Brewer Center For Health & Rehabilitation, LLC
74 Parkway South, Brewer, ME 04412 · For profit - Limited Liability company · 111 certified beds · (207) 989-7300 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- about 22% of its spending goes to commonly-owned related companies
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.3% | 24.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 12.2% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 2.2% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 11.4% | 11.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.0% | 4.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 25.0% | 25.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.6% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.9% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.2% | 29.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.8% | 20.2% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.4% | 74.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.2% | 20.8% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.2% | 16.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.56 | 1.45 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.29 | 2.01 | 1.80 | better |
‡ 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.
59.0% 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 192 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 92 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 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 59.0%CMS range 50.2–66.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.9–13.6 | 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 | 68.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.5% | 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 | 56.5% | 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 | 99.4% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.5% | 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 | 10.4%CMS range 6.9–14.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 111 beds and averages 102.5 residents a day — about 92% 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 4.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.32 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.95 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 4.28 hrs/resident/day on weekends vs 4.93 on weekdays — 13% thinner on weekends. RN hours go from 1.50 to 0.89 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% 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 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.
31 citations, most serious first. The 10 most serious are shown; the remaining 21 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-23 · 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 review of a reportable incident form, record review, and interviews the facility failed to ensure that a resident was free from injury when the facility staff failed to properly transfer a resident causing the resident to sustain a fractured rib for 1 of 1 residents reviewed for falls [Resident #1 (R1)].Findings:On 6/8/26, The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 6/5/26 at 1:00 p.m., Resident #1 had a controlled fall to the floor during a transfer. with an outcome of an 8th rib fracture.On 6/8/26, The Division of Licensing and Certification received the facility's 5 day Follow up on Incident reported 6/5/26, which indicated R1 experienced a fall during a mechanical lift transfer from wheelchair to bed in the resident's room while being assisted by 2 [Certified Nursing Assistants (C.N.A.s)]. During the transfer, the resident's legs were positioned on either side of the lift boom. The mechanical lift was stationary at the time of the incident. While staff were rotating the suspended resident to achieve proper…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-30 · 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 clinical record reviews and interviews, the facility failed to ensure physician orders were followed for 4 of 6 resident's reviewed for medications (Resident #45 [R45], R103, R125, and R74). Findings: 1. On 4/29/26, a review of R45's clinical record was completed. Documentation in the physician orders indicated that an order was written on 4/23/26 for Ceftriaxone Sodium (antibiotic) injection solution, reconstitute 1 gram (Ceftriaxone Sodium), inject 1 gram intramuscularly one time a day for a urinary tract infection for 5 days. A review of R45's Treatment Administration Record (TAR) indicated that the antibiotic was administered on 4/23/26, 4/24/26, 4/26/26 and 4/27/26. There was no evidence that the resident received the antibiotic on 4/25/26. On 4/29/26 at 11:58 a.m., in an interview with the surveyor, the Director of Nursing confirmed that the antibiotic Ceftriaxone had not been administered on 4/25/26. 2. On 4/28/26 at 12:53 p.m., during an interview with a surveyor, R103 stated he/she has had trouble with constipation and diarrhea since admission to the facility. 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 · E2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing dishes and food in a sanitary manner. In addition, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 4 days of survey (4/27/26 and 4/29/26).Findings:On 4/27/26 at 10:48 a.m., during the initial tour of the kitchen, a surveyor, the Food Service Director (FSD) and the Maintenance Director observed and confirmed that the ice machine had 3 draining pipelines, one drain pipeline extended several inches into the receiving vessel, and one was less than 1 inch from the receiving vessel, in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe…
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 F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 units observed for dining services (Unit A).Finding: On 4/27/26 at 12:50 p.m., a surveyor observed a Certified Nursing Assistant (CNA) serve lunch to 2 residents at a table of 3. Resident #98 (R98) was not served at that time. On 4/27/26 at12:54 p.m., a surveyor observed the CNA serve another table of 3 residents. R98 was still waiting to be served. R98 began calling out to staff in the room stating, is that mine? and gesturing toward a meal tray sitting at the other end of the room. On 4/27/26 at 12:58 p.m., a staff member stopped assisting a resident to eat in response to R98's request for food. The meal tray at the end of the dining room did not belong to R98. The staff member requested a meal tray from the kitchen for R98. On 4/27/2026 at 1:00 p.m., R98 was served their meal (10 minutes after his/her table mates). On 4/27/26 at 1:03 p.m., during an interview with a surveyor, the CNA stated that usually there are 4 staff assisting in…
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 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 interviews and clinical record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission that included the instructions needed to provide the minimum healthcare information necessary to properly care for 1 of 5 sampled residents (Resident #122 [R122]). Finding: On 4/27/26 at 11:42 a.m., in an interview with a surveyor, R122 stated he/she was admitted to the facility recently and the facility has not discussed his/her plan of care and thinks that it will be done today or tomorrow. R122's clinical record was reviewed and the clinical record lacks evidence that R122's baseline care plan was implemented or developed to provide the instructions needed to provide minimum healthcare necessary to properly care for R122 within 48 hours of admission. On 4/29/26 at 11:51 a.m., during an interview with the Regional Director of Clinical Operations, a surveyor confirmed that R122's baseline care plan was not developed within 48 hours of admission.
- Potential for harm · D2026-04-30 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly 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 observations, interviews, and record review, the facility failed to ensure bed mattresses were compatible with bed frames and identify areas of possible entrapment for 3 of 102 residents observed on survey [Resident #78 (R78, R47, and R45].Findings:1. On 4/28/26 at 8:56 a.m., a surveyor observed R78 lying in bed. The bed frame was observed to be larger than the mattress with several inches exposed at the foot end of the bed creating a potential area for entrapment of body parts. During an interview with the surveyor, R78 stated his/her foot has gotten caught in the gap more than once over the past several months when he/she attempted to get up to the bathroom at night.On 4/28/26 at 2:32 p.m., during an interview, a surveyor and the Maintenance Director observed and confirmed that R78 was lying in bed; the mattress did not fit the bed frame leaving a 5-inch gap at the foot of the bed creating the potential for entrapment of body parts.2. On 4/28/26 at 9:40 a.m., a surveyor observed R47 lying in bed. The bed mattress did not fit the bed frame with a 7-inch gap between the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · 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 review, facility investigation and interview, the facility failed to ensure that a resident's care plan was followed for transfer assist for 1 of 1 sampled resident (Resident #1 [R1]).On 2/19/26, R1's clinical record was reviewed. Documentation indicate that in the past year, R1 suffered a stroke and his/her left side is affected. R1's left arm is flaccid and R1 is unable to move the left arm. Documentation in a nurse note, dated 2/10/26, indicated CNA1 was transferring R1 from his/her wheelchair to the bed. The transfer failed and CNA1 lowered R1 to the floor. The charge nurse assessed the resident and no visible injuries were identified.A review of R1's care plan for the problem deficit in functional mobility, dated 7/28/25, indicated two staff are needed for transfers.A review of the facility investigation and CNA1's written statement regarding the incident was completed. CNA1 wrote that she did not follow the care plan which instructed that two staff are needed for R1's transfers.On 2/19/26 at 9:10 a.m., in an interview with the surveyor, 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 · E2025-03-06 · 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 observation, record review, and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 8 residents reviewed on survey (Resident #14 [R14], [R40] [R29], [R32], and [R82]). Findings: 1. On 3/3/25 at 12:36 p.m., a surveyor observed R14's oxygen concentrator filters to be heavily soiled with dust/debris. Record review indicates R14 receives oxygen 2 liters (L) / minute (min) continuously for the diagnosis of Chronic Respiratory Failure with Hypoxia (inadequate oxygen to the body), and Chronic Obstructive Pulmonary Disease (COPD). 2. On 3/3/25 at 12:40 p.m., a surveyor observed R40's oxygen concentrator filter to be heavily soiled with dust/debris. Record review indicates R40 receives oxygen 4 L/min continuously for the diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Respiratory Failure with Hypercapnia (elevated levels of carbon dioxide in the blood), and COPD. 3. On 3/3/25 at 1:32 p.m., a surveyor observed R29's oxygen…
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 · E2025-03-06 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record reviews and interview, the facility failed to ensure the attending physician made required visits, at least every 60 days for 6 of 8 sampled residents (Resident #1 [R1], [R25], [R37], [R40], [R8], and [R3]). Findings: 1. On 3/5/25, a review of R1's clinical record indicated that R1's last physician visit was on 11/26/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders was due on 2/5/25. The block orders were signed on 3/4/25; signed 26 days late. 2. On 3/5/25, a review of R25's clinical record indicated that R25's last physician visit was on 11/26/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders was due on 2/5/25. The block orders were signed on 3/4/25; signed 26 days late. On 3/5/25 at 11:45 a.m., in an interview with the surveyor, the Director of Nursing, confirmed that the last…
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 · E2025-03-06 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on performance evaluation reviews and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, CNA4). Findings: 1. CNA1 was hired on 11/7/2015. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. 2. CNA2 was hired on 8/29/2020. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. 3. CNA3 was hired on 3/19/2003. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. 4. CNA4 was hired on 6/18/2020. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024. On 3/6/24 at 2:40 p.m., in an interview with a surveyor, the Director of Nursing confirmed that the above CNA's annual performance evaluations for 2023 and 2024 were not completed.
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- Potential for harm · D2025-03-06 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to respect a resident's choice for the use of an incontinent product preference for 1 of 1 sampled resident (Resident #11 [R11]) who's incontinent product choice was denied. Finding: On 3/3/25, a review of R11's clinical record was completed. Documentation indicated that one of R11's medical concerns was incontinence. On 3/3/25 at 11:50 a.m., in an interview with the surveyor, R11 stated they have always worn yellow colored incontinent briefs during the day and wears the white colored incontinent briefs at night. R11 stated the white briefs at night make him/her feel safer as not to leak urine and is more comfortable. R11 stated on Fridays, the supply clerk stocks her dresser drawer with yellow and white briefs to last her over the weekend. R11 stated this past Friday, 3/1/25, the supply clerk was not working and R11's drawer was not stocked with white briefs; all that was left were yellow briefs. On 3/3/25 at 1:40 p.m., in an interview with the surveyor, the supply clerk stated he does stock R11's dresser with yellow briefs…
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 · D2025-03-06 · 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 record review and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive, and/or ensure a resident's right to formulate an advanced directive regarding code status (cardiopulmonary resuscitation [CPR]) was accurate in the electronic record for 2 of 10 residents (Residents #98 [R98] and [R8]). Findings: 1. During a record review R98 was admitted in January of 20251. A review of R98's paper and electronic clinical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive. On [DATE] at 2:15 p.m., during an interview with the Director of Nursing and the Regional Clinical Director the surveyor confirmed that some new admissions that were admitted after the facility identified an issue with Advanced Directives in [DATE] and after they developed a plan 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 · D2025-03-06 · 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 of a change in condition after a resident developed blisters after an incident with spilled hot soup for 1 of 4 residents reviewed for Accidents (Resident #203 [R203]). Finding: During a review of R203's clinical record and the facilities incident/accident reports. It was documented that R203 had an incident at 12:00 p.m. on 1/28/25. R203 nursing progress note documents that R203 accidentally dumped hot soup on his/her chest and upper abdomen. The chest and upper abdomen were reddened with a little bit of peeled skin. The provider was notified, and she gave a one-time order for topical bacitracin antibiotic. On 1/31/25 at 3:54 p.m., documentation of a late entry for 1/30/25 on this day I was doing treatments on the coccyx and noticed the blisters on the chest going to the right side of the body /breast, was told he/she burnt self with the coffee from A wing, resident did not complain of discomfort to the area, evening supervisor also saw the blisters. Review of R203's clinical records (paper 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 · D2025-03-06 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination-Maine Summary of Findings for 1 of 2 sampled resident's reviewed for PASRR evaluation (Resident #90 [R90]). Finding: R90's clinical record was reviewed and there was a PASRR Level I Screen Outcome, dated 11/26/24, that determined No Level II Required. R90's PASRR Level I Screen Outcome dated 11/26/24 did not include all R90's diagnoses. R90's care plan dated 12/16/24 was reviewed and stated, Focus: PASRR outcome: referred for Level II, awaiting assessment completion. Date initiated: 12/12/24; under Goal: Monitor resident for need of new PASRR screening throughout assessment period; and, under Interventions: Request PASRR screening as needed. On 3/6/25 at 1:45 p.m., during an interview with the Social Worker (SW), a surveyor requested additional information about if another PASRR screening was completed for R90. The SW obtained a copy of R90's PASRR Level I Screen Outcome determination dated 12/2/24 that stated to refer…
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 before2025-03-06 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination for 1 of 3 residents reviewed for PASRR (Resident #24 [R24]). Finding: On 3/6/25, clinical record review indicated R24 was admitted in December of 2024. Admitting diagnosis included Anxiety Disorder, Major Depression, and Obsessive Compulsive Disorder (OCD). Review of R24's PASRR, dated 10/28/24, indicated R24 had a Convalescence Categorical exemption (a time-limited 30 day exemption). Review of R24's care plan for PASRR, initiated 1/2/25 indicated, Will submit reassessment if resident remains in facility after 30 days of admission On 3/6/25 at 10:52 a.m., during an interview with a surveyor and the Social Worker (SW), the clinical record for R24 was reviewed. At this time the SW confirmed R24 was not referred for a PASARR level II determination after the 30 day…
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 · D2025-03-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, interviews and record review, the facility failed to provide recommended nutritional services to 1 of 1 resident (Resident #258 [R258]) observed during mealtimes for 1 of 3 lunch meals observed (3/3/25, lunch). Finding: During an initial observation of R258 on 3/3/25 at approximately 12:50 p.m. and interview with R258's spouse, the spouse remarked that R258 hasn't had lunch yet and that a lunch tray usually comes by 12:30 p.m. The surveyor observed a closed lunch cart in the hallway and on 3/3/25 at 1:20 p.m. in an interview with a surveyor, the LPN, charge nurse stated that all trays were passed and confirmed at this time that R258 did not receive a lunch meal.
- Potential for harm · Dcited before2025-03-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 1 of 5 residents reviewed for unnecessary medications (Resident #53 [R53]). Finding: On 3/6/25, a review of R53's clinical record was completed. Documentation in the physician orders indicated the resident had an insulin (Novolog) sliding scale for insulin coverage on Mondays, Wednesdays and Fridays (a sliding scale is the amount of insulin to be administered changes or slides up or down based on the persons blood sugar). A review of the pharmacist recommendations, dated 12/31/24 and 2/26/25 indicated the pharmacist recommendation for 12/21/24 was to confirm the Novolog sliding scale for Mondays, Wednesdays, and Fridays because there was no insulin coverage for the other days of the week. Documentation next to this recommendation indicated no changes to this order, but there was no evidence as to when this documentation occurred. On 2/26/25, during the pharmacist's monthly visit, again made a recommendation to confirm the Novolog sliding scale for Mondays, Wednesdays, 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 before2025-03-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure medications were labelled, stored at the appropriate temperature, and secured properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 3 survey days (3/5/25). Findings: On 3/5/25 at 9:31 a.m., during review of the B-unit Treatment Cart #1, a surveyor and the Unit Manager #1 (UM1) observed, an unopened Basaglar KwikPen (insulin glargine) 100 units (u) / milliliter (mL) was observed in the top drawer. The 3 mL pre-filled syringe was labeled with a refrigerate sticker. The UM stated it should be stored in the refrigerator until it is used. On 3/5/25 at 9:42 a.m., during review of the B-unit Medication Cart #1, a surveyor and Certified Nursing Assistant-Medications (CNA-M) observed: -a box labeled Breyna (Budesonide Formoterol Fumarate) 80 microgram (mcg)/ 4.5 mcg. The box was observed to contain 2 inhaler devices. One device had a dose of 80 mcg /4.5 mcg, the second device has a dose of 160 mcg/4.5 mcg and labeled with R53's initials. 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 · D2025-03-06 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 obtain dental services for a resident with broken teeth for 1 of 1 residents reviewed for dental services (Resident #8 [R8]). Finding: On 3/4/25 at 3:00 p.m., during an interview with R8, a surveyor observed R8's gums appeared red and enflamed with several broken teeth with visible decay. R8 stated they were painful. On 3/6/25, Review of R8's clinical record revealed the following: - On 3/31/16 the care plan was revised to include focus area The resident has oral/dental health problems [related to] Poor oral hygiene. The Intervention for this care area indicates Coordinate arrangements for dental care, transportation as needed/as ordered, and Document /report [as needed] any [signs or symptoms] of oral/dental problems needing attention: Pain .Teeth missing, loose, broken, eroded, decayed, . -On 5/29/24 the Pre-Care Conference Review Form indicated [R8] asks about dentist appt daily. -On 7/16/24 at 11:25 p.m., the provider wrote in a regulatory review note, When I ask how [R8] is doing, [R8] tells me he/she wants false…
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 before2024-02-15 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 6 residents reviewed (Resident #52 [R52]). Finding: During review of R52's medical record it contained a PASRR Level I Screen dated 8/10/23. The PASRR Level I Screen in the diagnosis section, did not include a current diagnosis of bipolar disorder. R52's current diagnosis list includes a diagnosis of bipolar disorder. The resident record lacked evidence that the PASRR Level I Screen was updated to include his/her diagnosis of bipolar disorder and was resubmitted/forwarded to the State-designated authority to determine if a Level II assessment was needed. On 2/14/24 at 12:50 p.m during an interview with the Licensed Social Worker, the surveyor confirmed that the PASRR Level I for R52 did not include a diagnosis of bipolar disorder and was not resubmitted to PASRR for an updated Level II.
- Potential for harm · Dcited before2024-02-15 · 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 interviews and record review, the facility failed to follow Physician orders for 1 of 1 sampled Resident receiving dialysis. (Resident #203, [R203]) and 1 of 2 sampled residents reviewed with insulin parameters [R21]. Findings: 1 On 2/13/24, during an interview with R203 and his/her family member, they stated that R203 is not receiving their medications (specifically their binding medications) at the correct times. R203 stated the medications are supposed to be given with meals and he/she is getting them either before a meal or after meals. A review of R203's clinical record was completed; the electronic medication administration record (eMAR) shows an order for Sevelamer Carbonate Oral Tablet 800 Milligram (mg) with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food. Sevelamer works by holding onto phosphate from the diet so that it can pass out of the body. Review of the meal caddie arrival times was reviewed with the Food Service Director to identify the approximate time R203 would receive 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 · D2024-02-15 · 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 — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to tube feedings, for 1 of 1 sampled resident reviewed with a feeding tube (Resident#39 [R39]). Finding: On 2/13/24, R39's clinical record was reviewed for January and February 2024 for treatments related to the resident's feeding tube. The Treatment Administration Record (TAR) contained a treatment, dated 1/25/22, that directed staff to check placement of feeding tube prior to each use (to be done on each 12 hour shift) and a treatment, dated 7/15/23, to check residual before starting the tube feed (TF) and every 8 hours while TF was running, to be checked at 7:00 p.m. and 3:00 a.m. A review of January's TAR indicated: On 1/3/24 at 3:00 a.m., there was no evidence of the residual being checked. On 1/15/24 at 3:00 a.m., there was no evidence of the residual being checked. On 1/19/24 during the 7 p.m. - 7 a.m., the placement check of the feed tube lacked evidence of it being checked. On 1/20/24 at 3:00 a.m., there was no evidence of the residual…
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 · D2024-02-15 · 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
Based on record review and interview, the facility failed to ensure that a physician's order for Ambien (a medication used to treat insomnia) was available and administered for 1 of 1 sampled residents (Resident #11[R11]). Finding: On 2/12/24, record review indicated R11 had a physician's order for Ambien 5 milligrams (mg) to be given at 8:00 p.m. for insomnia beginning 1/29/24. Documentation on R11's Medication Administration Record (MAR) indicated that on 1/31/24, 2/1/24, 2/2/24, 2/3/24, 2/4/24, 2/5/24, and 2/7/24 (7 days) Ambien was not given due to the medication being unavailable. On 2/14/24 at 9:48 a.m., in an interview with the Assistant Director of Nursing (ADON), she stated the resident did not receive the medications in relation to a missing delivery. On 2/14/24 at 11:17 a.m., in an interview with the Regional Director (RD) and the ADON, the RD stated the Ambien administered on 2/6/24 came from the Cubex (facility reserve supply). She stated the Cubex had a stock of 4 doses and does not know why staff did not use this for the other days missed. On 2/14/24 at 11:17 a.m., in…
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 before2024-02-15 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure the pharmacist identified an irregularity for as needed (PRN) psychotropic medication use for 1 of 5 residents reviewed for unnecessary medications (Resident#35 [R35]). Finding: On 2/14/24, R35's clinical record was reviewed. The surveyor reviewed physician orders from November 2023 to current and observed that the facility was renewing PRN Risperdal (anti-psychotic psychotropic medication) prior to the Medical Provider re-examining the resident to determine if the medication was still needed. On 2/14/24 at 3:50 p.m., during an interview with the Regional Director of Clinical Services, a surveyor confirmed that the PRN Risperdal is being renewed the day before the physician re-examined the resident. The Regional Director of Clinical Services and surveyor reviewed the most recent pharmacist review for R35, completed on 1/30/24, and was noted that there were no inconsistencies for the medication regimen review and did not identify this irregularity.
- Potential for harm · D2024-02-15 · 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 and interview, the facility failed to ensure the physician examined a resident to determine if an as needed (PRN) anti-psychotic medication was still needed before writing a new order to renew the same PRN anti-psychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident#35 [R35]). Findings: On 2/14/24, R35's clinical record was reviewed and contained a physician order to administer Risperdal (anti-psychotic) 0.5 milligrams, every 12 hours as needed. The physician orders contained an order for the PRN Risperdal which started on 11/27/23 with an end date of 12/11/23. The physician visited R35 on 12/12/23 but the PRN Risperdal was restarted on 12/11/23 at 2:04 p.m., prior to the examination of the resident. The physician orders contained an order for the PRN Risperdal which was renewed on 12/28/23 with an end date of 1/11/24. The physician visited R35 on 12/29/23 but the PRN Risperdal was renewed on 12/28/23 at 1:12 p.m., prior to the examination of the resident. The physician orders contained an order for the PRN Risperdal which was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interview, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 28 opportunities for (Resident #57 [R57]) and (Resident #[R205]). The medication error rate was 7.14%. Findings: 1. On 2/13/24 at 8:10 a.m., a surveyor observed Licensed Practical Nurse#1 (LPN1) prepare medications for R57. The medications included Metoprolol 12.5 milligrams (mg), and Wixela Fluticasone Salmeterol 500/50 (a metered dose inhaler), ordered to give 1 inhale orally 2 times per day. Prior to entering R57's room, LPN1 labelled the medicine cup, then placed it in the top drawer of the cart, she placed the inhaler in a separate side drawer of the cart. LPN1 entered R57's room to obtain a blood pressure. The resident was observed to be short of breath, R57 stated he/she accidentally spilled something and had been attempting to clean it up. LPN1 asked a Certified Nursing Assistant to assist with clean-up and requested R57 remain seated and relaxed to recover. After obtaining the blood pressure, LPN1…
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 before2024-02-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use, and tube feeding supplies were stored in a sanitary manner in 1 of 2 medication rooms reviewed (Medication Storage Room on Wing B). Finding: On 2/12/24 at 12:12 p.m., during a review of the Medication Storage Room on Wing B, the surveyor observed 1 unopened box of Humulin N (NPH isophane insulin human suspension) 100 units/milliliter (mL),10 mL container, with an expiration date of 10/2023 in the fridge available for use, and 1 bottle of Vital 1.5 cal (1.5 calories per mL) 1000 mL peptide base, Therapeutic Nutrition for Tolerance, was observed on the shelf available for use with a missing protective cap and a damaged seal. These were confirmed at the time of finding with the Certified Nursing Assistant Medication Aide (CNA-M).
- Potential for harm · D2024-02-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to implement appropriate infection prevention at point-of-care testing when Certified Nurse Assistant #2 (CNA2) did not apply gloves for a fingerstick procedure during blood glucose testing for 1 of 1 observation (2/15/24). Finding: On 2/15/24 at 10:53 a.m., during an interview with Resident #26 (R26) and family, CNA2 entered the room and requested to perform a glucose test on R26. The family interview was temporarily placed on hold and the surveyor observed the blood glucose testing procedure which was performed without the use of gloves. A review of the facility's procedures indicates the use of gloves to clean the glucometer prior to use, remove gloves and wash hands, then apply clean gloves, insert test strip into meter, obtain a drip of blood (wipe finger with alcohol prep then wipe same finger with tissue before pricking finger), apply blood to test strip. On 2/15/24, at approximately 11:45 a.m., a surveyor confirmed with the Director of Nursing that CNA2 was not following infection prevention practices and that the break…
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 · D2023-10-18 · 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 record review and interview, the facility failed to revise and implement an individualized person-centered care plan to render trauma informed care to a resident with a personal history of trauma related to verbal abuse and bullying for 1 of 1 residents reviewed (Resident #1). Finding: On 10/18/23, Resident #1''s clinical record was reviewed indicating the resident was originally admitted to the facility on [DATE] with multiple mental health diagnoses as well as Post Traumatic Stress Disorder (PTSD). The Minimum Data Set (MDS) Quartely 3.0, dated 8/15/23, indicated, under Active Diagnosis Section I6100, that the resident had PTSD. On 10/18/23 at 10:30 a.m., during an interview with a surveyor, the Bayview Social Worker (BSW) stated that Social Services was responsible to complete the trauma screen on admission and to complete the care plan. The surveyor explained that she was unable to determine what Resident #1's triggers might be based on this screen and review of the careplan. At 11:00 a.m., the BSW…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-18 · 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 facility reported incident and investigation, record review, facility policy review, and interviews, the facility failed to supervise a resident safety and complete a new elopement risk evaluation/assessment after a resident received a new power wheelchair and expressed the desire to leave the facility and go to the store. This failure enabled the resident to leave the facility's grounds without staff knowledge or supervision and cross a 3 lane street for 1 of 1 incidents reviewed (10/5/23). Findings: Review of the facility's incident report sent to the State Agency on 10/6/23 indicated that Resident #1 was seen by staff across the street on 10/5/23 at 2:13 p.m. after being let outside by a staff member at 1:54 p.m. Staff immediately went to get the resident when he/she was noticed and the resident was returned to the facility with no injuries. The facility's investigation was completed on 10/11/23 and included written statements from staff. Certified Nursing Assistant - Medication (CNA-M) completed a written statement on 10/5/23 that indicated he had seen Resident #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-02-15 · 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
Based on review of the facility's 'Influenza Immunization Policy,' admission Influenza Consent form and interview, the facility failed to provide the Resident and/or the Resident's Representative with the Vaccine Information Statement (VIS)' prior to immunizing a resident with the influenza vaccine for all residents receiving the influenza vaccine who are not new admissions. Finding: On 2/15/24, the facility's Infection Prevention and Control Program was reviewed and the immunization policy and procedure indicated residents will be offered the influenza vaccination yearly following the Centers for Disease Control and Prevention (CDC) guidelines. On 2/15/24 at 11:14 a.m., in an interview with the surveyor, the facility's Infection Preventionist (IP) stated that upon admission, the admission packet contains a consent form with information explaining the risks versus the benefits (called the VIS) of having the influenza vaccination. The IP stated she thought that this one consent form and VIS is good for the entire stay of the resident and was unaware that a VIS should be provided 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to NATIONAL HEALTH CARE ASSOCIATES — 42 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 4.1 | -1.1 vs chain |
The other 41 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 41; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| VK HEALTH FACILITIES LLC | Organization | DIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| MARVIN OSTREICHER FAMILY TRUST 2012 | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| MERIDIAN CAPITAL FOUNDATION | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| MSO ASSOCIATES LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| SUSAN OSTREICHER FAMILY TRUST 2012 | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| VENTAS NHV FUND | Organization | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| BOKOW, BARRY | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/28/2013 |
| GEFFNER, IRA | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| GLUCK, ROBERT | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| LOBELL, JONAH | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| LOWINGER, BEN | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| LOWINGER, JOSEPH | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| OSTREICHER, DAVID | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/28/2013 |
| OSTREICHER, MARC | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/28/2013 |
| OSTREICHER, MARVIN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/28/2013 |
| OSTREICHER, SUSAN | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/28/2013 |
| SCHOOR, KALMAN | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| STEG, YITZCHOK | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| WEINSTOCK, ABRAHAM | Individual | INDIRECT OWNERSHIP INTEREST | since 01/28/2013 |
| GILMARTIN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2016 |
| KULIKOWSKI, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/03/2025 |
| PORTER, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/14/2025 |
| DAVID, ALBERT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 11/26/2025 |
| SHAYA-MOGRABY, MOSHE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 11/26/2025 |
| BARRY BOKOW 2012 FAMILY TRUST | Organization | ADP OF THE SNF | since 08/07/2020 |
| BPB VENTURES LLC | Organization | ADP OF THE SNF | since 08/07/2020 |
| CEDAR HILL NG TRUST | Organization | ADP OF THE SNF | since 05/14/2025 |
| JUNIPER NG TRUST | Organization | ADP OF THE SNF | since 05/14/2025 |
| NATIONAL HEALTH CARE ASSOCIATES INC | Organization | ADP OF THE SNF | since 01/28/2013 |
| OAK DRIVE NG TRUST | Organization | ADP OF THE SNF | since 05/14/2025 |
| PREFERRED PROFESSIONAL SERVICES LLC | Organization | ADP OF THE SNF | since 01/28/2013 |
| PREFERRED THERAPY SOLUTIONS LLC | Organization | ADP OF THE SNF | since 01/28/2013 |
| ROLLING HILL NG TRUST | Organization | ADP OF THE SNF | since 05/14/2025 |
| ALMEIDA, ELIZABETH | Individual | ADP OF THE SNF | since 01/28/2013 |
| LOPIANSKY, REBECCA | Individual | ADP OF THE SNF | since 05/14/2025 |
| STEG, SHAYNA | Individual | ADP OF THE SNF | since 05/14/2025 |
CMS files one row per role, so the 46 rows in the source record cover these 36 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
15 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.9M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in ME
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maine Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205062. 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.