of R3's current provider orders, signed 4/24/26, included the following:An order originally written 6/12/25, for ipratropium 0.5 mg (milligrams) (2.5 mg base)/3 ml (milliliter) nebulization solution, (1) ampule for nebulization two times daily for COPD.An order originally written 12/18/25, for sodium chloride 3% for nebulization (1 unit) inhalation administer 1-3 ml every 4 hours via tracheostomy to help clear tracheal secretions. Review of R3's current care plan, with a revision date of 3/30/26, included the following focus areas and interventions: Respiratory: (R3) is unable…
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 · D2026-04-30 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure the Minimum Data Set (MDS) Version 3.0 assessments were accurately coded in the areas of Hospice for 1 of 2 sampled residents (Resident #48).Finding:A review of Resident #22's clinical record revealed a physician's order dated 8/27/25 Admit the resident to hospice if appropriate due to suspected 6 months or less .Resident #22's quarterly MDS Version 3.0 assessment dated [DATE], Section O - Special Treatments, Procedures, Programs, was incomplete in the section for Hospice.On 4/29/26 at 3:30 p.m MDS coordinator confirmed the above finding with 3 surveyors.
- Potential for harm · D2026-04-30 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — the official record, unedited, may be distressing
Based on policy review, observation, and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding for 1 of 1 resident reviewed for tube feeding (Resident #8).Finding:Enteral Tube Policy last revised 7/22 states, enteral feeding tube placement will be verified prior to the initiation of feeding and/or medication administration. X-ray's is the only way to verify placement.On 4/28/26 at 11:05 a.m., a surveyor observed Registered Nurse (RN) #1 administer medications via a gastrostomy tube for Resident #8 without checking tube placement.On 4/28/26 at 2:13 p.m in an interview with a surveyor, RN #1 confirmed they only check the tube placement if I feel something is wrong and they also confirmed that the order states to check placement each shift.
- Potential for harm · Dcited before2026-04-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to follow professional standards of practice with usage of Personal Protective Equipment (PPE) (Resident #39). Findings: On 4/27/26 at 10:41 a.m., a surveyor observed a Contact Precautions sign and Personal Protective Equipment (PPE) caddy posted on the door of room [ROOM NUMBER]. The Contact Precautions sign instructed staff to wear gloves and gown for all care and resident contact and to remove PPE prior to exiting the residents room. The surveyor observed RN #2 carrying a supply caddy containing diabetic testing supplies. RN #2 donned gloves upon entering the room, greeted the resident, and placed the supply caddy on the bed next to Resident #39's legs while obtaining the resident's blood glucose. Following the blood glucose check, RN #2 exited the room and removed his/her gloves. During an interview following the observation, RN #2 stated the Resident #39 is on Contact Precautions for Extended-Spectrum Beta-Lactamase (ESBL) in the urine. When asked…
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 · D2025-06-02 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the complaint report, facility internal investigation, clinical record review, facility General Dose Preparation and Medication Administration Policy and Procedure, and interviews, the facility failed to identify the resident prior to administering medications, failed to follow the facilities policy on resident identification resulting in Resident #1 being given another's residents medication resulting in the need for a hospital evaluation for 1 of 1 residents reviewed (Resident #1) Findings: The Division of Licensing and Certification received a complaint that indicated on the morning of 5/20/25, Resident #1 received another resident's medications which resulted in lethargy and poor oxygen profusion. Resident #1 was transported to the emergency room for further evaluation. On 6/2/25, a review of the facility's internal investigation was completed. The investigation indicated that on 5/20/25, during morning medication pass, Certified Nurse Assistant-Medication (C.N.A.-M #1) administered the wrong medications (Eliquis - an anticoagulant medication used to prevent…
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 · D2025-03-05 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to notify the physician when interventions were ineffective in relieving resident's distress. In addition, the facility failed to notify the physician after the resident was missing and required a search to locate or when the resident experienced a life-threatening elopement. Findings: On 2/17/25 the Division of Licensing and Certification received a facility reported incident, which indicated Resident #1 was found outside in a snowbank having fallen from a second story window. Review of facility policy Resident Elopement Policy last revised 9/23 states under: II. PROCEDURE -Section D vii - The physician and resident's responsible party will be notified. -Section G. The resident's plan of care is to be updated with appropriate interventions to meet the resident's current needs -Section H Document in medical record. Indicate time the search began and the time the search ended. On 2/19/25, druing review of Resident #1's the Medication Administration Record, stated a PRN (as needed) medication for anxiety was given with no…
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 · D2025-03-05 · tag F0655 — isolatedCreate 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 follow the baseline care plan implemented for Resident #1 in the area of Behaviors for 5 of 5 days that resident was in the facility. Findings: On 2/19/25, during review of Resident #1's baseline care plan, dated 2/12/25, stated in the area for Behaviors: Document behaviors in Treatment Administration Record (TAR) or on behavior monitoring form every shift. A review of Resident #1's Electronic Medical record (EMR) under TAR and Clinical Notes, failed to show documented behaviors for every shift between 2/12/25 and 2/17/25. On 2/28/25 at 8:51a.m., during an interview with CNA #1, who worked shifts with Resident #1 on 2/12/25, 2/13/25, 2/14/25, 2/15/25 and 2/16/25. CNA #1 stated that Resident #1 was wandering, exit seeking, refusing care, distressed frequently since arrival on B2 Unit. CNA #1 states that he/she was not told Resident #1 had eloped several times in Residential Care. On 2/28/25 at 9:49 a.m., during an interview with CNA #2, who worked shifts with Resident #1 on 2/12/25, 2/13/25, 2/15/25 and 2/16/25. CNA #2,…
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 · D2025-03-05 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to monitor targeted behaviors to support the use of antipsychotic and antianxiety medications for 1 resident reviewed for unnecessary medications and behavior monitoring. Findings: Review of Resident #1's Physician Order Sheet has the following orders for Psychotropic Medications: -Sertraline 100 mg(milligram) tablet one time daily oral for Unspecified dementia, Moderate, with mood disturabance. -Clonazepam 0.5 mg tablet two times daily oral for Generalized Anxiety disorder -Lorazepam 100 % power (0.25 ml) topical As needed Every Four Hours for Ninety Days for Generalized Anxiety Disorder Review of Resident #1's Physician Order Sheet order, dated 2/12/25 that states: Behavioral/Psychotropic Medication Monitor Notes: Behavior monitoring for psychotropic medications below: Antipsychotics, Antianxiety, Antidepressants, Sedative/hypnotics *Please document ALL behaviors including those Normal for the resident. Physical Monitors: 1. Behavioral Symptoms/Effective?/Non-Pharmacological Interventions/Number of Episodes/Psychoactive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Ecited before2024-06-26 · 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 in good repair and in sanitary condition for 2 of 2 units. Findings: On 6/26/2024 at 2:00p.m. during an environmental tour with a Cooperate Quality Improvement Nurse, the following were observed: On the Second Floor - B-2 Unit Resident room [ROOM NUMBER] - Window curtain stained, Resident room [ROOM NUMBER] - Window curtain off track, Resident room [ROOM NUMBER] - Stained ceiling tile above bed A Resident room [ROOM NUMBER] - Large chip out of the laminate on the front of the sink creating an uncleanable surface, Laminate on the left side of the sink is loose and could break creating a hazard. Resident room [ROOM NUMBER] - Window curtain stained, Resident room [ROOM NUMBER] - Resident bathroom toilet will not stop running. Next to Second floor Nurses' station hand sanitizer dispenser has had the drip catch cup torn away leaving screw holes in the wall that are rough and could be an injury…
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 before2024-06-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to follow the facility Falls Management Policy for 8 of 8 residents reviewed for falls thus far in 2024. Resident (#1,#6, #13,#30, #35, #36, #39 #41,) Findings: 1. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) for Resident #13 who was admitted on [DATE], for Long Term Care and found that Resident #13 had fallen six times (1/7/24, 2/29/24, 3/1/24, 3/19/24, 4/12/24, and 5/20/24). The falls lacked complete documentation per facility's Fall Management Policy, including updated Fall prevention interventions in the care plan. Review of Resident #13's Progress Notes dated 1/7/24, 2/29/24, 3/1/24, 3/19/24, 4/12/24, and 5/20/24 shows that Post Fall Observations were done but all other required documentation is lacking, i.e. documentation for three shifts post fall and documentation of the Director of Nursing (DON) follow-up as stated in the facility's policy. 2. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) 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 · Ecited before2024-06-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 initial kitchen observations completed on 6/24/24 and 6/25/24. Additionally, the facility failed to ensure that food temperatures were recorded. Findings: 1- On 6/24/24 at 8:50a.m. - Initial observation of the Kitchen: Observed two unlabeled and undated pans of deserts in the fridge - The Food Service Director (FSD) stated, That is today's desert. Observed soiled ceiling tiles - The FSD stated that the ceiling was last cleaned a couple of months ago. Observed a wall mounted fan with light to moderate dirt blowing on the cooking area. Observed a cart mounted fan with moderate to heavy dirt blowing on the cooking area When the cook was asked for the temperature log while cooking today's breakfast she stated, I did not get them on here. She showed the surveyor the log pages and it was noted that documentation of temperature while cooking was lacking since last Friday 6/21/2024. She stated that she was not here over the weekend, but that they have been…
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 · E2024-06-26 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 reviews and interviews, the facility failed to perform adequate screening and documentation for Pneumococcal and/or Influenza vaccination as required for 2 out of 5 residents screened for vaccinations. (Resident #1, Resident #6) Findings: 1. On 6/25/24, a surveyor reviewed Resident #1's Electronic Medical Record (EMR) and found no Pneumococcal vaccinations recorded under Immunizations. Resident #1 was admitted to the facility on [DATE]. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #1 had received, been offered, or refused the Pneumococcal vaccination. 2. On 6/25/24, a surveyor reviewed Resident #6's EMR and found no Pneumococcal or Influenza vaccinations were recorded. Resident #6 was admitted to facility on 10/26/23. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #6 had received, been offered, or refused the Pneumococcal or Influenza vaccinations. A surveyor reviewed the facility policy…
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 · E2024-06-26 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — 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 perform adequate screening and documentation for coronavirus (Covid-19) as required for 2 out of 5 residents screened for Covid-19 vaccinations. (Resident #1, Resident #6) Findings: 1. On 6/25/24, a surveyor reviewed Resident #1's Electronic Medical Record (EMR) and found no coronavirus (Covid-19) vaccinations recorded. Resident #1 was admitted to the facility on [DATE]. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #1 had received, been offered, or refused the Covid-19 vaccination. 2. On 6/25/24, a surveyor reviewed Resident #6's EMR and found no coronavirus (Covid-19) vaccinations recorded. Resident #6 was admitted to facility on 10/26/23. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #6 had received, been offered, or refused the Covid-19 vaccinations. Review of Centers for Disease Control (CDC) guidelines for Covid-19 vaccinations for Long…
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 before2024-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to provide a call bell to obtain assistance while on the bedside commode for 1 of 3 residents assessed to be a high risk for falls (Resident #1) Findings: On 6/25/24 a surveyor reviewed Resident #1's Electronic Medical Record and found that Resident #1 was admitted to facility on 1/26/24 with respiratory failure with hypoxia and since has had 8 unwitnessed falls. Resident #1 was rated upon admission as being a high risk for falls. On 6/25/24 a surveyor reviewed the progress notes in Resident #1's Electronic Medical Record (EMR) dated 3/22/24 and found a nurse's note that stated Resident was assisted to bed-side commode, CNA left her with call-bell not within reach. She then called out and fell to knees then onto her back (per resident). On 6/25/24, a surveyor reviewed the facility's Resident Incident Reporting Form, dated 3/23/24, for an incident that occurred 3/22/24 at 5:00a.m. that states (Resident #1 was assisted to bedside commode, then reaching for call bell fell onto floor mat and was found lying on her back. 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.
- Potential for harm · F2023-03-10 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to implement their Antibiotic Stewardship Program (ASP) related to tracking of infections. This has the potential to affect all residents for risk of infection. Finding: North Country Associates Policy & Procedure: Antibiotic Stewardship Program, revised 1/2019, under Infection Preventionist: A. Monitors and supports antibiotic stewardship activities through rounds, review of provider orders, documentation, and available reports. B. Tracks antibiotic therapy through use of line listings and pharmacy report. C. Reviews antibiotic resistance patterns: a. Monitors Healthcare-Associated Infections, Multidrug Resistant Organisms (HAI MDROs) on Monthly Line Listings and Infection Control Report looking for increased rates or trends. b. Compares with center antibiogram to look for commonalities The facility Matrix For Providers provided to the survey team indicates that two residents has a Urinary Track Infection and 1 resident has sepsis. On 3/8/23 at 1:36 p.m., the Quality Improvement Specialist (QIS) stated, I…
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 · F2023-03-10 · tag F0885 — failed to notify residents/families about COVID-19 — widespreadReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and Centers for Medicare and Medicaid Services' (CMS) Corona Virus Disease of 2019 (COVID-19) Long-Term Care (LTC) Facility guidelines, the facility failed to notify resident representatives of resident and/or confirmed positive cases of COVID-19 in a timely manner. This has the potential to affect all residents in the facility. Findings: On 3/9/23, a review of the facility's line listing for positive COVID-19 testing stated the following: On 1/22/23, 1 confirmed case was identified by Point of Care (POC) testing. On 1/23/23, 1 confirmed case was identified by POC testing. On 1/24/23, 1 confirmed case was identified by POC testing. On 1/28/23, 3 confirmed cases were identified by POC testing. On 1/30/23, 2 confirmed cases were identified by POC testing. On 2/1/23, 3 confirmed cases were identified by POC testing. On 2/3/23, 1 confirmed case was identified by POC testing. On 2/10/23, 1 confirmed case was identified by POC testing. On 2/13/23, 1 confirmed case was identified by POC testing. A review of the Centers for Medicare & Medicaid Services…
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 before2023-03-10 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 2 of 2 resident units (A1 and B2). In addition, the facility failed to provide a homelike environment in the area of dining by serving meals on paper products for an extended period of time. Findings: 1. On 3/6/23 at 10:30 a.m., on 3/7/23 at 10:08 a.m. and on 3/9/23 at 8:42 a.m., observation of room [ROOM NUMBER] bathroom to have an unlabeled urinal stored on top of toilet and room [ROOM NUMBER] to have a urine hat stored on the floor next to the toilet, a folded towel underneath the trash can and 3 graduate containers on the back of the toilet. On 3/6/23 at 3:20 p.m., room [ROOM NUMBER] privacy curtain was stuck half open on the tracks. On 3/9/23 at 8:51 a.m., the shower room on A1 unit had a black and orange color substance along base of tiles at floors edge. On 3/9/23 from 10:14 a.m. - 10:22 a.m., an environmental…
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 before2023-03-10 · 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 reviews and interview, the facility failed to follow physician orders for 2 of 5 residents reviewed for unnecessary medications (Resident #35, and #13). Findings: 1. On 3/9/23, Resident #35's clinical record was reviewed and included a physician order, dated 1/17/23, that directed staff to check vital signs every 6 hours x 3 days and call Provider if heart rate was greater than 100, systolic blood pressure was less than 100, respiratory rate was equal to or greater than 24, and temperature was greater than 100, for a diagnosis of UTI (urinary tract infection). Documentation in the Electronic Treatment Administration Record (TMAR) for January, indicated that on 1/17/23, 1/18/23, 1/19/23, 1/20/23, and 1/21/23 staff initialed that the temperature, pulse, respiratory rate, and blood pressures were taken; however, there was no evidence of temperature, pulse, respiratory rate, and blood pressures taken every 6 hours for three days from 1/17/23 through 1/21/23. On 3/9/23 9:47 a.m., in an interview with B2 Unit, Registered Nurse (B2-RN) she looked up vital signs from 1/17/23…
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 · E2023-03-10 · 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 3 medication carts reviewed and failed to ensure that medications were stored properly by having unlocked, unattended medication carts allowing residents and unauthorized persons access to medications, on 2 of 5 days of survey. Findings: 1. On 3/6/23 at 9:20 a.m. two surveyors observed an unlocked and unattended medication cart in the hallway of the A1 unit for approx. 5 minutes. During this time, 3 residents were observed in the hallway. Upon return to the medication cart the RN2 confirmed she had left the medication cart unlocked and unattended. 2. On 3/7/23 at 12:55 p.m., during review of medication cart #1, on B2 unit with the charge nurse, a surveyor observed a bingo card containing Tramadol 50 mg tabs with the expiration date of 1/31/23. This finding was confirmed with the charge nurse. 3. On 3/9/23 at 8:54 a.m., a surveyor observed RN2 walk away from an unlocked medication cart, walked down the hallway and enter a resident's room,…
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 before2023-03-10 · 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, and review of the facility's sink/bucket sanitizer form/policy and procedure and review of the food storage policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, failed to remove expired foods, failed to label and date foods in the walk-in freezer, and failed to monitor the chemical sanitizer levels for the sanitizing buckets for 2 of 5 survey days (3/6/23 and 3/7/23) in the kitchen. This has the potential to affect all residents. Findings: 1. On 3/6/23 at 9:13 a.m., during initial kitchen tour with the Food Service Director, the following findings were observed: - Stove top with flat grill: front and sides coded with dried food particle, oil dripping down sides/front, front open area of flat grill where the dials are located has heavy dust coded wires. - Steam table bottom shelf /base and legs have crumbs/debris, dried on food particles throughout. - Texture table bottom shelf with crumbs/debris, dried on food particles throughout - The Kitchen floor had dirt, trash and food debris around…
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 · E2023-03-10 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 2 of 3 dumpsters for 3 of 5 days of survey. (3/6/23, 3/7/23, 3/8/23) Findings: On 3/6/23 at 8:31 a.m., 2 surveyors observed a volunteer open dumpster #2's lid, leaving it open. Then at 8:44 a.m., 2 staff approached the open dumpster, dumped 2 bags of trash, leaving dumpster open. On 3/7/23 at 7:02 a.m., observation of both dumpster #1 and #2 with the lids left open. On 3/8/23 at 7:56 a.m., observation of dumpster #2 with 2 garbage bags on the ground next to the dumpster and scattered trash i.e., gloves, plastic ware and a paper cup on the ground next to dumpster. On 3/8/23 at 4:02 p.m., observation of an empty dumpster with of a bag of trash on top, the trash bag half sticking out and is ripped with contents on the ground. On 3/9/23 at 8:07 a.m., during an interview with 2 surveyors, the above was confirmed with the Administrator and the [NAME] President of Clinical Operations. During this interview the Administrator…
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 · E2023-03-10 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and document review, the facility failed to review and update the Facility Assessment at least annually (between 2017 -2022). Finding: On 3/6/23 at 9:40 a.m. during the entrance conference the survey team requested documents to include the Facility Assessment. On 3/9/23 at 8:00 a.m., the Administrator provided to the survey team the Facility Assessment, stating the date on the face sheet of the Facility Assessment is 2017, but it has been revised, it just has not been taken to QAPI as of yet. The survey team could not locate any evidence that a review or update of the Facility Assessment was completed between 2017-2022. The date of the most recent review/update to the Facility Assessment was noted to be dated 3/6/23, the date the survey team entered the facility for the annual survey and first request the Facility Assessment. On 3/9/23 at approximately 11:30 a.m., a surveyor confirmed the lack of review and updates to the Facility Assessment between 2017-2022, in an interview with the Administrator.
- Potential for harm · E2023-03-10 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and document reviews the facility's Quality Assurance Performance Improvement (QAPI) committee lacked documented attendance of the Administrator and the Medical Director. In addition, the facility failed to present evidence that a quarterly meeting was held 2 of 4 quarters (July 2022 and October 2022). Finding: On 3/7/23, at approximately 9:00 a.m. the Acting Director of Nursing gave the survey team a folder of information marked QAPI. The folder contained minutes from the 1/27/22 meeting, however, the attendance indicated that the Administrator and the Medical Director were not present. The next meeting that was mentioned in the folder was 4/21/22. There were no minutes and no attendance list. On 3/7/23, at 2:30 p.m., in an interview with the Acting Director of Nursing, she stated that there was no more QAPI information that she could find. On 3/8/23, at 8:00 a.m., in an interview with the Acting Administrator, he stated that there was no more documentation to present. He stated, The Committee has not met since April of 2022, due to one thing or another. 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 · D2023-03-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to include a resident in the development of his/her comprehensive plan of care for 1 of 33 sampled residents (#10). Finding: Resident #10 was admitted to the facility on [DATE]. In an interview with Resident #10 on 3/6/23 10:15 a.m., he/she stated I don't get invited, I haven't been to a care plan meeting. The surveyor then asked Would you go to a care plan meeting if you were invited? Resident #10 stated Yes. On 3/8/23 upon review of Resident #10's clinical record, the surveyor noted that the care plan meetings held on 7/15/22, 10/5/22 and 12/28/22, lacked evidence that the resident was invited to care plan meetings. On 3/9/23 1:05 p.m., during an interview with the Social Service Director, she confirmed that she did not invite Resident #10 to the care plan meetings on 7/15/22, 10/5/22 and 12/28/22. The Social Services Director stated that she had only invited the resident representative.
- Potential for harm · D2023-03-10 · 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications (#37). Finding: Resident #37's Physician Order Sheet signed by the physician on 7/21/22 indicated that Resident #37 had been receiving the antipsychotic Olanzapine 5 mg twice daily since 2/15/22. A Pharmacy GDR Tracking Report dated 2/15/23 indicated Resident #37's next GDR eval is due on 2/15/23 The clinical record lacked evidence that a gradual dose reduction was attempted or that a gradual dose reduction was clinically contraindicated for this resident between the dates of 1/26/22 and 2/15/23. The surveyor discussed this finding in an interview with the Quality Improvement Specialist (QIS) on 3/8/23 at 3:20 p.m.
- No harm found · B2026-04-30 · 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 ensure that mail was delivered to all residents on 1 of 6 days, Monday through Saturday. (Saturday) Finding: During a group interview on 4/27/26 at 2:15 p.m., four residents voiced concerns regarding not receiving mail on Saturdays.On 4/30/26 at 1:05 p.m., during an interview, the Senior [NAME] President of Development and Operations confirmed mail was not routinely delivered on Saturdays because mail had previously been lost. The Senior [NAME] President of Development and Operations stated the weekend supervisor will be delivering the mail as needed on Saturdays.
“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
$23,179 in federal fines across 2 penalties.
- $8,278 — penalty dated 2025-06-02
- $14,901 — penalty dated 2025-03-05
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 NORTH COUNTRY ASSOCIATES — 9 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 | 2.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 5 of 5 | 4.3 | +0.7 vs chain |
| Quality measures | 1 of 5 | 2.4 | -1.4 vs chain |
The other 8 homes this chain runs (chain average 2.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ORESTIS, JOHN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/11/2008 |
| CYR, GLEN | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 01/01/2008 |
CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
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 $605K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 205136. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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.