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Sedgewood Commons

22 Northbrook Dr, Falmouth, ME 04105 · For profit - Corporation · 91 certified beds · (207) 781-5775 Medicare & Medicaid certified

Call the home — (207) 781-5775 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • 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
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
367 U S Route-1, Suite 5-S · (207) 885-0414 · Call to confirm hours
Pharmacy
KabaFusion<0.1 mi
12 Northbrook Dr, Building B, Ste 1 · (877) 373-1523 · Call to confirm hours
Grocery
269 Foreside Rd · (207) 781-2128 · Call to confirm hours
Park
18 Longwoods Rd · (207) 699-5312 · Typically dawn to dusk
Place of worship
266 Foreside Rd · (207) 847-6890

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 2 of 5
Short-stay residentsrehab / post-hospital 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased36.3%24.4%15.4%worse
Long-stay residents who lose too much weight10.4%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%1.1%0.9%typical
Long-stay residents with a urinary tract infection4.4%2.2%2.0%worse
Long-stay residents with depressive symptoms24.3%11.6%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.7%4.1%3.3%worse
Long-stay residents whose ability to walk worsened35.4%25.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.4%17.4%18.9%better
Long-stay residents given the seasonal flu vaccine94.9%95.5%95.3%typical
Long-stay residents with pressure ulcers5.6%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control30.8%29.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table34.2%20.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine20.8%74.5%79.4%worse
Short-stay residents rehospitalized after admission7.2%20.8%22.6%better
Short-stay residents with an outpatient ER visit4.8%16.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.701.451.67better
Long-stay outpatient ER visits per 1,000 resident days0.382.011.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

34.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

34.1%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
28.1%U.S. median 56.6%
Met the expected recovery
0.51U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 28.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 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 0.51 therapist hours per resident per day in 2026Q1 — more than 81% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF34.1%CMS range 25.7–43.851.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.1–13.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge28.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge18.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay5.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened10.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.0–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.02
RN hours/ resident / day
0.43
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.93
Total nurse hours/ resident / day
0.84
RN hoursweekends
53.5%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 91 beds and averages 63.2 residents a day — about 69% occupied, or roughly 28 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.02 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.73 hrs/resident/day on weekends vs 4.02 on weekdays — 7% thinner on weekends. RN hours go from 1.08 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2025-06-04)
12
at the previous standard inspection (2024-03-29)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2025-06-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 36 of 56 resident rooms and on 3 of 3 units ([NAME], [NAME], and [NAME]). Findings: On 6/4/25 at 8:00 a.m. a surveyor conducted an environmental observation tour with the Administrator, and the Maintenance Supervisor following were observed: [NAME] Unit: -The room divider curtains are off track and do not fully close to allow for resident privacy in the following rooms: 2, 3, 5, 9, 14, and 15. -The closet doors are misaligned and do not fully close in the following rooms: 3, 8, and 9. -The window curtains are off track and do not fully close in the following rooms: 7, 9, 10, and 11. -room [ROOM NUMBER]: Bathroom toilet is on a [NAME] sticking out from the base. -room [ROOM NUMBER]: There is a stained ceiling tile outside the room. [NAME] Unit: -The room divider curtains are off track and do not fully close to allow for resident privacy…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured on 1 of 3 units ([NAME]) for 1 of 3 days of survey (6/2/25). Findings: 1. On 6/2/25 at 10:14 a.m., observation of an unsecured container of CaviWipes on a bedside table in room [ROOM NUMBER]. At this time, the Director of Nursing removed the CaviWipes from the resident's room, stating that these wipes should not be in resident rooms or care areas. The Safety Data Sheet for CaviWipes Section 4. First Aid Measures states Inhalation: Move the affected person to fresh air. Get medical attention if symptoms occur . Skin: Gently wash with plenty of soap and water. Seek medical attention if irritation develops . Eyes: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do so. Continue rinsing. If eye irritation persists: get medical advice/attention . Ingestion:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-04 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification, dated 6/4/25, were effective. The Federal citations F761 and F880 were cited again during the re-visit for the Annual Long Term Care Recertification Survey, completed 9/10/25.Finding:During the follow-up survey on 9/10/25, it was determined that F761 and F880 would be re-cited: F761 for failure to monitor medication refrigerator temperatures daily and F880 for failure to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to apply appropriate interventions relating to the use of Enhanced Barrier Precautions (see F761 and F880).On 9/10/25 at 2:55 p.m., the above was discussed during the exit conference with the Administrator and the Region [NAME] President of Operations.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to have an effective infection prevention and control program (IPCP) for the surveillance and transmission prevention of Gastrointestinal disease for 1 out of 6 residents reviewed for infection control. Findings: Reviewed Facility Policy Infection Control Policies and Procedures IC306 Transmission Based Precautions last revised 5/1/25. 8. Initiating Transmission Based Precautions: 8.1 Nursing Staff may place patients with suspected or confirmed infectious diarrhea, influenza or symptoms consistent with a communicable disease on Transmission Based Precautions/isolation (TBP) empirically while awaiting confirmation. 8.2 Notify the attending physician or Medical Director (in the absence of the attending physician) and the Infection Preventionist if there is reason to believe that an individual has an infectious disease. 8.3 An order for Transmission Based Precautions will be obtained for patients who are known or suspected to be infected or colonized with infectious agents that require additional controls 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to monitor temperature controls for 2 of 3 refrigerators observed and 3 of 3 months of medication refrigerator logs reviewed. Findings: 1. On 6/2/25 at 1:30 p.m., observation of the [NAME] medication storage room refrigerator with Registered Nurse #1 (RN) which contained 1 Pneumococcal 20 (PCV 20) vaccination, 6 multi-use vials of influenza vaccinations (Afluria), and a multi-use vial of Tuberculin Purified Protein. On 6/2/25 a surveyor reviewed the facilities Temperature Log For Medication/Vaccine Refrigerators for months of March, April, and May. March 1st through March 31st lacked evidence of twice daily temperature readings for 15 out of the 31 days. April 1st through April 30th lacked evidence of twice daily temperature readings for 24 out of the 30 days. May 1st through May 31st lacked evidence of twice daily temperature readings for 25 out of the 31 days. 2. On 6/2/25 at 2 p.m., observation of the [NAME] medication storage room refrigerator with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-24 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews, the facility failed to have a working system in place to communicate, separate and carry out the disposition of controlled substances. In addition, the facility failed to ensure that all scheduled medications were being received from the pharmacy by 2 licensed staff. Findings: 1. On 7/16/24 Division of Licensing received a complaint which a nurse gave Resident #1 a dose of morphine from Resident #2's morphine bottle using Resident #2's oral syringe was given another residents morphine on 7/12/24. On 7/24/24 at 10:30 a.m., a surveyor reviewed the Narcotics Logbook for the [NAME] unit medication cart, Page 169, a log for Resident #2's morphine showing it was in use on 7/12/24 and continued to be used until 7/18/24. The log failed to document the error from 7/12/24. On 7/24/24 at 10:55 a.m.,during an interview with the Unit Director for [NAME], stated the response to the incident on 7/12/24 was to immediately remove from use the bottle of morphine involved. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 3 units ([NAME] and [NAME]) for 1 of 1 environmental tour (3/29/24). Findings: On 3/29/24 from 8:30 a.m. to 9:01 a.m., an environmental tour was conducted with the Maintenance Director in which the following was observed: [NAME] Unit: >The shower room had a laydown shower chair with orange colored coating under the chair edge and rim, the floor next to shower stall was raised with cracks and cove base peeling away from the wall. >Resident #32 wheelchair seat is coated with dirt/debris. >room [ROOM NUMBER] the bedroom bottom door sticks making it difficult to open. >room [ROOM NUMBER] wall light near room door is missing the light cover. >Wallpaper peeling up and stapled to wall next to room [ROOM NUMBER]. >Wallpaper peeling up across from the TV viewing room. [NAME] Unit: >The shower room had a bariatric shower…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-29 · tag F0730 — pattern
    Observe 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 evaluations and interview, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled Certified Nursing Assistants (CNA #3, CNA #4, and CNA #5). Findings: 1. CNA #3 was hired on 3/4/20. CNA #3's last performance evaluation was a 90-day progress report completed on 8/14/20. The facility was unable to provide evidence of a completed annual performance evaluation for 2021, 2022, 2023, or 2024. 2. CNA #4 was hired on 5/11/15. CNA #4's last performance evaluation was completed on 5/3/19. The facility was unable to provide evidence of a completed annual performance evaluation for 2020, 2021, 2022, or 2023. 3. CNA #5 was hired on 7/31/18. CNA #5's last performance evaluation was completed on 9/26/19. The facility was unable to provide evidence of a completed annual performance evaluation for 2020, 2021, 2022, or 2023. On 3/27/24 at 4:15 p.m., in an interview with a surveyor, the Administrator, the Clinical Market Advisor, and the Market President confirmed staff performance evaluations had not been completed annually.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-29 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to properly store medications and biologicals in 2 out of 3 medication rooms refrigerators surveyed. ([NAME] House and [NAME] House) Findings: 1. On 3/26/24 at 11:38 a.m., a surveyor observed the [NAME] House medication room refrigerator with the Unit Manager and noted a dormitory style refrigerator with a freezer. Inside the refrigerator were influenza vaccines and a pneumococcal vaccine. A review of the recorded temperatures for the refrigerator showed an out-of-range temperature on 3/24/24 of 70.8 (F). A surveyor asked the unit manager what happened following the discovery of the out-of-range temperature, and they did not know. They were unable to deny or confirm that the vaccinations in the refrigerator were in the refrigerator at the time of the out-of-range temperature. 2. On 3/26/24 at 11:40 a.m., a surveyor observed the [NAME] House medication room refrigerator with a Licensed Practical Nurse (LPN), and found 2 opened and unlabeled…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 1 initial kitchen tour completed on 3/26/24. Additionally, the facility failed to ensure that food temperatures were recorded at the time of cooking breakfast on the morning of 3/26/24. Findings: 1. On 3/26/24 at 9:10 a.m., a surveyor conducted an initial tour of the kitchen with the [NAME] in which the following findings were observed and confirmed. - A light amount of dust, debris, and staining on the ceiling vents - A sticky, dusty film on all flat surfaces of the Kitchen - A lack of documentation of food temperatures being taken during dinner on 3/23/24, all day on 3/24/24, all day on 3/25/24 and breakfast on 3/26/24. The above findings were confirmed with the cook at that time.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2024-03-29 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's Pneumococcal Vaccination policy and procedure, interviews, and record review the facility failed to provide the Resident and/or the Resident's Representatives with the Vaccine Information Statement (VIS) prior to immunizing a resident with the pneumococcal vaccine (Prevnar) for all residents receiving the Prevnar vaccine. Findings: The facilities Pneumococcal Vaccination policy and procedure, revised on 11/1/23 states, Provide the patient/representative education (Vaccine Information Statement (VIS)) regarding benefits and potential side effects of vaccination. On 3/27/24 at 11:43 a.m., during an interview, the facility's Infection Preventionist (IP) confirmed that the facility does offer the recommended pneumonia vaccines (PPSV23, PCV13, PCV15, PCV20) for those residents who are illegible and upon admission. She then stated the admission packet contains the consent forms with information explaining the risks versus the benefits (called the VIS) for having the pneumococcal vaccination. The surveyor and the IP reviewed the facilities admission packet…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-29 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's COVID-19 Vaccination policy and procedures, interviews and record review the facility failed to ensure each resident, or the resident representative received education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine prior to immunizing a resident with the COVID-19 vaccine for all residents who received the COVID-19 vaccine. In addition, the facility failed ensure staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine. Findings: The facilities COVID-19 Vaccination policy and procedure revised, 2/7/24 states, Centers will provide the opportunity to receive COVID-19 vaccinations following Centers for Disease Control and Prevention (CDC) recommendation and the facility will obtain consent using the Patient Informed Consent or Declination COVID-19 form. On 3/27/24 at 11:43 a.m., during an interview, the facility's Infection Preventionist (IP) confirmed that the facility does offer the recommended COVID-19 vaccine for those residents who are illegible and upon…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-29 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on employee record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on Resident Rights for 2 of 5 Certified Nursing Assistant (CNA) staff reviewed (CNA #1, CNA #2). Findings: On 3/27/24, the following employee records were reviewed: 1. CNA #1 was hired on 12/26/23. There was no documented training regarding Resident Rights. 2. CNA #2 was hired on 12/4/23. There was no documented training regarding Resident Rights. On 3/27/24 at 4:15 p.m., in an interview with a surveyor, the Clinical Market Advisor confirmed there was no documentation of the staff attending the required annual training regarding Resident Rights.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-29 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to coordinate assessments for Pre-admission Screening and Resident Review (PASRR) Level I and Level II programs for 1 of 1 residents reviewed for PASRR (#46). Findings: A review of the clinical record for Resident #46 revealed he/she was admitted to the facility on [DATE], and had diagnoses including Dementia and Post Traumatic Stress Disorder. The clinical record lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority to determine if the resident met the State of Maine's definition of a serious mental health disorder and to determine if a Level II assessment was needed. On 3/27/24 at 1:35 p.m., in an interview with a surveyor, the facility's Social Worker confirmed that the PASRR Level I screening had not been completed and he/she would proceed with the PASSR at that time. On 3/27/24 at 2:19 p.m., the finding was discussed with the Market President.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interviews and record review, 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 (Resident #32). Finding: On 3/26/24 at 9:34 a.m., during an interview, Resident #32 stated he/she is not invited or remembers having care plan meetings. Review of Resident #32's medical record, the surveyor noted Minimum Data Set (MDS) Quarterly assessments, dated 11/2/23 and 2/2/24 were completed. The medical record lacked evidence that a care plan meeting had been held by the IDT after both assessments. On 3/28/24 at 1:31 p.m., during an interview, the Licensed Social Worker confirmed the above findings.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to meet the personal hygiene preferences for 1 of 6 residents who are dependent on staff to complete Activities of Daily Living needs. (Resident #49) Findings: On 3/26/24 at 11:22 a.m., a surveyor observed Resident #49 with an unshaven face, and long fingernails with a dark substance built up under the nails. The resident was dressed in day clothing asleep on the bed. Record review revealed Resident #49 was admitted to the facility on [DATE] with a diagnosis of dementia and lower extremity amputation. Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #49 was assessed to need staff assistance for personal hygiene which includes nail care and shaving. On 3/26/24 at 12:30 p.m., a surveyor interviewed Resident #49's Certified Nursing Assistant (CNA) who confirmed that Resident #49 hasn't been shaved for several days and they weren't sure about when the nails were last done. The CNA confirmed that Resident #49 was dependent…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for 1 of 2 residents reviewed for skin conditions (#343). Findings: On 3/26/24 at 12:27 p.m., during an interview with Resident #343's representative, the surveyor observed Resident #343 scratching/itching several small, scabbed areas on his/her upper right arm. At this time, the Resident Representative stated, the resident has a rash and was given a cream from the dermatologists that he will bring in. On 3/27/24 at 12:25 p.m., the surveyor observed Resident #343 wearing a long sleeve shirt and scratching/ itching at his/her right shoulder through the collar opening. On 3/28/24 at 11:37 a.m., during an additional interview with Resident #343's representative, the surveyor observed the resident continuing to scratch/itch at his/her right shoulder through the collar opening. At this time, the Resident Representative stated he had brought 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-29 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the annual Long Term Care Recertification Survey, dated 3/29/24, was effective. The Federal citation F584 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 5/20/24. Finding: During the annual Long Term Care survey, dated 3/39/24, a deficiency was cited at F584 for the facilities failure to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. The facility's POC, dated 4/30/24, indicated that the facility would ensure that the resident rooms/bathrooms would be in a sanitary condition with the POC completion date of 5/7/24. During the re-visit survey on 5/20/24, observations of [NAME] unit residents shared bathrooms 26-27 and 28-29 were found to have ongoing concerns regarding storage of urinals and bed pans. It…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-04-07 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessments, for 7 of 33 residents whose care plans were reviewed (#10, #24, #25, #33, #37, #39, #49). Findings: 1. A surveyor reviewed the clinical documentation of Resident #10, which included review of a comprehensive admission Minimum Data Set (MDS) 3.0 assessment dated [DATE]. The surveyor could not locate evidence a care plan meeting was held by the IDT that included, to the extent possible, participation of Resident #10 and/or his/her representative to review and revise the care plan. 2. A surveyor reviewed the clinical documentation of Resident #24, which included review of a comprehensive admission MDS 3.0 assessment dated [DATE] and Quarterly MDS dated [DATE], 11/16/21 and 2/15/22. The surveyor could not locate evidence, after completion of the above…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-07 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, review of the daily staffing postings, and the nursing working schedule, the facility failed to have a Registered Nurse on duty for at least 8 consecutive hours for 1 of 128 days reviewed for Sufficient and Competent Nurse Staffing. Finding: A review of the daily staffing postings, and nursing working schedule, indicated that on (Sunday)12/5/21, the facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours. On 4/6/22 at 10:10 a.m., in an interview with the Director of Nursing, the surveyor confirmed the finding above.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an as needed (PRN) psychotropic medication met the required 14-day limit for 1 of 5 residents reviewed for unnecessary medications (#80). Finding: A review of Resident #80's clinical record revealed an electronic physician's order, dated [DATE], instructing staff to administer Lorazepam (an anxiolytic medication) 0.5 mg (milligrams) - one tablet by mouth every 8 hours as needed (PRN) for dementia with behaviors. On [DATE] at 12:25 p.m., in an interview with the Clinical Lead, the surveyor discussed the PRN order did not have an end date and was valid for 14 days. The order had expired on [DATE]. The Clinical Lead confirmed the finding at this time.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-07 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 3 units, [NAME] House. Findings: On 4/4/22 at 10:45 a.m., during [NAME] House medication storage review, a surveyor observed the following: 1. In the medication room, an opened vial of Aspart insulin with an open date of 3/2/22. Manufacturer specifications on the insulin indicates that after first use to Discard after 28 days. At this time the Registered Nurse (RN) confirmed the insulin should have been discarded on 3/30/22, 5 days prior to discovery. 2. In the medication cart, a vial of Humalog insulin with a pharmacy delivery date of 3/26/22 and a Basaslar Kiwi Pen insulin with a pharmacy delivery date of 4/2/22. Both insulins were opened and undated with a manufacturer specification indicating after first use to discard unused medication after 28 days. At this time the Registered nurse confirmed the insulins were not dated however they were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to ensure a sanitary environment during 1of 2 dining observations of meal service on 1 of 3 units ([NAME]). Finding: 1. On 4/4/22 at 12:14 p.m., during lunch service on [NAME] house, a surveyor observed the Dietary Manager in Training (MIT) at the steam table preparing residents lunch plates. He was wearing gloves and was using the scoops provided to plate the meat and fruit however when he plated the garlic bread he used his gloved hands rather than the tongs visible next to the bread pan. He then exited the unit, still wearing gloves to return only a minute later with ungloved hands and carrying a stack of plates against his shirt. He then reapplied new gloves, picking up the delivered plates and continued to plate the entre' using his gloved hands to pick up the garlic bread again. At this time the surveyor asked the MIT why he was not using the tongs provided for the garlic bread, the MIT stated I didn't know I was supposed to use tongs. On 4/7/22 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, observation and interview the facility failed to ensure the Medication Administration Record (MAR) was accurately documented for removing a Lidoderm patch for 1 of 7 residents observed during medication administration review (#71). Finding: A review of Resident #71's physician order dated 3/18/22, instructs nursing to apply a Lidoderm patch to the residents lower back daily at 8:00 a.m. and remove the patch in the evening at 8:00 p.m. The MAR indicated, by nursing documentation, that on 4/4/22 at 7:12 p.m. the Lidoderm patch was removed. On 4/5/22 at 9:15 a.m., a surveyor observed a Licensed Practical Nurse (LPN) administering a new Lidoderm patch to Resident #71's lower back. The LPN had to remove to old patch on the residents lower back to then replace it with the new Lidoderm patch. At this time, the LPN confirmed that the old Lidoderm patch should have been removed the evening prior.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's immunization policy, and interview, the facility failed to implement their Pneumococcal Vaccine policy for 1 of 5 residents whose immunization records were reviewed (#26). Findings: The Facility's Pneumococcal Vaccination - Prevnar 13 (PCV13) or Pneumovax (PPSV23) policy, with a review date of 11/2020, indicated that Centers will provide the opportunity to receive pneumococcal vaccine to all patients, in adherence with current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC). The Section titled Process stated, 2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule. The Centers for Disease Control (CDC) Vaccine Information Statement (VIS) for the Pneumococcal Conjugate Vaccine (PCV13), dated 8/6/21,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-06-04 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 sampled residents transferred/discharged to an acute care facility. ( Resident #13 and #66) Findings: 1. Documentation in Resident 13's clinical record indicated that he/she was transferred to an acute hospital on 4/2/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative. 2. Documentation in Resident 66's clinical record indicated that he/she was transferred to an acute hospital on 5/7/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative. On 6/4/25 at 10:30 a.m., in an interview with the surveyor, the Market Clinical Advisor confirmed that she was unable to locate evidence that a transfer/discharge form for Resident #13 and Resident #66 was completed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-06-04 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to issue a written bed hold notice to a resident, known family member or legal representative for 2 of 3 sampled residents who had been transferred to an acute care facility (Resident #13 and #66). Findings: 1. in Resident #13's clinical record indicated that he/she transferred to an acute care hospital on 4/2/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. 2. Documentation in Resident #66's clinical record indicated that he/she transferred to an acute care hospital on 5/7/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. On 5/25/25 at 10:30 a.m., in an interview with the Market Clinical Advisor confirmed that she was unable to locate evidence that the facility issued a written bed hold notice to the resident, a family member, or a 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2022-04-07 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman, to a resident or their representative for 1 of 2 sampled residents transferred/discharged by the facility to an acute care hospital (#80). Finding: On review of the clinical record, the surveyor noted Resident #80 was transferred to an acute care facility on 12/23/21, and on 3/17/22, both for evaluation and treatment of hip pain after sustaining falls. There was no evidence in the clinical record that the facility issued a transfer/discharge notice to the resident, family member or legal representative. On 4/7/22 at 11:20 a.m., the Clinical Lead confirmed there was no evidence that transfer/discharge notices had been sent to the resident's representative for either transfer to the emergency department.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 4 of 52.5+1.5 vs chain
Quality measures 3 of 53.5-0.5 vs chain
The other 183 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Alexandria Care CenterLos Angeles, CA 1 of 5Bay Crest Care CenterTorrance, CA 1 of 5Bethlehem North Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bethlehem South Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bridgeville Rehabilitation & Care CenterBridgeville, PA 1 of 5Brightwood CenterFollansbee, WV 1 of 5Carlisle Skilled Nursing And Rehabilitation CenterCarlisle, PA 1 of 5Casa De Oro CenterLas Cruces, NM 1 of 5Devonshire Care CenterHemet, CA 1 of 5Gettysburg CenterGettysburg, PA 1 of 5Glenwood CenterFlorence, AL 1 of 5Heritage CenterHuntington, WV 1 of 5Hidden Valley CenterOak Hill, WV 1 of 5Inners Creek Skilled Nursing And Rehabilitation CeDallastown, PA 1 of 5Jersey Shore Skilled Nursing And Rehabilitation CeJersey Shore, PA 1 of 5Kingston Court Skilled Nursing And RehabilitationYork, PA 1 of 5Las Palomas CenterAlbuquerque, NM 1 of 5Lebanon Center, Genesis HealthCareLebanon, NH 1 of 5Lebanon Skilled Nursing And Rehabilitation CenterLebanon, PA 1 of 5Linden Grove Health Care CenterPuyallup, WA 1 of 5Magnolia RidgeGardendale, AL 1 of 5Marmet CenterMarmet, WV 1 of 5Meridian CenterHigh Point, NC 1 of 5Merry Wood LodgeElmore, AL 1 of 5Mount Olive CenterMount Olive, NC 1 of 5Mountain Ridge Center, Genesis HealthCareFranklin, NH 1 of 5Oak Grove CenterWaterville, ME 1 of 5Oceanside Skilled Nursing And RehabilitationHampton, NH 1 of 5Orchard Park Health Care & Rehab CenterTacoma, WA 1 of 5Parkersburg CenterParkersburg, WV 1 of 5Pembroke CenterPembroke, NC 1 of 5Pine LodgeBeckley, WV 1 of 5Playa Del Rey CenterPlaya del Rey, CA 1 of 5Pocahontas CenterMarlinton, WV 1 of 5Pottstown Skilled Nursing and Rehabilitation CentePottstown, PA 1 of 5Putnam CenterHurricane, WV 1 of 5Ridgewood CenterRidgewood, NJ 1 of 5Rio Rancho CenterRio Rancho, NM 1 of 5River City CenterDecatur, AL 1 of 5River Ridge CenterKennebunk, ME

Showing 40 of 183; 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 / managerTypeRoleShareSince
GENESIS HEALTHCARE OF MAINE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/02/2012
FC-GEN OPERATIONS INVESTMENT LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GEN OPERATIONS I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GEN OPERATIONS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GHC HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2008
SUN HEALTHCARE GROUP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
WHITMAN, ARNOLDIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
BERG, MICHAELIndividualCORPORATE OFFICERsince 12/01/2012
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 06/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 06/01/2024
MCLEAN, JOLENEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/30/2015
MORRIS, DIANEIndividualOPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 06/13/2025
STADLER, DANIELIndividualADP OF THE SNFsince 05/16/2022

CMS files one row per role, so the 19 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$11.3M
Net patient revenuemost recent cost report
-2.3%
Operating marginrevenue minus expenses
$1.8M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 62%Medicare 6%Other / private 32%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$368per resident / day
operating cost
$11,185per month
≈ monthly operating cost
$360per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in ME

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maine Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205159. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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