PINE POINT CENTER

67 PINE POINT RD, SCARBOROUGH, ME 04074 (207) 883-2468
For profit - Limited Liability company 61 Beds GENESIS HEALTHCARE Data: November 2025
Trust Grade
60/100
#40 of 77 in ME
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Last Inspection: April 2025

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

Overview

Pine Point Center in Scarborough, Maine has a Trust Grade of C+, which indicates it is slightly above average but not exceptional. It ranks #40 out of 77 nursing homes in the state, placing it in the bottom half, and #13 of 17 in Cumberland County, meaning only four local options are better. The facility's trend is worsening, with reported issues increasing from 11 in 2024 to 12 in 2025. Staffing is average, with a 3 out of 5-star rating and a turnover rate of 53%, which aligns with the state average. While the facility has had no fines, indicating good compliance, there are concerning findings, such as a resident being observed with an open wound that should have been covered and a lack of scheduled interdisciplinary team meetings to review care plans. Additionally, there were issues with insufficient staffing on weekends, which could impact the residents' daily needs. Overall, while there are strengths like good RN coverage, the increasing issues and specific incidents highlight areas that need attention.

Trust Score
C+
60/100
In Maine
#40/77
Bottom 49%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
11 → 12 violations
Staff Stability
⚠ Watch
53% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Maine facilities.
Skilled Nurses
✓ Good
Each resident gets 70 minutes of Registered Nurse (RN) attention daily — more than 97% of Maine nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
⚠ Watch
27 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 12 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

3-Star Overall Rating

Near Maine average (3.0)

Meets federal standards, typical of most facilities

Staff Turnover: 53%

Near Maine avg (46%)

Higher turnover may affect care consistency

Chain: GENESIS HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 27 deficiencies on record

Apr 2025 12 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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on record review, interviews, and facility policy, the facility failed to thoroughly investigate an Injury of Unknown Origin for 1 of 1 resident reviewed for Injuries of Unknown Origin. (Residen...

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Based on record review, interviews, and facility policy, the facility failed to thoroughly investigate an Injury of Unknown Origin for 1 of 1 resident reviewed for Injuries of Unknown Origin. (Resident #57) Findings: On 10/5/24 the Division of Licensing and Certification received a report that Resident #57 obtained an injury to his/her left ankle, while an unknown Certified Nursing Assistant was putting on the resident's shoe. Review of Resident #57 medical record contained a provider note, dated 10/4/24 of an evaluation of his/her left ankle, which resulted in the provider ordering an X-Ray. On 10/5/24 an X-Ray was obtained and showed no evidence of a fracture but showed soft tissue swelling. Further review of the medical record lacked evidence of any nursing documentation of an injury occurring or monitoring of his/her left foot. Review of the facility's investigation dated 10/7/24, consisted of the Director of Nursing's interview with Resident #57 and a family member, and a note from an Occupational Therapy (OT) student dated 10/7/24. The OT students note states that Resident #57 Reported to the OT student that his/her left leg hurt very badly and was bruised and swollen. Patient showed OT his/her left lower extremity, there was bruising on the anterior aspect of his/her knee and swelling with slight bruising on his/her left ankle. Patient reported that the injury occurred from an aid that was trying to help him/her put his/her shoes on but was painfully twisting his/her leg. Further review of the facilities investigation lacked evidence that the Director of Nursing thoroughly investigated Resident #57 injury of unknown origin by completing observations and interviews with staff who was working with Resident #57. The facility policy Abuse Prohibition, last revised on 10/24/22 states in Section 7, subsection 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent, clinical examination of signs and symptoms of injuries, if indicated, causative factors, and interventions to prevent further injury . The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnesses is included. On 4/8/25 at 11:20 p.m., during an interview, the Market Clinical Advisor was unable to find any additional documentation in the risk management portal or further investigations.
CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 on 1 of 5 units (Pleasant Hill House) for 1 of 4 days of survey (4/6/25). Findings: 1. On 4/6/25 at 10:07 a.m., observation of room [ROOM NUMBER] on Pleasant Hill House to have an unsecured container of Micro-Kill One Germicidal Alcohol Wipes and a bottle of toilet bowl cleaner. At this time, Registered Nurse #2 confirmed the chemicals should not be stored in a resident's bathroom and removed the chemicals. 2. On 4/6/25 at 11:47 a.m., observation of room [ROOM NUMBER] on Pleasant Hill House to have an unsecured container of Micro-Kill One Germicidal Alcohol Wipes. At this time, Registered Nurse #2 again confirmed that chemicals should not be stored in a resident's bathroom and removed the chemicals. The Safety Data Sheet for Micro-Kill One Germicidal Alcohol Wipes states in Section 4: First Aid Measures. If inhaled: remove person to fresh air and keep comfortable for breathing. Call Poison control center/doctor is you feel unwell . If on skin (or hair): take off immediately all contaminated clothing. Rinse skin with water . If in eyes: Rinse continuously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. If eye irritation persists, get medical advice/attention . Indigestion: Rinse mouth. Do not induce vomiting. Get medical attention if symptoms occur. Never give anything by mouth if the victim is unconscious or is convulsing. Obtain medical attention. The Safety Data Sheet for 3M Bathroom Disinfectant Cleaner Ready-to-Use states in Section 4: First Aid Measures. Inhalation: Remove person to fresh air. If you feel unwell, get medical attention . Skin Contact: Wash with soap and water. If signs/symptoms develop, get medical attention . Eye contact: Flush with large amounts of water. Remove contact lenses if easy to do. Continue rinsing. If signs/symptoms persist, get medical attention . If swallowed: Rinse mouth. If you feel unwell get medical attention. On 4/9/25 at approx 4:15 p.m., the above information was discussed during exit with the Administer, Director of Nursing and the Market Clinical Advisor
CONCERN (D)

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

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatizati...

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Based on record review and interview, the facility failed to identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include those triggers and interventions to prevent re-traumatization for 1 of 2 residents reviewed with a diagnosis of PTSD. (Resident #22) Finding: On 4/6/25 a review of Resident #22's medical record showed he/she was admitted in 2018 and had a current diagnosis of PTSD. Further review including assessments and the current care plan lacked evidence that the facility assessed the resident for what triggers might cause re-traumatization and failed to revise the care plan to include those triggers and interventions to prevent re-traumatization. On 4/7/25 at 3:30 p.m., during an interview, the Market Clinical Advisor confirmed the above and stated that nursing completed a trauma assessment today on Resident #22 which included triggers that may cause re-traumatization.
CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

Based on observations, interviews, and a lunch meal test tray, the facility failed to serve food at an appetizing and palpable temperature for 1 of 2 meals observed. Findings: On 4/6/25 at 9:53 a.m.,...

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Based on observations, interviews, and a lunch meal test tray, the facility failed to serve food at an appetizing and palpable temperature for 1 of 2 meals observed. Findings: On 4/6/25 at 9:53 a.m., during an interview, Resident #10 discussed concerns of the food not being hot when it gets to resident. On 4/7/25 at 10:50 a.m., a surveyor requested a sample tray,sample tray. During the observation, both Certified Nursing Assistant (CNA) #2 and CNA #3 started to serve the lunch trays for the 20 residents at 12:19 p.m. During this meal pass, both CNA's had to boost and turn 2 residents and one CNA had to take a resident to the bathroom. The last meal was served at 12:50 p.m., 31 minutes after the first tray was passed. At 12:51 p.m., the food on the sample tray food was tempted, in which the BBQ pulled pork sandwich was 121.7 degrees Fahrenheit and the seasoned potato wedges were 85 degrees Fahrenheit. On 4/7/25 at 1:20 p.m., during an interview, CNA #3 stated they occasionally get more help with passing trays, but it usually ends up being just 2 CNA's which results in cold food. On 4/7/25 at 1:00 p.m., the above information was discussed with the Market Clinical Advisor.
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 review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for nutrition (R...

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Based on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for nutrition (Resident #11). Finding: Resident #11 was admitted in 2024 with diagnoses to include protein-calorie malnutrition. Resident #11's clinical records contained an active physician order dated 1/17/25 for Start 8oz whole milk & full fat ice cream milkshake TID w/ meals and at bedtime with meals AND at bedtime. A physician progress note, dated 2/28/25 which stated, Did verify with staff that [he/she] is being given whole milk with [his/her] shakes however, unable to find the order for milkshakes on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). Did discuss this with unit manager . An additional physician progress note, dated 4/1/25 which stated, Weight loss .still do not see order for milkshakes on MAR or TAR to be signed out, will discuss with nurse manager again . Resident #11's MAR and TAR for January, February, and March 2025 lacked documentation of the milkshakes being given. On 4/8/25 at 8:51 a.m., during an interview with a surveyor, the unit manager reviewed Resident #11's entire clinical record and confirmed the January, February, and March 2025 MAR/TAR lacked evidence of Resident #11 being given and/or refusing a milkshake. On 4/8/25 at 11:44 a.m., the above was discussed with the Market Clinical Advisor.
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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #11's clinical record contained a Quarterly MDS Assessment, dated 1/11/25. The record lacked evidence of IDT meeting...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #11's clinical record contained a Quarterly MDS Assessment, dated 1/11/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. On 4/9/25 at 10:21 a.m., during an interview, the Social Services Director confirmed she does not have a process for scheduling IDT meetings and does not usually provide residents or their representatives advance notification of the meeting(s). Based on interviews and record review the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessment, for 3 of 10 residents whose care plans were reviewed. (Resident #22, #40, #11) Findings: 1. Resident #22's medical record contained a Significant Change MDS, dated [DATE], and Quarterly MDS' dated 8/9/24, 11/7/24, and 1/29/25. The record lacked evidence of IDT meetings being held within 7 days of the above MDS assessments. The medical record stated the last IDT meeting was held on 3/12/24. On 4/8/25 at 11:20 p.m., the above information was discussed with the Market Clinical Advisor. 2. Resident #40's clinical record contained Quarterly MDS' dated 12/13/24 and 3/15/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. In addition, the admission MDS dated [DATE] had a IDT meeting held on 9/16/24 with the resident in attendance, but not the family representative. On 4/8/25 at 2:27 p.m., during an interview, the Market Clinical Advisor confirmed that IDT meetings had not been held and there was no evidence that Resident #40's representative had been invited or had been provided with a copy of the resident care plan.
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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

2. On 4/6/25 at 10:02 a.m., and on 4/7/25 at 12:16 p.m., Resident #27 was observed with an uncovered, open wound on his/her right forearm. Resident #27's clinical record contained a physician order d...

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2. On 4/6/25 at 10:02 a.m., and on 4/7/25 at 12:16 p.m., Resident #27 was observed with an uncovered, open wound on his/her right forearm. Resident #27's clinical record contained a physician order dated 4/3/25 for, Mupirocin External Ointment 2 % (Mupirocin) Apply to Right forearm topically every evening shift for Biopsy for 11 Days. Cover with Band aid, Per dermatology On 4/9/25 at 10:30 a.m., during an interview, the Registered Nurse #2 stated Resident #27's right forearm wound is supposed to be covered with a bandage at all times. At this time, the finding was reviewed with the Unit Manager, and she stated Resident #27 does not typically refuse treatments or remove his/her wound dressing. 3. Resident #4 has diagnoses to include hemiparesis (paralysis) following cerebral infarction (stroke). On 4/6/25 at 11:49 a.m., a surveyor observed a brace on Resident #4's left wrist. At this time, Resident #4 stated he/she has had the brace since his/her stroke and that the nursing staff helps him/her put the brace on first thing in morning and take it off at night. Review of Resident #4's care plan stated, .Patient will tolerate left upper extremity wrist brace for no more than 4 hours daily to improve wrist range of motion . A physician progress note, dated 4/1/25, stated, Left hemiparesis .wearing [his/her] brace today Further review of the clinical record lacked evidence of a physician order for the left wrist brace. On 4/9/25 at approximately 1:00 p.m., during an interview, the Director of Rehabilitation and the Occupation Therapist stated their department provided Resident #4's left wrist brace while he/she was receiving therapy, and they would expect to see a physician order for the brace, but that is driven by nursing. On 4/9/25 at 2:10 p.m., the above finding was reviewed with the Market Clinical Advisor and the Director of Nursing. Based on record review and interviews, the facility failed to assess and monitor a surgical wound ( Resident#57), failed to follow physician orders for a wound care ( Resident#27) for 2 of 2 resident reviewed for wounds. In additon, the facility failed to obtain physician orders for 1 of 1 resident reviewed for positioning. (Resident #4) Findings: 1. Resident #57 was admitted to the facility in September of 2024, after having a left intertrochanteric femur fracture operation leaving him/her with a surgical wound. Review of the Treatment Administration Record indicated that he/she had Suture/staple removal one time only for Post op left proximal femur on 10/6/24. Upon further review, the medical record lacked evidence of an initial nursing assessment, continued monitoring, and assessments of the surgical site throughout his/her stay. On 4/8/25 at 11:20 p.m., the above information was confirmed with the Market Clinical Advisor.
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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Based on record review, observations 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 fo...

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Based on record review, observations 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 for weekends of the first quarter (October 1, 2024 - December 31, 2024). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs). Findings: 1. Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the first quarter of 2025 (October 1, 2024 - December 31, 2024). On 4/9/25 at 1:56 p.m., both the surveyor and the Director of Nursing reviewed the weekend staffing from October 1, through December 31, 2024. The Director of Nursing confirmed the facility did not ensure enough staff were on duty to meet resident needs on the weekends. 2. A review of the Resident Council Meeting Minutes revealed the following: -meeting minutes dated 2/26/25 stated Residents are concerned that staffing ratios aren't consistent. Especially 2nd shift, long waits noted .Residents are concerned that call lights are not consistently being responded to timely. -meeting minutes dated 3/26/25 stated, Residents are concerned that there is only one aide per unit on the second shift and they are not consistently available. On 4/6/25 at 10:54 a.m., during an interview, Resident #13 stated the lack of staff is a regular concern at Resident Council meetings and that he/she lets the Administrator know about the complaints about staffing. 3. Review of grievances filed by the Resident Council revealed the following: -a grievance filed 8/12/24 stated, Residents are concerned that call lights aren't consistently being responded to timely. - a grievance filed 9/23/24 stated, Residents are concerned that call lights aren't consistently being responded to timely.
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, the facility failed to properly secure medications on 1 of 2 (Short Stay Unit) units for 2...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to properly secure medications on 1 of 2 (Short Stay Unit) units for 2 of 4 days of survey, failed to ensure expired medications were removed from the supply available for use in 2 of 4 treatment/medication carts reviewed and failed to ensure expired lab supplies were removed from supply available for use on 2 of 2 units (Short Stay and Long Term Units). Findings: 1. On 4/6/25 at 9:02 a.m., observation of the Short Stay unit to have an unlocked and unattended treatment cart containing 4 residents insulin pens, pen needles and lancets, during this time 2 residents were present. At 9:05 a.m., the Certified Nurses Aid #1 confirmed the unlock treatment cart and locked it. 2. On 4/6/25 at 11:52 a.m., observation of the Short Stay unit medication room with the Licensed Practical Nurse #3 (LPN#3). The surveyor asked if nursing draws their own labs. The LPN#3 stated, We can, yes. I haven't for a while, we have a guy who comes in, he usually brings his own supplies. We will be next week; our guy goes on vacation. On the counter was a plastic tote containing 13 butterfly needles with expiration date of 9/21/24, 5 blue top blood vacutainers with expiration date of 10/31/23 and 6 yellow top vacutainers with expiration date of 1/31/25. The LPN#3 confirmed the supplies available for use were expired and stated there is a lab room on the other unit with additional supplies. 3. On 4/6/25 at 12:10 p.m., observation of the lab room on the long-term care units with the Registered Nurse #3 (RN#3) which contained 46 red top blood vacutainers with expiration date of 4/1/25, 41 white top vacutainers with exp. of 12/1/23, 175 green top vacutainers with exp. date of 12/3/23, 3 dark blue top vacutainers with exp. date of 11/30/24, 34 small yellow vacutainers with exp. date of 3/31/25, 100 gray top vacutainers with exp. date of 11/30/23, and 99 blue top vacutainers with exp. date 4/30/23. At this time, the RN#3 notified the Director of Nursing (DON) who observed the expired vacutainers. The DON stated nurses can draw labs, but they do have a guy who comes in to draw labs and brings his own supplies and will not be available the next week. 4. On 4/7/25 at 6:47 a.m., observation of the Short Stay medication cart unlocked and unattended. The surveyor was able to open and go through the medication cart which contained a bottle of Fish oil 1000 milligram (mg) with and expiration date of 1/11/25 and 21 tabs of Guaifenesin Extended Release tabs with expiration date of 2/25. During this time, 2 staff walked by and observed the surveyor in the medication cart, a Registered Nurse (RN) and Certified Nurses Aid (CNA) neither addressed the unlocked medication cart. At 6:53 a.m., the surveyor asked RN#1, who returned to the area, to lock the medication cart. On 4/7/25 at 6:55 a.m., the above was discussed with the Market Clinical Advisor 5. On 4/7/25 at 9:49 a.m., observation of [NAME] House medication cart with the LPN #2 which contained a blister pack of Fexofenadine 60mg with an expiration date of 10/2024. At this time, the LPN#2 confirmed and removed the expired medication.
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 and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, walls, the dishwasher and fans/vents, failed to ensure staff w...

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Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, walls, the dishwasher and fans/vents, failed to ensure staff were wearing proper hair restraints and failed to ensure that canned goods with a compromised seal were not available for use for 1 of 4 days of survey. (4/6/25) Findings: On 4/6/25 at approx. 9:00 a.m., during the initial tour of the kitchen the following was observed: 1. -The kitchen floor was dirty with food debris and trash around the entire floor and under the equipment and shelving. - The kitchen walls were covered with dirt and food debris. - The dish washer was covered with dirt and debris. - The vent above the grill was coated with dirt and debris. - The vents and fans throughout the kitchen had built up dust 2. Observation of the Dietary Aid #1 and #2 not wearing proper hair restraints while preparing food. After surveyor intervention, both Dietary Aid #1 and #2 applied hair restraints. 3. Observation of 3, #10 cans of peaches with denting along the seal and available for use. At this time, the [NAME] #1 stated that cans should be checked for damage upon arrival and if dented, placed in the designated area for compromised cans so they are not available for use. On 4/6/25 at 1:14 p.m., the above information was discussed with the Food Service District Manager.
CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/8/25 at 4:04 p.m., a Physical Therapy Assistant (PT-A) was observed exiting the Oak Hill unit, wearing a yellow isolatio...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/8/25 at 4:04 p.m., a Physical Therapy Assistant (PT-A) was observed exiting the Oak Hill unit, wearing a yellow isolation gown. The PT-A proceeded to walk past the surveyor, located next to the nurse's station and enter the main dining room, where she doffed the isolation gown and then exited the dining room. At this time, the surveyor asked where the PT-A was prior to leaving the Oak Hill unit, and the PT-A stated she had been in a room wearing gloves, a gown, an N95 mask, and eye protection because the resident was on transmission-based precautions (TBP). She then stated, while she was in the room with the resident, the nurse came in and informed her that the TBP had just been lifted and she removed her gloves, mask, and eye protection before she exited the room and should have removed the gown, but she forgot, so she doffed it in the dining room. On 4/8/25 at 4:11 p.m., the above was discussed with the Market Clinical Advisor. 2. On 4/7/25 at 12:25 p.m., during lunch meal pass on the Skilled Unit, a surveyor observed CNA #2 and CNA #3 turning and boosting a resident in his/her bed, both CNA's exited the residents room and without performing hand hygiene, CNA #2 grabbed a meal tray and delivered it to room [ROOM NUMBER] and CNA #3 grabbed a meal try and delivered it to room [ROOM NUMBER]. At 12:27 p.m., at this time the surveyor intervened, both CNA #2 and CNA #3 confirmed they should have performed hand hygiene after providing care to a resident and prior to tray delivery. On 4/7/25 at 1:00 p.m., the above information was discussed with the Market Clinical Advisor. Based on observations, interviews and record reviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to hand hygiene during medication administration and meal tray service observations and the use of Personal Protective Equipment (PPE) for 3 of the 4 days of survey. Findings: 1. On 4/7/25 at 8:02 a.m., just prior to medication administration observation, the Licensed Practical Nurse #2 (LPN #2) was observed at the nurse's station rubbing his eyes and nose multiple times. He then moved the medication cart onto Pleasant Hill House and without preforming hand hygiene prepared a resident medication, again rubbing eyes and nose, he then entered resident room, removed and applied a Lidoderm patch to the residents back, then administered the resident's medications all without performing hand hygiene. At this time, the LPN#3 stated, due to a condition, he frequently rubs his eyes, and he should have performed hand hygiene prior to preparing and administering medications. On 4/7/25 at approx. 8:30 a.m., the above was discussed with the Market Clinical Advisor
MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0578 (Tag F0578)

Minor procedural issue · This affected multiple residents

3. Resident #2 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the ...

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3. Resident #2 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #19 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. On 4/8/25 at 4:15 p.m., the above findings were reviewed with the Market Clinical Advisor. Based on record reviews, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive, for 4 of 14 residents reviewed for Advance Directives. (Resident#12, #18, #2 and #19) Findings: 1. Resident #12 was admitted to the facility in February 2025. A review of the residents electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. 2. Resident #18 was admitted to the facility in December 2024. A review of the residents electronic medical record and their paper medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an advanced directive to the resident and/or resident representative. On 4/6/25 at 3:00 p.m., the above information was Discussed with the Market Clinical Advisor.
Oct 2024 1 deficiency
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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to maintain a clean/sanitary environment on 1 of the 3 units. (Oak Hill...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to maintain a clean/sanitary environment on 1 of the 3 units. (Oak Hill House). Findings: On 10/7/24 at 9:14 a.m., the Department of Licensing received a complaint indicating that the bathrooms on the Oak Hill Unit were very dirty and smelled of an odor that resembled 'urine'. On 10/15/24 at 9:35 a.m., in an interview, the Housekeeping Manager stated that there are issues with the floors in some of the bathrooms on the Oak Hill Unit and that the floors tiles are loose, but they are afraid to use a scrubber & buffing machine on them because the tiles may become loose. On 10/15/24 at 9:45 a.m., during a tour, a surveyor observed the residents' bathrooms on the Oak Hill Unit. All resident bathroom floors were observed to have a buildup of wax and dirt. Bathrooms #2, #3, and #7 were observed to have extensive wax buildup. During the observation of bathroom [ROOM NUMBER], there was an overwhelming odor of what resembled urine. At this time the Housekeeping Manager confirmed the above findings. On 10/15/24 at 10:15 a.m., in an interview, the Maintenance Supervisor stated that the floors in the bathrooms on the Oak Hill Unit have been worked on in the past but should be cleaned by whatever means the Housekeepers need to use, to get them clean. If there is damage to the floors in the process, then he will have the floors fixed. On 10/15/24 at 1:00 p.m., a surveyor confirmed the above findings with the Administrator. . .
Mar 2024 10 deficiencies
CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observations and interviews, the facility failed to ensure a resident was treated with dignity and respect for 1 out of 14 residents reviewed during survey. (Resident #17) On 3/3/24 at 12:10...

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Based on observations and interviews, the facility failed to ensure a resident was treated with dignity and respect for 1 out of 14 residents reviewed during survey. (Resident #17) On 3/3/24 at 12:10 p.m., a surveyor observed a loud confrontation among a staff member, a family member, and Resident #17 in the Oak Hill Dining Room. The staff member was seen and heard yelling to the family member I need to talk to you. The staff member was observed pointing their finger at the family member. At this time, the staff member was escorted out of the room by another staff member. On 3/3/24 at 12:45 p.m., during an interview with the family member and Resident #17, they stated the family member had entered the facility and heard 3 staff members talking about Resident #17 in the lobby. The family member overheard one staff member say in an angry manner; I'll take care of this. The family member observed this staff member go directly to Resident #17 in the dining room and move his/her plate and loudly scold Resident #17. The family member and Resident #17 expressed feeling upset hearing staff talk that way. The resident stated, I'm not surprised, she doesn't like me. On 3/3/24 at 1:00 p.m., in an interview with the Administrator and Director of Nursing about the findings, the surveyor confirmed that it was not appropriate for staff to be talking about a resident in a public area.
CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Based on observation, interviews,record reviews, the facility's bathing schedule and facility's bathing documentation, the facility failed to ensure that resident's preferences were being followed in ...

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Based on observation, interviews,record reviews, the facility's bathing schedule and facility's bathing documentation, the facility failed to ensure that resident's preferences were being followed in the area of bathing for 2 of 6 residents reviewed. (Resident #14 and Resident #17) Findings: 1. On 3/3/24 at 8:58 a.m., during an obervation of Resident #14, the resident overheard asking a Certified Nurses Aide (CNA) for a shower. Resident #14 said, I was supposed to get a shower on Friday, but they told me they didn't have enough staff. I didn't get one last week either. During a review of the CNA bathing schedule indicated that the resident's scheduled weekly shower was on Thursdays. 2. On 3/4/24 at 9:15 a.m., during an interview with Resident #17, stated had not ever received a shower at the facility. A review of the admission record for Resident #17 showed an admission to the facility on 6/23/23. She/He stated, They said I am getting dandruff. I need a shower. A review of the CNA bathing schedule indicated that Resident #17's scheduled bathing day was Sunday. On 3/5/24, a surveyor reviewed the facility's bathing documentation for a 9-week period from 1/1/24 to 3/5/24. Resident #14 received one shower during this period on 2/18/24. There were no documented showers for Resident #17. On 3/6/24 at approximately 10:00 a.m., during an interview with a CNA, Resident #17 needs 2 staff members for bathing as well as a mechanical lift for transferring. On 3/6/24 at 10:15 a.m., a surveyor met with the Director of Nursing and shared the above findings.
CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that food was stored in the walk-in fridge correctly and that ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that food was stored in the walk-in fridge correctly and that the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen tour observations. Findings: 1. On 3/3/24 at 9:10 a.m., during the initial tour of Kitchen, a surveyor observed 2 uncovered, undated, and unmarked trays of deserts. Also observed, 2 wall mounted fans with a light to moderate amount of dirt, a ceiling vent with a small to moderate amount of dust and debris. The entire ceiling has a moderate to heavy amount of staining and spotting. The cook was made aware of the findings at that time. 2. On 3/5/24 at 1:00 p.m., during a return visit to the Kitchen tour with the Food Service Director. She stated that some new ceiling tiles have been ordered and that it is the responsibility of the Facility's Management to clean the ceiling, but it has not been done for the 3 years that she has been here. Inspection of the meat slicer found pieces of meat still on the back side of the slicer, Food Service Director stated that they usually use it only once a week. The Food Service Director was made aware of all the findings at that time. 3. On 3/6/24 at 2:00 p.m., observation of the Unit Refrigerator on the long-term-care Pleasant Hill Unit found that the fridge has Cranberry appearing stains and shelves and the bottom of the Unit. The Freezer unit has a moderate amount of staining. The [NAME] Hill Unit fridge had Cranberry staining on the shelves and the bottom of the unit and onto the floor. The freezer unit had a plate size area of brownish staining and debris on the bottom of freezer around the drain. Oak Hill Unit fridge has dirty stains on the top of the door when opened and on the shelves and the bottom of the unit. These were confirmed with the Charge Nurse on the units.
CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

Based on observations the facility's quality assurance committee failed to ensure that the plan of correction for identified deficiencies from the Annual Long Term Care Survey Process from 3/4/2024 th...

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Based on observations the facility's quality assurance committee failed to ensure that the plan of correction for identified deficiencies from the Annual Long Term Care Survey Process from 3/4/2024 through 3/6/2024 was effective. The following issue was again identified at this survey. Findings: At the Annual Long Term Care Survey Process from 3/4/2024 through 3/6/2024, the following deficiency was cited F812. On 5/2/2024, during the follow up visit, it was determined that F812 would be recited. F812 for failure to remove/clean stained ceiling tiles in the Kitchen, and clean Kitchen counter surfaces. A surveyor confirmed these findings with the Administrator on 5/2/2024 at 9:30 a.m.
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 maintain a safe, clean, comfortable and homelike environment on 2 o...

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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 safe, clean, comfortable and homelike environment on 2 of 2 units and in the Kitchen. Findings: 1. On 3/3/24 at 9:10 a.m., during the initial observation of the Kitchen with the cook, it was observed that the ceiling had multiple ceiling tiles that had moderate to heavy amounts of spotting and staining. On 3/6/24 at 11:15 a.m., in an interview with the Director of Maintenance, he stated that the Kitchen ceiling had not been cleaned in the 13 years that he has been here. He stated, I would not know how you would clean that. 2. On 3/6/24 at 11:20 a.m., during a tour of the Long Term Care Unit with the Director of Maintenance the following were observed: - Pleasant Hill House, resident room [ROOM NUMBER], the window curtains were off the track on both sides of the window. One stained ceiling tile at the nurses' station and 1 stained ceiling tile in the resident dining room. 3, On 3/6024 at 11:40 a.m., during a tour of the Short Stay Unit with the Director of Maintenance, the following were observed: - Stained ceiling tiles in resident room [ROOM NUMBER], just over the bed. - One stained ceiling tile at the Nurse's station, and one stained ceiling tile in the hallway just outside the dining room. The Director of Maintenance was made aware of the findings at that time and recorded them.
CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and observations, the facility failed to provide sufficient staffing to meet the acuity leve...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and observations, the facility failed to provide sufficient staffing to meet the acuity level and resident needs in a timely manner for 3 out of 3 units surveyed. (Pleasant Hill House, [NAME] House and Oak Hill House) Findings: 1. On 3/3/24 at 9:17 a.m a surveyor observed Resident #14 asking a CNA #2 for a shower. Resident #14 stated they should have gotten a shower on Friday but was told there wasn't enough staff that day. And it happened last week too. CNA #2 confirmed the resident's scheduled shower day was Thursday and it hadn't happened yet this week. A record review of Resident #14's bathing documentation revealed only 1 documented shower in the past 63 days. On 3/3/24 9:30 a.m., a surveyor interviewed CNA #5, There's a lot I can't get to. Changing, repositioning, it doesn't happen. Things we are supposed to do but can't get to it. I spend all my time looking for someone to help me. I find them and then I have to wait because they're busy. We should have 2 people over here. On 3/3/24 at 9:35 a.m., a surveyor interviewed CNA #3 We can't give the care we need because there isn't enough staff It's disruptive to my med pass when I am constantly pulled away from the med cart When asked if it feels safe to have so many disruptions during a medication pass, CNA #3 replied No. 2. On 3/3/24 at 9:38 a.m., a surveyor observed a call bell on Oak Hill Unit go unanswered for 40 minutes. 3. On 3/3/24 at 10:10 a.m., a surveyor interviewed Resident #17 and learned that she/he had requested to get up at 6:00 a.m. and wasn't helped up until 10:00 a.m. after being told they didn't have enough staff yet. 4. On 3/4/24 at 9:16 a.m., during an interview with CNA #2 and was told there is no support from licensed staff and that most wait for the CNAs to answer the call bells. 5. On 3/5/24 at 9:00 a.m., a surveyor interviewed Resident #12 after observing a 40 minute wait for the call bell to be answered. The resident stated it usually takes 30-45 minutes for someone to answer the call bell. That is not unusual. 6. On 3/5/24 at 9:05 a.m., a surveyor interviewed Resident #18 who said staffing was a problem, especially on the weekends; My roommate and I have talked and we feel like if we died on a Friday afternoon, that no one would find us until Monday morning 7. On 3/5/24 at 10:35 a.m., a surveyor interviewed Resident #14 who stated that the food was frequently cold by the time it was passed and the CNAs had to waste time heating up the food because it was always cold. 8. On 3/6/24 at 9:45 a.m., a surveyor interviewed CNA #1 and learned that 11 out of 39 residents on Pleasant Hill, [NAME] House and Oak Hill Units always need 2 staff members for care but sometimes it's more. It's hard to find someone to help explaining they get stuck in a room with a resident and can't get to the lights or they are waiting for someone to come help. 9. On 3/6/24 at 10:54 a.m., a surveyor observed CNA #1 come to the nursing station to request assistance and the licensed staff replied, Ok but this is why I don't get my dressings done. During an interview with the CNA #1 afterwards, she/he revealed that That nurse is one of the first ones to help when we ask but most don't. On 3/6/24 at 1:00 p.m., a surveyor brought the above findings to the attention of the Director of Nursing.
CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

Based on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for a nurse aide at least every 12 months, for 2 of 5 sampled Certified Nursing A...

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Based on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for a nurse aide at least every 12 months, for 2 of 5 sampled Certified Nursing Assistants (CNA) employed greater than 1 year (CNA1, CNA3). Findings: On 3/6/24, a surveyor reviewed the following employee files: 1. CNA1 was hired 12/13/16. The last annual evaluation was completed and signed on 10/21/2020. The next annual evaluation was dated for December for 2021-2022 year however, was not signed until 4/18/23. 2. CNA3 was hired 12/23/19. The last annual evaluation was completed and signed on 1/2/2020. The next annual evaluation was dated for 2021-2022 however, was not signed until 4/7/23. On 3/6/24 at 9:51 a.m., during an interview with a surveyor, the Administrative Assistant stated she was unable to find one for both CNA 1 and CNA 3 for 2023. At this time, the Administrative Assistant stated she was aware of the lack of annual evaluations at the end of 2023 and has not completed any of the past due evaluations at this time.
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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure that the clinical records contained accurate documentation ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure that the clinical records contained accurate documentation for 1 of 6 residents reviewed for medications (# Resident 154), and for 1 of 22 sampled residents ( Resident #111). Findings: 1. On 9/26/23 the Department of Health received a complaint that Resident #154 was not receiving medications correctly and the residents eye drops were found in another resident's room. During a record review, Resident #154 was admitted on [DATE] with physician orders for Ketorolac Tromethamine Ophthalmic Solution Instill 1 drop in left eye two times a day for inflammation. Review of the electronic medication administration record (EMAR), it was noted that the medication was held on the evening of 9/21/23, administered on both day and evening shifts on 9/22/23 and 9/23/23 then held again for both day and evening shifts on 9/24/23 and day sift on 9/25/23. Further review of the medical record showed EMAR notes stating, on 9/21/23, 9/24/23 and 9/25/23 the eye drops were held due to awaiting delivery from pharmacy. A provider order sheet dated 9/25/23 states, FYI: Patients daughter to bring in Ketorolac ophthalmic drops (0.5%) . (Omnicare out of this medication). Additionally, the pharmacy Proof of Delivery report states Resident #154's eye drops were delivered on 9/25/23. On 3/5/24 at 3:10 p.m., during an interview, the surveyor asked the Director of Nursing (DON) how the eye drops were administered on 9/22/23 and 9/23/23 when they were not delivered until 9/25/23, 4 days after admission. At this time, the DON confirmed inaccurate records. 2. Record review revealed Resident #111 was admitted to the facility on [DATE]. The baseline care plan was initiated on 8/8/23, and was revised on 8/11/23 to include activities. On 3/5/24 at 1:20 p.m., in an interview with a surveyor, the Marketing Clinical Advisor confirmed Resident #111 was not admitted until 8/10/23 and that predating a care plan prior to the actual admission was incorrect. On 3/5/24 at 1:30 p.m., the Director of Nursing (DON) stated that staff had anticipated Resident #111 would be admitted on [DATE], however, the hospital discharge was delayed. The DON stated staff had initiated the care plan, but the correct date of admission did not carry over. The DON confirmed that staff did not revise the care plan to reflect the correct date of admission.
CONCERN (E)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

Based on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that they held quarterly Meetings. There is documentation of 3 of 4 meeting...

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Based on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that they held quarterly Meetings. There is documentation of 3 of 4 meetings and that the required members were in attendance. The Administrator attended 3 of 4 quarterly QAA meetings and the Medical Director attended 3 of 4 quarterly QAA meetings. Findings: 1. On 3/4/24 a review of the QAA Agenda/Sign-in pages found that the there was no sheet for April, the month for one of the Quarterly Meetings. 2. Review for October, another of the Quarterly Meetings, the Administrator and the Medical Director were absent. 3. On 3/5/24 at 8:15 a.m., in an interview, the Administrator stated that the designated months for the Quarterly QAA meetings are January, April, July, and October. He could not account for the lack of April meeting documentation. He was informed of the finding at that time.
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 record reviews and interviews, the facility failed to perform adequate screening and documentation for the pneumococcal...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to perform adequate screening and documentation for the pneumococcal vaccination as required for 3 out of 5 Residents screened for vaccinations. Findings: 1. On 3/5/24, a surveyor reviewed Resident #14's Electronic Medical Record (EMR) and found no pneumococcal vaccinations recorded under Immunizations. A surveyor reviewed the physical medical record and found that Resident #14 had received the PPV13 (A type of pneumococcal vaccine) vaccination on 10/1/15 and the PPSC23 (A type of pneumococcal vaccine) vaccination on 10/31/08. These were not recorded in the EMR. 2. On 3/5/24, a surveyor reviewed Resident #26's EMR and found no pneumococcal vaccinations were recorded. A surveyor reviewed the physical medical record and found a signed undated consent refusing the PPVC 13 vaccination but no documentation showing the PCV 20 (A type of pneumococcal vaccine) vaccination was offered as required by facility policy. 3. On 3/5/24, a surveyor reviewed Resident #1's EMR and found no pneumococcal vaccinations under immunizations. A surveyor reviewed the physical medical record for Resident #1 and found the PCV 13 was given on 12/15/15. This was not recorded in the EMR. No documentation was located that the PCV 20 had been offered as required by facility policy. A surveyor reviewed the facility policy titled IC601 Pneumococcal vaccination last revised 11/1/23; Upon Admission, obtain the pneumococcal vaccination history of all patients. 1.2 Document pneumococcal vaccination history in the electronic medical record. And 2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated, or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule. 2.1 Offer the PCV20 vaccine to adults 19-[AGE] years of age with underlying medical conditions. On 3/5/24 at 11:14 a.m., a surveyor interviewed the Director of Nursing and notified of the above findings.
Nov 2022 4 deficiencies
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 that a resident, and/or resident representative, was involv...

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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 that a 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 8 residents sampled for new admissions (Resident #43). Finding: On 11/01/22 at 9:30 a.m., Resident #43 stated no one had met with him/her since admission to discuss care planning. Resident #43 stated he/she had not been provided a copy of the initial care plan. A review of Resident #43's clinical record indicated he/she was admitted to the facility on [DATE]. The baseline care plan was initiated on 10/5/22 and included several revisions, with10/18/22 being the most recent. The clinical record lacked evidence that the resident, and/or resident representative, were provided a summary of Resident #43's baseline care plan. On 11/1/22 at 2:10 p.m., the Clinical Lead confirmed the finding.
CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to update and include interventions on the resident's current comprehensive care plan for the areas of Activities of Daily Living for 1 of 31 ...

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Based on record review and interview, the facility failed to update and include interventions on the resident's current comprehensive care plan for the areas of Activities of Daily Living for 1 of 31 residents sampled (Resident #272). Finding: 1. Documentation in Resident #272's clinical record indicated on a physician's order sheet, dated 10/11/22, instructed staff that Resident #272 is to be Non-weightbearing to right lower extremity. A review of Resident #272's comprehensive care plan dated 10/11/22, under the problem areas of decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to recent fall with fracture and hospitalization resulting in fatigue and limited mobility. The care plan instructs staff to provide the resident with limited assist of 1-2 for transfers using a pivot transfer. Resident #272's comprehensive care plan failed to provide interventions addressing the recommendation for non-weightbearing status to the right lower extremity. On 11/1/22 at 1:59 p.m., the surveyor confirmed this finding in an interview with the Clinical Lead.
CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident a...

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Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative to review and revise the care plan after each assessment for 2 of 31 sampled residents (#14, #18). Findings: 1. On 11/1/22 at 8:53 a.m., during an interview with Resident #14, when asked if he/she is invited and/or participates in his/her plan of care, the resident stated he/she had about 2 of them and has been at the facility for 3 years and They may have had them on Mondays, Wednesdays or Fridays when I'm not here. Review of Resident #14's medical record, the surveyor noted a Minimum Data Set (MDS) Annual Review assessment, dated 4/7/22 and a Quarterly Review assessment, dated 7/8/22. The clinical record lacked evidence of an IDT meeting which included the resident, and/or resident's representative after both the 4/7/22 and 7/8/22 assessments. 2. Review of Resident 18's medical record, the surveyor noted a MDS Quarterly Review assessment, dated 12/8/21. The clinical record lacked evidence of an IDT meeting which included the resident, and/or resident's representative after the 12/8/21 assessment. On 11/2/22 at 1:09 p.m. the above findings were confirmed with the Clinical Lead Nurse.
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 observation and interviews, the facility failed to ensure expired medications were removed from the supply available fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 and 1 of 3 medication carts observed. Findings: 1. On 10/31/22 at 9:30 a.m., observations of the short stay medication room with the Certified Medication Technician (CNA-M), the surveyor noted one unopened bottle of Ferrous Gluconate with best by date of 7/22. On 10/31/22 at approx. 9: 52 a.m., during an interview with Clinical Nurse Lead and Director of Nursing a surveyor discussed the expired medication. 2. On 11/1/22 at 8:45 a.m., observation of medication cart for Pleasant unit rooms 1-7 and [NAME] unit rooms 4b-7 with the CNA-M, the surveyor noted the following: A medication card containing 1 tab of Famotidine 20mg with expiration date of 8/31/22, 2 medications cards containing 29 Omeprazole 20mg capsules with exp date of 9/30/22 and 2 medication cards containing 30 Omeprazole 20mg capsules both with the expiration date of 10/31/22. On 11/1/22 at 9:02 a.m., during an interview with Clinical Lead Nurse and the Director of Nursing, a surveyor discussed the above findings.
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
  • • 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.
Concerns
  • • 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.

About This Facility

What is Pine Point Center's CMS Rating?

CMS assigns PINE POINT CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Maine, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Pine Point Center Staffed?

CMS rates PINE POINT CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 53%, compared to the Maine average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Pine Point Center?

State health inspectors documented 27 deficiencies at PINE POINT CENTER during 2022 to 2025. These included: 26 with potential for harm and 1 minor or isolated issues.

Who Owns and Operates Pine Point Center?

PINE POINT CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 61 certified beds and approximately 54 residents (about 89% occupancy), it is a smaller facility located in SCARBOROUGH, Maine.

How Does Pine Point Center Compare to Other Maine Nursing Homes?

Compared to the 100 nursing homes in Maine, PINE POINT CENTER's overall rating (3 stars) is below the state average of 3.0, staff turnover (53%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Pine Point Center?

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 Pine Point Center Safe?

Based on CMS inspection data, PINE POINT CENTER 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 3-star overall rating and ranks #100 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 Pine Point Center Stick Around?

PINE POINT CENTER has a staff turnover rate of 53%, which is 7 percentage points above the Maine average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Pine Point Center Ever Fined?

PINE POINT CENTER 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 Pine Point Center on Any Federal Watch List?

PINE POINT CENTER 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.

PINE POINT CENTER

67 PINE POINT RD, SCARBOROUGH, ME 04074 | (207) 883-2468

C+
Trust Grade (60/100)
3.0
CMS Rating
27
Deficiencies

Strengths

  • Licensed facility

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025