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Cedars Nursing Care Center

630 Ocean Avenue, Portland, ME 04112 · Non profit - Corporation · 102 certified beds · (207) 772-5456 Medicare & Medicaid certified

Call the home — (207) 772-5456 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2023Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 65% of its spending goes to commonly-owned related companies

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
331 Veranda St · (207) 828-2402 · Call to confirm hours
Pharmacy
331 Veranda St Bldg 6 · (207) 791-3756 · Call to confirm hours
Grocery
804 Washington Ave · (207) 773-9357 · Call to confirm hours
Park
Ocean Ave · (207) 615-7328 · Typically dawn to dusk
Place of worship
510 Ocean Ave · (207) 773-6471

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 4 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 held steady at 4 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 rating4★
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 increased16.0%24.4%15.4%typical
Long-stay residents who lose too much weight3.5%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.9%1.1%0.9%typical
Long-stay residents with a urinary tract infection2.6%2.2%2.0%worse
Long-stay residents with depressive symptoms4.9%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 injury2.6%4.1%3.3%better
Long-stay residents whose ability to walk worsened18.7%25.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.1%17.4%18.9%worse
Long-stay residents given the seasonal flu vaccine94.2%95.5%95.3%typical
Long-stay residents with pressure ulcers5.8%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control35.6%29.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.0%20.2%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine71.1%74.5%79.4%worse
Short-stay residents rehospitalized after admission24.0%20.8%22.6%typical
Short-stay residents with an outpatient ER visit9.3%16.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.171.451.67better
Long-stay outpatient ER visits per 1,000 resident days1.242.011.80better

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.

73.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 289 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

73.6%U.S. median 51.5%
Got home and stayed home
8.0%U.S. median 10.7%
Went back to hospital
70.5%U.S. median 56.6%
Met the expected recovery
0.83U.S. median 0.31
Therapy hours / resident / day
0.38hours / resident / day
Physical therapy
0.37hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 70.5% 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 146 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 0.83 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF73.6%CMS range 69.0–77.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.0%CMS range 5.2–11.110.7%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 discharge70.5%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 discharge62.3%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 discharge68.5%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 identified99.4%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 setting97.4%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 stay1.7%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 worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.7%CMS range 3.5–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

1.53
RN hours/ resident / day
0.31
LPN hours/ resident / day
3.05
Aide hours/ resident / day
4.89
Total nurse hours/ resident / day
1.35
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 102 beds and averages 77.5 residents a day — about 76% occupied, or roughly 24 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 4.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.53 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.05 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.54 hrs/resident/day on weekends vs 5.03 on weekdays — 10% thinner on weekends. RN hours go from 1.60 to 1.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

8
deficiencies at the latest standard inspection (2025-06-25)
10
at the previous standard inspection (2024-04-03)

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2025-06-25 · 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 provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 Wings ([NAME], Black Wolf and [NAME]) and the common area/hallway for 3 of 3 days of survey. Findings: 1. On 6/23/25 at 9:40 a.m., [NAME] wing had 3 fans in the hallways, all of which were coated with a thick layer of dust. On 6/24/25 at 7:17 a.m., the surveyor discussed the observation of the dust covered fans observed in the hallways on 6/23/25. The Director of Nursing stated, they were filthy and were removed from the hallways. 2. On 6/24/25 at 1:34 p.m., an environmental tour was conducted with the Chief Operating Officer and the Director of Nursing for which the following was observed: [NAME] wing: room [ROOM NUMBER] next to the resident bed was a large area with exposed joint compound/sheetrock, creating an uncleanable surface. room [ROOM NUMBER]A had a fan coated with a thick layer of dust 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-25 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on performance evaluation reviews and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 5 of 5 sampled employees. (Certified Nursing Assistant (CNA) #2, #3, #4, #5, and #6) Findings: 1. CNA#2 was hired in April of 2023. The facility was unable to provide evidence of completed annual performance evaluations for 2024. 2. CNA#3 was hired in June of 2005. The facility was unable to provide evidence of completed annual performance evaluations for 2024. 3. CNA#4 was hired in March of 2017. The facility was unable to provide evidence of completed annual performance evaluations for 2024. 4. CNA#5 was hired in November of 2003. The facility was unable to provide evidence of completed annual performance evaluations for 2024. 5. CNA#6 was hired in October of 2020. The facility was unable to provide evidence of completed annual performance evaluations for 2024. On 6/24/25 at 2:07 p.m., the above information was confirmed with the Director of Nursing.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-25 · 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 and record reviews, the facility failed to demonstrate staff competency for Infection Control in the areas of Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) in 3 out of 3 units surveyed for Infection Control and Prevention. ([NAME] Unit, Black/Wolf Unit, and [NAME] Unit). Findings: Facility Policy Titled Transmission Based Precautions states: Contact Precautions: In addition to standard Precautions Contact Precautions for residents known or suspected of infection with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. It also directs Wear gloves (clean, non-sterile) when entering the room and wear a disposable gown upon entering the Contact Precautions room Facility Policy Titled Enhanced Barrier Precautions states: These residents will be identifiable by colored tint of their name plate outside their room. Personal Protective…

    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 · E2025-06-25 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to ensure that the CNA attended the mandatory yearly Resident Rights training for 5 of 5 CNA's reviewed. Furthermore, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 2 of 5 randomly selected CNAs employed greater than 1 year. (CNA #2, #3, #4, #5, #6) Findings: 1. CNA #2 was hired in April of 2023. Review of CNA #2 Employee In-service/attendance records lacked evidence of Resident Rights training for 2024. 2. CNA #3 was hired in June of 2005. Review of CNA #3 Employee In-service/attendance records lacked evidence of Resident Rights training for 2024. 3. CNA #4 was hired in March of 2017. Review of CNA #4 Employee In-service/attendance records lacked evidence of Resident Rights training for 2024. Furthermore, the record lacked evidence of the required 12 hours for continuing education for the year 2024. 4. CNA #5 was hired in November of 2003. Review of CNA #5 Employee In-service/attendance…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · 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 observations and interviews, the facility failed to promote care for residents in a manner that maintained the residents' dignity when staff failed to groom a resident on 1 of 3 days of survey (6/23/25) (Resident #34). Finding: On 6/23/25 at 11:09 a.m., observation of Resident #34 with long facial hair on the chin and upper lip. During an interview, Resident #34 stated he/she usually shaves every other day but hasn't since admission because he/she does not have a shaver. The surveyor asked if he/she would like staff to assist him/her with shaving, he/she stated, That would be nice, I noticed it was getting long. The Surveyor asked if staff has offered or asked him/her if he/she would like to be shaved, he/she stated No. On 6/24/25 at 3:22 p.m., After surveyor intervention, observation of Resident #34 with a clean shaven face. At this time, he/she confirmed it bothered him/her to have facial hair stating, Oh yeah, I had a really long one on my neck and I don't feel so subconscious. Review of the care plan initiated on 6/5/25 for ADL self-care performance deficit relating to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · 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 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 4 sampled residents reviewed for new admissions (Resident #281). Finding: Resident #281 was admitted in June of 2025 with a primary diagnosis of closed fracture of upper and lower end of left fibula, requiring a Enoxaparin (anticoagulant) injection daily. As of 6/25/25 Resident #281'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 6/25/25 at 11:15 a.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 before2025-06-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident for 1 of 25 reviewed for care planning. (Resident #65) On 6/23/25 at 9:26 a.m., during an interview, Resident #65 stated he/she has never heard of care plan meetings. Review of Resident #65's IDT care plan meeting notes showed IDTs occurring on 10/25/24, 1/28/25, 4/24/25, and 5/8/25. The medical record lacked evidence that he/she was invited and/or participated in his/her IDT meetings. On 6/25/25 at 1:00 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 before2025-06-25 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen observations, and in 1 of 3 Kitchenette observations. Findings: 1. On 6/23/25 at 8:50 a.m. during the initial observation of the kitchen with Food Service Manager (FSM) the following were observed and confirmed. - Floor of walk-in fridge and freezer had a sticky substance on the floor. - Several stained ceiling tiles and overall heavy concentration of dust build up on the ceiling above the area of the clean dishes, exit, the dish machine and other areas of the ceiling. - Flat surface near the entrance of the kitchen was covered in a heavy layer of dust and grease. 2. On 6/25/25 at 7:30 a.m. during observation of the [NAME] kitchenette, was a black powdery substance on the top shelf of the freezer door. The refrigerator contained an open unlabeled/dated container of fruit. At this time, the above was confirmed with the Registered Nurse #1. 3. On 6/25/25 at 8:15 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-03 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 3 of 3 residential units. Findings: On 4/3/2024 beginning at 9:00a.m., during a facility tour with the Maintenance Supervisor, the following findings were observed: [NAME] Unit: Stained ceiling tile in hallway just outside of restroom. Cobwebs attached to the light fixture and ceiling just outside of dining room. Black/[NAME] Unit: room [ROOM NUMBER] - Stained ceiling tile in the middle of the room room [ROOM NUMBER] - Debris stuck to floor from an area rug that was fixed to the floor Intravenous (IV) pole that is used for Tube feedings has stains and debris on base of IV pole room [ROOM NUMBER] - Stained ceiling tile in the middle of the room Unit exit door - has a buildup of sticky material on the door, staff member stated it was glue residue from a Velcro patch that was on the door. [NAME] Unit: Dining Room - Stained ceiling tiles 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-03 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to revise the care plan to reflect a resident's current status for 1 of 3 residents reviewed for skin conditions (#21) and 1 of 1 resident reviewed for limited range of motion (#8). Findings: 1. On 4/1/24 at 9:43 a.m., observation of Resident #21 to have compression wraps with kerlix and coban, to both lower extremities. Review of Resident #21's medical record contained the following: a care plan initiated on 2/22/21 for Edema, interfering with functional abilities with an intervention of put ted hose on in am, off at hs. A Wound Assessment Report initiated on 2/21/24 stated, a new wound identified, Venous Ulcer to right top of foot and a Provider order dated 2/21/24 for wound care for bilateral lower edema (BLE) every Tuesday and Saturday. Cleanse BLE with soapy water / cover wounds with Ag (Silver) Alginate / compression wraps with kerlix followed by coban mid foot -knee. On 4/2/24 at 12:08 p.m., during an interview, the Registered Nurse…

    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
Show the remaining 15 citations
  • Potential for harm · E2024-04-03 · 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 observation, interviews and record reviews, the facility failed to ensure that nursing obtained new orders for wound care and followed physician orders for 2 of 3 residents reviewed for skin conditions (Resident #21 [R21], R30) and the facility failed to follow physician orders to obtain a urine sample for 1 of 2 residents reviewed for falls (R3). Findings: 1. Review of R21's medical record contained a Provider order dated 2/21/24 for wound care for bilateral lower edema (BLE) every Tuesday and Saturday. Cleanse BLE with soapy water / cover wounds with Ag (Silver) Alginate / compression wraps with kerlix followed by coban mid foot -knee. Review of a Wound Assessment Report stated R21's venous ulcer to top of the right foot had resolved on 2/29/24. On 4/2/24 at approx. 11:34 a.m., during an interview, the wound nurse stated, R21 had an open area to his/her right lateral heel and legs were weepy due to edema, he/she did have an alginate dressing, but the wound healed, so now it's just kerlix and coban. During the observation of R21's BLE dressing change, the wound nurse did…

    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 before2024-04-03 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 3 of 3 neighborhoods observed ([NAME], [NAME], Black Wolf). Findings: The facilities Storage of Medication policy and Procedure effective January 2019 states, All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining, The facility should maintain a temperature log in the storage area to record temperatures at least once a day and The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC guidelines. 1. On 4/1/24 at 11:18 a.m., observation of medication storage on the [NAME] Neighborhood with the Certified Medication Technician the following was observed: The Certified Medication Cart contained an opened bottle of multivitamins with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner due to the Dietitian walking through the kitchen with hair not contained or covered. Additionally, the walk-in refrigerator contained a pan of green beans that was not labeled or dated. Findings: 1- 0n 4/1/2024, at 9:10 a.m., during the initial tour of the kitchen with the Dietary Director a surveyor observed a pan of green beans in the refrigerator unlabeled and undated. The Dietician was observed walking through the kitchen with hair uncontained and uncovered. The Food Service Director was present and aware of the findings at that time. 2- On 4/2/2024 @ 8:00 a.m. - Observation of serving breakfast on [NAME] Unit a surveyor observed food server with long hair not contained but wearing a hair net over the top of her head. Staff member stated that she is not a kitchen staff member, she works in Medical Records, and we train them to be able to serve the meals. 3- On 4/2/2024 @ 2:20p.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-03 · tag F0656 — failed to write and follow a full care plan — isolated
    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 — the official record, unedited, may be distressing

    Based on record review, observations and interview, the facility failed to implement a care plan in the area of nutrition for 1 of 1 sampled resident for tube feedings (#36). Finding: Review of Resident #36's nutrition care plan, revised 3/2/24, instructs nursing to, Verify that my tube placement is correct prior to administering any medications, tube feedings or flushing of the tube. On 4/1/24 at 12:01 p.m., during observation of a Registered Nurse (RN) administering medication and a feeding bolus via gastrostomy tube (GT); the RN failed to confirm placement of the G-Tube and check gastric residual volume (GRV) prior to administering medications and feeding bolus. In an interview with the RN, she stated she did not check placement or residual because, We don't have orders to. On 4/1/24 at 4:11 p.m., during an interview, the above was discussed with the [NAME] President of Nursing.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-03 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based in record review, observation and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding, for 1 of 1 resident reviewed for tube feeding. (#36) Finding: Facilities Medication Administration via Gastrostomy Tube, with no initiation or revision dates available states, of this procedure is to provide guidelines for the safe administration of medications through an enteral tube, with the following procedures to be completed before administration of medication and/or feeding; confirm placement of feeding tube and check gastric residual volume (GRV) to assess for tolerance of enteral feeding. On 4/1/24 at 12:01 p.m., during observation of Registered Nurse (RN#1) administering a feeding bolus and medication via gastrostomy tube for resident #36, RN#1 failed to confirm placement of the G-Tube and check GRV prior to administering the medication and feeding bolus. In an interview with RN#1, she stated she did not check placement or residual because, We don't have orders to. On 4/2/24 at 10:42 a.m., during an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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 and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to nebulizer and oxygen tubing for 2 of 2 residents reviewed for respiratory care. (#4, #82) Findings 1. On 4/1/24 at 9:48 a.m., Observation of Resident #21 to have a nebulizer pipe with tubing stored in a basin along with an exercise band and socks. At this time, during an interview, resident stated he/she has not used a nebulizer for, long time ago, only when I need it. On 4/2/24 at 2:29 p.m., both the Registered Nurse (RN#1) and surveyor observed the nebulizer pipe and tubing in the basin, the RN#1 removed/discarded the nebulizer pipe into the trash. On 4/2/24 at 3:50 p.m., during an interview, the [NAME] President of Nursing stated Resident #21's last nebulizer order was back in 3/24/20 and if a nebulizer is being used it should be rinsed out, dried and stored in a bag. 2. On 4/1/24 at 10:46 a.m., observation of Resident #170's oxygen concentrator with a nasal cannula tubing, unlabeled/dated and hanging off…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-03 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to conduct an annual review of it's Infection Prevention and Control Program (IPCP). Finding: On 4/2/24, during a review of the facility's IPCP policy and procedures, a surveyor noted various policies within the program lacked dates indicating a review and/or revision was completed. Policies included: Infection Control, undated; Pneumococcal Immunization for Resident with Prevnar 13 and Prevnar 23, undated; Infection Control: Influenza Vaccination for Residents, Administration of Covid-19 Vaccine, with a revision date of 1/4/22; Coronavirus Pandemic Strategies to Mitigate Healthcare Personnel Staffing Shortages, with a revision date of 3/11/22; Influenza Protocol, undated; Transmission Based Precautions, undated. On 4/2/24 at 11:00 a.m., in an interview with a surveyor, the Director of Nursing stated the facility reviews its policies and procedures, but confirmed the policies were unsigned and there was no evidence to show the policies related to the IPCP were reviewed and revised on an annual basis.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-03 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure 1 of 5 residents (#51) reviewed for immunizations was reviewed and offered pneumococcal vaccination in accordance with the United States Centers for Disease Control and Prevention (CDC) recommendations. Finding: A review of the CDC's Vaccine Information Statement (Interim) Pneumococcal Conjugate Vaccine, dated 5/12/23, stated Pneumococcal conjugate vaccine helps protect against bacteria that cause pneumococcal disease. There are three pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20). The different vaccines are recommended for different people based on age and medical status. Adults 65 years or older who have not previously received pneumococcal conjugate vaccine should receive pneumococcal conjugate vaccine. During a review of Resident #51's immunization record, the surveyor could not locate evidence that Resident #51 was reviewed, offered, or received a pneumococcal conjugate vaccination. The Resident is over [AGE] years of age. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-20 · 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 record review, facility policy review, and interview, the facility failed to ensure that a resident was free from an avoidable accident hazard by not removing a hot pack timely for 1of 1 residents reviewed for accidents (#1). Finding: A review of Resident #1s clinical record reveals a physician order dated 1/30/24 for Hot Pack q [every] 4 hours PRN [as needed] for back pain. A review of Resident #1s clinical record states that on the night of 2/3/24, a hot pack was placed on the resident's back for treatment of back pain. Review of a progress note dated 2/4/24 states a dime sized blister was observed on Resident #1s lower back, and there was a cold hot pack found in the resident's bed. Review of the facilities procedure for Hot Packs: Safe application and use states in Step #11 Assess the patient/resident's skin every fifteen minutes or frequently. In Step #12, it states, Remove and dispose of the pack after thirty minutes. Additional review of Resident #1s clinical record lacks evidence that the facility procedure for safe application of Hot Packs was followed as outlined…

    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 · D2023-08-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 review of the anonymous complaint report, review of the facility's Abuse /Neglect or Misappropriation of Resident Property policy, and interviews the facility failed to protect the resident's right to be free from emotional/mental abuse by staff which caused the resident to be temporarily embarrassed, humiliated, and fearful to ask for staff assistance for 1 of 3 residents reviewed for abuse allegations (Resident #1). Finding: Review of facility policy titled Reporting Resident Mistreatment, Abuse, Neglect, or Misappropriation of Resident Property policy and procedure states: Purpose: Residents of the [NAME] will be protected from any mistreatment. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation . On 8/10/23 at 11:30 a.m., the Division of Licensing and Certification received an anonymous complaint stating Resident #1 felt like a staff member was very harsh to him/her and made him/her feel uncomfortable pressing the help button so he/she would…

    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 · D2023-08-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and the facility's Abuse/Neglect or Misappropriation of Resident Property policy and procedure review, the facility failed to report an allegation of abuse to the Division of Licensing and Certification (DLC) (State Survey Agency (SSA)) for 1 of 3 residents sampled. (#1) Finding: On 8/10/23 at 11:30 a.m., the Division of Licensing and Certification received an anonymous complaint stating Resident #1 felt like a staff member was very harsh to him/her and made him/her feel uncomfortable pressing the help button so he/she would avoid calling for help. The staff member entered resident's room once with an angry face and heaved blankets onto Resident #1. Additionally, Resident #1 stated that the staff member was washing him/her with water that was way too hot and was providing very rough care in his/her private area. Further, Resident #1 was put on a toilet in his/her bathroom and the bathroom and room door were left open and another staff member entered the room which was embarrassing 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 date of correction
  • Potential for harm · Fcited before2022-12-01 · tag F0880 — failed to prevent and control infections — widespread
    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, and record reviews the facility failed to maintain an Infection Control Program designed to help prevent the development of infection related to personal equipment storage for 3 of 3 days of survey. In addition, the facility failed to assess and have measures in place to monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. Findings: 1. On 11/29/22 at 11:17 a.m.,11/30/22 at 8:33 a.m. and 12/1/22 at 7:35 a.m., observations of room [ROOM NUMBER] bathroom to have a piece of gauze wrap tied to the end of the call bell string and wrapped around the toilet handlebar. The gauze wrap was visibly soiled with a black substance. Under the sink was a basin and 3 containers of wipes stored on the floor. 2. On 11/30/22 at 8:20 a.m. and 2/1/22 at 7:36 a.m., observations of room [ROOM NUMBER] to have a bed pan stored behind the toilet between the plumbing and the wall. On 12/1/22 at 7:40 a.m., both the surveyor and the Licensed…

    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 before2022-12-01 · 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 store frozen foods in a safe and sanitary manner on 2 of 3 days of kitchen observations, and, failed to monitor chemical sanitizer levels for sanitizing buckets used to clean kitchen work areas. This has the potential to affect all residents. Findings: On 11/29/22 at 9:15 a.m., a surveyor observed within the walk-in freezer, a cardboard tray of burgers and another cardboard tray of quiche with loose, open, plastic wrap leaving the food uncovered and exposed. The finding was confirmed by the Executive Chef, who removed the products. On 11/30/22 at 12:15 p.m., a surveyor observed within the walk-in freezer, undated/unlabeled, open packages of chocolate chip cookies, raspberries, and an undated/unlabeled ziplock package of sausages. The finding was confirmed by the Executive Chef. On 11/30/22 at 12:05 p.m., a surveyor asked a dietary worker how often the sanitizer buckets used to clean the kitchen work areas are changed and tested. The worker stated he/she sets up the buckets once a day and does not test the sanitizer…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-01 · 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 ensure an as needed (PRN) antipsychotic medication order met the required 14-day time limit or provided the rationale to extend the time limit beyond the 14 days, with the indicated duration, for 1 of 5 residents reviewed for unnecessary medications (#31). Finding: During a review of Resident #31's clinical record, a surveyor noted a provider order, dated 10/6/22, for a antipsychotic medication, Risperdal 0.5 mg (milligrams) ODT (orally disintegrating tablet) once nightly and once daily PRN for physically/verbal aggressive behaviors. Diagnosis: Dementia with psychotic features. Hold for sedation. The surveyor noted no 14-day limit for the PRN order. On 12/1/22 at 10:50 a.m., the Informatics Nurse reviewed the record and confirmed there was no evidence that the PRN order had been renewed after 14 days and continued to be in effect.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-01 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms and 1 of 4 medication carts observed (Black Wolf House). Findings: 1. On 11/28/22 at 7:34 p.m., observations of the Black Wolf House medication room with the Licensed Practical Nurse (LPN), the surveyor noted an opened vial of Lispro insulin labeled with expiration date of 10/24/22 and an opened vial of Tuberculin Purified Protein Derivative (TB) with manufacturer's directions of once entered, vial should be discarded after 30 days, further observation reveals the TB vial was labeled with an open date of 10/23/22. At this time the LPN, discarded both the insulin and the TB vial. 2. On 11/28/22 at 7:56 p.m., observation of Black Wolf House medication cart #1 with the Registered Nurse (RN), the surveyor noted an open bottle of Melatonin 3mg with an expiration date of 6/22. At this time the RN discarded the bottle of melatonin. On 11/29/22 at approx. 9:02 a.m., during an interview with the Director of Nursing, a surveyor…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
JHA SERVICES, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/1989
CALLNAN, KATHRYNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 06/07/1976
PALANGE-HUNT, ANGELAIndividualW-2 MANAGING EMPLOYEEsince 08/30/2012
WATSON, JOHNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 08/30/2012

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.1M
Net patient revenuemost recent cost report
-25.1%
Operating marginrevenue minus expenses
$9.8M
Related-party expense65% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 18%Other / private 82%

This home reported $9.8M paid to related parties — landlords or management companies under common ownership — equal to about 65% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$650per resident / day
operating cost
$19,749per month
≈ monthly operating cost
$519per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in ME

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205003. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-25, 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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