No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Springbrook Center

300 Spring St, Westbrook, ME 04092 · For profit - Corporation · 123 certified beds · (207) 856-1230 Medicare & Medicaid certified

Call the home — (207) 856-1230 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Feb 20242 actual-harm citations$17,388 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • 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
  • the CMS record shows $17,388 in federal fines (most recent 2025-10-28)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • about 18% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 Harnois Ave · (207) 662-1360 · Call to confirm hours
Pharmacy
Omnicare0.6 mi
39 Eisenhower Dr · (207) 854-6400 · Call to confirm hours
Grocery
55 Bradley Dr · (603) 489-3321 · Call to confirm hours
Park
850 Main St · (207) 887-9122 · 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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.5%24.4%15.4%better
Long-stay residents who lose too much weight2.9%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.4%1.1%0.9%better
Long-stay residents with a urinary tract infection0.3%2.2%2.0%better
Long-stay residents with depressive symptoms20.7%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 injury2.0%4.1%3.3%better
Long-stay residents whose ability to walk worsened12.8%25.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.5%17.4%18.9%better
Long-stay residents given the seasonal flu vaccine98.9%95.5%95.3%typical
Long-stay residents with pressure ulcers4.7%4.3%4.7%typical
Long-stay residents with worsening bladder/bowel control27.0%29.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table35.6%20.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.6%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine73.9%74.5%79.4%typical
Short-stay residents rehospitalized after admission20.9%20.8%22.6%typical
Short-stay residents with an outpatient ER visit8.4%16.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.251.451.67better
Long-stay outpatient ER visits per 1,000 resident days0.822.011.80better

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.

53.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 216 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.7%U.S. median 51.5%
Got home and stayed home
7.5%U.S. median 10.7%
Went back to hospital
60.2%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 60.2% 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 118 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% 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 SNF53.7%CMS range 46.6–60.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF7.5%CMS range 5.5–10.210.7%Oct 2022–Sep 2024better than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 4.2–9.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.24
RN hours/ resident / day
0.28
LPN hours/ resident / day
2.27
Aide hours/ resident / day
3.79
Total nurse hours/ resident / day
0.85
RN hoursweekends
34.5%
Total nursing turnover
43.2%
RN turnover

How full it usually is: this home is certified for 123 beds and averages 115.2 residents a day — about 94% occupied, or roughly 8 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.24 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.49 hrs/resident/day on weekends vs 3.91 on weekdays — 11% thinner on weekends. RN hours go from 1.40 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below 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

11
deficiencies at the latest standard inspection (2024-07-19)
6
at the previous standard inspection (2023-04-27)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2025-10-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift. This resulted in a resident falling from the lift sling onto floor during the transfer from bed to wheelchair and sustaining fractured ribs, lacerated spleen, and a fractured left arm, for 1 of 3 residents reviewed for falls with major injury (#1).Findings:On 10/27/25, the Division of Licensing and Certification received a report from the facility stating on 10/25/25 a nurse was preparing medications in front of R1's room when he/she heard a loud sound and upon turning around, R1 was found lying face down on the floor. Staff reported that the resident fell from the total lift during transfer from bed to wheelchair. When the resident was turned onto his/her back, it was observed that one of the sling loops had come off the lift hook, resulting in the fall. The nurse's assessment revealed a contusion of the left forehead and bleeding from the nose. R1 complained of pain and limited range 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-05-12 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 the complaint intake form, clinical record reviews, interviews, and facility policy, the facility failed to identify the appropriate resident when passing medications resulting the CNA-M admisistering medications to the incorrect resident that resulted in a resident being transported to an Acute Care Emergency Department and later admitted to the hospital critical care unit for monitoring and treatment of low blood pressure. (Resident #1) Findings: The Division of Licensing and Certification received an Adult Protective Services (APS) complaint that indicated on 5/8/25, at 9:20 a.m., Resident #1 received another resident's medications which resulted in a hypotensive episode. Resident #1 was transported to the emergency room and subsequently admitted to the critical care unit (CCU). A review of nursing documentation dated 5/8/25 at 9:33 a.m., stated, [Med tech] approached me [Nurse] and stated that she gave the meds of [room [ROOM NUMBER]B to room [ROOM NUMBER]A]. On assessment, patient appears to be…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-28 · 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 observations, record review, and interviews the facility failed to implement the care plan interventions for 1 of 7 residents reviewed for transfers using a mechanical lift. (Resident #7) Findings: Resident #7's Minimum Data Set 3.0, quarterly assessment dated [DATE], section GG functional abilities and goals revealed he/she was dependent on staff and required full assistance with transfers. The most recent Lift Transfer evaluation completed on 11/4/25 indicated the residents weight was 195 pounds and required a purple (medium) sling for use with the electric mechanical lift. The care plan and the corresponding Kardex (used by the Certified Nursing Assistant) revised on 11/7/25 include the nursing interventions of Provide resident/patient with dependent assist of 2 for transfers using a mechanical lift with medium (purple) full body sling based on manufacturers guide and nursing assessment. On 11/20/25 at 8:50 a.m., observation of Resident #7 in his/her wheelchair with a green (large) sling underneath…

    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 before2025-10-28 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to revise a care plan to reflect the correct size sling used for transfers with a mechanical lift for 1 of 3 residents reviewed for falls with major injury (#1).Findings:On 10/28/25, R1's clinical record was reviewed. The record indicated R1 was admitted to the facility in November, 2020. Diagnoses included: dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, limited mobility, and other morbidities. The Minimum Data Set (MDS) 3.0, Quarterly Assessment, dated 10/17/25, Section GG. Functional Abilities and Goals, revealed R1 was dependent on staff and required full assistance with bed mobility, transfers, and toileting.The care plan and corresponding Kardex (used by Certified Nursing Assistants), revised on 8/5/25, included the intervention to provide R1 with assist of 2 (staff), using a mechanical lift and a green full body sling for all transfers. Review of the Lift-Transfer Evaluation for R1, dated 9/18/25, indicated R1's weight was 239.2 pounds, and the height was 60 inches. The assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure that sterile technique was maintained during a pressure ulcer dressing change for 1 of 1 residents observed. (Resident #1) On 7/31/25 at 10:57 a.m., LPN #1 was observed performing a dressing change on Resident #1's stage 4 sacrococcygeal pressure ulcer with tunneling. After cleansing the wound, LPN #1 retrieved a piece of silver alginate dressing that had been resting on the outer wrapper of the product packaging, a surface that is not sterile, and inserted it into the tunneling wound using a sterile cotton-tipped applicator. At that time, the surveyor intervened and asked whether the outer surface of the packaging was sterile. LPN #1 acknowledged that it was not and agreed that this action could have contaminated the dressing. Physician's orders dated 7/22/25 directed daily cleansing Vashe solution, drying, and application of silver alginate to the wound bed.The facilities policy titled Wound Dressings - Aseptic Technique includes the following directive: Step 17: Open dressing(s) without contaminating. Keep the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 4 of 7 units (Wayside, Mayflower, Saccarappa and King), the clean utility room, the 3rd floor common area for 1 of 1 Environmental tours. Findings: 1. On 7/19/24 from 10:15 a.m. to 10:45 a.m., a surveyor conducted an environmental tour with the Administrator in which the following findings were observed and confirmed: Wayside Unit: -Resident room [ROOM NUMBER] - the bathroom walls were observed to be gouged, and/or water damaged with sheetrock exposed around the toilet. -Resident room [ROOM NUMBER]- The bathroom wall had water damage. The floor had dirt/debris around the base of the toilet. Saccarappa Unit: -Resident room [ROOM NUMBER] - the entrance door had a missing piece from the door. -Resident room [ROOM NUMBER] - the area under the window sill was open to the outside. Mayflower Unit: -Resident room [ROOM NUMBER]-…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-19 · tag F0656 — failed to write and follow a full care plan — pattern
    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, interviews and record reviews, the facility failed to develop care plans in the area of oxygen therapy for 4 of 5 residents reviewed for respiratory care (#17, #56, #72 and #310). In addition, the facility failed to implement a care plan in the area of Activities of Daily Living (ADL), nutrition and incontinence for 1 of 2 residents reviewed for ADL's (#53). Findings: 1. On 7/15/24 at 9:30 a.m., a surveyor observed oxygen equipment at Resident #17's bedside. A Review of Resident #17's Electronic Medical Record (EMR) found orders dated 4/8/24 for Oxygen therapy and Continuous positive airway pressure (CPAP) therapy. A review of Resident #17's care plan failed to include a focus, goal or intervention in the area of oxygen or CPAP therapy. 2. On 7/15/24 at 9:35 a.m,. a surveyor reviewed Resident #56's EMR showed orders dated 7/17/24 for oxygen therapy. A review of Resident #56's care plan did not include a focus, goal or intervention in the area of oxygen therapy. 3. On 7/15/24 at 9:45 a.m., a surveyor observed Resident #72 with a nasal cannula for oxygen…

    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 before2024-07-19 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, observations and interviews the facility failed to provide Activities of Daily Living (ADL) care in the area of showers/bathing for 1 of 33 residents reviewed (#18), and in the area of nutrition for 1 of 2 sampled residents during 2 of 5 days of survey. (#53). Findings: 1. On 7/15/24 at 11:44 a.m., in an interview with a surveyor, Resident #18 stated a couple weeks ago (she) did not get her weekly shower, due on Sundays, for 2 weeks until her family said something to staff. A review of the clinical record for Resident #18 revealed diagnoses that included multiple sclerosis and an above the knee amputation of the left leg. The quarterly Minimum Data Set 3.0 (MDS) assessment, completed on 7/6/24, indicated Resident #18 required partial to moderate assistance for showering/bathing. The current care plan stated Resident #18 required extensive 1-person assistance for bathing, and a total mechanical lift, with 2-person assistance to transfer to a shower. A review of Certified Nursing Assistant (CNA) documentation noted Resident #18 received one shower in the month…

    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 · E2024-07-19 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy, record reviews, observations and interviews, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection related to Multidrug-Resistant Organisms (MDRO's) colonized in sputum and wound care for a 2 of 2 sampled residents (Resident #48 and #79) for 1 of 1 day of survey (9/23/24). This has the potential to affect all 21 residents on the Wayside Gardens unit. Findings: Facilities procedure for Enhanced Barrier Precautions, revised 5/1/24 states, all patients with any of the following: Infection or colonization with a targeted MDRO (Multidrug-resistant organisms) . and Chronic wounds and/or indwelling medical devices (e.g. central line, urinary catheter, enteral feeding tube, tracheostomy, or ventilator) regardless of MDRO colonization status. PPE (Personal protective Equipment) used for these situations during high contact patient cared activities: device care or use .tracheostomy, wound care; any skin opening requiring a dressing, and PPE required, Gown, gloves prior to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-19 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 19 residents reviewed. (Resident #419) Finding: On 9/23/2024 at 10:15 a.m., upon entrance to Saccarappa house, a surveyor observed the shower room door wide open, exposing a naked resident, sitting on a shower chair actively showering him/herself. A Certified Nurses Aid and a Registered Nurse were observed on the other side of the unit. Approx 1 min later, the Occupational Therapist (OT) came from the far end of the unit with a face cloth and a bottle. The Surveyor asked why the door was left open, the OT stated, I didn't mean to and entered the shower room and closed the door. At 10:29 a.m., both the resident and the OT exited the shower room. At this time, the above was confirmed with the OT. On 9/23/24 at approx. 10:45 a.m., the above was discussed with the Administrator

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, clinical record review, observations and interviews, the facility failed to notify the provider and obtained orders for 1 of 6 residents reviewed for respiratory care (#33) and 1 of 6 residents reviewed for pressure ulcers (#48). In addition, the facility failed to assess a resident after an unwitnessed fall and complete neurological assessments as per facility policy for 1 of 3 residents reviewed for falls (#407). 1. On 7/15/24 at 11:05 a.m., a surveyor observed Resident #33 asleep in his/her bed on the Wayside Unit. The surveyor observed oxygen delivered at 3.5 liters/minute via nasal cannula with 2 oxygen tubes connected to the wall unit and only 1 tube connected to Resident #33. At 11:14 a.m., the surveyor discussed with the charge nurse that the oxygen was running but one tube was not connected to the resident. The charge nurse stated the extra tube was to be used with the nebulizer and then proceeded to turn that oxygen tube off. Resident #33 awoke and asked what the oxygen was set at. The charge nurse stated 3.5 liters. Resident #33 asked for the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure that staff maintained the appropriate competency and skill required to provide tracheostomy care for 1 of 2 residents with tracheostomies on the Wayside Unit (#48). Finding: On 7/15/24 at 10:47 a.m., a surveyor observed a personal protective equipment station and signage advising Enhanced Barrier Precautions were required at the entrance of Resident #48's room The surveyor observed Resident #48 lying in bed, receiving oxygen via a tracheostomy. A review of Resident #48's clinical record revealed diagnoses including anoxic brain injury, seizure disorder, chronic respiratory failure with hypoxia, and developmental delay. The record revealed a history of drug resistant organisms in Resident #48's sputum: Methicillin Resistant Staphylococcus Aureus (MRSA) and Pseudomonas Aeruginosa. The quarterly Minimum Data Assessment (MDS) 3.0, completed 6/11/24, indicated Resident #48 is dependent upon staff for all ADLs and is nonverbal, requires suctioning, has a tracheostomy and receives oxygen. The current care…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-07-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, and interviews the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart on 1 of 7 resident units in the facility. In addition, the facility failed by leaving a resident's medications unattended at a bedside, allowing residents and unauthorized persons access to medications. (#33) (Saccarappa House Unit, Wayside Unit). Findings: 1. On 7/15/24 at 9:42 a.m., two surveyors observed the unlocked and unattended medication cart in the hallway on Saccarappa House Unit. At 9:46 a.m., the Certified Medication Technician returned to the unlocked medication cart and began to prepare a resident's medication. On 7/17/24 at 11:27 a.m., the above finding was discussed with the Administrator and the Market Clinical Advisor. 2. On 7/15/24 at 11:05 a.m., a surveyor observed Resident #33 asleep in bed. A cup of pills was observed on the overbed table next to Resident #33. At 11:14 a.m., the Wayside Unit charge nurse confirmed he/she had left the pills next to Resident #33, who must have forgotten to take them. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to follow through with a physician's order for a dental referral for 1 of 43 sampled residents (#29). Finding: Resident #29's clinical record contained a physician's order dated 3/18/23 instructing staff to refer the resident to a dentist for gingivitis and a cleaning. Resident #29's clinical record lacked evidence of any follow up with the dental referral. In an interview with the surveyor on 7/17/24 at 11:06 a.m. the Marketing Clinical Advisor confirmed that Resident #29's dental referral had not been scheduled.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-19 · 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 — the official record, unedited, may be distressing

    Based on observations, record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for Activities of Daily Living (ADL) (#53). Finding: On 7/15/24 lunch meal and on 7/16/24 breakfast meal, Resident #53 was observed sleeping through both of the meals with no cueing provided by staff and did not consume any of the food or fluids provided. Review of the certified nursing aid documentation for 7/15/24 lunch and 7/16/24 breakfast states the amount eaten my mouth was 50%. The documentation for eating: self-performance for 7/15/24 lunch states resident was supervision with encouragement or cueing, and the lunch on 7/16/24 the documentation states resident was independent with no help or staff oversight at any time. On 7/17/24 at 8:11 a.m., during an interview with the Administrator, the above concerns were discussed.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-19 · 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 Annual Long Term Care Survey Process for Federal Recertification dated 7/19/24, was followed and effective. The Federal citation F656 was cited again during the re-visit to the annual Long Term Care Recertification Survey. Finding: At Annual Long Term Care Survey Process for Federal Recertification, the following deficiency was cited, F656. During the follow up survey on 9/23/24, it was determined the F656 would be recited for the same issue: failure to implement a comprehensive person-centered care plan for each resident. On 9/23/24 at 4:15 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 · Dcited before2024-04-25 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 11 residents reviewed. (Resident #5) Findings: On 4/25/2024 at 8:20 a.m., Resident #5 was observed in the common area of Wayside Gardens Unit in his/her wheelchair sitting at the dining table naked from the waist down. Two CNAs were observed also in the dining area serving other residents and did nothing to preserve the resident's dignity. (CNA1 and CNA2) The LPN (LPN1) who was passing meds nearby was called to assist in removing resident to his/her room. At 8:30 a.m. the Director of Nursing came to the unit and the above findings were confirmed with him at that time.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide an environment free of accident hazards and supervision for 2 out 3 floors observed for accident hazards. Findings: 1. On 2/28/24 at 9:20 a.m., a surveyor and an Administrator in Training(AIT) observed a resident on [NAME] Unit in room [ROOM NUMBER] who exited their bathroom with a walker and had difficulty maneuvering around a commode being stored along the wall that was blocking the pathway back into his/her room. The resident was not assisted at any point by staff during our observation. 2. 0n 2/28/24 at 9:25 a.m., a surveyor and an AIT observed an empty wheelchair against the wall in [NAME] Unit room [ROOM NUMBER]. The footrests were raised and sticking out creating a potential tripping hazard in the direct pathway into the room for anyone entering or leaving the room. 3. On 2/28/24 at 11:10 a.m., a surveyor observed on the second floor, 5 walkers blocking access to the handrail in front of the physical therapy room. When I…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to follow the facility policy and failed to document adequate interventions taken to protect resident (Resident #7) from abuse following a resident-to-resident altercation for 1 of 2 residents reviewed for abuse allegations. Findings: On 2/13/24 at 12:40 p.m., Department of Licensing and Certification received a facility reported incident of abuse between two residents that took place at 2/12/24 at approximately 9:00 p.m. Resident #5 was found with his/her hands around Resident #7's neck and Resident #7 was screaming. They were immediately separated. A scratch was discovered on Resident #7's neck. On 2/28/24 at 12:12 p.m., during an interview with the Unit Director, discussed the documentation in the medical records for Resident #5 and Resident #7 does not show that the residents involved in the altercation had adequate supervision following the altercation, per facility policy. A room change did not occur until 4 days following the incident. No documentation of additional safety checks before this room change occurred were…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that the clinical records were complete and contained accurate documentation for 1 of 1 sampled residents ( #1). Findings: On 1/18/2024, during review of Resident #1 clinical record, it was discovered in the providers documentation of their visit on 12/11/2023, that the resident left the facility post 911 call made by the residents case manager because she was not getting the medical care she needed. The medical record lacked documentation of the resident's condition other than the provider's note. In addition, the medical record lacked documentation that the resident left the faciity on [DATE], and that the resident returned to the facility on [DATE]. On 1/18/2024 at 12:15 p.m,. in an interview with the Director of Nursing, he stated that any resident who needed to be taken from the facility as a result of a 911 call, no matter who made it, needed documentation in the clinical record as to their condition. He agreed that Resident #1's record…

    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 before2023-12-06 · 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

    Based on observations and interviews, the facility failed to adequately provide housekeeping, laundry, and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 4 units observed (Wayside Gardens, Saccarappa House). Findings: 1. On 12/6/23 at 10:15 a.m., two surveyors observed a rolling rack with residents' personal laundry hanging uncovered in the common area of the Wayside Gardens unit. On 12/6/23 at 11:15 a.m., a surveyor discussed the finding with the Housekeeping Manager, who stated he/she was not in charge of residents' personal laundry but would let staff know. The Housekeeping Manager stated the laundry is transported to Massachusetts, where it is laundered by a contracted company and transported back to the facility. The resident's personal laundry is then delivered to residents by activities or central supply staff. 2. On 12/6/23 at 11:35 a.m., two surveyors observed the shower room on the Saccarappa House unit. The edges and corners in the shower were noted to have a build-up of black, mildew-like material. The shower…

    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 before2023-12-06 · 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 revise a care plan to reflect the current needs for 2 of 3 residents reviewed for falls with injuries (#2, #3). Findings: 1. A review of Resident #2's clinical record revealed that he/she sustained unwitnessed falls on 10/8/23 and 10/26/23, resulting in rib fractures. Resident #2's physician orders were noted to contain an order, dated 10/5/23, which stated nonskid footwear for safety. The Minimum Data Set (MDS) 3.0, admission Assessment, completed 10/11/23, noted under section J1900, Resident #2 experienced 1 fall with injury and 1 fall with no injury since admission. The care plan, with the most recent revision on 11/2/23, did not include the use of nonskid footwear, as ordered by the physician. 2. A review of Resident #3's clinical record revealed that he/she sustained an unwitnessed fall on 11/4/23, resulting in a fracture of the left distal fibula. A provider note, dated 11/16/23, stated Seen by Ortho, significant swelling, stable fracture, recommend follow-up in additional 4 weeks. Continue nonweightbearing. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-28 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 7 of 7 Units. (Wayside Unit, Saccarappa Unit, [NAME] Hill Unit, [NAME] Unit, Valley Square Unit, Mayflower Unit & King Unit). Findings: On 11/28/23, between 9:45 a.m. and 11:30 a.m., the surveyor did an environmental tour with the Administrator and the following was observed with the Administrator and the Director of Nursing (DNS): - The Physical Therapy room had excessive dirt and debris on the floor. The kitchenette cabinet below the sink was cluttered with several empty soda cans overflowing in a bag. Wayside Unit: -The kitchenette had excessive dirt and debris on the floor and inside the upper and lower cabinets and 2 dead roaches and 1 dead roach in an [NAME] trap under the sink. A live roach along with dirt and debris was found under the refrigerator. -The unit floor had excessive dirt buildup on the floors…

    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 · D2023-04-27 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy, and interviews the facility failed to ensure a resident was adequately prepared and safely discharged for 1 of 1 resident reviewed for discharge (Resident #2). Findings: On [DATE] the Department of Licensing & Certification received an Adult Protective report indicating that Resident #2 was prematurely discharged on [DATE] and that a neighbor had to use his/her key to get into the apartment because Resident #2 was not able to get up independently and was found to be sitting in his/her own feces. As Resident #2 is unable to transfer or care for him/herself and an ambulance was called, and Resident #2 was readmitted into the hospital. Report further indicated that there was paperwork sent home with resident indicating Resident #2's inpatient coverage expired on [DATE] and had appeal information, but Resident #2 does not have the mental capacity to address this. Review of facility Discharge Policy dated [DATE] states Identify discharge needs and develop a discharge plan to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 2 of 5 residents reviewed for new admissions (Resdients #2 and #30). Findings: 1. Resident #2 was admitted to facility for skilled therapy on 3/16/23 with diagnoses to include surgical incisions with staples on right inner thigh and medial right leg, two unstageable pressure areas on right foot and a wound from a recent amputation of right 5th great toe due to gangrene. Review of Resident #2's skin assessment dated [DATE] states A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: Incision(s): Description: right inner thigh, medial right leg surgical incision with staples, right 5th toe incision with sutures, Pressure Area(s): Location(s): right heel pressure ulcers unstageable. Review of Resident #2'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations and interview, the facility's nursing staff failed to provide care in accordance with professional standards of quality by not following guidelines for the safe administration set management for 1 of 2 observations of intravenous (IV) medication administration. Finding: A review of the facility's policy, Administration of an Intermittent Infusion, Guidance, steps in Procedure, page 3, steps 10-13 stated, Using aseptic technique, remove protective cover from administration set spike and insert spike into solution container access port, Hang medication/solution container on IV pole, squeeze drip chamber 1/3 full. Slowly open roller clamp and Prime medication/solution through entire administration set purging air. Close clamp. On 4/25/23 at 8:36 a.m., a surveyor observed a Licensed Practical Nurse (LPN #2) during orientation, prepare and administer intravenous medication with the presence of the Registered Nurse (RN #5). LPN #2 was observed inserting the administration spiked end into the solution access port. She then hanged the solution bag on the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide personal hygiene related to bathing for 1 of 3 residents reviewed for Activities of Daily Living (Resident #80). Findings: Resident #80 was admitted to facility on 3/28/23 with diagnoses to include congestive heart failure, chronic myeloproliferative disease (blood cancer caused by changes in the stem cells inside bone marrow), chronic obstructive pulmonary disease, dysphagia, chronic respiratory failure with hypoxia, urinary tract infection. and recent history of subdermal hematoma. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #80 had a Brief Interview for Mental Status (BIMS) of 7 of 15 indicting a severe cognition impairment. Extensive assist with Activities of Daily Living. Review of Resident #80s care plan initiated on 3/28/23 revealed, focus: at risk for decreased ability to perform ADLS in bathing, personal hygiene, .related to recent illness, hospitalization resulting in fatigue, activity…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews, the facility failed to ensure that physician's orders were obtained and/or followed for 2 of 47 sampled residents (Residdent #70 and #312). Findings: 1. On 4/24/23 at 10:20 a.m., 4/25/23 at 9:21 a.m., and 4/26/23 at 8:41 a.m., Resident #72 was observed to have a mepilex dressing to the right elbow, left bicep and left forearm all labeled with a date of 4/23. On 4/26/23 at 9:49 a.m., during an interview with the Licensed Practical Nurse (LPN #1), she stated Resident #72 obtained a scratch on his/her left forearm approx. 1 week ago and the right arm skin tear was obtained from a fall on Saturday 4/22/23. LPN #1 was unaware of the wound dressing on residents left bicep. LPN #1 stated Typically, with skin tears, change every 7 days with cleansing, xeroform then mepilex. Surveyor asked about a physician orders for the dressings in place, LPN #1 stated, They are probably not in there, I will look at the orders. Review of Resident #72's medical record lacked evidence of a physician order for mepilex dressings and/or monitoring of these…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms observed (Wayside House). Findings: On 4/25/23 at 8:15 a.m., observations of the Wayside House medication room with the Registered Nurse (RN #3) the surveyor noted 2 unopened bottles of Docu Liquid stool softener with expiration date of 02/2023 and 2 boxes of Acetaminophen suppositories 650 milligrams with expiration date of 12/2022. At this time, RN #3 confirmed the medications were expired and removed them for availability. On 4/25/23 at 10:26 a.m., a surveyor discussed the above findings with the Director of Nursing.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-24 · 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 sanitary conditions on 6 of 7 units (Wayside, [NAME], Saccarappa, [NAME] Square, Mayflower, and King), the supply room, the kitchen hallway, and the Laundry Room for 2 of 2 Environmental tours. Findings: 1. On 6/23/2021 from 9:10 a.m. to 9:15 a.m., a surveyor and the District Manager for Healthcare Services conducted a tour of the laundry room, in which the following findings were observed: Laundry Room: -The cement floor between and behind the washing machines was exposed and untreated creating an uncleanable surface. -The chemical buckets, the wooden platforms under the buckets, and the drain piping behind the washing machines were built up with lint and dust. -The floor, in front of the clothes dryers, had a large area of chipped/missing floor surface, exposing untreated cement creating an uncleanable surface. -The wall mounted air…

    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

“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

$17,388 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $9,110 — penalty dated 2025-10-28
  • $8,278 — penalty dated 2025-05-12
  • Medicare payment denial — starting 2025-11-20 for 19 days

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

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 1 of 52.3-1.3 vs chain
Staffing 4 of 52.5+1.5 vs chain
Quality measures 5 of 53.5+1.5 vs chain
The other 183 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Alexandria Care CenterLos Angeles, CA 1 of 5Bay Crest Care CenterTorrance, CA 1 of 5Bethlehem North Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bethlehem South Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bridgeville Rehabilitation & Care CenterBridgeville, PA 1 of 5Brightwood CenterFollansbee, WV 1 of 5Carlisle Skilled Nursing And Rehabilitation CenterCarlisle, PA 1 of 5Casa De Oro CenterLas Cruces, NM 1 of 5Devonshire Care CenterHemet, CA 1 of 5Gettysburg CenterGettysburg, PA 1 of 5Glenwood CenterFlorence, AL 1 of 5Heritage CenterHuntington, WV 1 of 5Hidden Valley CenterOak Hill, WV 1 of 5Inners Creek Skilled Nursing And Rehabilitation CeDallastown, PA 1 of 5Jersey Shore Skilled Nursing And Rehabilitation CeJersey Shore, PA 1 of 5Kingston Court Skilled Nursing And RehabilitationYork, PA 1 of 5Las Palomas CenterAlbuquerque, NM 1 of 5Lebanon Center, Genesis HealthCareLebanon, NH 1 of 5Lebanon Skilled Nursing And Rehabilitation CenterLebanon, PA 1 of 5Linden Grove Health Care CenterPuyallup, WA 1 of 5Magnolia RidgeGardendale, AL 1 of 5Marmet CenterMarmet, WV 1 of 5Meridian CenterHigh Point, NC 1 of 5Merry Wood LodgeElmore, AL 1 of 5Mount Olive CenterMount Olive, NC 1 of 5Mountain Ridge Center, Genesis HealthCareFranklin, NH 1 of 5Oak Grove CenterWaterville, ME 1 of 5Oceanside Skilled Nursing And RehabilitationHampton, NH 1 of 5Orchard Park Health Care & Rehab CenterTacoma, WA 1 of 5Parkersburg CenterParkersburg, WV 1 of 5Pembroke CenterPembroke, NC 1 of 5Pine LodgeBeckley, WV 1 of 5Playa Del Rey CenterPlaya del Rey, CA 1 of 5Pocahontas CenterMarlinton, WV 1 of 5Pottstown Skilled Nursing and Rehabilitation CentePottstown, PA 1 of 5Putnam CenterHurricane, WV 1 of 5Ridgewood CenterRidgewood, NJ 1 of 5Rio Rancho CenterRio Rancho, NM 1 of 5River City CenterDecatur, AL 1 of 5River Ridge CenterKennebunk, ME

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 / managerTypeRoleShareSince
GENESIS HEALTHCARE OF MAINE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/02/2012
FC-GEN OPERATIONS INVESTMENT LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GEN OPERATIONS I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GEN OPERATIONS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GHC HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 03/02/2015
SUN HEALTHCARE GROUP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
WHITMAN, ARNOLDIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
BERG, MICHAELIndividualCORPORATE OFFICERsince 03/02/2015
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 06/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 06/01/2024
MORRIS, DIANEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/23/2023
POLISNER, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/09/2022
SAUCIER, EMILYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 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.

$15.2M
Net patient revenuemost recent cost report
+5.0%
Operating marginrevenue minus expenses
$2.7M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 14%Other / private 23%

This home reported $2.7M 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

$374per resident / day
operating cost
$11,363per month
≈ monthly operating cost
$393per day
avg. revenue, all payers

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

What families pay in ME

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 205068. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-19, 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.

What to do next