Pine Point Center
67 Pine Point Rd, Scarborough, ME 04074 · For profit - Limited Liability company · 61 certified beds · (207) 883-2468 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.0% | 24.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.1% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 2.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.1% | 11.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.7% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 58.9% | 25.6% | 16.1% | check this† — see note marked dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 9.5% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.9% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.7% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.2% | 29.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.6% | 20.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 73.3% | 74.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.2% | 20.8% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.7% | 16.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.14 | 1.45 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.02 | 2.01 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.5% 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 196 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 99 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.5%CMS range 61.8–73.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.5–12.6 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 54.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 44.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.5% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 91.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 95.7% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not 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 stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 3.4–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 61 beds and averages 56.8 residents a day — about 93% occupied, or roughly 4 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 3.84 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.18 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below 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 3.52 hrs/resident/day on weekends vs 3.97 on weekdays — 11% thinner on weekends. RN hours go from 1.32 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Ecited before2026-06-02 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 facility policy, record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for falls (Resident #3) and 3 of 3 residents reviewed for Medication Administration Records (MAR) and Treatment Administration Records (TAR) (Resident #1, #3, and #4). Findings: Facility Policy titled Falls Management states; Any patient who sustains a injury to the head from a fall and/or has a fall unwitnessed by staff will be observed for neurological abnormalities by preforming neurological checks, per facility policy. Facility Policy titled Neurological Evaluations states; Neurological evaluations will be performed: Every 15 minutes x two hours, then every 30 minutes x two hours, then every 60 minutes x four hours, then every 8 hours until at least 72 hours has elapsed. 1. On 6/2/26 a review of Resident #3's clinical record showed he/she sustained an unwitnessed fall on 4/19/26. Further review of the record showed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to clarify hospital discharge orders and provide a brand name medication for a resident for 1 of 3 residents reviewed for medications. Findings:During a medical record review, Resident #3's hospital Discharge summary, dated [DATE], Medications to continue, levothyroxine 112 mcg(microgram) tabs- take 112 mcg by mouth. Commonly known as: Synthroid, PATIENT TAKES BRAND NAME. Discharge Summary also included TSH level was 1.48 (5/9/23) (last known level).Medication Administration Record (MAR) for January, indicated Levothyroxine Sodium tab, 112 mcg. Start Date 1/21/26. End date 1/31/26.On 5/27/26 at 12:16 p.m., during an interview with the family, stated, Our family communicated repeatedly since admission that [Resident #3] cannot tolerate generic levothyroxine. Family indicated that the resident's husband has delivered brand-name Synthroid directly from home to the facility for this reason.Medication Administration Record (MAR) for February and March…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-02 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — the official record, unedited, may be distressing
Based on record reviews and interviews, the facility failed to follow up on laboratory orders when there were no results for a lab ordered for 1 of 3 residents whose record was reviewed for thyroid treatment (Resident #3).Findings:1. Resident #3's medical record indicated an order for Comprehensive Metabolic Panel (CMP), Complete Blood Count with Diff (CBC with diff), and Thyroid Stimulating Hormone, (TSH), dated 3/10/26. The lab results included CMP and CBC with diff, however, lacked evidence of TSH.2. Resident #3's medical record indicated an order for Comprehensive Metabolic Panel (CMP), Complete Blood Count without Diff (CBC w/o diff),and Thyroid Stimulating Hormone, (TSH), dated 4/5/26. The lab results included CMP and CBC with diff, however, lacked evidence of TSH.On 6/2/26 at 1:36 p.m., during an interview with two surveyors, the Marketing Clinical Director stated labs were drawn in March and April however, the lab did not process them for TSH even though it was requested. At this time, she confirmed there was no follow-up to the provider regarding the TSH labs to be redrawn.
- Potential for harm · Ecited before2025-04-09 · tag F0657 — failed to keep the care plan current — patternDevelop 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 3. Resident #11's clinical record contained a Quarterly MDS Assessment, dated 1/11/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. On 4/9/25 at 10:21 a.m., during an interview, the Social Services Director confirmed she does not have a process for scheduling IDT meetings and does not usually provide residents or their representatives advance notification of the meeting(s). 2. Resident #40's clinical record contained Quarterly MDS' dated 12/13/24 and 3/15/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. In addition, the admission MDS dated [DATE] had a IDT meeting held on 9/16/24 with the resident in attendance, but not the family representative. On 4/8/25 at 2:27 p.m., during an interview, the Market Clinical Advisor confirmed that IDT meetings had not been held and there was no evidence that Resident #40's representative had been invited or had been provided with a copy of the resident care plan. Based on interviews and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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
2. On 4/6/25 at 10:02 a.m., and on 4/7/25 at 12:16 p.m., Resident #27 was observed with an uncovered, open wound on his/her right forearm. Resident #27's clinical record contained a physician order dated 4/3/25 for, Mupirocin External Ointment 2 % (Mupirocin) Apply to Right forearm topically every evening shift for Biopsy for 11 Days. Cover with Band aid, Per dermatology On 4/9/25 at 10:30 a.m., during an interview, the Registered Nurse #2 stated Resident #27's right forearm wound is supposed to be covered with a bandage at all times. At this time, the finding was reviewed with the Unit Manager, and she stated Resident #27 does not typically refuse treatments or remove his/her wound dressing. 3. Resident #4 has diagnoses to include hemiparesis (paralysis) following cerebral infarction (stroke). On 4/6/25 at 11:49 a.m., a surveyor observed a brace on Resident #4's left wrist. At this time, Resident #4 stated he/she has had the brace since his/her stroke and that the nursing staff helps him/her put the brace on first thing in morning and take it off at night. Review of Resident #4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility for weekends of the first quarter (October 1, 2024 - December 31, 2024). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs). Findings: 1. Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the first quarter of 2025 (October 1, 2024 - December 31, 2024). On 4/9/25 at 1:56 p.m., both the surveyor and the Director of Nursing reviewed the weekend staffing from October 1, through December 31, 2024. The Director of Nursing confirmed the facility did not ensure enough staff were on duty to meet resident needs on the weekends. 2. A review of the Resident Council Meeting Minutes revealed the following: -meeting minutes dated 2/26/25 stated Residents are concerned that staffing ratios aren't consistent. Especially 2nd shift, long waits noted .Residents are concerned that call lights…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 properly secure medications on 1 of 2 (Short Stay Unit) units for 2 of 4 days of survey, failed to ensure expired medications were removed from the supply available for use in 2 of 4 treatment/medication carts reviewed and failed to ensure expired lab supplies were removed from supply available for use on 2 of 2 units (Short Stay and Long Term Units). Findings: 1. On 4/6/25 at 9:02 a.m., observation of the Short Stay unit to have an unlocked and unattended treatment cart containing 4 residents insulin pens, pen needles and lancets, during this time 2 residents were present. At 9:05 a.m., the Certified Nurses Aid #1 confirmed the unlock treatment cart and locked it. 2. On 4/6/25 at 11:52 a.m., observation of the Short Stay unit medication room with the Licensed Practical Nurse #3 (LPN#3). The surveyor asked if nursing draws their own labs. The LPN#3 stated, We can, yes. I haven't for a while, we have a guy who comes in, he usually brings his own…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, walls, the dishwasher and fans/vents, failed to ensure staff were wearing proper hair restraints and failed to ensure that canned goods with a compromised seal were not available for use for 1 of 4 days of survey. (4/6/25) Findings: On 4/6/25 at approx. 9:00 a.m., during the initial tour of the kitchen the following was observed: 1. -The kitchen floor was dirty with food debris and trash around the entire floor and under the equipment and shelving. - The kitchen walls were covered with dirt and food debris. - The dish washer was covered with dirt and debris. - The vent above the grill was coated with dirt and debris. - The vents and fans throughout the kitchen had built up dust 2. Observation of the Dietary Aid #1 and #2 not wearing proper hair restraints while preparing food. After surveyor intervention, both Dietary Aid #1 and #2 applied hair restraints. 3. Observation of 3, #10 cans of peaches with denting along the seal and available for use.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 4/8/25 at 4:04 p.m., a Physical Therapy Assistant (PT-A) was observed exiting the Oak Hill unit, wearing a yellow isolation gown. The PT-A proceeded to walk past the surveyor, located next to the nurse's station and enter the main dining room, where she doffed the isolation gown and then exited the dining room. At this time, the surveyor asked where the PT-A was prior to leaving the Oak Hill unit, and the PT-A stated she had been in a room wearing gloves, a gown, an N95 mask, and eye protection because the resident was on transmission-based precautions (TBP). She then stated, while she was in the room with the resident, the nurse came in and informed her that the TBP had just been lifted and she removed her gloves, mask, and eye protection before she exited the room and should have removed the gown, but she forgot, so she doffed it in the dining room. On 4/8/25 at 4:11 p.m., the above was discussed with the Market Clinical Advisor. 2. On 4/7/25 at 12:25 p.m., during lunch meal pass on the Skilled Unit, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and facility policy, the facility failed to thoroughly investigate an Injury of Unknown Origin for 1 of 1 resident reviewed for Injuries of Unknown Origin. (Resident #57) Findings: On 10/5/24 the Division of Licensing and Certification received a report that Resident #57 obtained an injury to his/her left ankle, while an unknown Certified Nursing Assistant was putting on the resident's shoe. Review of Resident #57 medical record contained a provider note, dated 10/4/24 of an evaluation of his/her left ankle, which resulted in the provider ordering an X-Ray. On 10/5/24 an X-Ray was obtained and showed no evidence of a fracture but showed soft tissue swelling. Further review of the medical record lacked evidence of any nursing documentation of an injury occurring or monitoring of his/her left foot. Review of the facility's investigation dated 10/7/24, consisted of the Director of Nursing's interview with Resident #57 and a family member, and a note from an Occupational Therapy (OT) student dated 10/7/24. The OT students note states that Resident #57…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2025-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 on 1 of 5 units (Pleasant Hill House) for 1 of 4 days of survey (4/6/25). Findings: 1. On 4/6/25 at 10:07 a.m., observation of room [ROOM NUMBER] on Pleasant Hill House to have an unsecured container of Micro-Kill One Germicidal Alcohol Wipes and a bottle of toilet bowl cleaner. At this time, Registered Nurse #2 confirmed the chemicals should not be stored in a resident's bathroom and removed the chemicals. 2. On 4/6/25 at 11:47 a.m., observation of room [ROOM NUMBER] on Pleasant Hill House to have an unsecured container of Micro-Kill One Germicidal Alcohol Wipes. At this time, Registered Nurse #2 again confirmed that chemicals should not be stored in a resident's bathroom and removed the chemicals. The Safety Data Sheet for Micro-Kill One Germicidal Alcohol Wipes states in Section 4:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include those triggers and interventions to prevent re-traumatization for 1 of 2 residents reviewed with a diagnosis of PTSD. (Resident #22) Finding: On 4/6/25 a review of Resident #22's medical record showed he/she was admitted in 2018 and had a current diagnosis of PTSD. Further review including assessments and the current care plan lacked evidence that the facility assessed the resident for what triggers might cause re-traumatization and failed to revise the care plan to include those triggers and interventions to prevent re-traumatization. On 4/7/25 at 3:30 p.m., during an interview, the Market Clinical Advisor confirmed the above and stated that nursing completed a trauma assessment today on Resident #22 which included triggers that may cause re-traumatization.
- Potential for harm · D2025-04-09 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and a lunch meal test tray, the facility failed to serve food at an appetizing and palpable temperature for 1 of 2 meals observed. Findings: On 4/6/25 at 9:53 a.m., during an interview, Resident #10 discussed concerns of the food not being hot when it gets to resident. On 4/7/25 at 10:50 a.m., a surveyor requested a sample tray,sample tray. During the observation, both Certified Nursing Assistant (CNA) #2 and CNA #3 started to serve the lunch trays for the 20 residents at 12:19 p.m. During this meal pass, both CNA's had to boost and turn 2 residents and one CNA had to take a resident to the bathroom. The last meal was served at 12:50 p.m., 31 minutes after the first tray was passed. At 12:51 p.m., the food on the sample tray food was tempted, in which the BBQ pulled pork sandwich was 121.7 degrees Fahrenheit and the seasoned potato wedges were 85 degrees Fahrenheit. On 4/7/25 at 1:20 p.m., during an interview, CNA #3 stated they occasionally get more help with passing trays, but it usually ends up being just 2 CNA's which results in cold food. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
Based on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for nutrition (Resident #11). Finding: Resident #11 was admitted in 2024 with diagnoses to include protein-calorie malnutrition. Resident #11's clinical records contained an active physician order dated 1/17/25 for Start 8oz whole milk & full fat ice cream milkshake TID w/ meals and at bedtime with meals AND at bedtime. A physician progress note, dated 2/28/25 which stated, Did verify with staff that [he/she] is being given whole milk with [his/her] shakes however, unable to find the order for milkshakes on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). Did discuss this with unit manager . An additional physician progress note, dated 4/1/25 which stated, Weight loss .still do not see order for milkshakes on MAR or TAR to be signed out, will discuss with nurse manager again . Resident #11's MAR and TAR for January, February, and March 2025 lacked documentation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-15 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 — 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 maintain a clean/sanitary environment on 1 of the 3 units. (Oak Hill House). Findings: On 10/7/24 at 9:14 a.m., the Department of Licensing received a complaint indicating that the bathrooms on the Oak Hill Unit were very dirty and smelled of an odor that resembled 'urine'. On 10/15/24 at 9:35 a.m., in an interview, the Housekeeping Manager stated that there are issues with the floors in some of the bathrooms on the Oak Hill Unit and that the floors tiles are loose, but they are afraid to use a scrubber & buffing machine on them because the tiles may become loose. On 10/15/24 at 9:45 a.m., during a tour, a surveyor observed the residents' bathrooms on the Oak Hill Unit. All resident bathroom floors were observed to have a buildup of wax and dirt. Bathrooms #2, #3, and #7 were observed to have extensive wax buildup. During the observation of bathroom [ROOM NUMBER], there was an overwhelming odor of what resembled urine. At this time the Housekeeping…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 2 of 2 units and in the Kitchen. Findings: 1. On 3/3/24 at 9:10 a.m., during the initial observation of the Kitchen with the cook, it was observed that the ceiling had multiple ceiling tiles that had moderate to heavy amounts of spotting and staining. On 3/6/24 at 11:15 a.m., in an interview with the Director of Maintenance, he stated that the Kitchen ceiling had not been cleaned in the 13 years that he has been here. He stated, I would not know how you would clean that. 2. On 3/6/24 at 11:20 a.m., during a tour of the Long Term Care Unit with the Director of Maintenance the following were observed: - Pleasant Hill House, resident room [ROOM NUMBER], the window curtains were off the track on both sides of the window. One stained ceiling tile at the nurses' station and 1 stained ceiling tile in the resident dining room. 3, On 3/6024 at 11:40 a.m., during a tour of the Short Stay Unit 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.
- Potential for harm · Ecited before2024-03-06 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 observations, the facility failed to provide sufficient staffing to meet the acuity level and resident needs in a timely manner for 3 out of 3 units surveyed. (Pleasant Hill House, [NAME] House and Oak Hill House) Findings: 1. On 3/3/24 at 9:17 a.m a surveyor observed Resident #14 asking a CNA #2 for a shower. Resident #14 stated they should have gotten a shower on Friday but was told there wasn't enough staff that day. And it happened last week too. CNA #2 confirmed the resident's scheduled shower day was Thursday and it hadn't happened yet this week. A record review of Resident #14's bathing documentation revealed only 1 documented shower in the past 63 days. On 3/3/24 9:30 a.m., a surveyor interviewed CNA #5, There's a lot I can't get to. Changing, repositioning, it doesn't happen. Things we are supposed to do but can't get to it. I spend all my time looking for someone to help me. I find them and then I have to wait because they're busy. We should have 2 people over…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-06 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for a nurse aide at least every 12 months, for 2 of 5 sampled Certified Nursing Assistants (CNA) employed greater than 1 year (CNA1, CNA3). Findings: On 3/6/24, a surveyor reviewed the following employee files: 1. CNA1 was hired 12/13/16. The last annual evaluation was completed and signed on 10/21/2020. The next annual evaluation was dated for December for 2021-2022 year however, was not signed until 4/18/23. 2. CNA3 was hired 12/23/19. The last annual evaluation was completed and signed on 1/2/2020. The next annual evaluation was dated for 2021-2022 however, was not signed until 4/7/23. On 3/6/24 at 9:51 a.m., during an interview with a surveyor, the Administrative Assistant stated she was unable to find one for both CNA 1 and CNA 3 for 2023. At this time, the Administrative Assistant stated she was aware of the lack of annual evaluations at the end of 2023 and has not completed any of the past due evaluations at this time.
- Potential for harm · Ecited before2024-03-06 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 interview, the facility failed to ensure that the clinical records contained accurate documentation for 1 of 6 residents reviewed for medications (# Resident 154), and for 1 of 22 sampled residents ( Resident #111). Findings: 1. On 9/26/23 the Department of Health received a complaint that Resident #154 was not receiving medications correctly and the residents eye drops were found in another resident's room. During a record review, Resident #154 was admitted on [DATE] with physician orders for Ketorolac Tromethamine Ophthalmic Solution Instill 1 drop in left eye two times a day for inflammation. Review of the electronic medication administration record (EMAR), it was noted that the medication was held on the evening of 9/21/23, administered on both day and evening shifts on 9/22/23 and 9/23/23 then held again for both day and evening shifts on 9/24/23 and day sift on 9/25/23. Further review of the medical record showed EMAR notes stating, on 9/21/23, 9/24/23 and 9/25/23 the eye drops…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-06 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that they held quarterly Meetings. There is documentation of 3 of 4 meetings and that the required members were in attendance. The Administrator attended 3 of 4 quarterly QAA meetings and the Medical Director attended 3 of 4 quarterly QAA meetings. Findings: 1. On 3/4/24 a review of the QAA Agenda/Sign-in pages found that the there was no sheet for April, the month for one of the Quarterly Meetings. 2. Review for October, another of the Quarterly Meetings, the Administrator and the Medical Director were absent. 3. On 3/5/24 at 8:15 a.m., in an interview, the Administrator stated that the designated months for the Quarterly QAA meetings are January, April, July, and October. He could not account for the lack of April meeting documentation. He was informed of the finding at that time.
- Potential for harm · E2024-03-06 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to perform adequate screening and documentation for the pneumococcal vaccination as required for 3 out of 5 Residents screened for vaccinations. Findings: 1. On 3/5/24, a surveyor reviewed Resident #14's Electronic Medical Record (EMR) and found no pneumococcal vaccinations recorded under Immunizations. A surveyor reviewed the physical medical record and found that Resident #14 had received the PPV13 (A type of pneumococcal vaccine) vaccination on 10/1/15 and the PPSC23 (A type of pneumococcal vaccine) vaccination on 10/31/08. These were not recorded in the EMR. 2. On 3/5/24, a surveyor reviewed Resident #26's EMR and found no pneumococcal vaccinations were recorded. A surveyor reviewed the physical medical record and found a signed undated consent refusing the PPVC 13 vaccination but no documentation showing the PCV 20 (A type of pneumococcal vaccine) vaccination was offered as required by facility policy. 3. On 3/5/24, a surveyor reviewed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure a resident was treated with dignity and respect for 1 out of 14 residents reviewed during survey. (Resident #17) On 3/3/24 at 12:10 p.m., a surveyor observed a loud confrontation among a staff member, a family member, and Resident #17 in the Oak Hill Dining Room. The staff member was seen and heard yelling to the family member I need to talk to you. The staff member was observed pointing their finger at the family member. At this time, the staff member was escorted out of the room by another staff member. On 3/3/24 at 12:45 p.m., during an interview with the family member and Resident #17, they stated the family member had entered the facility and heard 3 staff members talking about Resident #17 in the lobby. The family member overheard one staff member say in an angry manner; I'll take care of this. The family member observed this staff member go directly to Resident #17 in the dining room and move his/her plate and loudly scold Resident #17. The family member and Resident #17 expressed feeling upset hearing staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews,record reviews, the facility's bathing schedule and facility's bathing documentation, the facility failed to ensure that resident's preferences were being followed in the area of bathing for 2 of 6 residents reviewed. (Resident #14 and Resident #17) Findings: 1. On 3/3/24 at 8:58 a.m., during an obervation of Resident #14, the resident overheard asking a Certified Nurses Aide (CNA) for a shower. Resident #14 said, I was supposed to get a shower on Friday, but they told me they didn't have enough staff. I didn't get one last week either. During a review of the CNA bathing schedule indicated that the resident's scheduled weekly shower was on Thursdays. 2. On 3/4/24 at 9:15 a.m., during an interview with Resident #17, stated had not ever received a shower at the facility. A review of the admission record for Resident #17 showed an admission to the facility on 6/23/23. She/He stated, They said I am getting dandruff. I need a shower. A review of the CNA bathing schedule indicated that Resident #17's scheduled bathing day was Sunday. On 3/5/24, a surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-06 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that food was stored in the walk-in fridge correctly and that the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen tour observations. Findings: 1. On 3/3/24 at 9:10 a.m., during the initial tour of Kitchen, a surveyor observed 2 uncovered, undated, and unmarked trays of deserts. Also observed, 2 wall mounted fans with a light to moderate amount of dirt, a ceiling vent with a small to moderate amount of dust and debris. The entire ceiling has a moderate to heavy amount of staining and spotting. The cook was made aware of the findings at that time. 2. On 3/5/24 at 1:00 p.m., during a return visit to the Kitchen tour with the Food Service Director. She stated that some new ceiling tiles have been ordered and that it is the responsibility of the Facility's Management to clean the ceiling, but it has not been done for the 3 years that she has been here. Inspection of the meat slicer found pieces of meat still on the back side of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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
Based on observations the facility's quality assurance committee failed to ensure that the plan of correction for identified deficiencies from the Annual Long Term Care Survey Process from 3/4/2024 through 3/6/2024 was effective. The following issue was again identified at this survey. Findings: At the Annual Long Term Care Survey Process from 3/4/2024 through 3/6/2024, the following deficiency was cited F812. On 5/2/2024, during the follow up visit, it was determined that F812 would be recited. F812 for failure to remove/clean stained ceiling tiles in the Kitchen, and clean Kitchen counter surfaces. A surveyor confirmed these findings with the Administrator on 5/2/2024 at 9:30 a.m.
- Potential for harm · Ecited before2022-11-03 · tag F0657 — failed to keep the care plan current — patternDevelop 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 interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative to review and revise the care plan after each assessment for 2 of 31 sampled residents (#14, #18). Findings: 1. On 11/1/22 at 8:53 a.m., during an interview with Resident #14, when asked if he/she is invited and/or participates in his/her plan of care, the resident stated he/she had about 2 of them and has been at the facility for 3 years and They may have had them on Mondays, Wednesdays or Fridays when I'm not here. Review of Resident #14's medical record, the surveyor noted a Minimum Data Set (MDS) Annual Review assessment, dated 4/7/22 and a Quarterly Review assessment, dated 7/8/22. The clinical record lacked evidence of an IDT meeting which included the resident, and/or resident's representative after both the 4/7/22 and 7/8/22 assessments. 2. Review of Resident 18's medical record, the surveyor noted a MDS Quarterly Review assessment, dated 12/8/21.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-11-03 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observation and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms and 1 of 3 medication carts observed. Findings: 1. On 10/31/22 at 9:30 a.m., observations of the short stay medication room with the Certified Medication Technician (CNA-M), the surveyor noted one unopened bottle of Ferrous Gluconate with best by date of 7/22. On 10/31/22 at approx. 9: 52 a.m., during an interview with Clinical Nurse Lead and Director of Nursing a surveyor discussed the expired medication. 2. On 11/1/22 at 8:45 a.m., observation of medication cart for Pleasant unit rooms 1-7 and [NAME] unit rooms 4b-7 with the CNA-M, the surveyor noted the following: A medication card containing 1 tab of Famotidine 20mg with expiration date of 8/31/22, 2 medications cards containing 29 Omeprazole 20mg capsules with exp date of 9/30/22 and 2 medication cards containing 30 Omeprazole 20mg capsules both with the expiration date of 10/31/22. On 11/1/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-03 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that a resident, and/or resident representative, was involved in the development of the resident's baseline care plan and was provided a summary of the care plan for 1 of 8 residents sampled for new admissions (Resident #43). Finding: On 11/01/22 at 9:30 a.m., Resident #43 stated no one had met with him/her since admission to discuss care planning. Resident #43 stated he/she had not been provided a copy of the initial care plan. A review of Resident #43's clinical record indicated he/she was admitted to the facility on [DATE]. The baseline care plan was initiated on 10/5/22 and included several revisions, with10/18/22 being the most recent. The clinical record lacked evidence that the resident, and/or resident representative, were provided a summary of Resident #43's baseline care plan. On 11/1/22 at 2:10 p.m., the Clinical Lead confirmed the finding.
- Potential for harm · D2022-11-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 and include interventions on the resident's current comprehensive care plan for the areas of Activities of Daily Living for 1 of 31 residents sampled (Resident #272). Finding: 1. Documentation in Resident #272's clinical record indicated on a physician's order sheet, dated 10/11/22, instructed staff that Resident #272 is to be Non-weightbearing to right lower extremity. A review of Resident #272's comprehensive care plan dated 10/11/22, under the problem areas of decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to recent fall with fracture and hospitalization resulting in fatigue and limited mobility. The care plan instructs staff to provide the resident with limited assist of 1-2 for transfers using a pivot transfer. Resident #272's comprehensive care plan failed to provide interventions addressing the recommendation for non-weightbearing status to the right lower extremity. On 11/1/22 at 1:59 p.m., the surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-04-09 · tag F0578 — failed to honor advance directives / code status — patternHonor 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
3. Resident #2 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #19 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. On 4/8/25 at 4:15 p.m., the above findings were reviewed with the Market Clinical Advisor. Based on record reviews, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GENESIS HEALTHCARE — 184 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 4 of 5 | 2.5 | +1.5 vs chain |
| Quality measures | 4 of 5 | 3.5 | +0.5 vs chain |
The other 183 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 183; lowest-rated first.
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GENESIS HEALTHCARE OF MAINE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/02/2012 |
| FC-GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GHC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/02/2012 |
| SUN HEALTHCARE GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/15/2022 |
| WHITMAN, ARNOLD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 03/02/2015 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| LOWES, ROY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/03/2025 |
| MORRIS, DIANE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/23/2023 |
| STADLER, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
CMS files one row per role, so the 19 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
9 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.
This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maine Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-09, 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.