PINNACLE HEALTH & REHAB AT N BERWICK

47 ELM ST, NORTH BERWICK, ME 03906 (207) 676-2242
For profit - Limited Liability company 64 Beds Independent Data: November 2025
Trust Grade
80/100
#31 of 77 in ME
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Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Pinnacle Health & Rehab at N Berwick has a Trust Grade of B+, indicating it is above average and recommended for families seeking care. It ranks #31 out of 77 nursing homes in Maine, placing it in the top half of facilities statewide, and #4 out of 9 in York County, meaning there are only three local options rated higher. The facility is improving, as issues decreased from 8 in 2023 to 5 in 2024. Staffing is a strength, with a 4/5 star rating and a turnover rate of 23%, significantly lower than the Maine average of 49%, suggesting that staff are more likely to stay and build relationships with residents. However, there are concerns with RN coverage, as it has less than 96% of Maine facilities, which could impact patient care. Specific incidents noted by inspectors include a failure to keep the kitchen clean, with visible dirt and expired food found, and a lack of adherence to infection control protocols regarding Legionella, which could affect all residents. Additionally, the facility has not maintained adequate housekeeping services, leading to uncleanable surfaces and a generally neglected environment in some areas. While there are notable strengths in staffing and improvement trends, these cleanliness and infection control issues present significant weaknesses that families should consider.

Trust Score
B+
80/100
In Maine
#31/77
Top 40%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
8 → 5 violations
Staff Stability
✓ Good
23% annual turnover. Excellent stability, 25 points below Maine's 48% average. Staff who stay learn residents' needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Maine facilities.
Skilled Nurses
○ Average
Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Maine. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
18 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 5 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • Low Staff Turnover (23%) · Staff stability means consistent care
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover is low (23%)

    25 points below Maine average of 48%

Facility shows strength in staffing levels, staff retention, fire safety.

The Bad

No Significant Concerns Identified

This facility shows no red flags. Among Maine's 100 nursing homes, only 1% achieve this.

The Ugly 18 deficiencies on record

Oct 2024 5 deficiencies
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based 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 manner ...

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Based 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 manner pertaining to floors for 1 of 1 facility tour (10/30/24). Findings: A surveyor conducted a facility environment tour on 10/30/24 from 1:20 p.m. to 1:35 p.m. with the Maintenance Director in which the following findings were observed: The entrance from the hallway into the resident room floor had black tape on the floor going from each side of the door frame for Rooms 19, 20, 21, 22, 23, 25, 27, 28, 31, 32, and 34. The hallway floor located near B unit, near the nursing station, had black tape on the floor that went widthwise across the floor from hall to hall that was scuffed, torn, and worn, creating an uncleanable surface. The hallway floors on A unit, B unit, and C unit, with a concentration at the end of the hallway on D unit had gaps in the flooring, creating uncleanable surfaces. On 10/30/24 at 1:35 p.m., in an interview with the Maintenance Director, a surveyor confirmed the above findings.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to provide oxygen therapy in a sanitary manner for 4 of 5 sampled residents using oxygen (#6, #9, #22, #29) Findings: 1. On 10/28/24 at 9:30 ...

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Based on observations and interviews, the facility failed to provide oxygen therapy in a sanitary manner for 4 of 5 sampled residents using oxygen (#6, #9, #22, #29) Findings: 1. On 10/28/24 at 9:30 a.m., a surveyor observed Resident #29's oxygen concentrator and found the intake filter coated in dust and debris. 2. On 10/28/24 at 9:45 a.m., a surveyor observed Resident #9's oxygen concentrator and found the intake filter coated in dust and debris. In addition, Resident #9's oxygen tubing was being stored in an unsanitary manner coiled on top of the concentrator with the tubing touching the floor. 3. On 10/28/24 at 10:09 a.m., a surveyor observed Resident #22 wearing oxygen via nasal cannula attached to an oxygen concentrator. The concentrator filter located on the back of the machine was dusty. 4. On 10/29/24 at 10:08 a.m., a surveyor observed Resident #6 wearing oxygen via nasal cannula attached to an oxygen concentrator. The concentrator filter located on the back of the machine was dusty. On 10/30/24 at 1:15 p.m., in an interview with the Assistant Director of Nursing/Infection Preventionist. a surveyor confirmed that Resident #9 and Resident #29's oxygen concentrator filters are dusty. On 10/30/24 at 1:40 p.m. in an interview with the Licensed Practical Nurse (LPN) #2 , a surveyor confirmed that Resident #6 and Resident #22's oxygen concentrator filters are dusty. LPN #2 stated they should be cleaned and stated she would clean them today.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's immunization policy, record review and interview, the facility failed to implement their pneum...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's immunization policy, record review and interview, the facility failed to implement their pneumococcal immunization policy for 3 of 5 residents whose immunization records were reviewed (#4, #25, #48) Findings: The facility's Pneumococcal Vaccine policy and procedure revised on 2/1/2020 states, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series with in (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated and Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Resident #4 was admitted on [DATE], the clinical record contained a Resident Immunization Consent Form signed on 1/11/24, which gave consent for the administration of the Pneumonia vaccines per CDC recommendations. As of 10/29/24, Resident #4's medical record lacked evidence of the facility offering and/or administrating the current Pneumonia vaccine as per CDC recommendations. 2. Resident #25 was admitted on [DATE], the clinical record contained a Resident Immunization Consent Form signed on 4/27/23, which gave consent for the administration of the Pneumonia vaccines per CDC recommendations. As of 10/29/24, Resident #25's medical record lacked evidence of the facility offering and/or administrating the current Pneumonia vaccine as per CDC recommendations. 3. Resident #48 was admitted on [DATE], the clinical record contained a Resident Immunization Consent Form signed on 8/31/23, which gave consent for the administration of the Pneumonia vaccines per CDC recommendations. As of 10/29/24, Resident #48's medical record lacked evidence of the facility offering and/or administrating the current Pneumonia vaccine as per CDC recommendations. On 10/29/24 at 1:48 p.m., during an interview, a surveyor confirmed the findings with the Infection Preventionist/Assistant Director of Nursing.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a clean kitchen floor and ensure products in the walk-in r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a clean kitchen floor and ensure products in the walk-in refrigerator and freezer were labeled and/or dated and failed to remove expired foods available for use for 1 of 3 kitchen tours. Findings: A surveyor completed Initial Kitchen Tour on 10/28/24 from 9:30 a.m. to 10:15 a.m. with the Food Service Director in which the following findings were observed: - The floor in the kitchen had a significant amount of visible crumbs/dirt debris and was discolored/stained in many areas and worn in appearance. During an interview with the Food Service Director, it was revealed that the flooring throughout the kitchen was very porous and was difficult to clean. - The food slicer had dried food particles on the blade and blade protector. - The floor in the dry storage room had excessive dirt debris and food particles on the floor. The Walk-in refrigerator contained the following open/undated or expired foods: --one 6 lb. block of moldy Mill Dance brand [NAME] cheese -one 5 lb. of moldy Sysco Block and [NAME] Swiss cheese -The walk-in freezer contained the following open/undated or expired foods: -one large bag of garlic bread -one 2 lb bag of chicken tenders -one 2 lb bag of chicken breast -one loaf of french bread -siz loaves of cranberry bread -one bag of 8 waffle's -one plastic container of ground sausage and sausage links -sixteen Strawberry Turnovers -one Gluten Free Meatloaf -one Container of Seafood pie dated 9/20 use by 10/20 -one Container of Breakfast Casserole dated 7/25 -thirteen plain muffins -one plate with a Western Omelet, dated 7/14 -one large container of chocolate chip cookie dough, dated 2/21/24 On 10/28/24 at 11:00 a.m., a surveyor discussed the above with the Administrator.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection relating to Legion...

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Based on record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection relating to Legionella and failed to implement the elements of the Legionella Water Management Program. This has the potential to effect all 59 residents. Finding: The facility's Legionella Water Management Program initiated on 10/18/19, states Specific measures used to control the introduction and/or spread of Legionella (e.g. temperature, disinfectants), The control limits or parameters that are acceptable and that are monitored, A diagram of where control measures are applied, A system to monitor control limits and the effectiveness of control measures and documentation of the program On 10/30/24 at 11:10 a.m., during an interview, the Administrator confirmed the facility is not following its own Legionella Water Management policy, by not having measures in place to control the introduction of, assess and monitor areas where Legionella and opportunist waterborne pathogen can grow and spread and a diagram where these measures are applied.
Aug 2023 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**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 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, for 1 of 1 environmental tour. Findings: On 8/21/23 at 2:30 p.m., a surveyor observed 2 fracture bedpans and a pink wash basin on the floor next to the toilet in the shared bathroom for resident rooms [ROOM NUMBERS]. At this time, the B Unit charge nurse confirmed the finding and asked staff to remove the items. The charge nurse stated the items should not be stored like that. On 8/23/23 at 10:00 a.m., during an observational environment tour with the Administrator, the following were observed: Resident Rooms: room [ROOM NUMBER] - Observed plunger in resident bathroom next to the toilet. room [ROOM NUMBER] - Observed the laminate around sink and on front of sink is chipped and has a sharp edge. room [ROOM NUMBER] - Observed in bathroom - toilet base caulking is discolored. room [ROOM NUMBER] - Observed in bathroom - floor tile chipped behind toilet. room [ROOM NUMBER] - Observed in bathroom - loose & chipped laminate on bathroom sink. room [ROOM NUMBER] bathroom - caulking around toilet peeling away from base. Laundry Room: Observed a moderate to large amount of dust on all flat surfaces of dryers and shelves in room. All the above findings were confirmed with the Administrator aon 8/23/23 at 10:45 a.m.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**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 4...

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**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 minimum health care information needed to properly provide care for a newly admitted resident. In addition, the facility failed to ensure the resident, and/or resident representative, was involved in the development of the resident's baseline care plan and was provided a summary of the care plan for 1 of 1 residents sampled for new admissions (#158). Finding: On 8/21/23 at 2:37 p.m., Resident #158 stated no one had met with him/her since admission to discuss care planning, and he/she had not been provided a copy of the initial care plan. A review of Resident #158's clinical record indicated he/she was admitted to the facility on [DATE]. The baseline care plan was initiated on 8/15/23 and was noted to lack any interventions to address the problem areas of Impaired Mobility, Activities of Daily Living Self-Care Performance, and Alteration in Thought Processes. The clinical record lacked evidence that the resident, and/or resident representative, were provided a summary of Resident #158's baseline care plan. On 8/23/23 at 10:30 a.m., in an interview with the Director of Nursing (DON), Infection Preventionist, and Assistant Director of Nursing, the surveyor discussed Resident #158 had stated he/she had not been included in development of the baseline care plan and had not received a copy. The surveyor also discussed the record lacked evidence that Resident #158's representative had been included in the development of the care plan and had been provided a copy. Additionally, the baseline care plan had not been completed 9 days after Resident #158's admission. The DON confirmed the findings.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to include the resident and/or resident's representative, in the development of the resident's care plan, for 1 of 23 residents whose care pla...

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Based on interview and record review, the facility failed to include the resident and/or resident's representative, in the development of the resident's care plan, for 1 of 23 residents whose care plans were reviewed. (Resident #30). Finding: 8/21/23 at 1:28 p.m., in an interview with Resident #30, a surveyor asked if the facility invited him/her, or the Power of Attorney (POA), to attend a meeting and participate in the development of the resident's care plan. Resident #30 stated They've never had one for me. If they had one, I would want to go. A review of Resident #30's clinical record noted the most recent Minimum Data Set (MDS) 3.0 Quarterly Assessment was dated 6/12/23. The surveyor noted several progress notes from members of the interdisciplinary team completed on 6/22/23. Resident #30's care plan was noted with a revision date of 6/22/23. The record lacked evidence that a care plan meeting had been held and that the resident and/or her representative had been invited to attend. On 8/23/23 at 9:30 a.m., in an interview with a surveyor, the facility's Director of Social Services stated the MDS Coordinator schedules care plan meetings and sends out invitations. The Director of Social Services stated the MDS Coordinator completes an attendance form at the time of the meeting and confirmed that a care plan meeting was held on 6/27/23, but was unable to say if the resident and/or the representative was invited or attended. On 8/23/23 at 10:10 a.m., in an interview with a surveyor, the facility's MDS Coordinator stated he/she develops the care plan schedule but does not attend care plan meetings. The MDS Coordinator stated he/she schedules the team meetings based on the MDS Assessment Reference Dates and then distributes the schedule to the Interdisciplinary Team. He/she stated the facility's secretary then sends out invitations to resident families for the care plan meetings. The MDS Coordinator stated a care planning meeting was held on 6/27/23 and was attended by the nurse, social worker, activities, and therapy staff. The MDS Coordinator stated Resident #30's POA did not attend the meeting and that copies of the care plan are not sent to the family or resident representative that he/she is aware of. The MDS Coordinator stated if a family member wanted to know the details of the care plan meeting, the social worker would call them and discuss over the phone. On 8/23/23 at 10:30 a.m., in an interview with the Director of Nursing (DON), Infection Preventionist, and Assistant Director of Nursing, the surveyor discussed Resident #30 had stated he/she had not been included in development of the care plan and would like to be included. The surveyor also discussed the record lacked evidence that Resident #30's POA had been invited to participate in the development of the care plan. The DON confirmed the findings.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 23 sampled residents (#158). Finding: 1. A review ...

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Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 23 sampled residents (#158). Finding: 1. A review of the clinical record of Resident #158 noted an admission date of 8/14/23. The baseline care plan included the following focus area: (Resident #158) has an established advanced directive order in place. Resident is a Do Not Resuscitate, Do Not Intubate, Do Not Hospitalize (DNR/DNI/DNH). The most recent physician's progress note, dated 8/18/23, stated Code Status: DNR, DNI, DNH, [NAME] Hospice. A review of the physician's orders since admission could not locate a signed order addressing the resident's code status. On 8/23/23 at 10:30 a.m., in an interview with the Director of Nursing (DON), the Infection Preventionist, and the Assistant Director of Nursing, the surveyor discussed that Resident #158's clinical record noted he/she was a hospice patient, however the record lacked a physician's order specifying the resident's wish to be a DNR, DNI, DNH. The DON reviewed Resident #158's record and noted that the care plan addressed Resident #158's Advanced Directive, but confirmed the Physician Orders did not specify a code status.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, Pinnacle - North [NAME] failed to label and/or dispose of opened vials of Tuberculin purif...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, Pinnacle - North [NAME] failed to label and/or dispose of opened vials of Tuberculin purified protein derivative (Tubersol), available for resident and staff tuberculosis screenings, in 1 out of 2 medication storage refridgerators . Finding: Observed on 8/21/23 at 11:05 a.m. in the AB unit medication room refrigerator: - Tubersol vial with no open date - Tubersol vial opened date7/16/23 - Tubersol vial opened date 7/17/23 Package Insert located in the box for Tubersol states, A vial of Tubersol which has been entered in use for 30 days should be discarded and Do not use after expiration date. On 8/22/23 9:20 a.m. this surveyor confirmed with Registered Nurse #3 the above findings and she/he removed and disposed of them immediately.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations, interviews, and record reviews, the facility failed to ensure food is stored, served and prepared in a safe, sanitary manner as evidenced by improper food storage in the dry sto...

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Based on observations, interviews, and record reviews, the facility failed to ensure food is stored, served and prepared in a safe, sanitary manner as evidenced by improper food storage in the dry storage area, and failure of staff to utilize beard restraints on 1 of 2 days of kitchen observations (8/21/23). In addition, the facility failed to maintain evidence of: temperature monitoring of food temperatures for 6 meals served in June and July, 2023; monitoring for sanitizer solution levels in sanitizing buckets; and maintain proper temperature ranges for the dishwasher machine, and refrigerators in 2 of 2 nursing unit kitchenettes. This has the potential to affect all residents. Findings: On 8/21/23 at 9:30 a.m., a surveyor completed the initial tour of the kitchen with the Food Service Director (FSD) and observed: 1. Several undated and open bags of rice, tri-color rotini, dry beans, and panko in the dry storage area. The FSD removed the items from stock. 2. The FSD confirmed that the facility does not maintain records of results of sanitizer solution checks of the sanitizing buckets (to ensure correct levels in parts per million [ppm] for proper sanitizing). On 8/21/23 at approximately 11:30 a.m., a surveyor observed the noon meal service and noted the following: 3. Three male staff with beards and mustaches were without beard restraints. 4. One staff donned gloves, picked up a bag of hamburger buns, removed a bun and carried it in his/her open hand to the stove. The staff then placed a hamburger patty, which was cooking on the stove, onto the bun, which remained in his/her hand, and then placed the hamburger onto a plate. At the time of the observations, the surveyor brought the findings to the attention of the FSD, who confirmed beards should be covered and food should not be handled in such a manner. A review of the facility's, Policy/Procedure: Food Preparation and Serving, for the Dietary Department, last revised 3/18/22, stated 10. A hairnet or baseball cap is to be worn by all kitchen employees at all times when in the kitchen, all hair must be covered with no hair dangling (including bangs and facial hair). And, the facility's Procedure and Policy for Taking Food, Freezer, Refrigerator and Dish Machine Temperatures, Times for Meals and Left Over Foods, last revised 6/20/23, stated All food temperatures will be taken 10 minutes before serving and written down on temperature sheet. 11. Freezer 0 or lower. 12. Diet kitchen, bayview refrigerator 41 or lower. Dish machine temps taken by person that is washing dishes for each meal. If not at proper temps, reset booster, put dishes through again, if still not at temps, make note and notify Food Service Director (FSD) and call Ecolab to put in a call for service for the dish machine. Morning cook takes temps of the walk-in and freezer and puts out the sanitizer container for cleaning on cook's side and tray side. AM tray side that stocks the kitchen takes temps for the country kitchens. 5. On 8/22/23, a surveyor reviewed the kitchen temperature logs. The logs lacked evidence that temperatures for meals were tested prior to being served to residents at the following times: 6/5/23: supper 6/19/23: supper 6/21/23: lunch 6/22/23: breakfast and lunch 7/23/23: lunch 8/1/23: lunch 6. A review of temperature logs for refrigerators in the nursing unit kitchenettes noted the following: In May, 2023, there were 11 out of 31 days with out of range temperatures (5/5/23, 5/9/23, 5/11/23, 5/12/23, 5/14/23, 5/17/23, 5/23/26, 5/26/23, 5/27/23, 5/30/23, 5/31/23). In June, 2023, there were 7 out of 30 days with out of range temperatures (6/8/23, 6/11/23, 6/17/23, 6/20/23, 6/21/23, 6/22/23, 6/28/23). In July, 2023, there were 3 out of 31 days with out of range temperatures (7/4/23, 7/10/23, 7/24/23). 7. A review of temperature logs for the wash and rinse cycles of the dishwasher machine noted the following out of range temperatures (in degrees Fahrenheit [F]), or lack of evidence of temperature monitoring: 5/2/23 - No temperatures Recorded for Lunch and Dinner 5/7/23 - Supper Rinse Temperature = 179 F 5/8/23 - Lunch Wash Temperature = 140 F 5/22/23 - Breakfast Wash Temperatures = 140, 157 F; Rinse = 160 F 5/24/23 - Supper Rinse Temperature = 170 F 5/30/23 - No Supper Wash or Rinse Temperatures Recorded 5/31/23 - No Lunch & Supper Wash or Rinse Temperatures Recorded 6/12/23 - Breakfast Rinse Temperature = 175 F 6/19/23 - Lunch Rinse Temperature = 175 F 6/27/23 - Breakfast Rinse Temperature = 174 F 7/9/23 - No lunch Rinse Temperature Recorded 7/16/23 - Lunch Rinse Temperature = 175 F 7/17/23 - Lunch Rinse Temperature = 170 F 7/24/23 - Lunch Rinse Temperature = 175 F 8/8/23 - Breakfast Rinse Temperature = 170 F 8/19/23 - Breakfast Rinse Temperature = 175 F On 8/22/23 at 2:00p.m., in an interview with a surveyor, the FSD confirmed the logs lacked evidence of consistent temperature monitoring for meals and equipment, as required per facility policy, and stated that out of range refrigerator and dishwashing machine temperatures should have been rechecked and reported.
Jan 2023 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the daily staffing postings, and the nursing working schedule the facility failed to have a Regis...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the daily staffing postings, and the nursing working schedule the facility failed to have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week for 7 of 92 days reviewed for Sufficient and Competent Nurse Staffing. Finding: A review of the daily staffing postings, and nursing working schedule, indicated that on Saturday - [DATE], Saturday - [DATE], Thursday - [DATE] - Thanksgiving, Saturday - [DATE], Saturday - [DATE], Sunday - [DATE], and Saturday - [DATE], 2/24/19, the facility did not have an RN on duty for at least 8 consecutive hours. On 1/3/2023 at 11:45 a.m., in an interview with the Director of Nursing, the findings were discussed. The surveyor confirmed the lack of sufficient RN coverage.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations, interviews, and review of documentation, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, food was not stored in safe and sanitary manner...

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Based on observations, interviews, and review of documentation, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, food was not stored in safe and sanitary manner, the facility failed to produce evidence that food temperatures were being taken during preparation and that the facility failed to produce evidence that temperatures were being taken during the running of the high temp dish washer. Findings: Facility procedure and policy titled Temperature Policy with a revised date of 3/18/22 states All food temperatures will be taken 10 minutes before serving and written down on a temperature sheet Facility procedure and policy titled Food Preparation and Serving with a revised dated of 3/18/22 states .and temperatures are in compliance for both hot (150-170 degrees Fahrenheit) and cold (38-41 degrees Fahrenheit) foods. On 1/3/2023, at 9:15 a.m., during the initial tour of the kitchen with the [NAME] and the Dietician and again at 10:00 a.m. with the Dietician, the surveyor could not locate documented temperatures of food prepared and served for the breakfast meal. During an interview with the Cook, she stated she did not take temperatures of food during breakfast preparation. Facility procedure an policy titled Sanitary Conditions: with a revised date of 3/18/22 states Food is stored six inches above the floor and is properly refrigerated if necessary Kitchen and dish room floor are swept an mopped at least daily Refrigerator and freezer temperatures are monitored and recorded daily left over food is wrapped, dated and identified before storing .Water temperatures at the dishwasher are maintained at 150 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the rinse cycle, these temperatures are monitored and recorded daily . On 1/3/2023, at 9:15 a.m., observed an open box of food found on the floor of the walk-in freezer, as well as two unopened boxes of food observed on freezer floor On 1/3/2023, at 9:15 a.m., observed a small amount of dirt/dust around the ceiling vents above the food preparation area in kitchen. On 1/3/2023, at 10:00 a.m., observed that there was a lack of evidence that temperatures were consistently being taken for the refrigerator in the kitchen, for the walk-in refrigerator, and for the walk-in freezer. On 1/3/2023, at 9:15 a.m., observed unlabeled and undated hard-boiled eggs in a plastic bag, a large unfrosted cake, and 2 trays of fruit in individual cups. On 1/3/2023, at 9:15 a.m., observed lack of evidence that temperatures were being taken when running the high temperature dish washer. On 1/3/2023, at 9:20 a.m. and 9:45 a.m., the surveyor discussed the above dietary issues with Administrator, and the Dietician.
May 2021 5 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation and interviews, the facility failed to ensure a resident had leg/foot rests attached to their wheelchair to ensure proper postioning for 1 of 3 residents reviewed for positioning....

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Based on observation and interviews, the facility failed to ensure a resident had leg/foot rests attached to their wheelchair to ensure proper postioning for 1 of 3 residents reviewed for positioning. (#21) Findings: 1. On 5/03/2021 at 10:37 a.m., Resident #21 was observed in a wheelchair with both feet dangling from the wheelchair, not touching the floor and no foot/leg rests in place. 2. On 5/05/2021 at 7:50 a.m., and again at 9:46 a.m., Resident #21 was observed in a wheelchair with both feet dangling from the wheelchair, unable to touch the floor and no foot/leg rests in place. On 5/05/2021 at 8:00 a.m., in an interview with the Registered Nurse, she confirmed Resident #21 is currently working with physical therapy but is unaware of the resident utilizing foot/leg rests for positioning stating, not that I've seen. On 5/05/2021 at 1:45 p.m., in an interview with the Physical Therapists (PT), the surveyor discussed the observations of Resident #21 in the wheelchair without the foot/legs rest. The PT confirmed Resident #21 should have foot/leg rest while up in the wheelchair stating, because they forgot to put the foot/leg rests on otherwise [Resident #21's] feet do not hit the ground and they were not on and I told them [Resident #21] needs [his/her] foot/leg rests. On 5/05/2021 at 1:52 p.m., in an interview with a Certified Nurses Aid (CNA) #1 she stated, Resident #21 usually has foot/leg rests on the wheelchair so [his/her] feet will not dangle. On 5/05/2021 at 1:57 p.m., in an interview with CNA #2, who provided the a.m. care for Resident #21, confirmed he/she should have foot/leg rests in place on the wheelchair. When asked why the leg/foot rests were not on she stated, I didn't want [him/her] to fall, [he/she] always puts [his/her] feet behind the leg/foot rests I'm afraid [he/she] is going to hurt [his/her] feet and therapy is working with [him/her]. On 5/05/2021 at 2:15 p.m., a surveyor confirmed Resident #21 did not have the leg/foot rests attached to his/her wheelchair, causing his/her legs to dangle without touching the floor, thus not providing proper positioning in an interview with the Director of Nursing.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure that the Consultant Pharmacist, during monthly review of medication, identified and reported to the Attending Physician and the Dire...

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Based on record review and interview, the facility failed to ensure that the Consultant Pharmacist, during monthly review of medication, identified and reported to the Attending Physician and the Director of Nursing that adequate monitoring for an antipsychotic medication (Risperidone) was completed, for 1 of 5 residents reviewed for unnecessary medications (#23). Finding: A review of Resident #23's clinical record revealed a diagnosis of Alzheimer's Disease and a history of psychotic behaviors controlled with Risperidone. The record lacked evidence of adequate monitoring for the presence of extrapyramidal symptoms (EPS) and Tardive Dyskinesia (TD), neurological side effects that can occur at any time from the first few days of treatment with an antipsychotic medication to years later. The clinical record revealed an AIMS test, (Abnormal Involuntary Movement Scale), which detects the occurrence and severity of EPS and TD symptoms over time in patients receiving antipsychotic medication, was completed on 8/28/2019. The pharmacist's medical record reviews (MRR) failed to evaluate and report on the potential adverse consequences of failure to adequately monitor for the emergence or presence of neurological side effects for a resident receiving an antipsychotic medication. On 5/06/2021 at 1:15 p.m., the Interim Director of Nursing (DON) stated all residents on antipsychotics should have an AIMS test completed every 6 months. The DON confirmed that Resident #23's last AIMS test was completed on 8/28/2019, and was not noted by the consultant pharmacist on monthly review.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications for 1 insulin vial available for use, in 1 ...

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Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications for 1 insulin vial available for use, in 1 of 2 treatment carts and failed to secure medication properly on 1 of 3 units, (Unit C). Findings: 1. On 5/03/2021 at 2:25p.m., observation of C unit treatment cart contained an open vial of Humulin 70/30 not labeled with an open and/or discard date. Manufacturer specifications on the insulin vial instructs to Discard unused portion 31 days after first opening. On 5/3/2021 at 2:34p.m., observation was discussed with the Director of Nursing. 2. On 5/03/2021 at 2:01 p.m., observation of Unit C medication cart, left unlocked and unattended for approximately 2 minutes. At 2:03 p.m., observation was confirmed with the Certified Medication Technician as she returned to the cart.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide maintenance services necessary to maintain the b...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide maintenance services necessary to maintain the building in good repair and sanitary conditions on 3 of 3 units (Unit A, Unit B & Unit C) for 1 of 1 environmental tours. Findings: On 5/05/2021 from 10:00 a.m. to 11:00 a.m , two surveyors and the Licensed Social Worker conducted an environmental tour of the facility in which the following findings were confirmed: Unit A Resident room [ROOM NUMBER]: Floor mat with multiple cracks creating an uncleanable surface. Unit B Resident room [ROOM NUMBER]-2: The windowsill missing varnish creating an uncleanable surface. Resident #46's bilateral wheelchair arms with multiple cracks creating an uncleanable surface. Resident room [ROOM NUMBER]-1: Sink countertop with rough edges creating an uncleanable surface. The windowsill without varnish creating an uncleanable surface. Resident #33's wheelchair with moderately soiled pink tape on both arm rest areas creating an uncleanable surface. Resident room [ROOM NUMBER]: The windowsill missing varnish creating an uncleanable surface. Resident room [ROOM NUMBER]: The windowsill missing varnish creating an uncleanable surface. Resident room [ROOM NUMBER]: Edge of door and door jam heavily marred. The wall by the sink heavily gouged. Unit C Resident room [ROOM NUMBER]: Heater cover partially off creating sharp edges. Resident room [ROOM NUMBER]: The windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident room [ROOM NUMBER]: The windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident room [ROOM NUMBER]: Heater cover partially off creating sharp edges. The windowsill without varnish creating an uncleanable surface. Resident room [ROOM NUMBER]: Inside of the bathroom heavily gouged. The base of the toilet with brown caulking. Resident room [ROOM NUMBER]: Chipped pain on door below the sink, wood molding on closet door marred, heater cover partially off creating sharp edges. Resident room [ROOM NUMBER]: Molding around the closet marred. Windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident room [ROOM NUMBER]: The windowsill without varnish creating an uncleanable surface. Heater cover partially off creating sharp edges. Resident room [ROOM NUMBER]: Bed-2 floor with moderate dirt and dust. Resident room [ROOM NUMBER]: Molding marred around the closet and bathroom door. The windowsill without varnish creating an uncleanable surface. Resident room [ROOM NUMBER]: The windowsill without varnish creating an uncleanable surface. The lower portion of the bathroom door is heavily splintered creating sharp edges. A small area of the tile in front of the sink is missing. The window drape is unattached. The fourth drawer and door under the sink with chipped paint.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen tour observations. Findings: On 5/03/2021, 9:30 a.m. and...

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Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen tour observations. Findings: On 5/03/2021, 9:30 a.m. and 10:30 a.m. a tour of the kitchen was completed with the Food Service Director and the Administrator in which the following were observed: -The dishwash room was missing pieces of floor tile creating an uncleanable surface on the floor in front of the dishwashing sink. -A moderate amount of dirt and debris was observed under the sink and all along the baseboard. - Dishwasher unit and tray rollers were heavily soiled with food debris on the outside. -The food preparation area of the main part of the kitchen; had loose base board and molding in areas running behind the white container of oatmeal, steamer units, warmers, and refrigerators. - 2 steamers, refrigerator, and 2 warmers were heavily soiled and food debris , food debris was also noted on the outside on the euipment. -No documentation of a cleaning schedule or regular assignments for cleaning tasks: Director submitted 16 assorted pieces of paper with dates of: 6/16/2020, 12/1/2020, 1/21/2021, 3/11/2021, and April 9 (without a year noted). On 5/03/2021 at 9:30 a.m., and 10:30 a.m., two surveyors confirmed the kitchen was not maintained in a clean and sanitary manner with the Director of Food Services and the Administrator.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Grade B+ (80/100). Above average facility, better than most options in Maine.
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Maine facilities.
  • • 23% annual turnover. Excellent stability, 25 points below Maine's 48% average. Staff who stay learn residents' needs.
Concerns
  • • 18 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Pinnacle Health & Rehab At N Berwick's CMS Rating?

CMS assigns PINNACLE HEALTH & REHAB AT N BERWICK an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Maine, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Pinnacle Health & Rehab At N Berwick Staffed?

CMS rates PINNACLE HEALTH & REHAB AT N BERWICK's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 23%, compared to the Maine average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Pinnacle Health & Rehab At N Berwick?

State health inspectors documented 18 deficiencies at PINNACLE HEALTH & REHAB AT N BERWICK during 2021 to 2024. These included: 18 with potential for harm.

Who Owns and Operates Pinnacle Health & Rehab At N Berwick?

PINNACLE HEALTH & REHAB AT N BERWICK is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 64 certified beds and approximately 55 residents (about 86% occupancy), it is a smaller facility located in NORTH BERWICK, Maine.

How Does Pinnacle Health & Rehab At N Berwick Compare to Other Maine Nursing Homes?

Compared to the 100 nursing homes in Maine, PINNACLE HEALTH & REHAB AT N BERWICK's overall rating (4 stars) is above the state average of 3.0, staff turnover (23%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Pinnacle Health & Rehab At N Berwick?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Pinnacle Health & Rehab At N Berwick Safe?

Based on CMS inspection data, PINNACLE HEALTH & REHAB AT N BERWICK has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Maine. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Pinnacle Health & Rehab At N Berwick Stick Around?

Staff at PINNACLE HEALTH & REHAB AT N BERWICK tend to stick around. With a turnover rate of 23%, the facility is 23 percentage points below the Maine average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 25%, meaning experienced RNs are available to handle complex medical needs.

Was Pinnacle Health & Rehab At N Berwick Ever Fined?

PINNACLE HEALTH & REHAB AT N BERWICK has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Pinnacle Health & Rehab At N Berwick on Any Federal Watch List?

PINNACLE HEALTH & REHAB AT N BERWICK is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

PINNACLE HEALTH & REHAB AT N BERWICK

47 ELM ST, NORTH BERWICK, ME 03906 | (207) 676-2242

B+
Trust Grade (80/100)
4.0
CMS Rating
18
Deficiencies

Strengths

  • 4-star staffing
  • Low turnover (23%)

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025