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Pinnacle Health & Rehab At South Portland

42 Anthoine St, So Portland, ME 04106 · For profit - Limited Liability company · 73 certified beds · (207) 799-8561 Medicare & Medicaid certified

Call the home — (207) 799-8561 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
230 Waterman Drive
Pharmacy
Moby Rx0.2 mi
225 Waterman Dr · (207) 899-4600 · Call to confirm hours
Grocery
Shaw's0.4 mi
180 Waterman Dr · (207) 799-8149 · Call to confirm hours
Park
98 Hinckley Dr · (207) 767-7670 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.0%24.4%15.4%worse
Long-stay residents who lose too much weight3.0%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.1%0.9%better
Long-stay residents with a urinary tract infection3.4%2.2%2.0%worse
Long-stay residents with depressive symptoms7.9%11.6%6.5%worse
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 injury3.4%4.1%3.3%typical
Long-stay residents whose ability to walk worsened13.0%25.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.4%17.4%18.9%better
Long-stay residents given the seasonal flu vaccine98.3%95.5%95.3%typical
Long-stay residents with pressure ulcers1.2%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control31.9%29.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.8%20.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine70.0%74.5%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.661.451.67typical
Long-stay outpatient ER visits per 1,000 resident days1.532.011.80better

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

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

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

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

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

0.17U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

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

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

Staffing

0.57
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.57
Aide hours/ resident / day
4.06
Total nurse hours/ resident / day
0.24
RN hoursweekends
41.7%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 73 beds and averages 66.3 residents a day — about 91% occupied, or roughly 7 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 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.81 hrs/resident/day on weekends vs 4.16 on weekdays — 8% thinner on weekends. RN hours go from 0.71 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as 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

12
deficiencies at the latest standard inspection (2025-09-17)
9
at the previous standard inspection (2022-12-08)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Potential for harm · E2025-09-17 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 meals (Bayview and 200 unit) and failed to maintain a homelike environment for 2 of 2 meals observed on 2 of 3 survey days.Findings:1. During a meal observation on the 200 unit on 9/15/25 between 12:24 and 12:43 p.m. the following was observed:Table 1 contained 2 residents. One resident received their meal tray at 12:24 p.m., the staff served multiple other tables before returning to table 1 to give the second resident their meal at 12:34 p.m.Table 2 contained 2 residents. One resident received their meal tray at 12:26 p.m. The staff served multiple other tables before serving the second resident their meal at 12:29 p.m.Table three contained three residents. One resident was served at 12:27 p.m., the second resident was served at 12:39 p.m. At this time staff sat down with the second resident and provided feeding assistance although there were still residents that had not been served yet. The third resident was served at 12:43 p.m.2.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-17 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure a residents call bell was within reach for 4 of 25 sampled residents for 2 of 3 days of survey with multiple observations. (Resident #5, #54, #7, and #67).Findings: 1. On 9/16/25 at 9:10 a.m., a surveyor observed Resident #5 seated in his/her Broda chair in his/her room, with the call bell tucked underneath the pillow on his/her bed, out of reach. At this time, Resident #5 stated he/ she was trying to get into bed and that he/she usually has to holler to get help. At 9:11 a.m., a surveyor pressed the call bell, and Certified Nursing Assistant #2 entered the room and stated that Resident #5 usually likes to go back to bed after breakfast and that the call light should not be under his/her pillow and should be within reach. On 9/16/25 at 9:27 a.m., the above finding was discussed with the Director of Nursing. 2. On 9/15/25 at 9:49 a.m., observation of Resident #54's call bell was hanging over the recliner chair at the head of the bed. At the foot of the bed, Resident #54 was in the wheelchair with the tray table in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-17 · 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 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, for 8 of 25 residents reviewed for advanced directives (Residents #4, #8, #29, #57, #68, #52, #34, #50).Findings: 1. Resident #4 was admitted to the facility in June 2022. A review of the entire electronic 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. 2. Resident #8 was admitted to the facility in October 2023. A review of the entire electronic 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…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-17 · 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 maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 3 Units (100's and 200's).Findings: 1. During an initial observation of room [ROOM NUMBER] on 9/15/25 at 9:22 a.m., the footboard on B bed was observed to have missing/peeling areas of luminant, making it an uncleanable surface. On 9/16/25 at 12:51 p.m., during an observation of room [ROOM NUMBER] with Licensed Practical Nurse (LPN) #2 in the presence of Resident #57, LPN#2 observed the footboard and stated that she's never noticed it before, but it definitely needed to be fixed. At this time, Resident #57 stated I don't know how, since it's been like that for at least two years. On 9/16/25 at 2:31 p.m., during and interview, the above was confirmed with Administrator and Director of Nursing. 2. On 9/15/25 at 10:06 a.m., observation of 105 and 107's shared bathroom had 2 stained ceiling tiles near and around the light…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-17 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to hold an Interdisciplinary Team Meeting (IDT) within 7 days of a completed Minimum Data Set (MDS) for 6 of 6 Residents reviewed for Minimum Data Set (MDS) (Resident's #4, #8, #13, #57, #5 and #16).Findings: 1. Review of Resident #4's clinical record revealed the following: -Annual MDS with completion date 6/23/25. Further review of Resident #4's clinical record revealed the IDT meeting was held on 7/7/25 (14 days after completed MDS). -Quarterly MDS with completion date 3/24/25. Further review of Resident #4's clinical record revealed the IDT meeting was held on 4/14/25 (21 days after completed MDS). -Quarterly MDS with completion date 12/20/24. Further review of Resident #4's clinical record revealed the IDT meeting was held on 1/9/25 (20 days after completed MDS). 2.Review of Resident #8's clinical record revealed the following: -Quarterly MDS with completion date 7/31/25. Further review of Resident #8's clinical record revealed the IDT meeting was held on 8/14/25 (14 days after the completed MDS). -Quarterly MDS 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, interviews and the facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 3 residents reviewed for respiratory care (Resident's #31, #19 and #57).Findings: Review of facility policy Oxygen Therapy, revised 12/6/22 states, .Change mask and/or cannula weekly and as needed . 1. On 9/15/25 at 9:25 a.m., observation of Resident #31 utilizing an oxygen nasal cannula tubing with a date of 9/5/25. Review of the electronic medical record lacked evidence of an order and/or the nasal cannula being changed weekly. On 9/16/25 at 10:00 a.m., during an interview, the Director of Nursing (DON) confirmed the above and stated all oxygen tubing is changed weekly by nursing and there should be an order in the resident's chart. 2. On 9/15/25 at 8:50 a.m. a surveyor observed Resident #19 utilizing an oxygen nasal cannula tubing with a date of 8/25/25. Review of the Treatment Administration Record (TAR) revealed, Oxygen maintenance weekly…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-17 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to monitor and document targeted behaviors and side effects of psychotropic medication to support the use of psychotropic medications for 3 of 5 residents reviewed for unnecessary medications (Resident #4, #6, and #31).Findings: 1. Resident #4 was admitted with diagnoses to include anxiety and psychosis and has diagnoses to include dementia, anxiety and a psychotic disorder. Review of Resident #4's pertinent medication orders revealed he/she was taking antipsychotic medication Risperdal Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth two times a day, and antianxiety medication Lexapro Oral Tablet 10 MG (Escitalopram Oxalate) Give 10 mg by mouth in the morning. Further review of Resident #4's clinical record lacked evidence he/she was being monitored for side effects and behaviors for these medications. On 9/16/25 at 11:35 a.m. during a review of Resident #4's clinical record with Licensed Practical Nurse (LPN) #2, she confirmed Resident #4 is taking antipsychotic medication Risperdal and antianxiety 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-17 · 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

    Based on observations, record review and interviews, the facility failed to ensure expired medications were removed from the supply available for use and failed to ensure that medications were stored properly as per manufacturers' recommendations for 2 of 3 medication rooms reviewed for medication storage (100 unit and 300 unit).Findings:1. On 9/15/25 at 1:05 p.m., observation of the 100 unit medication room with the Licensed practical Nurse #1 the following was observed: 2 unopened bottles of liquid acetaminophen with expiration date of 8/2025 and an unopened bottle of Iron 325mg tablets with expiration date of 8/2025.2. On 9/15/25 at 1:38 p.m., observation of the 300 unit medication room with the Registered Nurse #1 the following was observed: an unopened bottle of Vitamin D 25 micrograms with expiration date of 8/2025. The refrigerator contained an opened vial of Tuberculin Purified Protein with manufactures directions to Store at 35 degrees to 46 degrees (F) Fahrenheit. Review of the refrigerator temperature logs from 8/25 through 9/15/25 revealed the lack of temperature…

    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 · D2025-09-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy, observation, interviews and record review the facility failed to ensure a smoking assessment of resident capabilities and deficits to determine resident safety was completed for 1 of 1 resident reviewed for smoking (Resident #48).Finding:Review of facility policy, Resident Smoking/Vaping Policy, revised 9/5/19 states, .designated as a non-smoking facility. Residents and/or staff are prohibited from smoking tobacco or any other substance in any enclosed area of the building. The residents.are prohibited from smoking/vaping both inside and outside the facility. Potential admissions. are informed prior to admission that is a non-smoking facility. On 9/15/25 at 8:34 a.m., during an interview, Licensed Practical Nurse (LPN) #2 stated that Resident #48 goes outside to smoke and that he/she has a cell phone and a call pendant and hands a corresponding pager off to the nurse because Resident #48 goes off facility property unsupervised to smoke.On 9/15/25 at 9:12 a.m. during an interview, Resident #48 stated he/she goes outside to smoke but is not permitted to smoke…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-17 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to identify a resident's past history of trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include trauma informed care for 1 of 1 residents reviewed for trauma. (#38) A review of the clinical record noted Resident #38 was admitted in May 2025. Medical diagnoses included vascular dementia. A brief trauma questionnaire, completed on 6/9/25, indicated Resident #38 had a history of significant trauma. The questionnaire stated family had identified showers provided by men were a trigger, and that showers should be provided by women only. The record lacked evidence that the results of the brief trauma questionnaire had been communicated to Resident #38's provider. The most recent MDS (Minimum Data Set) 3.0 Quarterly Assessment, dated 8/19/25, noted a BIMS (Brief Interview of Mental Status) score of 7, indicating severe cognitive impairment. The care plan, last revised 9/9/25, did not include the resident's history of trauma or interventions to prevent re-traumatization during…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2025-09-17 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 1 walk in refrigerators on 1 of 3 survey days.Findings:During an observation of the walk in refrigerator on 9/15/25 at 8:20a.m., with Certified Dietary Manager (CDM), a surveyor observed a double fan on the right side over the shelving units containing food to have obvious built up/debris. CDM states that she will clean it. During an interview on 9/16/2025 at 2:31p.m., the above was confirmed with Administrator and Director of Nursing.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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

    Based on record review and interviews, the facility failed to ensure records were complete and contained accurate information for 1 of 1 resident reviewed for pacemaker (Resident [R]13).FindingsResident [R]13 was admitted in 2022 and was admitted for end of life (Hospice) with diagnoses to include heart dysrhythmia with presence of a pacemaker.Review of R13's care plan updated 7/17/25 states [R13] has a pacemaker r/t Dysrhythmias .Observe for/document/report PRN any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P. Review of R13's active orders lacked evidence that orders were obtained for the pacemaker.During an interview on 9/16/25 at 11:36 a.m. Licensed Practical Nurse (LPN)2 provided document dated 4/29/22 which states Reason for exam Dx: Pacemaker .Implanted date 4/9/22 .Encounter Summary: Scheduled device follow up Plan for routine follow up Review of R13's clinical record with UM lacked evidence that this was done. UM confirmed there were no orders or…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Complaint Survey Process dated 7/30/24, was effective. The federal citation F880 was cited again during the re-visit to the Complaint Survey, dated 9/25/24. Finding: At the Complaint Survey Process, the following deficiency was cited, F880. During the follow up survey on 9/25/24, it was determined the F880 would be recited for the same issue: failure to maintain and implement an infection control program to help prevent the development and transmission of disease and infection. On 9/25/24 at approx. 1:30 p.m., during and interview, the above was confirmed with the Administrator and Director of Nursing.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, and interviews, a staff member (LPN#1) failed to follow the facility's Infection and Prevention Policy and Update of 7/18/24. to prevent the introduction and spread of Coronavirus Infectious Disease 2019 (COVID-19) in the facility. Findings: On 7/30/24 at 7:45a.m., a surveyor entered the facility and observed signs stating that there were 5 (five) cases of COVID-19 in the facility and they were located on Unit 300. For staff to enter that unit a N-95 mask is required, and for care of a resident that is COVID-19 positive, full Personal Protective Equipment (PPE) is required including N-95, eye protection, gown, and gloves. On 7/30/24 at 8:05a.m. a surveyor observed LPN#1 enter room [ROOM NUMBER] to give a resident medication, LPN#1 was wearing only an N-95 mask, no other PPE was donned as per the facility policy. There was a sign on the door warning of respiratory precautions and a 3-drawer cabinet just to the right of the door filled with PPE. When LPN#1 she exited…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-08 · 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 3 of 3 Units (100s Unit, 200s Unit and 300s Unit), the laundry room and the front lobby sitting area for 1 of 1 Environmental Tour. Findings: On 12/8/22 from 8:45 a.m. to 9:15 a.m., an Environmental Tour was conducted with the Environmental Services Director in which the following findings were observed: > The front lobby sitting area had nine tan cloth chairs that were soiled with dried liquid residue on the backs, arms and seats. 100 Unit: > The hallway floor-carpet hard numerous large brownish stains and was heavily soiled. > Resident room [ROOM NUMBER] - The wall behind the head of bed A was gouged/cracked creating an uncleanable surface. The privacy curtain had missing hooks and was hanging in disrepair. > Resident room [ROOM NUMBER] - Bed A privacy curtain had missing hooks and was hanging in disrepair. >…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-08 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview 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 after each assessment for 2 of 25 sampled residents (#7, #60). Findings: 1. During review of Resident 7's medical record, the surveyor noted a IDT Social Services Progress note dated 9/19/22 which stated, [Resident #7] was not invited r/t her dx. On 12/8/22 at 9:58 a.m., during an interview, the Licensed Social Worker (LSW) stated Resident #7 was not invited the IDT meeting due to the resident's cognitive status stating, I did not extend an invitation to him/her. The surveyor asked if all residents with cognitive deficits were not invited to their IDT meeting. she stated, it really depends, we look at the level of cognitive loss or understanding she then stated, she recently had a discussion with Resident #7 regarding his/her money and where Resident #7 wanted it to be distributed. At this time, the surveyor asked, why the resident can make decisions about…

    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 before2022-12-08 · 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 interview, the facility failed to maintain adequate pharmaceutical services to ensure that outdated medications, and medication no longer in use be removed from availability as discovered in 2 of 3 medication carts and 1 of 3 medication storage rooms. Findings: 1. On [DATE], at 7:30 a.m. a surveyor observed in medication cart B for Unit 200, 1 bottle of Vitamin C with an expired date of 11/22. At this time, this was confirmed with the Licensed Practical Nurse. 2. On [DATE], at 8:00 a.m. a surveyor observed in the medication cart on Unit 300, a box of liquid Morphine Sulfate with strips of paper tape across the open box with writing that said, Do not use. This bottle corresponds to page 37 in the narcotic book. The page in the indicates that there should be around 7.5 ml there and with observation it appears to be less than 5ml. The last date of use of the narcotic was [DATE] and should have been removed from the medication cart and taken to the Director of Nursing to be locked 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall mounted fans, a window fan, the hood system, ceiling lights, ceiling tiles and the dry storage room. Additionally, the facility also failed to ensure products in the walk-in refrigerator and walk-in freezer were labeled and dated. Further, the facility failed to label whipped topping with a thaw date. Findings: On 12/5/22 from 9:10 a.m. to 9:40 a.m., a kitchen tour was conducted with the Certified Dietary Manager in which the following findings were observed: > The wall mounted fan, by a food storage shelf, was dusty/dirty. > Two wall mounted fans, in the dish room, were dusty/dirty and were blowing on clean dishes. > The window fan, in the dish room, was dusty/dirty and was blowing on a clean dish area. > The hood system filter was heavily soiled with dust/dirt. > Two ceiling lights had dust/dirt and debris in and on the lenses. > One ceiling light, in the dish room, had dust/dirt and debris in and on the lens. Additionally, the lens was cracked. >…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interview, the facility failed to develop/implement a care plan in the area of respiratory and failed to implement the intervention for the care area of physical mobility for 2 of 25 sampled residents. (#7, #39) Findings: Facilities policy: Oxygen therapy, reviewed on 12/6/22 states, Oxygen administration requires a physician order. In an emergency, a nurse may administer O2 and obtain an order within 24 hours and Change mask and or cannula as needed if it becomes soiled. Update care plan in resident profile as needed. 1. On 12/5/22 at 10:01 a.m., observation of Resident #7 to have Oxygen (O2) on at 3.5 liters per minute via nasal cannula, the tubing did not have a date in place and the nasal cannula had darkened yellowish prongs. At this time in an interview with the resident, he/she stated the oxygen is used all the time and he/she is not sure if the tubing is changed frequently stating, I wondered about that, I thought they are supposed to. Review of the medical record revealed nursing documentation confirming Resident #7 had been using…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · 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 record review, observation and interview, the facility failed to follow their own policy on Oxygen (O2) therapy and failed to obtain physician orders for oxygen for 1 of 2 residents reviewed for respiratory care. (#7) Findings: Facilities policy: Oxygen therapy, reviewed on 12/6/22 states, Oxygen administration requires a physician order. In an emergency, a nurse may administer O2 and obtain an order within 24 hours and Change mask and or cannula as needed if it becomes soiled. Update care plan in resident profile as needed. On 12/5/22 at 10:01 a.m., observation of Resident #7 to have Oxygen (O2) on at 3.5 liters per minute via nasal cannula, the tubing did not have a date in place and the nasal cannula had darkened yellowish prongs. At this time in an interview with the resident, he/she stated the oxygen is used all the time and he/she is not sure if the tubing is changed frequently stating, I wondered about that, I though they are supposed to. A review of Resident #7's medical record lacked evidence of a physician order for oxygen therapy and orders for O2 tubing changes.…

    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 · D2022-12-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to maintain adequate pharmaceutical services to ensure the removal of controlled medication to avoid misuse and diversion in 1 of 3 medication carts observed. In addition, the facility failed to follow their policy for removal of controlled substances from use. Findings: The facility policy: Controlled Medications/Medication Management, on page 2, number 5 states that (Discontinued Schedule II drugs/controlled drugs awaiting disposal by the pharmacist must be removed from circulations and double locked. On 12/6/2022, observation of medication cart on Unit 300, revealed a box of Liquid Morphine Sulfate with tape across the top that said Do not use This bottle corresponds to page 37 in the narcotic book. The page indicates that there should be around 7.5 ml there is less than 5 ml. The Director of Nursing has made an entry in the narcotic log that there had been math errors and that this medication should be removed. The latest date marked in the narcotic book is 11/27/2022. This was confirmed with Registered…

    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 · D2022-12-08 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure that a patient lift, used for transferring residents, was maintained in good repair and safe operating condition for 1 of 4 days of survey (12/5/22) on I of 3 Units (200 Unit). Finding: On 12/05/22 at 10:16 a.m., a surveyor observed the 200 Unit Invacare/Jasmine patient lift was missing a safety latch on one of the sling hooks. In an interview at this time, the Administrator confirmed the patient lift was not in good repair and was not safe for use. The lift was taken out of service at this time.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-12-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility staff failed to develop a care plan to address behaviors and the use of an antipsychotic medication for 1 of 6 residents reviewed for unnecessary medications (Resident #10). Finding: On review of Resident #10's most recent signed medication orders, dated 12/3/19, the surveyor noted an order for an antipsychotic medication, Risperdal Tablet 0.5 MG (milligrams) - Give 0.5 mg by mouth in the afternoon for agitation/anxiety related to psychotic disorder with delusions due to known physiological condition, with an original date of 6/7/19. A review of Resident #10's quarterly Minimum Data Sets 3.0 (MDS), dated [DATE] and 9/16/19, revealed the resident received antipsychotic medication for 7 days during each of the assessments' look back period. The surveyor reviewed Resident #10's care plan. The care plan did not address any behaviors nor the use an antipsychotic medication. On 12/05/19 at 9:19 a.m., in an interview with the Director of Nursing, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-12-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews the facility failed to ensure as needed (PRN) psychotropic medications met the required 14-day limit for 2 of 6 residents reviewed for unnecessary medications (Resident #2 and #14). Findings: 1. A review of Resident #2's Physician Orders, revealed Resident #14 with an order, signed 9/6/19, for Hydroxyzine (an antianxiety medication) 25 milligrams (mg), give by mouth (PO) every 6 hours as needed (PRN) for anxiety with no stop date. The medical record lacked evidence of clinical rational to continue the (PRN) medication. A review of Resident #2's Physician Orders, revealed that Resident #2 with an order, signed 11/8/19, for Lorazepam intensol (an antianxiety, liquid medication) 2 mg/milliliters (ml) concentrate 3 mg/1.5 ml PO/sublingual (sl) every 4 hours as needed for agitation/anxiety with no stop date. The medical record lacked evidence of clinical rationale to continue the as needed (PRN) medication. On 12/04/19 at 11:32 a. m., in an interview with the Nurse Manager, the surveyor confirmed the above findings. 2. A review of Resident #14'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-12-08 · 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 — the official record, unedited, may be distressing

    Based on record reviews and interviews, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 1 of 3 residents sampled for hospitalizations. (Resident #27) Findings: Documentation in Resident #27's clinical record indicated that the resident was transferred to an acute care hospital on 9/16/22 and again on 10/7/22 and subsequently admitted . The clinical record lacked evidence that Resident #27 and/or the resident representative were provided with a written transfer/discharge notice upon transfer. On 2/7/22 at 12:40 p.m., in an interview, the Nurse Manager for the 200 Unit confirmed that written transfer/discharge notices were not provided to the residents and/or resident representatives in writing for either transfer.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
NACHFOLGER, ISRAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF99%since 07/01/2020
NACHFOLGER, MIRIAMIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; GENERAL PARTNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNFsince 07/01/2020
BERMAN, ARIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/23/2025
KETCHUM, JEFFREYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/23/2025
ANTHOINE ST REALTY LLCOrganizationADP OF THE SNFsince 07/01/2020

CMS files one row per role, so the 15 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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

What families pay in ME

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205121. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-17, 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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