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St Mary's D'youville Pavilion

102 Campus Ave, Lewiston, ME 04240 · Non profit - Corporation · 210 certified beds · (207) 777-4200 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$22,205 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • 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
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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
  • the CMS record shows $22,205 in federal fines (most recent 2026-04-15)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
99 Campus Ave · (207) 777-8810 · Call to confirm hours
Pharmacy
373 Sabattus St · (207) 783-3539 · Call to confirm hours
Grocery
8 Warren Ave · (207) 618-3368 · Call to confirm hours
Park
Central Avenue · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 5 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 fell from 2 to 1 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 rating1★
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 increased30.0%24.4%15.4%worse
Long-stay residents who lose too much weight7.1%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%1.1%0.9%better
Long-stay residents with a urinary tract infection1.5%2.2%2.0%better
Long-stay residents with depressive symptoms3.9%11.6%6.5%better
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 injury2.7%4.1%3.3%better
Long-stay residents whose ability to walk worsened30.0%25.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.6%17.4%18.9%better
Long-stay residents given the seasonal flu vaccine95.3%95.5%95.3%typical
Long-stay residents with pressure ulcers2.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control26.7%29.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.6%20.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.3%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine70.8%74.5%79.4%worse
Short-stay residents rehospitalized after admission23.6%20.8%22.6%typical
Short-stay residents with an outpatient ER visit9.7%16.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.791.451.67typical
Long-stay outpatient ER visits per 1,000 resident days1.322.011.80better

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.

54.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 259 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.6%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
64.5%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 64.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 121 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF54.6%CMS range 48.5–61.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 7.1–13.310.7%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 discharge64.5%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 discharge66.1%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 discharge45.5%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 identified98.1%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%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 worsened0.0%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 hospitalization6.1%CMS range 3.1–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 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

1.17
RN hours/ resident / day
0.38
LPN hours/ resident / day
2.46
Aide hours/ resident / day
4.01
Total nurse hours/ resident / day
1.17
RN hoursweekends
50.0%
Total nursing turnover
37.2%
RN turnover

How full it usually is: this home is certified for 210 beds and averages 165.2 residents a day — about 79% occupied, or roughly 45 beds typically open. It usually has some room. 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 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 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 3.93 hrs/resident/day on weekends vs 4.05 on weekdays — 3% thinner on weekends. RN hours go from 1.17 to 1.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-03-28)
12
at the previous standard inspection (2024-01-26)

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 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-04-15 · 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 record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to ensure a resident was free from an avoidable accident and environmental hazards. Specifically, Resident #1 [R1] exited their assigned unit onto an exterior courtyard/patio area without staff knowledge. The resident remained outdoors, inadequately dressed for the weather, for approximately 30 minutes before being discovered face down on the snow-covered ground. This failure created an immediate jeopardy situation.Findings: The Department of Licensing and Certification [State Agency] received an anonymous complaint which stated R1 was found outside on the ground in wet/snowy conditions in the early morning hours of March 21, 2026. A review of R1's clinical records stated R1 was admitted in March 2026 following an evaluation in the emergency department after a fall at home resulting in fractured ribs. Diagnoses included Alzheimer's disease and dementia complicated by psychosis. During…

    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 · D2026-06-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy, record reviews, and interviews, the facility failed to thoroughly investigate a resident-to-resident altercation, ensure that the facility's investigation was completed, and failed to send the investigation to the State Agency within 5 business days of the incident for 2 of 3 facility reported incidents investigated on 1 of 5 units (Resident #35, Resident #39, Resident #59, and Resident #186).Findings:Review of the facility Freedom from Abuse, Neglect, & Exploitation policy last revised 01/2025 under Investigation Procedures states, Report of potential abuse can be received from any source and will be investigated. The investigation will be conducted by any of the following: nursing, social services, administration. Immediate medical attention for the resident/patient will be obtained as needed. The reporter, witnesses, alleged abuser and resident/patient will be interviewed. The results of investigations must be reported immediately to the administrator or designee and to other officials in accordance with State law (including to the state survey 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-04-15 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to notify the State agency of a resident's elopement within 24 hours of the incident; and failed to provide the State agency with a 5 day follow up report for 1 of 1 investigated incident of neglect. (#1) Finding: The Department of Licensing and Certification [State Agency] received an anonymous complaint which stated R1 was found outside on the ground in wet/snowy conditions in the early morning hours of March 21, 2026. A review of a Late Entry note for March 21, 2026, stated R1 had went out of [his/her] room into the stairwell . [he/she] was observed by staff and brought back to [his/her] room, and states that R1 continued to be restless. A review of a Fall/Details note stated on March 21, 2026, R1 was in bed at 5:00 a.m., and at 5:30 a.m. R1 was noted to not be in [his/her] room, at 5:40 a.m., R1 was found outside lying on the grass. A review of facility records included nursing documentation, video surveillance, written staff statements and interviews…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ddisputed · IDR2025-11-21 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 review of the facility's incident report, record reviews, interviews, and internal investigation, the facility failed to ensure staff spoke to residents in a dignified manner for 2 of 3 residents reviewed for abuse (R1, R2).Findings: On 9/24/25, the facility reported an incident to the Division of Licensing and Certification, which stated on 9/10/25, staff observed CNA1 (Certified Nursing Assistant) shout at R1 and stated Keep your damn hands to yourself, if you hit me, (I) am hitting you back. Later during the shift, the staff reported CNA1 was heard yelling in R2's room. When the staff entered, CNA1 was observed stating to the resident Why don't you just die already. The staff reported having observed CNA1 yell at residents who are wandering during the night to go back to bed, go to your f*ing room, I am sick and tired of you all. Staff stated no attempt was made to determine if residents needed assistance. Due to R1 and R2's level of cognitive impairment, neither demonstrated an awareness of the incidents. A review of R1's clinical record revealed diagnoses including…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2025-03-28 · 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 adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 3 units (3rd floor unit and 4th floor unit) and the laundry rooms for 1 of 1 environmental tour (3/28/25). Findings: On 3/28/25 from 8:20 a.m. to 8:45 a.m., an Environmental Tour was conducted with the Administrator, the Quality Assurance and Performance Improvement Program (QAPI) Manager and the 3rd Floor Unit Manager in which the following findings were observed: Laundry rooms >Clean Linen Area: There were 4 wall mounted fans that were dusty/dirty. There were 2 wall mounted air conditioning units that were dusty/dirty. > Soiled Linen Area: There were 2 wall mounted fans that were dusty/dirty. The ceiling air system, just inside the entrance door, had dusty/dirty filters. 3rd Floor Units (East and West) > The hallway walls were marred with black marks. >Resident room [ROOM NUMBER] - The privacy curtains were…

    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 · E2025-03-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care on 3 of 4 days of survey (3/25/25, 3/26/25 and 3/27/25) for 9 of 13 residents reviewed for respiratory care. (#40, #52, #153, #370, #366, #42, #24, #468 and #472) Findings: 1. On 3/25/25 from 9:24 a.m. to 10:23 a.m., and again on 3/26/25 at 7:25 a.m., the following was observed: > Resident #40 had an unlabeled/dated nebulizer pipe stored on the bedside dresser. In a brief interview, the resident stated he/she hasn't had to use the nebulizer in a week. > Resident #52 room had an unlabeled/dated oxygen nasal cannula tubing with the nasal prongs lying on the floor. > Resident #153 room had an unlabeled/dated oxygen nasal cannula tubing wrapped up under the concentrator handle. > Resident #370 room had an unlabeled/dated nebulizer tubing with the open tubing end hanging over the nebulizer handle. 2. On 3/25/25 at 10:29 a.m., Resident #366 had an oxygen concentrator running, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-28 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 ensure that a resident who requires Hemodialysis receives such services, consistent with the professional standards of practice and failed to ensure the care plan contained the needed information, including emergency interventions necessary to properly care for 2 of 2 residents reviewed for Hemodialysis. (#105 and #32) Findings: 1. On 3/26/25 at 8:32 a.m., the surveyor observed Resident #105 with a bandage to the upper arm. At this time, during an interview, Resident #105 stated he/she has an AVF (Arteriovenous Fistula) and has been going to dialysis for a couple of years. He/she then stated, Next Friday they are going to do something with my site, the past couple times they couldn't stop me from bleeding and I had to go to the hospital. The surveyor asked if and when the nurses assess and how they monitor his/her AVF site. He/she stated, They have never touched it and no monitoring. Review of the medical record states Resident #105 was admitted to the facility with a diagnosis of End-Stage Renal Disease…

    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 · E2025-03-28 · tag F0699 — pattern
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to assess resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 2 of 3 sampled residents reviewed with a current diagnosis of PTSD (Resident #39 and #110). Findings: 1. A review of Resident #39's Annual Minimum Data Set (MDS) 3.0, dated 2/18/25, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #39 has an active diagnosis for PTSD. The surveyor was unable to find information in the clinical record that indicates what Resident #39's PTSD was caused by, what trigger(s) might cause re-traumatization, and measures to avoid trigger(s) that might cause re-traumatization. In addition, Resident #39's care plan lacked evidence of a trauma informed care plan with identified triggers and interventions to prevent re-traumatization. On 3/26/25 at 3:12 p.m., the surveyor confirmed the finding above with the Administrator and the Director of Social Services. 2. A review of Resident #110 's clinical record, 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 before2025-03-28 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 8 sampled residents reviewed for new admissions (Resident #36). Finding: Resident #36 was admitted in early March of 2025 with a primary diagnosis of fall with right ankle fracture requiring a Lovenox (anticoagulant) injection daily. As of 3/26/25 Resident #36's medical record lacked evidence of a baseline care plan that included the instructions necessary to properly care for him/her, in the area above. On 3/26/25 at 4:39 p.m., the above was discussed with the Director of Nursing.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-28 · 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

    Based on observations, interviews and record reviews, the facility failed to ensure a physician's order and care plan was followed for 1 of 11 residents reviewed for oxygen therapy (#42). Finding: On 3/25/25 at 10:43 a.m., observation of Resident #42 receiving oxygen (O2) via nasal cannula with the oxygen concentrator set at 3 Liters Per Minute (LPM). At this time, the resident stated he/she is on 3 LPM of oxygen. On 3/26/25 at 7:29 a.m., an additional observation of Resident #42 receiving oxygen via a nasal cannula with the oxygen concentrator set at 3 LPM. Review of the medical record contained a Provider order dated 3/7/25 for Apply O2 at 4L to keep sats at 93 at rest and 88 with activity. every shift. The resident care plan for oxygen therapy r/t CHF (congestive heart Failure), Respiratory illness initiated: 2/28/25. Has interventions of oxygen settings: O2 via nasal cannula @ 4 L continuous. Further review of the nursing documentation states on 3/10/25, 3/11/25 and 3/15/25 he/she was on 3 LPM of oxygen via nasal cannula. On 3/26/25 at 11:07 a.m., during an interview, both 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-28 · 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

    Based on observations, interviews, and record reviews, the facility failed to ensure a smoking assessment of resident capabilities and deficits to determine resident safety was completed for 1 of 1 resident reviewed for smoking (105). Finding: On 3/26/25 at 8:44 a.m., during an interview with Resident #105, a Registered Nurse (RN) entered the resident's room and removed a lighter from the open nightstand drawer and explained to the resident that having the lighter in his/her room is a hazard and he/she can obtain the lighter prior to going out to smoke. The resident stated he/she is going outside to smoke after breakfast. Review of Resident #105's Smoking Safety Interaction dated 3/18/25, states he/she uses tobacco products, has Poor vision or blindness and Unable to extinguish tobacco or marijuana safely. The rest of the form includes the section Clinical Suggestions which has; Apply smoking apron, Set up cigarette holder, Staff to extinguish cigarette, Refer to interdisciplinary Team, if Resident deemed unsafe to smoke and Ensure eyeglasses are on, was not completed. On 3/26/25 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-03-28 · 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 — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 4 survey days. (3/25/25) Finding: On 3/25/25 at 9:15 a.m., a surveyor observed 2 unlocked medication carts located in the hall across from the nurses station on the 3 [NAME] Unit. Two staff were observed in an area behind the nurses station and one staff was seated at the nurses station. The surveyor asked the staff seated at the nurses station who the charge nurse was and the staff person pointed to the two staff seated behind her and stated they both are. At this time, the surveyor opened both medication carts and went through each drawer. No one responded to this. One of the identified nurses got up and walked away. Finally, the surveyor walked over to the remaining nurse and informed her that both medication carts were unlocked. The nurse immediately got up, locked the carts and confirmed the finding.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-28 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on an interview and review of the facility's Quality Assurance and Performance Improvement (QAPI), the facility failed to present evidence that the required members attended 2 of 4 quarters provided (April 2024 and July 2024). Finding: On 3/25/25 at 2:43 p.m., a surveyor requested a copy of the attendance sheets for the QAPI quarterly meetings. The Quality Assurance and Performance Improvement Manager provided the surveyor with the meeting attendance sheets. A review of the April 2024 QAPI attendance sheet lacked evidence that the Medical Director attended the meeting. The July 2024 QAPI attendance sheet lacked evidence that the Administrator, Director of Nursing and the Infection Preventionists attended the meeting. On 3/27/25 at 9:19 a.m., during an interview, the above was confirmed with the Quality Assurance and Performance Improvement Manager.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-02 · 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 and interviews, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection for 1 of 7 residents on contact precautions (Resident #6). Findings: On 1/2/25 at 8:00 a.m., a surveyor observed a contact precaution sign on Resident #6's door instructing all staff to wear the following Personal Protective Equipment (PPE) for all direct care; gown, gloves and goggles (if there is high chance of liquid exposure). Hanging on the outside of the door was a yellow precaution bag containing the PPE required for Resident #6's direct care. At this time, 2 Certified Nursing Assistants (CNA#1 and CNA#2) entered Resident #6's room wearing only a mask. CNA#1 began preparing the resident for the transfer. The surveyor intervened, and asked CNA #1 if Resident #6 is on contact precautions and what should be worn. CNA #1 stated a gown, and gloves are to be worn with direct patient care and if there is high change of liquid exposure to wear goggles, then closed the door on the surveyor. At this…

    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 before2024-01-26 · 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 1 of 3 floors (3rd) and the laundry rooms for 1 of 1 environmental tour. (1/26/24) Findings: On 1/26/24 from 9: 20 a.m. to 10:10 a.m., an Environment tour was conducted with the Plant Operations Manager in which the following findings were observed: Laundry Rooms > The soiled laundry linen room had 1 wall fan that was dusty/dirty. The cement floor had chipped/missing paint and the non-skid floor tape was missing pieces/sections creating uncleanable surfaces. > The clean laundry linen room had 3 wall fans that were dusty/dirty. The cement floor had chipped/missing paint creating an uncleanable surface. > The laundry room had 30 broken/missing floor tiles. The cement floor, behind and under the washing machines, had chipped/missing paint creating uncleanable surfaces. 3rd Floor East > The wheelchair scale had…

    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 · E2024-01-26 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to develop or implement the care plan interventions for the residents' current needs for 6 of 33 sampled residents/care plans reviewed (Resident #2, #20, #52, #101, #166 and #173) Findings: 1. Resident #2's clinical record was reviewed and revealed the resident has muscle weakness, unsteadiness on feet and has had falls. The current care plan noted the following: [Resident #2] requires floor mats when in bed on both sides of bed for fall safety. [Resident #2]will have no injuries if a fall occurs before the review date. Staff to pick up and place mats out of the way from wheelchair accessibility in room when out of bed and will lay them next to bed on both sides when in bed. On 1/24/24 at 2:05 p.m., a surveyor observed Resident #2 in bed with no floor mats placed on the floor on both sides of the bed. On 1/24/24 at 2:10 p.m., in an interview, Registered Nurse, RN. #3 confirmed that Resident #2 was in bed and the floor mats were not put on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · 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

    Based on record review and interview, the facility failed to revise a care plan to reflect the current needs for 3 of 33 sampled residents/care plans reviewed (#104, #135 and #144) Findings: 1. A review of Resident #104's clinical record revealed that Hospice was initiated on 9/2/23 for terminal diagnosis of Parkinson's Disease. A Significant Change in Status Minimum Data Set (MDS) 3.0 assessment was completed on 9/4/23 with the Interdisciplinary Team (IDT) meeting held on 9/22/23 and the most recent Quarterly MDS completed on 12/5/23 with the IDT meeting held on 12/8/23. The most recent care plan revision was completed on 12/12/23. As of 1/26/24 Resident #104's care plan lacked evidence of a revision to reflect Hospice services after both MDS assessments and IDT meetings. On 1/26/24 at 11:24 a.m., during an interview with Assistant Director of Nursing, the above was confirmed. 2. A review of Resident #135's clinical record revealed a progress note dated, 1/9/24 at 12:24. Progress note states resident had a verbal outburst and was yelling out this a.m. for help, and made reference…

    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 · Ecited before2024-01-26 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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

    Based on record review and interviews, the facility failed to follow a physician order for obtaining daily weights for 1 of 8 sampled residents for rehospitalization (#114) and failed to follow physician orders for making a referral to a specialist for 1 of 5 residents reviewed for unnecessary medications. (#144) Finding: 1. On 1/24/24, Resident #114's clinical record was reviewed and contained a physician order dated 10/12/23, for Daily weight in the morning for edema. Review of Resident #114's weights from 10/13/23 to 1/21/24 revealed that weights were not completed on 10/17/23-10/19/23, 10/21/23, 10/22/23, 10/24/23, 10/25/23, 10/31/23, 11/1/23, 11/5/23, 11/7/23, 11/9/23-11/15/23, 11/18/23-11/20/23, 11/23/23-11/29/23, 12/1/23-12/9/23, 12/11/23-12/16/23, 12/18/23-12/25/23, 12/27/23, 12/28/23, 12/31/23, 1/1/24-1/3/24, 1/6/24, 1/9/24-1/13/24, 1/15/24, 1/17/24, 1/19/24, 1/20/24, 1/22/24 and 1/23/24. On 1/24/24 at 10:05 a.m., during an interview with the Assistant Director of Nursing, she confirmed that Resident #114's weights had not been taken daily between 10/13/23 to 1/21/24 as 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · 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 — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean manner on 1 of 1 days of survey (1/22/24) for ceiling vents, ceiling tiles, and an auto bag machine; failed to ensure the male kitchen staff were wearing facial hair protection, failed to ensure wet sacking of glasses, and failed to ensure foods were dated and/or labeled in freezers and refrigerators. Further, the facility failed to monitor temperatures of the dish washing machine and the refrigerators and freezers. In addition, the facility failed to ensure that proper hand sanitizing and proper food handling, during lunch service, was followed for 1 of 2 lunch observations (1/22/24) on the 3rd floor [NAME] Unit. Findings: Refrigeration Temperature Log(documented at the bottom of the Refrigeration Temperature Log)- This log will be maintained for each refrigerator and freezer(both walk in and reach in units) in the facility. Employee will record the time, air temperature and their initials (preferably upon arrival) once in the morning and once(preferably just before leaving 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection related to Methicillin Resistant Staphylococcus Aureus (MRSA- a Multidrug-Resistant Organism) colonized in sputum and urine for a 2 of 2 sampled residents (Resident #20 and #148) diagnosed MRSA for 1 of 5 days of survey (1/22/24). This has the potential to affect all 39 residents on the 4 East unit. Findings: 1. Resident #20's clinical record was reviewed and revealed a diagnosis of Quadriplegia, tracheostomy, a carrier of MRSA in his/her sputum and chronic respiratory failure with Oxygen supplement. Physician order dated 7/23/23 for Tobramycin (antibiotic) inhalation nebulization solution, 3ml (milliliters) inhale orally via nebulizer two times a day 28 days on and 28 days off for respiratory MRSA. The care plan for MRSA - colonization (respiratory) revised on 10/11/21, instructs staff to wear…

    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 · D2024-01-26 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident's right to formulate an advance directive regarding cardiopulmonary resuscitation (CPR) or Code Status was accurate in the clinical record for 1 out of 7 sampled residents reviewed for advanced directives (Resident #108). Findings: Resident #108 was admitted to the facility on [DATE]. On [DATE] at 10:51 a.m. during an interview with a Unit Secretary (US#1) a surveyor learned that Resident #108's Code Status was unknown. US#1 remembered that Resident #108 had requested a while ago to change their Code Status to CPR and she reportedly told a unit manager, but the chart indicated a Code Status of No CPR. On [DATE] at 11:00 a.m., a surveyor confirmed during an interview with the Unit Manager that Resident #108 makes his/her own decisions. On [DATE] at 11:10 a.m., a surveyor interviewed Resident #108 in his/her room and learned Resident #108 wanted his/her Code Status to be CPR and he/she had already talked to staff about this. On [DATE]…

    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 · D2024-01-26 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to conduct a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a resident experienced a significant change of condition and hospice services were initiated for 1 of 4 sampled residents receiving hospice services (R173). Finding: On review of R173's clinical record, a surveyor noted the resident received hospice services, initiated on 10/5/23. On further review, the surveyor noted the most recent comprehensive MDS 3.0 assessment was completed on 9/7/23 and no comprehensive MDS 3.0 assessment was completed within 14 days of the initiation of hospice services. On 1/26/24 at 12:45 p.m., the Director of Nursing confirmed a comprehensive assessment should have been completed within 14 days after the resident began hospice services

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-26 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 new admissions requiring Transmission Based Precautions (TBP). (Resident #160). Finding: Resident #160 was admitted to the facility on [DATE] with a primary diagnosis of: Sepsis (a serious condition in which the body responds improperly to an infection), acute kidney injury and recurrent Clostridioides Difficile (C-Diff) (a highly contagious bacterium that causes diarrhea and inflammation of the colon - which requires TBP, contact precautions while providing care, that is gloves and gown) requiring antibiotic use. Resident #160's clinical record was reviewed and revealed; Physician order dated 11/21/23 for Fidaxomicin oral tablet 200 milligram (mg), give 200 mg by mouth two times a day for septicemia, this order was discontinued on 11/27/23 and another Physician…

    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 · D2024-01-26 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure the pharmacist provided services to identify that a physician's order for the psychiatric evaluation was completed for 1 of 5 residents reviewed for unnecessary medications (Resident #144). Finding: On 1/23/24 during review of Resident #144's clinical record, a Physicians order dated 9/13/23 to start Sertraline (Antidepressant) 50 milligrams daily for depression and for a Psych evaluation for depression. As of 1/23/24 the medical record lacked evidence of a psychiatric evaluation. The Pharmacist reviewed Resident #144's medication regimen on 9/29/23, 10/29/23, 11/29/23 and 12/26/23. There was no evidence in Resident #144's clinical record that the Pharmacist identified the lack of a Psychiatric evaluation for depression with use of Sertraline. On 1/24/24 at 11:00 a.m., the above was confirmed with the Registered Nurse Manager on 4 East unit

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · 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

    Based on record review and interview, the facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (#52). Finding: Resident #52's Physician Order Sheet signed by the physician on 11/18/23 indicated Resident #52 had been receiving the antipsychotic medication Quetiapine 25 milligrams (mg) one tablet every morning and Quetiapine 50 mg two times daily, since 11/26/22. Between 11/26/22 and 1/25/24, there was no documentation in the clinical record that a GDR was attempted or that a GDR was clinically contraindicated for Resident #52. The surveyor discussed this finding in an interview with the Assistant Director of Nursing on 1/26/24 11:15 a.m.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · 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

    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 1/26/24, was effective. The Federal citation F584 and F812 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 3/21/24. Findings: During the annual Long Term Care survey, dated 1/26/24, 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 and at F812 for the facilities failure to ensure foods were dated and/or labeled in a freezer and refrigerator. The facility's POC, dated 2/12/24, indicated that the facility would ensure that the resident rooms/bathrooms would be in a sanitary condition by clean ceiling fans weekly and all rooms/bathrooms in the facility will have bed pans/commodes stored appropriately, and the facility would ensure kitchen staff would date 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-09 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 1 of 4 residents with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASARR) evaluation and determination (#152). Finding: Resident #152 was admitted to the facility on [DATE] with diagnosis of Depression and Bipolar Disorder. Resident #152's clinical record contained a PASARR Level I determination letter dated 8/15/19 that stated further PASARR evaluation is not required due to Resident #152 met the criteria for a short-term convalescence admission. Resident #152 was not discharged after a short stay and was assessed to be Nursing Facility(NF) level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASARR Level I was forwarded again to the State Mental Health Authority to determine if a Level II evaluation and determination was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-09 · 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

    Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, ceiling lights, ceiling tiles, ceiling grids and food mixers. In addition, the facility failed to ensure that foods were labeled and dated in the walk-in freezers and the walk-in refrigerators. Further, the facility failed to monitor the chemical sanitizer levels for the sanitizing sink and the sanitizing buckets for 1 of 1 kitchen tours on 1 of 4 days of survey (3/6/22). Findings: The facility Policy & Procedure Manual Chapter 3: Food Production and Food Safety noted the following: Procedure: 6. c. Food will be dated as it is placed on the shelves if required by state regulation. 12. Leftover food will be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. 13. Refrigerated food storage: f. All foods will be covered, labeled, and dated and routinely to assure that foods(including leftovers)will be consumed by their safe use be dates, or frozen(where applicable), or…

    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

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$22,205 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $22,205 — penalty dated 2026-04-15
  • Medicare payment denial — starting 2026-05-21 for 4 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to COVENANT HEALTH — 8 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 1 of 53.0-2.0 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 4 of 52.9+1.1 vs chain
The other 7 homes this chain runs (chain average 3.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
ST. MARYS HEALTH SYSTEMOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/16/1983
COVENANT HEALTHOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 01/29/1992
ANTHOINE, MARKIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/01/2008
DAVILA, JEFFREYIndividualCORPORATE DIRECTORsince 05/29/2019
GEIGER, DAVIDIndividualCORPORATE DIRECTORsince 05/29/2019
ISAACSON, JOHNIndividualCORPORATE DIRECTORsince 03/30/2022
MCMANUS, KATHYIndividualCORPORATE DIRECTORsince 11/03/2016
OUELLETTE, STEVENIndividualCORPORATE DIRECTORsince 05/29/2019
WOOD, JOSEPHIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
GRUBBS, STEPHENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/19/2025

CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

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 205053. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-28, 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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