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Seal Rock Healthcare

88 Harbor Drive, Saco, ME 04072 · For profit - Corporation · 105 certified beds · (207) 283-3646 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Apr 20261 immediate-jeopardy citation$75,433 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2026
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $75,433 in federal fines (most recent 2025-04-02)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (56%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 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
Pharmacy
461 Main St · (207) 284-4363 · Call to confirm hours
Grocery
Hannaford1.4 mi
532 Main St · (207) 282-4152 · Call to confirm hours
Park
75 Beach St · (207) 283-3139 · Typically dawn to dusk
Place of worship
3 Stone St · (207) 282-4172

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 1 of 5
Short-stay residentsrehab / post-hospital 4 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 2 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 rating2★
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 increased27.7%24.4%15.4%worse
Long-stay residents who lose too much weight9.7%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%1.1%0.9%typical
Long-stay residents with a urinary tract infection0.4%2.2%2.0%better
Long-stay residents with depressive symptoms2.5%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 injury6.1%4.1%3.3%worse
Long-stay residents whose ability to walk worsened33.7%25.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.7%17.4%18.9%worse
Long-stay residents given the seasonal flu vaccine98.6%95.5%95.3%typical
Long-stay residents with pressure ulcers5.9%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control28.9%29.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table23.2%20.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.7%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine43.4%74.5%79.4%worse
Short-stay residents rehospitalized after admission34.3%20.8%22.6%worse
Short-stay residents with an outpatient ER visit17.5%16.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.431.451.67better
Long-stay outpatient ER visits per 1,000 resident days2.542.011.80worse

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.

68.0% 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 157 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.0%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
64.9%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 64.9% 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 111 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 SNF68.0%CMS range 61.4–74.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.3–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge64.9%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 discharge52.2%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 discharge56.8%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 identified93.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.9%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 worsened1.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 4.0–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 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

0.84
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.96
Aide hours/ resident / day
4.48
Total nurse hours/ resident / day
0.73
RN hoursweekends
56.3%
Total nursing turnover
47.6%
RN turnover

How full it usually is: this home is certified for 105 beds and averages 90.5 residents a day — about 86% occupied, or roughly 14 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 4.48 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.96 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 4.14 hrs/resident/day on weekends vs 4.61 on weekdays — 10% thinner on weekends. RN hours go from 0.88 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is well above the national median of 45%. 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

5
deficiencies at the latest standard inspection (2026-04-03)
11
at the previous standard inspection (2022-07-27)

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · K2025-04-02 · 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 review, the facility failed to identify and implement isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis and failed to follow the Nurse Practitioner's recommendation to ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. In addition, the facility failed to ensure all staff were knowledgeable about which residents were experiencing these symptoms and ensure PPE were used while providing care. This resulted in the spread of gastroenteritis [nflammation that spreads from your stomach into your intestines, causing pain, vomiting and diarrhea symptoms] (GI) symptoms creating an immediate jeopardy situation to 17 out of 90 residents', on 6 of 7 units: Eagle Island, Ram Island, Bluff Island, [NAME] Islan, Beach Island and Gooseberry Island. (Resident #27 #26, #25, #22, #9, #10, #13, #14, #16, #34, #4, #32, #6, #5, #7, #33, and #3) Findings: 1. On 3/17/25 the Division of Licensing 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-03 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 10 of 23 residents reviewed for advance directives (Resident #1, #6, #8, #17, #36, #50, #89, #103, #107, and #110). 1.Resident #1 was admitted to the facility in January of 2026. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 2. Resident #6 was admitted to the facility in May of 2015. A review of the resident's electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 3.…

    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 · E2026-04-03 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident remained free of misappropriation of property in the form of theft of a resident's personal credit card and multiple unauthorized purchases for 1 of 27 residents screened for abuse and misappropriation in the initial pool.Findings: On 3/30/26 at 10:30 a.m., in an interview with a surveyor, Resident #89 stated, I had someone take my credit card and my social security card on Christmas Eve (2025). She (Certified Nursing Assistant - CNA) also took the debit card of the resident across the hall, and someone downstairs, and another lost a necklace, $900 something on her card. I was lucky, she (CNA) got a lot out of the lady across the hall. Resident #89 stated there were all kinds of charges, (to a) motel, gas station, Target, etc. They (the stores) all had cameras and they caught them. Resident #89 stated he/she reported the charges on his/her credit card to the facility and staff acted on it immediately. Resident #89 stated I called the (credit card) company and they took the charges off. The CNA 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 a patient lift on 1 of 1 unit and the storage of chemicals being properly secured for 1 of 1 observation for 1 of 4 days of survey. (3/30/26 through 4/2/26)Findings:1. On 3/30/26 at 10:10 a.m., 2 surveyors observed an EZ Sit to Stand Lift missing both of its safety pins available for use outside of room [ROOM NUMBER].On 3/30/26 at 10:14 a.m., in an interview with Registered Nurse #1, who confirms that the sit to stand lift is missing it's safety pins. At this time, she removes the lift from the unit.On 3/30/26 at 2:08 p.m., in an interview with the Director of Nursing (DON), the above information was confirmed. At this time, she states maintenance has taken the machine off the floor and ordered new pins that should be here in a few days. 2. On 3/31/26 at 8:26 a.m., observation of an unsecured container of CaviWipes on the medication…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-03 · tag F0947 — failed to train nurse aides adequately — isolated
    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 Abuse and Neglect along with Resident Rights training for 1 of 6 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 1 of 6 randomly selected CNAs employed greater than 1 year. (CNA #1)Findings:CNA #1 was hired in June of 2023. Review of CNA #1 Employee In-service/attendance records lacked evidence of Resident Rights training and Abuse and Neglect training for 2025. Furthermore, the record lacked evidence of the required 12 hours for continuing education for the year 2025.On 4/2/26 at 1:30 p.m., in an interview with the Director of Nursing (DON) who confirmed CNA #1 did not have 12 hours of education, Abuse and Neglect training, and Resident Rights training. She then add that CNA#1 is a per-diem employee and is unsure how many hours she worked in 2025.On 4/2/26 at 4:00 p.m., in an interview with the Senior Healthcare…

    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 · E2025-04-02 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 review the facility failed to ensure nursing staff immediately initiated isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis (GI) (i.e. diarrhea, vomiting, abdominal pain, and/or fever) and ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. This has resulted in the spread of GI symptoms throughout the facility which began on 3/24/25 and Norovirus being confirmed on 4/2/25. Findings: 1. On 4/2/25 at 8:45 a.m., upon entry to the facility, 2 surveyors observed no posting or signage on the door of any infections/symptoms occurring in the building. In an interview, the Administrator stated there is something GI going around, a few residents have had it and believed there is one resident who was having symptoms. She then stated that both the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionists (ADON/IP) were out sick with nausea, vomiting 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-02 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review the Administration failed to follow the facility's Infection - Clinical Protocol policy and procedures by not following the Family Nurse Practitioner's (FNP) recommendation of isolation/contact precautions for residents who were exhibiting symptoms of gastroenteritis (GI) (i.e. diarrhea, vomiting, abdominal pain, and/or fever) and ensure that Personal Protective Equipment (PPE) supplies were available for use for these residents. In addition, Administration failed to ensure the infection Preventionist was following the facilities Infection prevention and Control Program which included oversight, outbreak management, prevention of infection and monitoring employee health and safety. This has resulted in the spread of GI symptoms throughout the facility. The administration was notified of the potential outbreak on 3/26/25 and Norovirus being confirmed on 4/2/25 Finding: On 4/2/25 at 8:45 a.m., upon entry to the facility, 2 surveyors observed no posting or signage…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-02 · 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

    Based on record review and interview, the facility failed to ensure that resident's Power of Attorney (POA) was notified of a significant change in medical condition for 1 of 2 residents reviewed for Respiratory Syncytial Virus (RSV) (Resident #29). Findings: On 3/17/25 Division of Licensing received a complaint that Resident #29, was transported to the hospital on 3/15/25 due to mental status changes. The hospital notified the POA that, according to the facility records, Resident #29 had tested positive for RSV on 3/7/25. The POA was not made aware of this diagnosis. On 4/2/25, a review of Resident #29's medical record lacked evidence of nursing documentation and/or labs to verify that he/she was tested or positive for RSV. At 3:25 p.m., during an interview with the Advance Practice Registered Nurse (APRN) she confirmed that Resident #29 was seen by the provider and swabbed for RSV on 3/7/25, which resulted in him/her testing positive for RSV. The APRN was able to obtain the positive lab results through the lab documentation. The medical record lacked evidence of his/her POA being…

    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 · Dcited before2025-04-02 · 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 record review and interviews, the facility failed to ensure a physician order was followed for 1 of 1 resident reviewed for diabetes management. (Resident #29) Findings: On 4/2/25 a surveyor reviewed Resident #29 clinical record which showed an active physician order initiated on 11/5/24 for blood glucose monitoring one time a day every Tuesday and to call the provider if blood sugars are less than 100 or above 200. Further review shows the blood sugar levels on 3/4/25 was 285, on 3/11/25 was 311, on 3/25/25 was 298, and on 4/1/25 was 253. The clinical record lacked evidence of physician notification for the above levels. On 4/2/25 at 4:38 p.m. and at 5:50 p.m., during an interview, the Family Nurse Practitioner stated that she was aware of Resident #29 blood sugar being elevated on 4/1/25. However, she was unable to recall if she was made aware of any other elevated glucose levels for Resident #29. On 4/2/25 at 4:38 p.m., during an interview, Licensed Practical Nurse #1 stated, when he gets a high blood sugar reading, he will either call the provider, if the provider 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 · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the facility's Bowel Maintenance Program was followed, and the staff did not notify the physician of resident's condition for 1 of 8 sampled residents (#1). Finding: Review of Resident #1's clinical record indicated on Physician's Notes from 6/5/2023 to 7/24/2023 list diagnosis of Chronic Diarrhea and Constipation. Resident #1's Stool Output record demonstrated that the resident had no documented bowel movement (BM) for a period of 5 days (7/10/2023, 7/11/2023, 7/12/2023, 7/13/2023, and 7/14/2023. Medical record indicates resident was hospitalization on 7/24/2023. The Medication admission Record (MAR) demonstrated that the resident continued to receive Imodium 2mg (milligrams) twice daily until the resident was hospitalized on [DATE]. The Bowel Maintenance Program states: If no bowel movement for 3 days, follow physicians orders for bowel management. Constipation: No BM times 3 days check for impaction. If impacted, notify MD, if 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-07-27 · 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 good repair and in a sanitary condition on 2 of 7 units, for 1 of 1 Environmental Tours. (Bluff Island and [NAME] Island). Findings: On 7/27/22 at 9:28 a.m., an environmental tour was conducted with the Administrator in which the following findings were observed: Bluff Island: room [ROOM NUMBER]A - the wall beside the recliner was gouged and had chipped/missing paint with exposed sheetrock. room [ROOM NUMBER]A and B - the wall behind both recliners were large areas of gouged wall with chipped/missing paint exposing sheetrock. room [ROOM NUMBER]B- the bed foot board had gouged and peeling laminate exposing rough wood. [NAME] Island: room [ROOM NUMBER]- the bathroom door frame was deeply marred exposing rough wood causing sharp and uncleanable surface, The above concerns were confirmed with the Administrator at the time of observations. On 7/26/22, at 8:20…

    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
Show the remaining 16 citations
  • Potential for harm · E2022-07-27 · tag F0655 — pattern
    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 interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 8 of 27 residents reviewed for care plans (#24, #31, #52, #57, #58, #65, #324 and #374). Findings: 1. In review of Resident #24's medical record, he/she was admitted on [DATE] with diagnosis to include depression, Celiac Disease (gluten allergy) hypertension and heart failure. Further review of Resident #24's clinical record revealed his/her baseline care plan failed to include the gluten allergy. 2. In review of Resident #31's medical record, he/she was admitted on [DATE] with diagnosis to include type II diabetes melitus, hypertension, atrial fibrillation, heart failure and dementia. Further review of Resident #31's clinical record revealed his/her baseline care plan was not initiated until 6/16/22 (18 days after admission) and failed to include goals and interventions…

    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 before2022-07-27 · 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, observation and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 1 of 2 medication rooms observed, failed to date and/or store biological's after opened and according to manufacturer specifications and failed to dispose of expired medications on 3 of 3 units observed. (Eagle Island/Ram Island, Bluff Island/[NAME] Island and Beach Island/Gooseberry Island) Finding: PharMerica policy and procedure for Controlled Medication Storage, revised 11/17 states: #3 The access system (key, security codes) used to lock controlled medications and other medications subject to abuse cannot be the same access system used to obtain the non-scheduled medications. #4 Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. On 7/25/22 the following was observed: 1. At 11:08 a.m., observation of the Skilled unit (Eagle Island and Ram Island) medication room 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 · E2022-07-27 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, and Facility Reported Incident review, the facility failed to ensure that clinical records were complete and contained accurate information for 4 of 4 sampled residents reviewed for medications (Resident(s)#24, #31, #48 and #374). Findings: Review of Resident #24's signed provider orders for June 2022 revealed the following: -order with start date on 6/2/22 for [Oxycodone HCI 5 milligrams (mg) Give one tablet by mouth three times a day x 30 days]. Review of Resident #24's MAR lacked evidence this was completed on 6/9/22 at 1400, 6/15/22 at 1400, 6/25/22 at 1400, 7/6/22 at 2200. -order with start date 6/11/22 for (Diclofenac Sodium 1% Gel (2 gram) apply to right knee four times a day. Review of Resident #24's MAR lacked evidence this was completed on 6/15/22 at 8:30 a.m. and 12:30 p.m., 6/25/22 at 12:30 p.m. and 6/6/22 at 2100 -Order with start date of 5/18/22 for MCR/skilled charting, chronic lower extremity wounds/right sacral wound daily, Review of Resident #24's TAR…

    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 · E2022-07-27 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the 8/17/2022 statement of deficiencies and plan of correction (POC) in effect from the annual Long Term Care Survey Process, record review and interview, the facility's Quality Assurance Performance Improvement committee failed to ensure that the plan of correction was followed and effective for F761. Finding: On 7/25/2022 through 7/27/2022, during the annual Long Term Care Survey Process (LTCSP), a deficiency was cited at F761 for the failure to ensure expired medications were removed from medication carts and refrigerators. On 10/4/2022, during the survey revisit, a surveyor observed expired stock medications in medication carts on the Beach/Gooseberry and Eagle/Ram units. In addition, expired medications were observed in the medication room refrigerators on the Bluff/[NAME] and Eagle Ram units. Unit charge nurses confirmed the findings as they occurred, and the Interim Director of Nursing was notified. On 10/4/2022 at 1:00 pm, the findings were discussed with the Administrator.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-27 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to maintain a clean/sanitary environment on 3 or 7 units observed (Ram Island, Bluff Island and [NAME] Island) for 3 of 3 days of survey. Findings: On 7/25/22, 7/26/22 and 7/27/22 the following was observed: 1. Ram Island: room [ROOM NUMBER] - bathroom had a bed pan stored between the handrail and the wall. 2. Bluff Island: room [ROOM NUMBER]A - bathroom had 2 graduates, only one labeled 131B, stored on the back of the toilet. room [ROOM NUMBER]B - bathroom has a bed pan stored between the handrail and the wall. 3. [NAME] Island: room [ROOM NUMBER] - bathroom had a urine hat stored behind the toilet, between the handrail and the wall. room [ROOM NUMBER] - bathroom had 2 urinals hanging on the handrail and a basin on the floor under the sink. On 7/27/22 at 9:28 a.m., the surveyor and Administrator observed the above concerns

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to ensure that Activity of Daily Living (ADL) assistance was provided to 1 of 1 Resident (#374) reviewed for ADLs on 2 of 3 survey days. Findings: Resident #374 was admitted to the facility on [DATE] with diagnoses to include recent hip fracture, and congestive heart failure, and skin cancer. Review of Resident # 374's Activities of Daily Living (ADL) documentation for July 2022 revealed that he/she is scheduled to receive a whirlpool or shower on Thursdays. Further review of ADL charting reveled that Resident #374 received a bath on 7/25/22. No other documentation to indicate he/she received hygiene care was provided. Review of Resident #374's Minimum Data Set (MDS) dated [DATE] indicated that Resident #374 is a total assist for bathing and needs extensive assistance with hygiene and dressing needs. During an interview on 7/25/22 at 11:03 a.m., Resident #364 indicated he/she has only had one bath since coming to the facility and they have not been…

    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 · D2022-07-27 · 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, interview, and record review, the facility failed to provide respiratory services as directed by physician orders related to humidification for 1 of 4 residents reviewed who received oxygen services (Resident #48). Finding: On 7/25/22 at 10:25 a.m., 7/26/22 at 7:01 a.m. and 7/27/22 at 6:33 a.m., a surveyor observed an oxygen concentrator with connecting nasal cannula (undated) and lying on the floor. On 7/25/22 at approx. 10:25 a.m., during an interview, Resident #48 stated he/she has no idea why it is in the room because he/she has never used it. During review of Resident #48's medical record, a provider order with a start date of 3/4/22, instructs nursing to apply oxygen at 2L (liters) per NC (nasal cannula) for SOB (shortness of breath) and/or 02 (oxygen) sat of less than 90% and Notify Provider as needed. The Medication Administration Resident dated July 2022 revealed that resident #48 did not receive oxygen from July 1st through July 26th. On 7/27/22 at 7:01 a.m. the Licensed Practical Nurse (LPN) confirmed that resident #48 has not needed supplemental…

    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 before2019-11-07 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to safely secure drugs and biologicals on 3 of 7 wings during 2 of 4 survey days. Furthermore, the facility failed to ensure that drugs and biologicals were dated when opened, and expired medication removed, from 2 of 4 medication storage refrigeration units on 1 of 4 days of survey. Findings: 1. On [DATE] 8:02 a.m. to 8:20 a.m., the surveyor observed 1 unlocked unattended medication cart on Beach Island wing and 1 unlocked unattended treatment cart on the Gooseberry Island wing; both in corridors where residents and unauthorized personnel cross through. The medication cart contained a bottle of acetaminophen, a bottle of aspirin, prescribed bubble packaged medications, and several bottles of prescribed medications. The treatment cart contained syringes with needles. On [DATE] at 8:20 a.m., the surveyor informed the Certified Medication Technician (CMT), who returned to the unlocked cart on Gooseberry Island wing and the surveyor demonstrated the cart 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-07 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to inform a resident or their representative, in advance, of treatment risks and benefits, options, and alternatives related to use of an antipsychotic medication for 1 of 25 sampled Residents (#47). Finding: On 11/7/19, in review of Resident #47's record, there was no evidence the resident or representative were informed in advance of treatment risks and benefits, options, and alternatives prior to the use of Risperdal, an antipsychotic, initially prescribed 8/12/19 for aggressive behavior related to a diagnosis of Vascular Dementia With Behavioral Disturbance. On 11/7/19 at 9:50 a.m., in an interview with the Beach Island Wing Nurse Manager, the surveyor inquired about verbal or written information provided to the resident or their representative in advance of treatment outlining risks and benefits related to use of the antipsychotic, and he/she could not confirm if the facility informed the resident or their representative in advance of treatment risks and benefits related the use of Risperdal. On 11/7/19 at 11:03 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-07 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure that a resident's choice in the area of bathing frequency were being followed for 1 of 15 resident/family interviewed (Resident #65). Finding: On 11/06/19 at 12:16 p.m., two (2) family members stated during an interview with the surveyor that their mother (Resident #65) has not received showers or whirlpools as often as she/he would desire, at least once a week. The surveyor confirmed with the family members and through clinical record review and screening the resident that the resident could not be reliably interviewed. On 11/06/19 at 02:46 p.m., during an interview with the surveyor, Resident #65's primary Certified Nursing Assistant (CNA) stated she gave the resident a shower today. She stated that [the Resident] was scheduled for Mondays but [he/she] wasn't getting them so the shower day was changed to Wednesdays. Further interviews with CNAs during the survey revealed that staffing did not affect the shower schedule. The surveyor reviewed Resident #65's clinical record and noted the CNAs' electronic bathing…

    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 · D2019-11-07 · tag F0675 — failed to support quality of life — isolated
    Honor each resident's preferences, choices, values and beliefs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview, the facility failed to provide services to a resident necessary to attain the highest practicable level of care related to positioning during 1 of 4 observed meal services (Resident #19). Finding: On 11/04/19 at 11:58 a.m., in the first floor long term care unit dining room, a surveyor observed Resident #19 seated in a Broda chair with the back of the wheelchair in a slightly reclined position. The resident's plate was set to the left of the resident. The resident proceeded to bring him/herself up in an upright position, fully extend his/her right arm to reach the plate, place food on the fork, then lay back into the chair and take a bite of the food. The surveyor observed the resident do this for approximately 3 minutes when a Certified Nursing Assistant (CNA) offered and proceeded to cut up the resident's meat, repositioned the plate directly in front of the resident and then left the resident in the same reclined position. The surveyor then observed Resident #19 continue to feed him/herself by sitting upright, fully extending his/her right arm…

    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
  • No harm found · Bcited before2026-04-03 · 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair. On 4/1/26 at 12:40 an environmental tour was done with the Administrator and the Director of Maintenance and the following were found and confirmed at that time. First floor - room [ROOM NUMBER] - the floor threshold between the room and the bathroom has duct tape on each side, creating an uncleanable surface. Second floor - room [ROOM NUMBER], the wall on the right upon entrance has many small gouges in it from her wheelchair. The are also abrasions on the wall behind her lift chair from it rubbing the wall when it rises. room [ROOM NUMBER], the wall in the bathroom has a hole just below the towel rack.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-08-08 · tag F0550 — failed to protect resident dignity and rights — widespread
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interviews and record review, the facility failed to serve residents meals in a homelike manner by serving meals on paper/plastic dishware plates and plastic cutlery. That has the ability to effect all residents in facility. Findings: On 8/8/2023, during and interview with Resident #3, the resident stated I am tired of always being served on paper plates and plastic. It makes me feel like a kid, and not in a good way. On 8/08/2023, during an interview with Resident #4, the resident stated It is very bad, and everyone knows it. And then they serve it to you in 'doggie dishes' which makes it even worse. On 8/8/2023 at 11:10 a.m., during an interview with Food Service Manager( FSM) he stated , the dishwasher is broken and are awaiting on a new dishwasher. The FSM also stated We have not had the staff for that for a long time. For over a year. FSM said that he had no idea and no documentation of when the dishwasher might be repaired. On 8/8/2023 at 11:20 a.m., a surveyor discussed the finding of plastic/paper dishware and plastic cutlery with the Administrator.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-07-27 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 2 sampled residents transferred/discharged to an acute care facility (#58 & #374). Findings: 1. Documentation in Resident #58''s clinical record indicated that he/she transferred to an acute care hospital on 7/10/22 and subsequently admitted . The surveyor could not locate evidence in the clinical record that Resident #58's and his/her representative was notified in writing of the transfer/discharge to the hospital. During an interview on 7/27/22 at 11:12 a.m. the Social Worker confirmed that transfer/discharge documents were not completed and provided to Resident #58 and his/her representative. 2. Review of Resident #374's clinical record a surveyor noted resident was transferred to an acute care facility on 7/15/22 and subsequently admitted . The surveyor could not locate evidence in the clinical record that Resident #374 and his/her representative was notified in writing of 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 Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-07-27 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to issue a written bed hold notice to a resident, known family member or legal representative for 2 of 6 sampled residents who had been transferred to an acute care facility (#58, #374). Findings 1. Documentation in Resident #58''s clinical record indicated that he/she transferred to an acute care hospital on 7/10/22 and subsequently admitted . The clinical record contained no evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. On 7/27/22 at 11:12 a.m., a surveyor confirmed the finding in an interview with the Director of Social Services. 2. Documentation in Resident #374's clinical record indicated that he/she was transferred to an acute care facility on 7/15/22 and subsequently admitted . The clinical record contained no evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer. During an interview with Resident #374 on 7/26/22, at approximately 8:45 a.m., he/she could…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-07-27 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to for facility census for 3 of 3 survey days. Findings: During observations of facility on 7/25/22 at 1:12 p.m., 7/26/22 at 11:11 a.m., and 7/27/22 at 8:30 a.m., there was no evidence of posted daily staffing ratios for the facility. During an interview on 7/27/22 at 8:30 a.m., Office Assistant (OA) indicated that she's responsible to post staffing and keeps it in a binder behind the lobby desk. At this time OA confirmed that daily staffing is not posted and readily accessible to residents and visitors. During an interview on 7/22/22 at approximately 1:09 p.m. a surveyor discussed with Director of Nursing that staffing has not been posted during 3 of 3 survey days.

    Nursing and Physician Services 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

$75,433 in federal fines across 1 penalty.

  • $75,433 — penalty dated 2025-04-02

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

Part of a chain

This home belongs to FIRST ATLANTIC HEALTHCARE — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.4-1.4 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 9 homes this chain runs (chain average 3.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
FARADAY HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF67%since 06/29/2019
KWB HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 06/29/2019
BOWDEN, KENNETHIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 06/29/2019
OTIS-HIGGINS, ANDREAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/11/2015
PELKEY, WANDAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
FIRST ATLANTIC HEALTHCARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/26/2025
BERMAN, ARIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2019
GILBERT, JESSICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
COFFIN, CRAIGIndividualADP OF THE SNFsince 06/30/2019

CMS files one row per role, so the 19 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$13.5M
Net patient revenuemost recent cost report
+1.1%
Operating marginrevenue minus expenses
$417K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 51%Medicare 10%Other / private 39%

This home reported $417K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$434per resident / day
operating cost
$13,202per month
≈ monthly operating cost
$439per day
avg. revenue, all payers

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

What families pay in ME

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205103. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-03, 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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