Gregory Wing Of St Andrews Village
145 Emery Lane, Boothbay Harbor, ME 04538 · Non profit - Corporation · 42 certified beds · (207) 633-6996 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
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) | 3 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 | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 | 41.3% | 24.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 5.2% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 13.9% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.9% | 2.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.0% | 11.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.8% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 29.9% | 25.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 4.0% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 33.0% | 29.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.2% | 20.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 74.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 11.0% | 20.8% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 22.7% | 16.1% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
54.6% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.6% 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 32 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 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 34% 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 | 54.6%CMS range 43.8–62.5 | 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 | 10.0%CMS range 5.8–15.6 | 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 | 40.6% | 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 | 46.9% | 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 | 37.5% | 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 | 91.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 2.9–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.72 | 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 42 beds and averages 39.0 residents a day — about 93% occupied, or roughly 3 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 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.75 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.24 hrs/resident/day on weekends vs 4.73 on weekdays — 10% thinner on weekends. RN hours go from 0.69 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · E2025-08-15 · 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 for 1 of 2 units([NAME] Wing), an activity office and the Laundry/kitchen areas on 3 of 3 environmental tours.1. On 8/11/25 from 10:00 a.m. to 10:20 a.m., a surveyor and the Facilities Manager toured the laundry room and the [NAME] Wing hallway and observed the following findings:Laundry: - There was a ceiling tile, over the stackable dryers, that was broken and had fallen out of place. - The entire floor was dirty and heavily soiled with dirt. - There were approximately 10 cracked/broken floor tiles throughout the laundry room. - There were three stained ceiling tiles in the soiled area of the laundry room. [NAME] Wing hallway- A laundry cart had a ripped cover and also had tape on it holding some of the cover together.On 8/11/25 at 10:20 a.m., in an interview with a surveyor, the Facilities Manager confirmed the findings.…
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 before2025-08-15 · 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
Based on record review, interview, and facility policy, the facility failed to ensure an Interdisciplinary Meeting was held within 7 days of completed Minimum Data Set (MDS)/ Assessment Reference Date (ARD) for 3 of 14 Residents reviewed (Resident's (7, 19 and 35). 1. Review of facility policy Care Plans-Comprehensive-Preliminary dated 3/1998 states . The resident's/patient's comprehensive care plan is developed within seven (7) days of the completion of the resident's/patient's comprehensive assessment (MDS) . Review of Resident [R]7's Quarterly MDS/ARD dated 7/18/25. Review of R7's clinical record revealed the IDT was held 7/16/25 (2 days prior to MDS/ARD) completion. During an interview on 8/12/25 at 11:21 a.m., the Licensed Social Worker (LSW) stated that she is supposed to schedule IDTs within 7 days of the MDS /ARD date. At this time LSW confirmed R7's IDT was held 2 days prior to MDS/ARD completion date. 2. Review of Resident (R) 35's clinical record revealed a Minimum Data Set (MDS) admission Assessment was completed on 7/30/25. Further review of the clinical record lacked…
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 before2025-08-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, interviews and facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 2 residents reviewed for respiratory care (Resident [R] 6). Additionally, the facility failed to ensure physician orders were followed for 1 of 2 residents receiving oxygen therapy (R1) and failed to ensure complete and accurate documentation of the assessment and monitoring of the resident's respiratory condition for 2 of 2 residents receiving oxygen therapy (R1, R6). 1. On 8/11/25 at 9:09 a.m. and 11:22 a.m., R1 was observed wearing oxygen (O2) via a nasal cannula (NC) with the concentrator flow rate set at 1.5 liters per minute (L/min). On 8/12/25 at 9:34 a.m. during a follow-up observation, Resident #1 was wearing oxygen via nasal cannula with the concentrator flow rate set at 1L/min. Review of R1's clinical record revealed the following orders: -order with a start date of 6/5/25 for Oxygen 2L/min via NC PRN [as needed] for dyspnea [shortness of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, the facility's Storage - Food and Non Food Items policy, the facility's Sanitation-Warewashing-Mechanical/Manual Cleaning/Sanitizing policy, and the facility's Dish machine Temperature and Cleaning Records, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap cover, floor drain covers and the walk-in freezer; failed to ensure kitchen staff wore appropriate hair coverings; failed to ensure foods were properly dated, labeled and/or discarded past the manufacturer's best used by date for 1 of 1 kitchen tour.(8/11/25)The facility's Sanitation-Ware washing-Mechanical/Manual Cleaning/Sanitizing policy effective date: 04/20/12 noted: Procedure: d) Check temperatures. Record daily the wear washing machines temperatures of both the wash and the rinse cycles on the dishwasher temperature record form. Temperatures shall be maintained in accordance with the manufacturer's instructions.The facility's Storage - Food and Non Food Items…
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 before2025-08-15 · 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 observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (8/11/25, 8/12/25 and 8/13/25).1. On 8/11/25 at 8:30 a.m., two surveyors observed one of two dumpsters with the front right lid open exposing trash. There was also trash on the ground around the two dumpsters. Additionally, two surveyors observed a trash storage area, outside the maintenance shop area, that had trash piled in and on 3 large, uncovered trash receptacles. On 8/11/2025 at 9:12 a.m., in an interview with a surveyor, the Administrator confirmed the finding. 2. On 8/11/25 at 8:30 a.m., a surveyor and the Facilities Manager observation of trash storage area outside the maintenance shop area. 1 of 3 large, uncovered trash receptacles had trash in it. At this time, in an interview with a surveyor, the Facilities Manager confirmed that the staff puts trash in the bins daily to take to the dumpsters at the end of the day and the bins are not covered. 3. On 8/12/25 at 8:15 a.m., a surveyor 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 · Dcited before2025-08-15 · 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 — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 11 residents reviewed for baseline care plans (Resident #19 (R19).R19 was admitted in February 2025. Review of R19's clinical record lacked evidence that a baseline care plan, including goals and interventions, was developed and implemented within 48 hours of admission. On 8/12/25 at 4:00 p.m. during an interview, the Nurse Manager reviewed R19's baseline care plan and confirmed it was not developed and implemented until 4 days after admission.
- Potential for harm · Dcited before2025-08-15 · 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
Based on observation, interview, and record review, the facility failed to ensure a resident's care plan was developed in the area of oxygen use for 1of 2 residents reviewed for respiratory care (Resident [R] 1).On 8/11/2025 at 9:09 a.m. and 8/12/25 at 9:00 a.m., R1 was observed wearing oxygen via a nasal cannula.Review of R1's clinical record indicated he/she has diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) and aspiration pneumonia. Review of R1's Quarterly Minimum Data Set assessment, dated 6/9/25, indicated oxygen therapy while a resident. Review of R1's physician orders revealed the following:-order with a start date of 6/5/25 for Oxygen 2L/min [2 liters per minute] via NC [nasal cannula] PRN [as needed] for dyspnea [shortness of breath], comfort, and/or 02 [oxygen] sat [saturation] below 90% .-order with a start date of 8/11/25 for Oxygen 2L/min via NC every shift for dyspnea, comfort.Review of R1's care plan lacked evidence that goals/interventions for oxygen were implemented until after the start of the survey (8/11/25).On 8/12/2025 at 4:00 p.m. during an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-15 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of performance evaluations and interviews, the facility failed to complete annual performance evaluations timely, at least once every 12 months, for 2 of 5 Certified Nursing Assistants (CNA's 1 & 2).1.Review of CNA1's 2024 Annual Performance Appraisal initiated by Nurse Manager on 10/10/24 states Impersonation Mode You are currently impersonating another user. To stop impersonating, click on the user menu and select Stop Impersonating. I understand that my electronic signature carries the same legal weight and authority as my written signature. Name [CNA1] date 8/12/25. sign: is blank. This evaluation lacks evidence that it was reviewed/or signed by CNA1.During an interview on 8/13/25 at 10:55 a.m., CNA1 reviewed 2024 Annual Performance Appraisal dated 8/12/24 and stated she did not receive or sign an evaluation yesterday (8/12/25), and she was working all day and never went onto a computer all day long.2. Review of CNA2's 2024 Annual Performance Appraisal initiated by Nurse Manager on 10/28/24 states . I understand that my electronic signature carries the same legal…
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 · D2025-08-15 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure 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 Certified Nurse's Aide (CNA) employee education reviews and interview, the facility failed to monitor and ensure that a CNA attended the required 12 hours of annual in-service education, for 1 of 5 randomly selected CNA's employed greater than 1 year. (CNA1).Certified Nursing Assistant (CNA1) was hired on 4/11/16.CNA1 's yearly Inservice education records from 4/11/24 through 4/11/25 state she received 7.09 hours of Inservice hour education and not the required 12 hours. During a review of CNA1's in-service hours on 8/13/25 at 11:03 a.m., Nurse Manager confirming CNA1 did not receive the required 12 hours of in-service education.
- Potential for harm · F2024-05-15 · tag F0909 — failed to maintain a comfortable temperature — widespreadRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for 37 of 37 beds. Findings: On 5/14/24 at 11:42 a.m., a surveyor met with the Director of Facilities and asked for the bed gap measurements and side rail gap measurement documentation. The Director of Facilities stated that he had never heard of those before and he would check with the other maintenance men. He came back and stated that they had never heard of them either. At this time, the Director of Facilities confirmed that the facility had never completed bed gap measurements and/or side rail gap measurements at the facility for any of the resident's beds. On 5/14/24 at 11:50 a.m., in an interview with the Administrator and the Director of Facilities, the Administrator stated that she had never heard of bed gap measurements or side rail gap measurements. At this time, the Administrator confirmed that the facility had never completed bed gap measurements and/or side rail gap…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Ecited before2024-05-15 · 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, interview and the facility's Storage - Food and Non Food Items policy effective date: 04/20/12, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap base, floor drains, ceiling vents, lights and ceiling tiles; failed to ensure facial hair protection was worn; and failed to ensure foods in the walk-in freezer were dated and/or labeled. Findings: On 5/13/24 from 9:10 a.m. to 9:35 a.m., an initial kitchen tour was conducted with the Food Service Director in which the following findings were observed: > The cement base under the grease trap had chipped/missing paint creating an uncleanable surface. > There were 3 floor drain grates that had chipped/missing paint creating uncleanable surfaces. > There were 3 ceiling vents, above food preparation areas, and surrounding ceiling tiles that were moderately soiled with dust. > The dry storage room had a ceiling vent and a light that were moderately soiled with dust. > There was a male kitchen worker with facial hair that was not wearing facial hair protection while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-15 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (5/13/24, 5/14/24 and 5/15/24). Findings: 1. On 5/13/24 at 9:00 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. 2. On 5/14/24 at 8:15 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. 3. On 5/15/24 at 8:15 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. On 5/15/24 at 10:50 a.m., in an interview, the surveyor discussed the findings with the Administrator and the Director of Nursing at the survey Exit meeting.
- Potential for harm · D2024-05-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 facility policy, record reviews and interviews, the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 6 residents reviewed for advanced directives (Resident's #24 and #26). Findings: Review of facility policy titled Advance Directives effective date 10/1991 states Purpose: To comply with Federal and Critical access hospitals conditions of participation, the Federal Patient Self-Determination Act, the Main Uniform Health Care Decisions Act and to provide the community with a method for healthcare decision making, [NAME] health has adopted this Advance Directive Policy to provide: 1. B. Written information to patients and or their support person concerning their right to make decisions about medical care. C. Documentation of patients declaration of an advanced healthcare directive form. 2.B.1. [NAME] health will provide written information to all adult patients,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy, record review and interviews, the facility failed to report in a timely manner, an injury of unknown origin with serious injury to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) for 1 of 1 residents sampled for injuries/accidents. (#27) Finding: Review of the facility's Abuse. Neglect, and/or Exploitation Reporting Policy # 02-7080-246, effective date: 05/1999, noted in 1. Policy Statement: 2. All personnel who suspect any incident of resident abuse, neglect or exploitation, including injuries of an unknown source or misappropriation of resident property, must promptly report the incident to (the Department of Health and Human Services)DHHS through the Division of Licensing and Regulatory Services(DLRS) within 24 hours of the incident and to Adult Protective Services. Attachment one: 1. All incidents: All incidents must be reported to DHS through the division of licensing and regulatory services DSLRs . Within 24 hours of the incident or the next working day, when the incident…
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 before2024-05-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 3 residents that were reviewed for new admissions. (#189) Finding: On 5/13/24 at 10:25 a.m., During an interview, Resident #189 stated, he/she has a pacemaker which is checked via his/her phone. Resident #189 was admitted to the facility on [DATE]. The hospital history and physical included information that the resident had a pacemaker placed for tachybradycardia syndrome and heart block. Further review indicates resident #189's code status as Do Not Resuscitate. Review of the clinical record lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #189's immediate health and safety needs for the above concerns. On 5/14/24 at 10:19 a.m., during an interview,…
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 before2024-05-15 · 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
Based on record reviews, interviews and facility policy, the facility failed to update/implement goals and interventions in the area of antibiotic medication use for 1 of 6 residents reviewed for medications (Resident #15). Findings: Review of facility policy Care Planning/Interdisciplinary Team/Family Participation dated 3/98 states .A comprehensive care plan is developed within seven days of completion of the resident comprehensive assessment (MDS).Reviewing care plans to assure that: They reflect the resident's actual needs . Review of Resident 15's care plan initiated 3/22/23 revealed .Focus: I have a Urinary Tract Infection; Goal: UTI will resolve without complications; Interventions: Administer antibiotic as prescribed by Provider Review of Resident 15's clinical record revealed order with start date of 2/23/24 for Amoxicillin-Pot Clavulanate 875-125 mg tablet. Give 1 tab by mouth twice daily for 7 days for UTI [Urinary Tract Infection]. Further review of Resident #15's clinical record lacked evidence his/her care plan was updated after this medication was completed. 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 · Dcited before2024-05-15 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 7 sampled residents (Resident #17). Findings: Review of facility policy Care Planning/Interdisciplinary Team/Family Participation dated 3/98 states .A comprehensive care plan is developed within seven days of completion of the resident comprehensive assessment (MDS).Reviewing care plans to assure that: They reflect the resident's actual needs . Resident #17 was admitted to the facility on [DATE]. During review of Resident #17's medical record, the surveyor noted quarterly Minimum Data Set (MDS) Assessments dated 2/6/24. The clinical record lacked evidence that a care plan meeting was held by the IDT, resident and/or representative for this assessment. In addition, the last documented IDT meeting was held on 11/14/23. On 5/14/24 at 2:32 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents reviewed for discharge (Resident #33). Findings: Resident #33 was admitted to facility on 2/9/24 for skilled services. On 2/24/24 resident #33 was discharged to the community. The clinical record lacked evidence a recapitulation of the resident's stay was completed at discharge. On 5/15/24 at 10:09 a.m., during an interview, the Director of Nursing indicated that she reviewed Resident #33's clinical record and was unable to find evidence that a recapitulation of stay was completed for this resident.
- Potential for harm · D2024-05-15 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a commode for 1 of 3 days of survey. (5/13/24) Finding: On 5/13/24 at 10:05 a.m., two surveyors observed a commode over a toilet in Resident room [ROOM NUMBER]'s bathroom. The left armrest had been worn down and the right armrest was broken open with sharp/jagged plastic edges exposed. On 5/13/24 at 10:13 a.m., in an interview with two surveyors, the Director of Nursing confirmed that the sharp/jagged plastic edges on the armrest was an accident hazard.
- Potential for harm · Dcited before2024-05-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate documentation for 1 of 3 sampled residents reviewed for Oxygen (#189). Finding: On 5/13/24 at 10:25 a.m. and on 5/14/24 at 9:56 a.m., observations of Resident #189 on Oxygen set at 2 Liters Per Minute (LPM) via nasal cannula. Review of the hospital discharge history and physical states the resident has diagnosis of chronic respiratory failure with hypoxia and obstructive sleep apnea and required oxygen at home at 2LPM continuously. The Assessment and Plan states, Patient on continuous home oxygen, 2 LPM via nasal cannula. Review of the Physician order dated 5/7/24 states O2 every day and night shift for ILD (Interstitial Lung Disease), the order lacked the amount of oxygen / LPM to be administered. On 5/14/24 at 10:19 a.m., during an interview, both the surveyor and the Registered Nurse (RN) admission Coordinator reviewed the admission orders which indicated the 2LPM. The RN stated she will update the orders immediately to reflect the LPM of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and facility policy, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, failed to determine that drug records are in order and that an account of all controlled drugs is maintained, failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for 1 of 2 units reviewed for medication storage ([NAME] Wing). Findings: Review of facility policy Controlled Substance Storage dated 5/1/18 states .At each shift change, or when key are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two appropriately licensed/certified personnel and is documented . 1. Review of controlled substance logbook labeled [NAME] Wing Book #16 index revealed page 81 was blank. Further review revealed page 81 belonged to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · 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
Based on record review, interview and facility policy, the facility failed to show evidence of documentation to justify the use of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications (#17 and #28). Findings: Review of facility policy Restraints, Physical/Chemical dated 2/98 states .Psychotropic Medication Implementation: .The facility will follow pharmacy recommendations for indication, gradual dose reduction and monitoring . 1. Resident #17 was admitted to on 10/30/23 with a diagnosis of anxiety. Review of Resident #17's clinical record revealed Pharmacy Review dated 2/28/24 stating Patient has an order for Lorazepam 0.5mg [milligram] tab give 1 tab po [by mouth] as needed. [He/she] uses this medication infrequently. According to the regulations this medication is a psychotropic and requires 2 attempts at a gradual dose reduction in the first year and then every year after. If it is not appropriate to attempt a dose decrease at this time, the provider may wish to document rational for contraindication. [Provider response]: Disagree. Further review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-04 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain the dignity of 2 residents (Residents #7 and #133) related to urinary collection bags and locomotion during 2 of 3 days of survey (5/2/22 and 5/3/22). Findings: 1. On 5/2/22 at 12:11 p.m., a surveyor observed from the hallway an uncovered urinary catheter collection bag containing urine attached to Resident #133's bed frame. 2. On 5/3/22 at 7:29 a.m. and at 11:37 a.m., a surveyor observed from the hallway an uncovered urinary catheter collection bag containing urine attached to Resident #133's bed frame. At 11:47 a.m., the surveyor discussed with dignity concern with the [NAME] Unit Charge Nurse, Registered Nurse (R.N.). On 5/3/22 at 2:20 p.m., a surveyor observed Resident #7 being transported in a wheelchair down the long term care unit hallway, facing backwards with his/her feet dragging on the floor. The surveyor stopped the R.N. who was locomoting (moving from one place to another) the resident backwards and explained the dignity concern.…
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 · D2022-05-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, facility policy review, and interview, the facility failed to ensure that neurological assessments were completed as directed by facility policy for 1 of 1 residents who had fallen and sustained a head injury (Resident #21). Finding: The Facility's policy, Fall Prevention, effective 10/1/13, directed staff under Post Fall Interventions: Perform and document vital signs and neurological assessment for any unwitnessed fall or if the patient's head contacts a hard surface e.g. floor or counter, regardless of the absence of apparent neurological injury. Vitals should be performed every 15 minutes times (x) 4, than every hour x 4, then every 4 hours x 48 hours. The Neurological Monitoring Form directed that the assessment was to include the date, time, conscious state, pupil response, pupil size, hand grasp, blood pressure, pulse, respiratory rate and pattern, and nausea/vomiting. Resident #21's clinical record contained documentation under progress notes - On 4/22/22 at 07:00, Resident #21 was found on floor in front of his/her bathroom with walker to his/her…
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 · D2022-05-04 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that a Medical Provider made required visits, reviewed the total plan of care, and wrote a progress note as often as required for 2 of 13 sampled residents (Resident #7 and #21). Findings: 1. Documentation in Resident #7's clinical record indicated that the physician visited the resident and wrote a progress note on 2/11/22. The next required physician visit and progress note was due by 4/23/22 (with a 10 day grace period was 11 days overdue). On 5/3/22 at 2:43 p.m., in an interview with a surveyor, the Director of Nursing confirmed that the physician visit was late. 2. Documentation in Resident #21's clinical record stated that the resident was admitted on [DATE]. A Medical Provider visited on 12/17/21, reviewed the total plan of care, and wrote a progress note. The next required physican vist and progress note was due by 1/21/22 (with a 10 day grace period). The next date the Medical Provider visited that included reviewing the total plan of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-04 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure that cooked foods were handled in a sanitary manner for 1 of 3 days of survey (5/3/22). Finding: The Facility's policy, Sanitation - Preparation of Food, revised on 7/21, stated, Do not handle, with bare hands, food items that are to be served uncooked or are ready to eat. Use tongs, deli sheets or gloves when handling these foods. On 5/3/22 at 9:15 a.m., during a tour of the kitchen, a surveyor observed a dietary staff member peeling and touching cooked eggs with bare hands. On 5/3/22 at 11:18 a.m., during an interview with the Food Service Director, a surveyor confirmed this observation.
- No harm found · B2024-05-15 · 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 review of the quarterly Quality Patient Resident Safety Committee meeting attendance sheets and interview, the facility failed to ensure that the Infection Preventionists attended 4 of 4 quarterly meetings. Finding: A review of the quarterly Quality Patient Resident Safety Committee meeting attendance sheets indicate that the Infection Preventionists did not attend the 5/24/23, 8/23/23, 11/15/23 and 2/28/24 quarterly meetings. In addition, the facilities Senior Living Performance Improvement & Safety Plan for 2023/2024 under section Program Organization states, The Senior Living Performance Improvement Committee is a Board Committee . Membership of the Committee shall consist of representation from the following constituents: Administration, Board of Trustees, Quality and Safety, Medical Director and/or designee if unable to attend, Pharmacist, Risk Management, Director of Nursing Services and/or designee if unable to attend and three others members of the facility staff. The improvement plan lacks the federally required Infection Preventionists as a committee member. 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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MAINEHEALTH SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 08/26/1996 |
| BEAULE, LISA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| BOOTHBY, LESLIE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| BRESNAHAN, ANN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 10/01/2023 |
| CHIN, MATTHEW | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| CIMINO, CHRISTOPHER | Individual | CORPORATE DIRECTOR | — | since 10/01/2025 |
| COSTER, KATHERINE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| FISHER, MORRIS | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| HASENFUS, NANCY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| HENTZEL, QUINCY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| HERLIHY, KATHLEEN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| KENT, JENNIFER | Individual | CORPORATE DIRECTOR | — | since 10/01/2025 |
| KUMAKI, DAVID | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| LOFFREDO, BRETT | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| LOISELLE, DANIEL | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| MANNING, PETER | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| MCCARTHY, MARIE | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| NOYES, BRIAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| ORLANDO, MATTHEW | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 10/01/2024 |
| RAND, AMANDA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| RYAN, THOMAS | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2019 |
| TERRY, LINDA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| WATSON, STUART | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| WOOD, PETER | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| BAYMAN, CHARLES | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 10/01/2025 |
| ELKINS, KELLY | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| HUNTER, ROBERT | Individual | CORPORATE OFFICER | — | since 12/01/2025 |
| KELSCH, BETH | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 01/01/2025 |
| MUELLER, ANDREW | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 07/15/2024 |
| PRINTY, WAYNE | Individual | CORPORATE OFFICER | — | since 07/01/2003 |
| SHANKLIN, HEATHER | Individual | CORPORATE OFFICER | — | since 10/01/2025 |
| ALAMO, AQUILINO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2024 |
| CHASSE, ALISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| ROSE, KATHARINE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2024 |
| TUTT, DAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| WUSTERBARTH, CHERYL | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/01/2024 |
CMS files one row per role, so the 65 rows in the source record cover these 36 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
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 205158. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-15, 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 →
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