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Rumford Community Home

11 John F Kennedy Lane, Rumford, ME 04276 · Non profit - Corporation · 32 certified beds · (207) 364-7863 Medicare & Medicaid certified

Call the home — (207) 364-7863 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
10 Railroad Street
Pharmacy
Walgreens1.7 mi
7 Portland St · (207) 364-2969 · Call to confirm hours
Grocery
341 Cumberland St · (207) 364-2062 · Call to confirm hours
Park
6 Bridge St · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.0%24.4%15.4%worse
Long-stay residents who lose too much weight4.0%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.1%0.9%better
Long-stay residents with a urinary tract infection0.9%2.2%2.0%better
Long-stay residents with depressive symptoms5.6%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 worsened29.4%25.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.1%17.4%18.9%worse
Long-stay residents given the seasonal flu vaccine96.9%95.5%95.3%typical
Long-stay residents with pressure ulcers3.8%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control22.9%29.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table14.6%20.2%17.1%better

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

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

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

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

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

0.36U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

1.04
RN hours/ resident / day
0.29
LPN hours/ resident / day
2.72
Aide hours/ resident / day
4.05
Total nurse hours/ resident / day
1.01
RN hoursweekends
36.1%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 32 beds and averages 29.6 residents a day — about 92% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 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 3.84 hrs/resident/day on weekends vs 4.14 on weekdays — 7% thinner on weekends. RN hours go from 1.05 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

10
deficiencies at the latest standard inspection (2026-04-22)
14
at the previous standard inspection (2025-02-10)

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.

  • Actual harm · Gcited before2025-05-14 · 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, facility policies, review of a reportable incident form, and interviews the facility failed to ensure that a resident was free from injury when the facility staff failed to properly transfer a resident causing the resident to sustain a laceration on the nose and several lacerations with hematomas to the head for 1 of 13 residents requiring a mechanical lift for transfers. (Resident #1) Findings: On 5/5/25, The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 5/4/25 at 1:50 p.m. Resident #1 was being transferred out of bed to a Broda chair using a mechanical lift (hoyer). The legs of the hoyer lift were not opened and the hoyer lift fell over sideways while the resident was in the sling. The resident fell to his/her left side onto the floor resulting in a laceration to the back of the head and the bridge of his/her nose. Review of nurses note dated 5/4/25 at 2:42 p.m., stated, This nurse was called to resident's room. Resident 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2026-04-22 · 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 a sanitary, orderly, and comfortable environment on 2 of 2 units (East and West) and the laundry room for 3 of 3 facility observations/tours. (4/21/26 and 4/22/26)Findings:1. On 4/21/26 at 10:27 a.m., a surveyor observed a specialized gel cushion stored on the floor by the window. At this time, in an interview with a surveyor, Certified Nursing Assistant (CNA #1) confirmed the finding.2. On 4/21/26 at 10:50 a.m., a surveyor observed a wash basin on the bathroom floor in Resident room [ROOM NUMBER]. At this time, in an interview with a surveyor, CNA #1 confirmed the finding.3. On 4/22/26 from 11:30 a.m. to 12:00 p.m., a surveyor conducted an Environmental Tour with the Maintenance Director in which the following findings were discussed and/or observed. East Unit:- Resident room [ROOM NUMBER] - A privacy curtain was missing hooks, hanging down and in disrepair.…

    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 before2026-04-22 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessment, for 7 of 14 residents whose care plans were reviewed (Resident #1, #5, #6, #7, #15, #27, #29). Findings: 1. Review of Resident #6's clinical record revealed an MDS Quarterly Assessment was completed on 4/13/26. Further review of Resident #6's clinical record revealed that an IDT meeting was held 4/9/26 (prior to completion of the assessment). 2. Review of Resident #29's clinical record revealed an MDS Quarterly Assessment was completed on 4/2/26. Further review of Resident #29's clinical record revealed that an IDT meeting was held 3/31/26 (prior to completion of the assessment). 3. Review of Resident #7's clinical record revealed an MDS Quarterly Assessment was completed on 3/3/26. Further review of Resident #7's clinical record revealed that 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 1 of 2 days of survey (4/22/26). Findings:Safety Data SheetsPure Bright Germicidal Ultra Bleach4. First Aid MeasuresEye Contact: Immediately flush with plenty of water. After initial flushing, remove any contact lenses and continue flushing for at least 15 minutes.Skin contact: Wash skin with soap and water.Inhalation: Remove to fresh air.Ingestion: Do not induce vomiting. Clean mouth with water and drink afterwards plenty of water. If symptoms persist, call a physician. Micro-Kill Q3 Concentrated Disinfectant, Cleaner & Deodorizer4. First Aid MeasuresInhalation: Remove person to fresh air and keep comfortable for breathing. If experiencing respiratory symptoms: Call a poison center or a doctor. Causes irritation of the respiratory tract. Dizziness. Headache. Skin contact: Take off immediately all contaminated clothing and wash it before reuse. Rinse skin…

    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 · E2026-04-22 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews the facility failed to ensure annual performance reviews were completed at least once every 12 months for 3 of 5 Certified Nursing Assistants selected for reviews (CNA) (Staff #2, Staff #4 and Staff #5).Findings:1.Staff #2's was hired 11/1/16. Staff #2's personnel file lacked evidence that an annual performance evaluation was reviewed and signed by CNA #2 in 2024 and 2025.2. Staff #4 was hired 6/20/22. Staff #4's personal file lacked evidence that a performance evaluation was reviewed and signed in 2024 and 2025.3. Staff #5 was hired 12/10/97. Staff #5's personnel file lacked evidence that a performance evaluation was reviewed and signed in 2024 and 2025.During an interview with Director of Nursing and Administrator on 4/22/26 at 11:36 a.m., the DON confirmed that only 3 of the 5 annual reviews were signed by staff. Administrator states they are currently changing the process of annual evaluations because they are done online and they can't see when they are completed.During a follow up interview on 4/22/26 at 11:51 a.m. the Administrator stated…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-22 · 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, interviews, and review of the Food Storage policy (dated 2013), the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a hood system, floors, a small reach-in standing freezer, a grease trap and a large walk-in freezer; and failed to ensure foods were labeled and dated in a walk-in freezer for 1 of 1 kitchen tour for 1 of 2 days of survey. (4/21/26)Findings:The facility's Food Storage policy, dated 2013 noted: Procedure-13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. 14. Refrigerated Food Storage-f. All foods should be covered, labeled and dated .15. Frozen Foods-c. All foods should be covered, labeled and datedOn 4/21/26 from 9:00 a.m. to 9:30 a.m., a surveyor completed an initial kitchen tour with a cook in which the following findings were observed:- The cook stove hood system was dusty/dirty. - The small reach-in standing freezer had dried food particles and dried liquid residue on the unit shelving and door shelving.…

    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 · D2026-04-22 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interviews, the facility failed to promote care for resident in a manner that maintains the resident's dignity by allowing an uncovered colostomy bag to be seen by passersby for 1 of 2 residents (Resident #1) observed for dignity related to urinary/colostomy bags during 1 of 2 days of survey (4/21/26). Findings:On 4/21/26 at 10:30 a.m., a surveyor observed Resident #1's colostomy bag hanging on the side of the bed, containing brownish/reddish waste, visible from the hallway. At this time, in an interview with a surveyor, Resident #1 indicated he/she would like to have it covered and would be embarrassed if people could see it from the hallway. On 4/21/26 at 10:46 a.m., in an interview with a surveyor, Certified Nursing Assistant (CNA #1) confirmed that Resident #1's colostomy bag containing brownish/reddish waste was visible to passersby in the hallway.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify a provider when a resident verbalized desire to self-harm for 1 of 14 residents reviewed during the survey process (Resident [R]#16).Findings: Resident #16 was admitted in 2019 and has diagnoses to include multiple sclerosis, and major depressive disorder. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status (BIMS) of 14 of 15 indicating he/she is cognitively intact. Review of Resident #16's clinical record revealed progress note dated 4/14/26 at 8:06 a.m. Behavior Note stating: 'Resident in the dining room for breakfast and was noted to be talking very loudly on the phone. [He/she] was yelling that [he/she] wanted to kill [himself/herself] and that [he/she] did not want to be in this facility anymore. When the cook asked [him/her] if [he/she] needed anything else before [he/she] left the dining room the resident responded, a gun. Per the CNA after this nurse left the dining room [he/she]…

    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 · D2026-04-22 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to update a care plan to include goals and interventions in the area of suicidal ideation for 1 of 14 sampled residents (Resident (R)#16).Findings: Resident #16 was admitted in 2019 and has diagnoses to include multiple sclerosis, and major depressive disorder.Review of Resident #16's clinical record revealed progress note dated 4/14/26 at 8:06 a.m. Behavior Note stating: 'Resident in the dining room for breakfast and was noted to be talking very loudly on the phone. [He/she] was yelling that [he/she] wanted to kill [himself/herself] and that [he/she] did not want to be in this facility anymore. When the cook asked [him/her] if [he/she] needed anything else before [he/she] left the dining room the resident responded, a gun. Per the CNA after this nurse left the dining room [he/she] continued to say[ he/she] wanted to kill [himself/herself] . Review of R#16's care plan reviewed 3/16/26 [R #16] has a behavior problem (occasionally refuses to eat, verbal outburst to staff, emotional distress by disease process r/t paraplegia,…

    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 before2026-04-22 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 trash dumpsters for 1 of 2 days of survey (4/21/26).Findings:On 4/21/26 at 8:30 a.m., three surveyors observed the top right lid of 1 of 2 dumpsters to be open exposing trash. On 4/21/26 at 8:35 a.m., in an interview with a surveyor, the Administrator confirmed the finding.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-22 · 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 record review and interviews, the facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP). Finding:On 4/22/26, initial review of the facility's infection control policies lacked evidence that the facility had developed and implemented written policies and procedures for their IPCP in the areas of hand hygiene and standard and transmission-based precautions.On 4/22/26 at 12:40 p.m. the surveyor discussed the above concern during an interview with the Director of Nursing (DON). At this time, the DON was unable to provide the above policies to the surveyor and stated that she was not sure if the facility had these policies, but that she would look.On 4/22/26 at 1:33 p.m. the DON provided the requested policies, and surveyor review of the policies revealed the following:Facility policy, Hand Hygiene, dated 12/20/2017, last reviewed 7/22/24Facility policy, Standard Precautions Used for All Patients, dated 3/31/23, lacked evidence that the policy has been reviewed and/or revised.Facility policy, Droplet Precautions, dated 3/31/23, lacked…

    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
Show the remaining 17 citations
  • Potential for harm · Fcited before2025-02-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, interviews, review of the Dish Machine Temperature Logs (dated 2013), and review of the Food Storage policy (dated 2013), the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling tiles, floors, and a wall mounted fan; failed to ensure foods were sealed, labeled and dated in a reach-in freezer and in a walk-in refrigerator; failed to ensure that the kitchen ice machine was plumbed in accordance with code requirements to prevent food contamination and failed to ensure that the dish machine was monitored for proper wash and rinse temperatures to ensure clean and sanitized utensils and dishes, all for 1 of 1 kitchen tour for 1 of 1 day of survey (2/4/25). Findings: 1. On 2/4/25 from 9:10 a.m. to 10:00 a.m., a surveyor conducted a kitchen tour with the Food Service Director in which the following findings were observed: - There were three ceiling tiles above a food preparation area that had brown stains on them. - There was trash and food debris on the floor under the equipment and around the edges of the floor. - The dish…

    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 · F2025-02-10 · tag F0909 — failed to maintain a comfortable temperature — widespread
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 32 of 32 beds. This has the potential to affect the safety of all residents. Finding: On 2/10/25 at 11:30 a.m., a surveyor asked the Administrator for the bed gap measurements and side rail gap measurement documentation. A surveyor received and reviewed the documentation with the Administrator and she confirmed that the bed gap measurements and side rail gap measurements had not been completed since February 2023. On 2/10/25 at 12:05 a.m., a surveyor and the Director of Ancillary Services reviewed the bed gap measurements and side rail gap measurement documentation. At this time, in an interview, the Director of Ancillary Services confirmed that regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment and bed gap measurements and side rail gap measurements have not been completed since February…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-10 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    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 resident preferences were followed for 2 of 3 residents reviewed for bathing ( Residents #23 #8). Findings: 1.Resident #23 and has a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating he/she is moderately cognitively impaired. Review of Resident #23's care plan revealed, . requires extensive assist by 1 staff with bathing BID [2 times a day] and as necessary .often refuses care reapproach and offer several times as needed . Review of East/West Bath Schedule, updated 1/25/25, revealed that Resident #23 is to receive a shower or bed bath on Thursday day shift. Review of Resident #23's clinical record lacked evidence that he/she was offered/refused a shower or bed bath on 10/10/24, 1/2/25, 1/9/25, 1/16/25, 1/30/25, and 2/6/25. During an interview on 2/5/25 at 11:33 a.m., Certified Nursing Assistant (CNA) #7 stated Resident #23 primarily receives bed baths but is showered occasionally and sometimes refuses to bathe, though not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-10 · 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 maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 2 units (East and West), a laundry cart, the conference room and the laundry room for 2 of 2 environmental tours (2/5/25 and 2/6/25). Findings: 1. On 2/05/25 at 10:30 a.m., a surveyor and the Administrator observed a laundry cart being used in the East Unit Hallway that had untreated wood holding the laundry bin to the wheeled unit. At this time, in an interview, the Administrator confirmed the wood was not treated and created uncleanable surfaces. 2. On 2/06/25 from 8:35 a.m. to 9:10 a.m., an environmental tour was conducted with the Director of Ancillary Services in which the following findings were observed: Conference Room - There were four(4) ceiling lights that had dirt/debris in them. East Unit - Resident room [ROOM NUMBER] - The baseboard heater was coming apart, hanging down and in a disrepair. The room…

    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 · E2025-02-10 · 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 and interviews, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 days of survey. (2/4/25, 2/5/25 and 2/10/25) Findings: 1. On 2/4/25 at 10:40 a.m., a surveyor observed Resident #13's oxygen concentrator tubing and nasal cannula was observed stored on top of resident's bureau on some of his/her personal belongings and not bagged. The resident stated to the surveyor that he/she only wears oxygen at night and it is stored during the day. 2. On 2/5/25 at 8:15 a.m., a surveyor observed Resident #13's oxygen concentrator tubing and nasal cannula was observed stored on top of her concentrator and not bagged. On 2/05/25 at 10:25 a.m., in an interview, the Administrator confirmed that the oxygen tubing and nasal canula should be stored in a bag and not just draped on the resident's belongings on the night stand or coiled up and stored on top of the O2 concentrator. At this time, the surveyor asked for the oxygen/respiratory policy…

    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 · E2025-02-10 · 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 monitor and ensure that the Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training for 5 of 5 randomly selected CNAs employed greater than 1 year (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5). Findings On 2/6/25, a surveyor reviewed the following employee education files: 1. CNA #1 was hired 3/27/23. A review of CNA #1's education records revealed they had not received the required 12 hours of education/in-service training including Resident Rights, Dementia, Quality Assurance and Performance Improvement Program (QAPI), and Infection Control in 2024. 2. CNA #2 was hired 4/10/23. A review of CNA #2's education records revealed they had not received the required 12 hours of education/in-service training including Resident Rights, QAPI, and Infection Control in 2024. 3. CNA #3 was hired 1/8/24. A review of CNA #3's education records revealed they had not received the required 12 hours of education/in-service training…

    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 · D2025-02-10 · 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 interviews, record reviews, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 15 residents reviewed for baseline care plans. (Resident #15). Findings: Review of policy Baseline Care Plan Policy and Procedure revised 3/17/23 noted: .The baseline care plan must (i) Be developed within 48 hours of a resident's admission ., (ii) include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a. initial goals based on admission orders, b. Physician orders-Code status, c. dietary orders, d. therapy service e. social service- discharge, f. PASRR recommendations (if applicable). On 2/04/25 at 12:54 p.m., a surveyor observed Resident #15 sitting in his/her room in his/her recliner chair with his/her foley catheter bag hanging on his/her walker. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-10 · 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 interviews, observations, and record review, the facility failed to document and adequately monitor a resident after an unwitnessed fall for 1 of 2 residents reviewed for falls (Resident #28). In addition, the facility failed to ensure that physician orders were followed for 1 of 2 residents reviewed. (Resident #8 & (Resident #7) Findings: 1. Review of Resident #28's clinical record indicated that he/she sustained an unwitnessed fall on 1/23/25 at 10:45 p.m. Further review of the clinical record lacked evidence that a fall risk assessment and Post Fall Observation Tool were completed or that neurological checks were initiated following the unwitnessed fall. Review of policy, Falls Management Policy, revised 12/4/24, states, Complete a fall risk assessment upon admission .quarterly .and after a fall .Complete Post Fall Observation Tool, following a fall .If the fall is unwitnessed .neurological checks will be initiated as outlined on the Neurological Assessment Flow Sheet . On 2/10/25 at 10:53 a.m., during an with the Director of Nursing (DON) stated it is her expectation…

    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 before2025-02-10 · 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 observation, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 1 of 5 days of survey (2/10/25). Findings: . The Safety Data Sheet for Oxivir Tb Wipes(Virucidal - Bactericidal - Fungicidal - Tuberculocidal) Disinfectant Cleaner wipes noted the following: 4. First Aid Measures: Eyes: Rinse with plenty of water. If irritation occurs and persists, get medical attention. Ingestion: IF SWALLOWED: Call a Poison Center or Doctor/Physician if you feel unwell. On 2/10/25 at 8:00 a.m., a surveyor observed a 1.8 pound container of Oxivir Tb Wipes(Virucidal - Bactericidal - Fungicidal - Tuberculocidal) Disinfectant Cleaner wipes in the conference room which had the door open. The chemical was not secured and accessible to confused and vulnerable residents who ambulate and residents who also move about the facility in wheelchairs. On 2/10/25 at 8:35 a.m., in an interview, the Administrator confirmed the wipes were left unsecured 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 · D2025-02-10 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 antidepressant medication for 1 of 5 residents reviewed for unnecessary medications (#5.) Finding: Resident #5 has diagnosis of Bipolar Disorder, Major Depressive Disorder. Resident #5's Medication Administration Record (MAR) indicated that Resident #5 had been receiving the antidepressant medication Venlafaxine Extended Release (ER) 225 milligrams (mg) once daily, since 6/15/24. A Pharmacy Report dated 11/20/24 indicated that Resident #5 had been receiving antidepressant Venlafaxine ER 225 mg daily since 6/15/24. Consider gradual dose reduction (GDR) or document contraindication. The clinical record lacked evidence that a GDR was attempted or documented that it was clinically contraindicated for this resident between the dates of 11/20/24 and 2/7/25. The surveyor discussed this finding in an interview with the Administrator on 2/6/25 at 7:45 a.m.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-10 · 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 2/6/25, 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/Exposure Control Plan Review Policy revised 9/2018, North Country Associates: Infection Control Immunizations - Influenza, Pneumococcal Policy revised 9/2018, COVID-19 (Vaccine Policy revised 5/2/23 and National: Clinical Services Infection Prevention & Control Policy dated 6/1/23. On 2/6/25 at 10:07 a.m., the Administrator confirmed that the IPCP policies and procedures had not been reviewed on annually.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-10 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and policy review, the facility failed to designate a qualified staff member to function as the Infection Preventionist, who is responsible for the facility's Infection Control Program since 12/4/22. Finding: On 2/4/25 at approximately 9:37 a.m., during an interview with the Director of Nursing (DON), the surveyor inquired who was responsible for the facilities infection control program. The DON stated that she had been the facilities Infection Preventionist until she transitioned to the DON position on 12/4/22 and a new acting IP and (Assistant Director of Nursing) ADON was hired in January 2024. As of today, the new acting IP has not completed the infection control training for the IP role. A review of the Infection Prevention & Control Policy indicates under Roles and Responsibilities: Administration: Designate one or more individual(s) as the Infection Preventionist(s) who is responsible for the facility's IPCP. The IP will: i. Have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field. ii. Be…

    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 · D2025-02-10 · 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

    Based on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their Influenza, Pneumococcal, COVID policy for 1 of 5 residents whose immunization records were reviewed. (#19) Finding: The facility's Infection Prevention & Control Policy revised 6/1/23 indicated under Immunizations- Influenza: It is the policy of this facility that every fall, residents will be offered immunization against influenza. The time for immunization will follow the recommendations of the Centers for Disease Control and Prevention (CDC) and the state department of health. Residents or their responsible party will be educated about the risk/benefit of the vaccine. Resident #19's clinical record indicated that the resident was admitted to the facility on 6/2023. Resident #19's immunization records lacked evidence that the resident's Influenza Vaccination was administered as directed by the facility's Infection Prevention & Control Policy. On 2/6/25 at 8:30 a.m., the Director of Nursing (DON) stated that Resident #19's consent for the Influenza…

    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 · D2025-02-10 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their Infection Prevention & Control Policy for 1 of 5 residents whose immunization records were reviewed. (#19) Finding: The facility's Infection Prevention & Control Policy revised 6/1/23 indicated under Immunizations - COVID: The facility will offer the COVID-19 vaccine series to all eligible residents as per recommendations of the Center for Disease Control and Prevention. (CDC) Vaccines are offered by the facility or through an arrangement with a pharmacy partner, local health department or other appropriate health entity. Residents and/or healthcare representative (s) will be provided with education by a physician or licensed nurse regarding COVID-19 immunization using the Emergency Authorization Use (EAU) Fact Sheet for Recipients and Caregivers. Any new vaccine information will be dispersed as they become available. Resident #19's clinical record indicated that the resident…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-08 · 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 interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a baseboard heater, the grease trap, the cement floor, a standing floor fan, the food disposal unit, the large food mixer, the dish machine, and the hood system filters for 1 of 3 days of survey (11/6/23). Additionally, the facility failed to ensure all staff with facial hair were wearing facial hair protectors for 1 of 3 days of survey (11/8/23). Findings: On 11/6/23 from 6:05 a.m. to 6:35 a.m., an initial kitchen tour was conducted with the [NAME] in which the following findings were observed: 1. > The dish room baseboard heater had chipped/missing paint creating an uncleanable surface. The grease trap cover was rusty on the top and around the edges of the lid. The cement floor portion had chipped/missing paint creating an uncleanable surface. The standing floor fan was dusty/dirty and had dried liquid residue on the blades. > The food disposal unit had dried liquid residue on it. > The large food mixer had dried food particles on the mix arm and 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 · Dcited before2023-11-08 · 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 — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to review and revise the care plan to reflect the current needs of a resident in the area of pressure ulcers. (#22) Finding: A review of Resident #22's clinical record noted diagnoses which included: Diabetes Mellitus and past history of stroke with hemiplegia/hemiparesis of the right side. A dietitian's note, dated 10/28/23, indicated Resident #22 had a recently healed Stage II pressure ulcer. Physician's orders, dated 10/5/23, instructed staff to have the resident get up to chair daily in the afternoon for two hours, or as tolerated. In addition, an order dated 10/2/23, instructs staff to apply Barrier ointment to right hip (resolved pressure ulcer area) twice daily for preventive skin care. A review of Resident #22's care plan, last revised on 10/17/23, noted Resident #22 was at risk for pressure ulcer development related to immobility. The section titled Interventions was noted to be blank. On 11/7/23 at 11:20 a.m., in an interview with a surveyor, the Director of Nursing confirmed the care plan had not been revised 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-08 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 trash dumpster for 1 of 3 days of survey. (11/6/23) Finding: On 11/6/23 at 6:00 a.m., a surveyor observed a trash dumpster with the front right lid open exposing trash. 0n 11/6/23 at 6:35 a.m., in an interview, the [NAME] confirmed the findings. 0n 11/6/23 at 7:40 a.m., in an interview, the surveyor discussed the findings with the Food Service Director.

    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.

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
CENTRAL MAINE HEALTHCARE CORPORATIONOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 05/27/2026
CULVER, DEVOREIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 02/16/2026
PEPIN, LINDAIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 02/16/2026
DOAN, CHRISTOPHERIndividualCORPORATE OFFICER; TRUSTEE OF THE SNFsince 02/16/2026
PAULOSKY, DAVIDIndividualCORPORATE OFFICER; ADP OF THE SNFsince 06/13/2022
SHEW, ELIZABETHIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; TRUSTEE OF THE SNF; ADP OF THE SNFsince 03/01/2022
STEFANEK, ALLENIndividualCORPORATE OFFICER; ADP OF THE SNFsince 02/16/2026
BODGER, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/06/2016
BURROWS, STEPHANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/08/2021
FRENCH, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/08/2021
HATTAN, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/10/2025
ST. PETER, KRISTENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/08/2021

CMS files one row per role, so the 27 rows in the source record cover these 12 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.

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 205099. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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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