Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
5E
0F
Potential for minimal harm
0A
1B
0C
November 18, 2025Standard inspection · 6 citations
- E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's physician and representative were notified immediately of a significant change in the resident's medical condition and failed to follow its own policy and procedure for Notification of Change in Resident Condition or Treatment plan for 2 of 5 residents reviewed for significant changes. (Resident's #47 and #110). The facilities Notification of Change in Resident Condition or Treatment Plan policy dated 8/20/24 states under Family Notification. The resident's representative will be notified if the resident chooses and/or: there is a change in the resident's physical, mental or psychosocial status. The resident is involved in an accident or occurrence. Except in medical emergencies, representative notifications will be made within 24 hours. [...]
- E
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.
Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 4 wings (Freedom Bay (FB) and Eagle's Landing (EL) and a common area for 3 of 3 facility tours.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and review of the facility's Food Storage and Protection policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall fan, a food disposal unit, and the floor; and failed to ensure foods were labeled in the walk-in refrigerators, the walk-in freezer and the dry storage area for 2 of 2 observations on 1 of 4 days of survey (9/29/25). In addition, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 1 of 1 kitchen tours (9/29/25).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on medical record review and interview the facility failed to ensure that a resident's drug regimen was free from unnecessary medication by prescribing an antipsychotic medication (a drugs that treats symptoms that happen with schizophrenia and other conditions that involve psychosis) without adequate indications for 1 of 5 reviewed for unnecessary medications (#107).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of hearing aids for 1 of 1 sampled resident reviewed for communication difficulty and/or sensory problems. (Resident #3) (R3)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, the facility failed to assess and monitor a resident after unwitnessed falls and failed to follow their own Neurological Assessments policy and procedure by obtaining neurological assessments after the unwitnessed falls for 1 of 5 residents reviewed for falls. (Resident #47). FindingsThe facilities Neurological Assessments policy dated 5/8/24 states, A neurological assessment will be completed and documented in ECS after any incident or fall in which a head injury is suspected. In the case of an unwitnessed fall, the resident will be considered to have hit their head unless he/she can reliably state he/she did not. Assessments will be completed every 15 minutes for the first hour after the fall; every 30 minutes for the subsequent 4 hours; every shift for the next 72 hours. [...]
October 23, 2024Standard inspection · 4 citations
- E
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.
Inspectors wroteBased on facility policy review, record reviews, and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 9 of 13 residents reviewed for advanced directives. (Resident [R] , R70, R78, , R12, R5, R42, R101, R61, R80 and R94).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to follow professional standards of practice with usage of Personal Protective Equipment (PPE) and to provide a sanitary environment to help prevent the development and transmission of disease and infection related to hand hygiene during a medication pass on 1 of 3 days of survey. In addition, the facility failed to post enhanced barrier precautions (EBP's) pertaining to Resident's with urinary Foley catheters, and multi drug resistant organisms [MDRO] for 3 of 3 days of survey (10/21/24, 10/22/24 and 10/23/24) (Resident #34 [R34]).
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which included appeal rights and liability of payment, were provided at least 2 days prior to the resident's last covered day, for 1 of 3 residents whose Medicare Part A services were discontinued, and remained in the facility (Resident [R]56).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to update goals and interventions on the resident's current comprehensive care plan for the areas of mood/behavior for 1 of 1 residents reviewed for behaviors (Resident #9[R9]).
January 26, 2023Standard inspection · 2 citations
- D
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.
Inspectors wroteBased on record reviews, facility policy review, and interview, the facility failed to ensure a resident's preferred code status was accurate in the clinical record for 1 of 3 newly admitted residents admitted in December 2022 reviewed (Resident #64).
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately in the area of Active Diagnosis for 2 of 2 sampled residents with the diagnosis of Post Traumatic Stress Disorder (PTSD)(Resident #57 and #71).
Fire safety inspections
15 fire safety citations on file: 6 on November 18, 2025, 4 on October 23, 2024, 5 on January 26, 2023.
Every fire safety citation15 citations
- F
Address subsistence needs for staff and patients.
E 15 · November 18, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 18, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · November 18, 2025 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 18, 2025 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · October 23, 2024 · Corrected (the home has a date of correction)
- E
Use approved construction type or materials.
K 161 · October 23, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 23, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 23, 2024 · Corrected (the home has a date of correction)
- F
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · January 26, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 26, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · January 26, 2023 · Corrected (the home has a date of correction)