Cummings Health Care Facility
5 Crocker Street, Howland, ME 04448 · For profit - Corporation · 34 certified beds · (207) 732-4121 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0568)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,824 in federal fines (most recent 2024-03-05)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 |
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 1 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 | 25.8% | 24.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.0% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.1% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.5% | 2.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 50.8% | 11.6% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.5% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 26.2% | 25.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.0% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 47.7% | 29.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.8% | 20.2% | 17.1% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.76 | 1.45 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.57 | 2.01 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 34 beds and averages 31.0 residents a day — about 91% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 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 3.81 hrs/resident/day on weekends vs 4.22 on weekdays — 10% thinner on weekends. RN hours go from 0.87 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2024-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide necessary assistance to prevent accidents by failing to ensure that a two-person mechanical lift assist was provided during transfer for 1 of 1 resident (Resident#1 [R1]) reviewed for an incident with injury. This fall resulted in R1 falling during an improper transfer from bed to shower chair and R1 sustaining a fractured left arm and left ankle. Findings: On 3/5/24, R1's clinical record was reviewed. The record indicated R1 was diagnosed with dementia, weakness, neuropathy, limited mobility, and other morbidities. On 12/7/23 at 1:30 p.m., a nurse note indicated: C.N.A.1 had another staff member tell writer (Registered Nurse [RN]) to come to residents' room immediately. Resident was laying supine on floor by his/her bed, C.N.A.1 stated that one corner of the Hoyer sling came undone and resident fell to the floor hitting his/her left shoulder and leg. Resident complained of severe left leg/shoulder pain. On 12/12/23, the Nurse Practitioner…
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 · F2025-06-11 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews, the facility failed to ensure the Food Service Supervisor (FSS) met the qualifications of a Certified Food Service Director. This had the potential to affect all the residents (32 residents). Finding: On 6/9/25 at 10:45 a.m., during an interview with a surveyor, the FSS stated that she has been in this role for about one year. She stated that she does not have the qualifications for the job and that she is currently not enrolled in any qualifying course or a Managerial Servsafe course. She then stated the facility's dietician is on a consultant basis and comes in monthly. On 6/11/25 at 2:00 p.m., during an interview with the Administrator, the surveyor confirmed that the facility has failed to have a qualified Food Service Supervisor and uses a consultant dietician who is not employed by the facility in a full-time position.
- Potential for harm · F2025-06-11 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews related to mandatory submission of staffing information, the facility failed to ensure complete and accurate direct care staffing information based on payroll data was submitted to CMS (Centers for Medicare and Medicaid Services) for fiscal year quarter 2 2025 (January 1 - March 31, 2025). This has the potential to affect all residents (32 Residents). Findings: Interview with the Administrator on 6/9/25 at 10:30 a.m. revealed that he/she is the responsible person for the submission to CMS of staffing information based on payroll data. A document titled PBJ Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) 1705D FY (Fiscal Year) Quarter 2 2025 (January 1 -March 31) states that the facility Failed to Submit Data for the Quarter was triggered. Triggered' was defined as no data submitted for quarter. A facility document titled Daily Census, printed 6/9/25, documented there were 32 residents living in the facility. On 6/9/25 at 10:15 a.m. in an interview with a surveyor, the Administrator stated there were 32 residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · 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 observations and interviews, the facility failed to promote care for residents in a manner that maintains the resident's dignity and respect during resident observations on 2 of 3 days of survey (6/9/25 and 6/10/25) (Resident #27 [R27], and R12). Findings: 1. On 6/9/25 at approximately 1:30 p.m., staff were observed assisting R27 who is dependent on staff for all Activities of Daily Living tasks, with personal incontinence care. It was observed from the hallway by a surveyor that R27 was being asked to roll on their side for the staff to perform incontinence care. At this time the surveyor observed the privacy curtain was closed but the window curtains were open, and the window was facing the parking lot, potentially exposing R27. On 6/9/25 at 1:35 p.m. the surveyor asked the charge nurse to observe the task being conducted with R27. At this time the Surveyor confirmed the window curtain was not closed and R27 was exposed to the parking lot while receiving incontinence care. The charge nurse closed the window curtains at this time and informed staff to ensure resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · 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 — the official record, unedited, may be distressing
Based on facility policy review, record review, and interview, the facility failed to ensure that the resident and/or resident representative received assistance/follow up assistance to complete the written information provided concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, for 1 of 16 residents reviewed for advanced directives. (Resident #22 [R22]). Finding: Review of facility policy Advanced Directives under the Optional Section: We will assist you to make an Advanced Directive . and by answering your questions about the forms. These services are available from the Social Service Director. On 6/11/25, a review of R22's electronic medical record was completed. The medical record lacked evidence that the facility offered assistance or followed up with the resident and/or resident representative concerning the right to accept or refuse medical or surgical treatment and to ensure the completion of the resident's advanced directive wishes.
- Potential for harm · Dcited before2025-06-11 · 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 review and interviews, the facility failed to ensure that a resident's physician was notified of a significant health change/abnormal lab result with a dieticians recommendation for 1 of 1 resident reviewed (Resident #23 [R23]). Finding: On 6/9/25 at 1:44 p.m. R23's clinical record was reviewed, a nutrition/dietary note documented that R23 has a low albumin level with a suggestion/recommendation for 2 scoops of protein powder to be added to a beverage or soft vegetable such as mashed potato daily. Further review of R23's clinical record indicated that on 3/19/25 the facility wrote a communication to the provider with the problem listed as Albumin 3.0 and asked if they could get a diagnosis for protein/calorie malnutrition. On 3/19/25 R23 had the new diagnosis of protein/calorie malnutrition and was added to his/her diagnosis list. On 6/10/25 at 3:08 p.m. during an interview with a surveyor, the Director of Nursing (DON) stated that if the dietician made a recommendation/suggestion we would write it on a communication form for the provider and get an order. She stated…
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 before2025-06-11 · 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 clinical record reviews and interviews, the facility failed to follow physician orders for 1 of 16 residents reviewed. (Resident #30 [R30]). Finding: On 6/10/25 at 11:44 a.m., during a clinical record review for R30 there is documentation that shows he/she had an order dated 5/29/25 for Boost (supplement) twice a day between meals with a diagnosis of protein, calorie malnutrition. The clinical record lacks evidence that R30 has received this supplement. During this clinical record review a physician progress note dated 6/2/25 that documents that R30 also has protein-calorie malnutrition with albumin of 2.6, decreased from 2.9 in February. Boost nutritional supplements twice daily was added to her regimen to increase caloric intake. The provider was not aware that R30 was not receiving the Boost supplement as ordered. A physician progress note dated 6/9/25 addresses R30's protein-calorie malnutrition and documents the Continuing nutritional supplement twice daily. Consider adding lactase enzyme before meals if there is any discomfort following meals. At this time R30 still…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0711 — isolatedEnsure 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 record reviews and interviews, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders in a timely manner for 2 of 6 residents reviewed for unnecessary medications (Residents #14 [R14], and R23). Findings: 1. On 6/10/25, R14's clinical record was reviewed. A review of the physician visits and medication orders indicated that on 2/10/25, the first required 30-day physician visit (for a newly admitted resident) was completed and R14's admission orders were signed. On 2/24/25, the physician made a visit and medication orders signed. On 3/26/25, the second required 30-day physician visit (for a newly admitted resident) was completed and the medication orders signed. On 4/26/25, the third required 30-day physician visit was completed, but there was no evidence that the medication orders were signed at that visit. On 6/11/25 at 8:15 a.m., during an interview with the surveyor, the Director of Nursing (DON) confirmed that on 4/26/25 the physician made 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 · D2025-06-11 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to incorporate in a care plan the collaboration and responsibilities shared by the facility and Hospice for 1 of 2 Hospice residents reviewed (Resident #5 [R5]). Finding: On 6/10/25, a review of R5's clinical record was completed. Documentation in R5's clinical record indicated R5 is receiving Hospice services. Documentation in R5's care plan had a problem for terminal cancer and the name of the Hospice organization. There was no evidence of goals or interventions that indicated the collaboration of care between the facility and Hospice and there was no evidence of interventions that identified and directed the care between the two. On 6/10/25 at 2:00 p.m., in an interview with the surveyor, the Director of Nursing confirmed that Hospice responsibilities was not integrated in with facility care plan.
- Potential for harm · Ecited before2024-07-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to store food in a sanitary manner on 1 of 3 survey days, and the facility failed to keep accurate and complete temperature logs of the walk-in refrigerator, walk-in freezer, and refrigerator/freezer in the kitchen (7/15/24). Findings: On 7/15/24 from 10:35 a.m. through 11:10 a.m. during the initial observation of the kitchen with the Food Safety Supervisor (FSS), it was observed: 1. Thirty chocolate Hormel Magic dessert cups and thirty-five vanilla Hormel Magic dessert cups in the freezer portion of the refrigerator/freezer had a thick buildup of ice crystals around them, and one chocolate Hormel Magic dessert cup was open. Approximately half of the dessert cups were affected by the thick buildup of ice crystals. 2. Two large bins/containers of white dry substances (flour and sugar per interview during observation with the FSS) not labeled or dated in kitchen to the left of the oven. 3. One bag of confectioner sugar open and not dated, and one large open box of chocolate chips in an open bag inside the box, not sealed, 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 · Ecited before2024-07-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to develop a water management program to prevent the growth and spread of legionella and other water-borne pathogens, and the facility failed to develop policy and procedures for enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms. Findings: 1. On 7/16/24 at 1:36 p.m., a surveyor and the facility's Director of Nursing (DON) reviewed the facility's infection control policies. The DON stated there is not a policy for enhanced barrier precautions. The surveyor confirmed at this time that the facility did not have policy and procedures for enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms 2. On 7/16/24 at 1:36 p.m., in an interview with a surveyor, the DON stated not knowing of a water management policy for legionella and directed the surveyor to the Administrator. On 7/17/24 at 8:27 a.m., in an interview with a surveyor, the Maintenance Technician stated he did not know of a program that identifies where standing water would be and referred to 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.
Show the remaining 18 citations
- Potential for harm · E2024-07-17 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, and interview, the facility failed to offer Pneumococcal Vaccinations (Prevnar 20) to 3 of 5 residents reviewed (Resident #10 [R10], R28, and R32). Findings: On 7/16/24 at 9:02 a.m., clinical record review indicated: 1. R10 was admitted on [DATE]. There was no evidence R10 had received, been offered, or refused the Prevnar 20 vaccination. 2. R28 was admitted on [DATE]. There was no evidence R28 had received, been offered, or refused the Prevnar 20 vaccination. 3. R32 was admitted on [DATE]. There was no evidence R32 had received, been offered, or refused the Prevnar 20 vaccination. On 7/16/24 at 1:45 p.m., review of the Influenza, Pneumococcal, and COVID-19 Immunization Policy indicated, each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. On 7/17/24 at 8:23 a.m., in an interview with the DON, a surveyor confirmed the Prevnar 20 vaccine was not offered to R10, R28, 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 · E2024-07-17 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on employee file reviews and interviews, the facility failed to ensure that a Certified Nursing Assistant (C.N.A.) received at a minimum 12 hours of annual in-service training that included abuse prevention, resident rights and dementia for 1 of 5 Certified Nursing Assistants (C.N.A.s) reviewed (Certified Nurse Assistant #1 [C.N.A.1]). Finding: On 7/17/24 at 9:45 a.m., a surveyor, the Office Manager and Administrator reviewed C.N.A.1's employee file for in-service training during C.N.A.1's annual evaluation period from 2/21/23 to 2/21/24. There was no evidence that C.N.A.1 completed abuse training, resident rights or dementia in-servicing for her annual evaluation period. The Office Manager and Administrator confirmed this finding at the time of review.
- Potential for harm · D2024-07-17 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a resident experienced a significant change of condition, when hospice services were discontinued for 1 of 1 sampled residents (Resident #5 [R5]). Finding: On 7/15/23, during a review of R5's clinical record, a surveyor could not find evidence that R5 was receiving hospice services even though the most recent MDS, dated [DATE], indicated under section O110-K1 that R5 was. On 7/15/24 at 1:17 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated that R5 ended hospice services on 6/3/24. The surveyor asked both the DON and MDS Coordinator if a significant change MDS was completed when hospice services ended and both replied no. The surveyor confirmed that when a resident comes off of hospice a significant change MDS needed to be done.
- Potential for harm · Dcited before2024-07-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to follow their fall protocol for neurological assessments and failed to follow physician orders for 1 of 1 residents reviewed for hospitalization (Resident #22 [R22]). Finding: The facility's policy, Falls Protocol, undated, indicated that staff were to initiate Neuro Checks if a resident sustained a head injury and/or had an unattended fall and directed the licensed nurse to complete a Neurological Evaluation. The Neurological Assessment flowsheet directed staff to complete these every 15 minutes times (x) 4, 30 minutes x 4, 2 hours x 4, and every 4 hours x 4. On 7/16/24, R22's clinical record was reviewed and indicated that R22 had a fall on 6/8/24 at 7:30 a.m., bumped his/her head, and was sent to the hospital later in the day. A review of the Neurological Assessment flowsheet completed for R22 indicated that the assessments were not completed for the 9:45 a.m. and 10:15 a.m. assessment times, but were completed after those times up to 2:15 p.m., thereafter the resident was at the hospital. On 7/16/24 at 11:39 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on monthly schedule reviews and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 6 days of 2 months reviewed for staffing (January and February 2024). Findings: On 7/17/24 at 8:20 a.m., a surveyor, Office Manager and Administrator, reviewed the schedules for January and February 2024. The following were confirmed: 1. For January, on 1/9/24, 1/11/24 and 1/29/24, the facility failed to ensure that an RN was working for 8 consecutive hours. 2. For February, on 2/9/24, 2/10/24 and 2/22/24, the facility failed to ensure that an RN was working for 8 consecutive hours.
- Potential for harm · D2024-07-17 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of Employee Job Performance Evaluations and interview, the facility failed to complete an annual performance evaluation at least every 12 months, for 2 of 5 sampled Certified Nursing Assistants (C.N.A.) employed greater than 1 year (Certified Nurse Assistant #2 [C.N.A.2] and Certified Nurse Assistant-Medications [C.N.A.-M]). Findings: On 7/17/24 at 10:00 a.m., a surveyor and Administrator reviewed C.N.A.2 and C.N.A.-M's employee files with the following confirmed: 1. C.N.A.2 was hired on 5/9/2018. The annual evaluation was due by 5/9/2024. There was no evidence that the evaluation had been completed as of 7/17/2024. 2. C.N.A.-M was hired on 8/17/2009. The annual evaluation was due by 5/9/2023. There was no evidence that the evaluation had been completed as of 7/17/2024.
- Potential for harm · D2024-07-17 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for one trash dumpster for 1 of 3 days of survey (7/17/24). Finding: On 7/17/24 at 7:40 a.m., a surveyor observed a trash dumpster with the top right lid open with two black bags on top of the dumpster exposing trash. On 7/17/24 at 7:44 a.m., in an interview and observation of the trash dumpster with the Administrator, a surveyor confirmed the above finding.
- Potential for harm · D2024-07-17 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated 2023-2024 Coronavirus (COVID-19) vaccine for 1 of 5 residents reviewed (Resident #28 [R28]). Finding: On 7/16/24 at 9:02 a.m., clinical record review indicated R28 was admitted on [DATE] and is currently [AGE] years old. R28's last documented COVID-19 vaccination was on 4/28/22. There was no evidence R28 had received, been offered, or refused the COVID-19 vaccination. On 7/16/24 at 1:45 p.m., review of the Influenza, Pneumococcal, and COVID-19 Immunization Policy indicated each resident is offered a COVID-19 immunization unless the immunization is medically contraindicated, or the resident has already been immunized. On 7/16/24 at 1:36 p.m., in an interview with a surveyor, the Director of Nursing (DON) stated she uses the CDC website as a resource. Review of the CDC website, Stay Up to Date with COVID-19 Vaccines | CDC, indicated that CDC…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-11 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to inform a resident or their representative, of a treatment that would be held due to unavailability for 1 of 1 resident reviewed. (Resident #12). Finding: On 5/10/23 during a clinical record review for Resident #12, it was observed that he/she has an order for Imatinib Mesylate 400 milligrams (mg) give 1 tablet by mouth one time a day (at breakfast) for Chronic Myeloid Leukemia. This medication is used to manage and treat chronic myelogenous leukemia. Resident #12's clinical record indicated that he/she last received this medication on 2/3/23. On 2/4/23, his/her clinical record reflects that the order for Imatinib was documented as not being available and Resident #12 did not receive that dose. On 2/6/23, the facility was made aware that this medication is not covered by his/her insurance and the pharmacy was not able to send the medication to the facility. Resident #12's clinical record in the section labeled Progress notes (nursing notes), documents that on 2/13/23, the facility made the resident and his/her Power of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-11 · tag F0580 — failed to tell family and doctor about changes — patternImmediately 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 review and interview the facility failed to notify a Practitioner and an Oncologist of resident changes in medications not being received due to unavailability for 1 of 1 resident reviewed (Resident #12) Findings: On 5/10/23 during a clinical record review for Resident #12, it was observed that he/she has an order for Imatinib Mesylate 400 milligrams (mg) give 1 tablet by mouth one time a day (at breakfast) for Chronic Myeloid Leukemia. This medication is used to manage and treat chronic myelogenous leukemia. During a clinical record review, the electronic medication administration records for February and March indicated that the medication was held from 2/4/23 to 3/25/23, for a total of 50 days/doses The clinical record shows that on 2/14/23, the Practitioner was made aware of the medication not being available due to not being covered by insurance and wrote an order will hold until available. The Practitioner was made aware 11 days after his/her last dose was received. During further review of Resident #12's clinical record, it showed evidence that on 2/21/23 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.
- Potential for harm · Ecited before2023-05-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of the facility's Infection Prevention and Control Policy (IPCP) and interviews, the facility failed to conduct an annual overall review of the facility's Infection Prevention and Control Policy for 1 of 1 IPCP review. In addition, the facility failed to follow it's cleaning policy for a resident diagnosed with Clostridium difficile (C-diff) (a bacterium that causes an infection in the large intestines) for 1 of 1 resident reviewed with C-diff (Resident #32). Findings: 1. On 5/10/23 at 10:03 a.m., a review of the facility's Infection Prevention and Control Program was discussed with the Director of Nursing/ Infection Preventionist (DON/IP). The DON/IP confirmed that the Infection Prevention and Control Program has not been reviewed yearly. 2. Review of facility protocol for C-diff stated, Protocol for C-diff - 6. Housekeeping is notified of infected resident and a system is to be set up to ensure that the resident's room is decontaminated with bleach. 3. On 5/10/23 at 12:35 p.m., a review of the facility's Protocol for C-diff disinfection was discussed…
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 · D2023-05-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 2 Units. (A-Unit and B-Unit) for 1 of 1 environmental tours. In addition, the facility failed to maintain a sanitary and clean nebulizer machine for 1 of 1 resident nebulizer machines observed (Resident #5). On 5/11/23 at 9:45 a.m., a surveyor did an environmental tour with the facility Administrator in which the following were observed: A-Unit room [ROOM NUMBER]: Bed-1's resident fan that blows on the resident's bed is heavily soiled with clumps of dust. room [ROOM NUMBER]: To the left of Bed-1, the floor is stained with a rust colored substance. The tiles under the sink are separated creating an uncleanable surface. room [ROOM NUMBER]: Bed-1, To the left of the room sink, the molding is chipped. To the right of the bathroom door, the cove base is missing. B-Unit room [ROOM NUMBER]: Above the room sink, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-11 · 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 observation, record reviews, and interviews the facility failed to ensure that physician orders were followed for 1 of 5 resident's (Resident #15) observed during medication administration, and 1 of 5 resident's reviewed for unnecessary medications (Resident #32). 1. On 5/8/23 at 6:21 p.m., during a medication administration observation for Resident #15, who had an order for Metoprolol 50 milligrams (mg) twice a day with directions to hold if pulse is below 60. The Certified Nursing Assistant Medication aide (CNA-M) prepared his/her medications for administration. The CNA-M went into the resident's room and administered the Metoprolol 50 mg without taking Resident #15's pulse. The surveyor questioned the CNA-M about not taking the pulse before administering the Metoprolol and he stated that the order had been discontinued. The surveyor and the CNA-M reviewed the orders on the Electronic Medication Administration Record (E-MAR) and the directions to hold if pulse is below 60 showed as an active order. On 5/8/23 at 6:47 p.m., the surveyor asked the Charge Nurse if Resident…
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 before2023-05-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to label whipped topping with a thaw date on 1 of 4 days of survey (5/9/23), in addition the facility failed to label and date food in the resident's refrigerator located in the kitchenette on 1 of 4 days of survey (5/9/23). Findings: 1. On 5/9/23 at 8:21 a.m., during the initial tour of the kitchen, the surveyor found in the walk-in refrigerator 3 packages of thawed whipped topping with no thaw date. The storage instructions on the packages are that the item has a 2-week (14 day) shelf life once thawed. There is no evidence of when these whipped toppings were thawed. On 5/9/23 at 9:00 a.m., the surveyor confirmed this finding with the Food Service Manager. 2. On 5/9/23 at 9:30 a.m., during an observation of the residents kitchenette, the surveyor found 2 containers in the refrigerator that were unlabeled (name and date). On 5/9/23 at 9:41 a.m., during an interview with the Director of Nursing (DON), the surveyor confirmed that the containers were not labeled with a name and date. The DON asked staff members if they knew what…
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 · B2024-07-17 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews and record reviews, the facility failed to ensure quarterly statements were provided to the Resident or Resident representative for 1 of 1 Resident with a trust account (Resident #8 [R8]). In addition, the facility failed to ensure quarterly statements were provided to all Residents or Resident representatives with trust accounts. Finding: On 7/15/24 at 12:25 p.m. during a resident interview, R8 stated that he/she did not recall receiving any quarterly statements with an accounting of his/her resident trust account. On 7/17/24 at 8:41 a.m. during an interview with a surveyor, the Accountant stated they were unable to find documentation to support that R8 was sent his/her quarterly statements and that quarterly statements are not sent out to Residents unless a statement is sent with a cost of care statement or their trust account drops to a negative balance. A surveyor confirmed, at this time, with the Accountant that R8 did not receive any quarterly statements, and that quarterly statements are not sent out to Residents or Resident representatives.
- No harm found · B2024-07-17 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives, the results of the most recent survey of the facility in 2 of 2 survey folders (located in the dining room and entrance foyer). Findings: On 7/16/24 at 8:15 a.m., a surveyor observed the survey folder located in the dining room, located on a rack on the wall. This folder included the State Survey results, with the most recent results from a survey dated 2/11/20, although the State Agency had completed multiple surveys after that date. On 7/16/24 at 8:20 a.m., during an interview with a surveyor, the Administrator stated there were two survey folders, one in the dining room and one in the entrance foyer area for family members, The Administrator and surveyor observed both survey folders with the most recent survey in the entrance foyer folder was 5/11/23, although the State Agency had completed an additional survey after that date on 3/5/24; the Administrator and surveyor also observed the folder in the dining room with the most…
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 · B2024-07-17 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the Annual Minimum Data Set (MDS) 3.0 was coded accurately on two annual MDS assessments to indicate that a resident had a State Level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 sampled residents reviewed for PASRR (Resident #21 [R21]). Finding: On 7/15/24, R21's clinical record was reviewed and included a PASSR, dated 3/4/20, that indicated that R21 qualified for Level II services. Review of R21's annual MDS, dated [DATE], Section: A1500 was coded to indicate that R21 did not have a Level II PASRR and had been coded incorrectly starting with the 8/12/22 annual MDS. On 7/16/24 at 10:12 a.m., during an interview with a surveyor, the MDS Coordinator stated that R21 did have a Level II PASRR and that the MDS was coded inaccurately. The surveyor confirmed this finding during this interview.
- No harm found · B2023-05-11 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, and a breakdown of the number of hours of registered and unlicensed nursing staff responsible for direct resident care for 3 of 4 survey days, and the facility failed to keep a copy of the posted daily nurse staffing information for 18 months. (5/8/23, 5/9/23, and 5/10/23) Findings: 1. On 5/8/23 at 6:15 p.m., a surveyor observed that the nurse staffing information located at the nurses station was posted on an erasable white board. The nurse staffing information posted did not include the name of the facility, the total number of hours and the actual hours worked for registered and unlicensed nursing staff responsible for direct resident care for 5/8/23. 2. On 5/9/23 at 8:22 a.m., a surveyor observed that the nurse staffing information located at the nurses station was posted on an erasable white board. The nurse staffing information posted did not include the name of the facility, the total number of hours and the actual hours worked for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$8,824 in federal fines across 1 penalty.
- $8,824 — penalty dated 2024-03-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GOSLIN, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 02/05/2008 |
| GOSLIN, MELINDA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 02/05/2008 |
| GOSLIN, ADDISON | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/07/2021 |
CMS files one row per role, so the 11 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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 205143. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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.