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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
24E
1F
Potential for minimal harm
0A
4B
0C
November 25, 2025Complaint inspection · 2 citations
- 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 ensure that residents receive treatment and care in accordance with professional standards of practice by failing to follow a physician's orders for daily weights for 1 of 3 residents reviewed during a complaint investigation (Resident #1).
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to maintain adequate pharmaceutical services to ensure the receipt and administration of physician ordered medication was available to meet the needs of 1 of 3 residents requiring anti-seizure medication reviewed during a complaint investigation (Resident #1).
September 18, 2025Standard inspection, Complaint inspection · 7 citations
- 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 6 of 6 Units (Mt. [NAME], Mt. Blue, Sugarloaf, Porter, Rangeley and [NAME]), the laundry room and a common area for 3 of 4 days of survey.(9/15/25, 9/16/25 and 9/18/25).
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that care plans were updated to reflect the residents current needs for 2 of 39 resident care plans reviewed (Resident #44 [R44] and R11).
- 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 Warewashing policy/procedure and the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food disposal, a mouse trap, the floor, the stove hood, house flies, ceiling air vents, ceiling tiles and the ceiling metal grid; failed to ensure foods were dated, labeled and/or secured in a walk-in refrigerators and a walk-in freezer; and failed to ensure that the dish machine was monitored for proper wash and rinse temperatures to ensure clean and sanitized utensils and dishes, for 2 of 4 days of survey (9/15/25 and 9/17/25). In addition, the facility failed to ensure that expired food was removed and food dishes were covered in unit refrigerators, for 1 of 4 days of survey (9/15/25).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 1 of 4 days of survey (9/15/25).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record reviews, and interview, the facility failed to follow a physician order for the use of continuous oxygen for 1 of 2 residents (Resident #30 [R30]) reviewed for oxygen use.
- B
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on performance evaluation reviews and interview, the facility failed to complete 2 annual performance evaluations that were due to be completed at least every 12 months, for 1 of 3 sampled employees employed greater than 1 year (Certified Nursing Assistant #1 [CNA1]).
- B
Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews, the facility failed to post the nurse staffing information in an area visible to residents for 3 of 4 days of survey (9/15, 9/16, and 9/17/25).
July 30, 2025Complaint inspection · 1 citation
- J
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on the facility reported incident, record reviews and interviews, the facility failed to provide the appropriate textured meal to Resident #1 who was identified with swallowing issues and required a dysphagia advanced texture for all meals. This failure to provide the correct texture at the supper meal on 7/24/25 resulted in the resident choking, needing transfer to the hospital and subsequently passing away for 1 of 12 residents reviewed that were requiring dysphagia advanced texture meals. This failure determined an immediate jeopardy situation existed. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements. [...]
August 8, 2024Standard inspection, Complaint inspection · 16 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs).
- 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 record review and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 7 of 15 residents reviewed for advanced directives (Resident's #7, #33, #51, 65, #16, #34, #69).
- 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 interior for the 6 of 6 units (Mt. [NAME], Mt. Blue, Sugarloaf, [NAME], Rangeley and Porter), the upper level common area, the lower level common area, a patio and the laundry for 1 of 1 facility tours (8/8/24).
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record reviews and interview, the facility failed to ensure that 3 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Residents #48, #66 and #68).
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote2. Resident #69 was admitted on [DATE] with a diagnosis of COPD and Congestive Heart Failure (CHF). A review of Resident #69's July 2024 Medication Administration Records (MAR) indicates that the resident received Oxygen at 2 liters per nasal cannula continuously from 5/1/24 - 7/29/24. A review of Resident #69's care plan did not include a focus, goals or interventions in the area of oxygen therapy. On 8/7/24 at 1:46 p.m., a surveyor confirmed the above finding during an interview with the Market Clinical Advisor. Based on record reviews and interviews the facility failed to update and/or implement goals and interventions for 2 of 23 care plans reviewed for respiratory care, and 1 of 1 careplans reviewed for Post-Traumatic Stress Disorder (PTSD). (Resident's #28, #69, #26).
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' care plans were reviewed and revised by the interdisciplinary team (IDT) within 7 days after each comprehensive assessment for 4 of 4 residents reviewed for IDT meetings (Resident's #7, #32, #33 and #65). In addition, the facility failed to ensure a a resident's care plan was revised to address nutrition and weight loss (#42).
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews and interviews, the facility failed provide respiratory care consistent with professional standards of practice by failing to ensure that respiratory equipment was replaced for 1 of 1 resident (Resident #28) and failed to change oxygen tubing for 1 of 2 residents reviewed (Resident #69).
- E
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.
Inspectors wroteBased on observations and interviews, the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications, on 1 of 4 days of survey. In addition, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication storage rooms and 1 of 3 medication carts reviewed.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observations and interviews, the facility failed to offer nourishing snacks to residents who want to eat at non-traditional times or outside of scheduled meal service times on 6 of 6 units (Mt. [NAME], Mt. Blue, Sugarloaf, [NAME], Rangeley and Porter), for 2 of 4 days of survey.
- 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, the facility's Refrigerated/Frozen Storage policy revision date 6/15/18, the facility's Environment: policy HCSG 028 revised 9/2017, the facility's Warewashing policy HCSG 022 revised 2/2023, the facility's Food Storage: Cold Storage revised 2/2023, the facility's Food Storage: Dry Goods revised 9/2017, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, ceiling tiles, ceiling lights, he hood system, the food slicer, the food mixer, and cement blocks. Additionally, the facility failed to ensure that foods in the dry storage room, the reach-in refrigerator and the walk-in refrigerator were labeled and/or dated. Further, the facility failed to ensure refrigerator temperatures were monitored for an area refrigerator.
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 2 trash collection container for 4 of 4 days of survey. (8/5/24, 8/6/24, 8/7/24 and 8/8/24)
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 residents reviewed for activities of daily living (#183), and 1 of 2 residents reviewed for oxygen use (#69).
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of the quarterly Quality Assurance Performance Improvement/Quality Assurance Assessment (QAPI/QAA) Committee meeting attendance sheets and interview, the facility failed to ensure that the Infection Preventionist attended 4 of 4 quarterly meetings.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a desk wall laminate covering for 1 of 3 days of survey. (8/5/24)
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and interviews, the facility failed to provide documentation of monitoring of psychotropic medication side effects for 1 of 5 residents reviewed for unnecessary drug use (#7).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate infection control procedures were followed related to hand sanitizing during the medication pass task for 1 of 2 medication passes observed.
April 29, 2024Complaint inspection · 2 citations
- 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 interview, the facility failed to adequately maintain housekeeping and maintenance services necessary to maintain in good repair and sanitary condition unit refrigerators, kitchenette cabinet doors, dining tables, microwave ovens on 7 of 7 kitchenettes. (Mount Blue, Sugarloaf, Mount [NAME], Rangely Lake, [NAME] & [NAME], First floor recreation)
- 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 and interviews, the facility failed to properly store, label and date food in the walk-in refrigerator and unit refrigerators for 6 units, first floor recreation area and kitchen 1 of 1 days of survey (4/29/24).
October 3, 2023Complaint inspection · 3 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 residents reviewed for pressure ulcer care (#1, #2).
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interviews and record review, the facility failed to provide a resident with care and services (incontinence care/mobility assistance) to promote physical, mental health, and well-being in a timely manner for 1 of 3 residents sampled (Resident #2).
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and interview, the facility failed to ensure that physician's orders were followed for 1 of 2 residents reviewed for pressure ulcer care ( Resident #1).
September 12, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and interviews, the facility failed to complete a medication reconciliation to ensure that correct physician orders were implemented for 1 of 2 sampled residents (Resident #1) admitted from an acute care hospital.
October 28, 2022Standard inspection · 13 citations
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on interviews and observations, the facility failed to ensure that call lights were within reach for residents that are capable of using a call bell for 2 of 5 days of survey (10/24/22, 10/25/22).
- E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on record review and interview, the facility was unable to provide evidence that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055, which included appeal rights and liability of payment was provided at least two days prior to the resident's last covered day for 2 of 3 residents whose Medicare Part A services were discontinued, and the resident remained in the facility (#41 and #230).
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record reviews and interviews, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 4 of 5 residents sampled for hospitalizations. (Residents #6, #25 #27, and #55)
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews, review of the electronic Medication Administration Record (MAR) and interviews, the facility failed to administer a physician ordered medication that was available for use for 2 days, for 2 of 31 residents reviewed. (Residents #27 and #173).
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an as needed anti-psychotropic medication met the requirements for continued use beyond 14 days, for 2 of 5 residents reviewed for unnecessary medication use (Resident #6 and #17).
- 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 and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the floor, the food disposal control box, ceiling vents, ceiling tiles, a wall mounted fan, a food slicer, ceiling lights, and window air conditioners. Additionally, the facility also failed to ensure dishes were not wet-stacked.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview, the facility failed to maintain the dignity of 1 of 6 residents (Resident#27) reviewed for dignity related to urinary collection bags during 1 of 5 days of survey (10/24/22).
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on interview and record review, the facility's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for a resident to keep a medication at bedside and self-administer the medication for 1 of 31 Residents reviewed. (Resident #172).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 of 3 residents with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASARR) evaluation and determination (Resident #27).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interviews, the facility failed to change oxygen tubing for 1 of 2 sampled residents reviewed for Respiratory Care (Resident #224).
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to ensure that the Consultant Licensed Pharmacist reported an identified required gradual dose reduction (GDR) for an antipsychotic medication, to the attending physician and Director of Nursing, for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #27). Additionally, the facility failed to ensure that the physician documented a GDR attempt or the reason for a contraindication of a GDR.
- B
Post nurse staffing information every day.
Inspectors wroteBased on observation, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to for facility census for 4 of 5 survey days.
- B
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on an interview and review of the facility's Quality Assurance and Performance Improvement (QAPI), the facility failed to present evidence that the required members attended 2 of 4 quarters provided (January 2022 and April 2022).
Fire safety inspections
20 fire safety citations on file: 6 on September 18, 2025, 9 on August 8, 2024, 5 on October 28, 2022.
Every fire safety citation20 citations
- F
Address subsistence needs for staff and patients.
E 15 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · September 18, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 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 · September 18, 2025 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · September 18, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · September 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 · August 8, 2024 · Corrected (the home has a date of correction)
- D
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 · August 8, 2024 · 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 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · August 8, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 8, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 28, 2022 · 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 · October 28, 2022 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 28, 2022 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 28, 2022 · Corrected (the home has a date of correction)
- C
Address subsistence needs for staff and patients.
E 15 · October 28, 2022 · Corrected (the home has a date of correction)