PINNACLE HEALTH & REHAB AT SOUTH PORTLAND

42 ANTHOINE ST, SO PORTLAND, ME 04106 (207) 799-8561
For profit - Limited Liability company 73 Beds Independent Data: November 2025
Trust Grade
85/100
#12 of 77 in ME
Share this report: Email Text Facebook WhatsApp
Last Inspection: December 2022

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Pinnacle Health & Rehab at South Portland has a Trust Grade of B+, which indicates it is above average and recommended for families considering care options. It ranks #12 out of 77 nursing homes in Maine, placing it in the top half of facilities statewide, and #3 out of 17 in Cumberland County, meaning only two local options are better. The facility is improving, with issues decreasing from nine in 2022 to just two in 2024. Staffing is rated 4 out of 5 stars, but the 53% turnover rate is average compared to the state. There have been no fines, which is a positive sign, but the RN coverage is concerning as it is less than 89% of Maine facilities, meaning there may be fewer registered nurses available to catch potential problems. However, there are some weaknesses. Recent inspections found issues such as dirty common areas, a failure to involve residents in care plan discussions, and the presence of outdated medications in storage areas. Families should weigh these strengths and weaknesses when considering this facility for their loved ones.

Trust Score
B+
85/100
In Maine
#12/77
Top 15%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
9 → 2 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
○ Average
Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Maine. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
14 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★★
5.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2022: 9 issues
2024: 2 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Staff Turnover: 53%

Near Maine avg (46%)

Higher turnover may affect care consistency

The Ugly 14 deficiencies on record

Jul 2024 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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Complaint Surve...

Read full inspector narrative →
Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Complaint Survey Process dated 7/30/24, was effective. The federal citation F880 was cited again during the re-visit to the Complaint Survey, dated 9/25/24. Finding: At the Complaint Survey Process, the following deficiency was cited, F880. During the follow up survey on 9/25/24, it was determined the F880 would be recited for the same issue: failure to maintain and implement an infection control program to help prevent the development and transmission of disease and infection. On 9/25/24 at approx. 1:30 p.m., during and interview, the above was confirmed with the Administrator and Director of Nursing.
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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, and interviews, a staff member (LPN#1) failed to follow the facility's Infection a...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, and interviews, a staff member (LPN#1) failed to follow the facility's Infection and Prevention Policy and Update of 7/18/24. to prevent the introduction and spread of Coronavirus Infectious Disease 2019 (COVID-19) in the facility. Findings: On 7/30/24 at 7:45a.m., a surveyor entered the facility and observed signs stating that there were 5 (five) cases of COVID-19 in the facility and they were located on Unit 300. For staff to enter that unit a N-95 mask is required, and for care of a resident that is COVID-19 positive, full Personal Protective Equipment (PPE) is required including N-95, eye protection, gown, and gloves. On 7/30/24 at 8:05a.m. a surveyor observed LPN#1 enter room [ROOM NUMBER] to give a resident medication, LPN#1 was wearing only an N-95 mask, no other PPE was donned as per the facility policy. There was a sign on the door warning of respiratory precautions and a 3-drawer cabinet just to the right of the door filled with PPE. When LPN#1 she exited the room, she confirmed in an interview with the surveyor that the resident in the room was COVID-19 positive, and further stated that because she was only in the room briefly, she thought it was okay to only wear the N-95 mask, versus wearing the full PPE. On 7/30/24 at 8:15a.m. in an interview with the Director of Nursing, (DON) and the Infection Preventionist, the surveyor confirmed that all staff entering a room with a COVID-19 positive resident will wear Full PPE - N95, face shield, gown, and gloves.
Dec 2022 9 deficiencies
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 observations, record review and interview, the facility failed to develop/implement a care plan in the area of respiratory and failed to implement the intervention for the care area of physic...

Read full inspector narrative →
Based on observations, record review and interview, the facility failed to develop/implement a care plan in the area of respiratory and failed to implement the intervention for the care area of physical mobility for 2 of 25 sampled residents. (#7, #39) Findings: Facilities policy: Oxygen therapy, reviewed on 12/6/22 states, Oxygen administration requires a physician order. In an emergency, a nurse may administer O2 and obtain an order within 24 hours and Change mask and or cannula as needed if it becomes soiled. Update care plan in resident profile as needed. 1. On 12/5/22 at 10:01 a.m., observation of Resident #7 to have Oxygen (O2) on at 3.5 liters per minute via nasal cannula, the tubing did not have a date in place and the nasal cannula had darkened yellowish prongs. At this time in an interview with the resident, he/she stated the oxygen is used all the time and he/she is not sure if the tubing is changed frequently stating, I wondered about that, I thought they are supposed to. Review of the medical record revealed nursing documentation confirming Resident #7 had been using oxygen since October 2022. Further review, the medical record lacked evidence that a care plan was developed/implemented for the resident's respiratory needs and monitoring. On 12/6/22 at 12:38 p.m., during an interview, the Director of Nursing confirmed the above findings. 2. Resident #39's care plan initiated on 6/2/22, states the resident has a limited physical mobility with interventions for Teds [thromboembolic deterrant] hose as indicated - on in AM / off HS. A physician order dated 10/27/22 instructs nursing to apply Teds on in the am off QHS, in the morning for edema. On 12/5/22 at 10:19 a.m., observation of Resident #39 in bed with both lower extremities elevated on a pillow, both ankles were observed to be edematous, and he/she did not have Teds in place. On 12/6/22 at 8:13 a.m., observation of resident #39 standing at the sink, wearing slippers, he/she did not have Teds in place. On 12/6/22 at 11:46 a.m., additional observation of Resident #39 in the recliner with both lower extremities elevated, no Teds in place. The resident removed his/her slippers revealing an imprint of the slippers due to the edema. At this time, during a resident reprehensive interview it was reported that Teds were supposed to be ordered, but I haven't seen them on [him/her]. I looked for them. In the morning they should be put on. Haven't seen them and It would be something that would have to be washed, but I haven't seen any. The resident representative stated he/she visits Resident #39 two to three times weekly. On 12/6/22 at 12:09 p.m., during an interview with the Certified Nurse Assistant (CNA), she confirmed Resident #39 is to have Teds on daily and whoever is assigned to the resident is supposed to put them on. At this time both the surveyor and the CNA observed resident #39 without Teds on. The CNA seared the resident's room and could not find any pairs of Teds. On 12/6/22 at 12:38 p.m. the above findings were discussed with the Director of Nursing.
CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on record review, observation and interview, the facility failed to follow their own policy on Oxygen (O2) therapy and failed to obtain physician orders for oxygen for 1 of 2 residents reviewed ...

Read full inspector narrative →
Based on record review, observation and interview, the facility failed to follow their own policy on Oxygen (O2) therapy and failed to obtain physician orders for oxygen for 1 of 2 residents reviewed for respiratory care. (#7) Findings: Facilities policy: Oxygen therapy, reviewed on 12/6/22 states, Oxygen administration requires a physician order. In an emergency, a nurse may administer O2 and obtain an order within 24 hours and Change mask and or cannula as needed if it becomes soiled. Update care plan in resident profile as needed. On 12/5/22 at 10:01 a.m., observation of Resident #7 to have Oxygen (O2) on at 3.5 liters per minute via nasal cannula, the tubing did not have a date in place and the nasal cannula had darkened yellowish prongs. At this time in an interview with the resident, he/she stated the oxygen is used all the time and he/she is not sure if the tubing is changed frequently stating, I wondered about that, I though they are supposed to. A review of Resident #7's medical record lacked evidence of a physician order for oxygen therapy and orders for O2 tubing changes. On 12/7/22 at 12:18 p.m., during an interview, the Director of Nursing confirmed the above and stated O2 tubing should be changed weekly, as an addition of the policy.
CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observations, record review, and interviews, the facility failed to maintain adequate pharmaceutical services to ensure the removal of controlled medication to avoid misuse and diversion in 1...

Read full inspector narrative →
Based on observations, record review, and interviews, the facility failed to maintain adequate pharmaceutical services to ensure the removal of controlled medication to avoid misuse and diversion in 1 of 3 medication carts observed. In addition, the facility failed to follow their policy for removal of controlled substances from use. Findings: The facility policy: Controlled Medications/Medication Management, on page 2, number 5 states that (Discontinued Schedule II drugs/controlled drugs awaiting disposal by the pharmacist must be removed from circulations and double locked. On 12/6/2022, observation of medication cart on Unit 300, revealed a box of Liquid Morphine Sulfate with tape across the top that said Do not use This bottle corresponds to page 37 in the narcotic book. The page indicates that there should be around 7.5 ml there is less than 5 ml. The Director of Nursing has made an entry in the narcotic log that there had been math errors and that this medication should be removed. The latest date marked in the narcotic book is 11/27/2022. This was confirmed with Registered Nurse #1 at that time. This was confirmed with the Director of Nursing at approximately 3:00 p.m. On 12/8/2022, The Director of Nursing, stated that the Pharmacist comes to the facility once a month to destroy drugs. The date of the last visit was 10/12/2022. There was a visit scheduled for 11/9/2022, but was canceled due to the COVID-19 outbreak. The date of the next scheduled visit is 12/19/2022.
CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure that a patient lift, used for transferring residents, was maintained in good repair and safe operating condition for 1 of 4 days of su...

Read full inspector narrative →
Based on observation and interview, the facility failed to ensure that a patient lift, used for transferring residents, was maintained in good repair and safe operating condition for 1 of 4 days of survey (12/5/22) on I of 3 Units (200 Unit). Finding: On 12/05/22 at 10:16 a.m., a surveyor observed the 200 Unit Invacare/Jasmine patient lift was missing a safety latch on one of the sling hooks. In an interview at this time, the Administrator confirmed the patient lift was not in good repair and was not safe for use. The lift was taken out of service at this time.
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 housekeeping and maintenance services necessary ...

Read full inspector narrative →
**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 on 3 of 3 Units (100s Unit, 200s Unit and 300s Unit), the laundry room and the front lobby sitting area for 1 of 1 Environmental Tour. Findings: On 12/8/22 from 8:45 a.m. to 9:15 a.m., an Environmental Tour was conducted with the Environmental Services Director in which the following findings were observed: > The front lobby sitting area had nine tan cloth chairs that were soiled with dried liquid residue on the backs, arms and seats. 100 Unit: > The hallway floor-carpet hard numerous large brownish stains and was heavily soiled. > Resident room [ROOM NUMBER] - The wall behind the head of bed A was gouged/cracked creating an uncleanable surface. The privacy curtain had missing hooks and was hanging in disrepair. > Resident room [ROOM NUMBER] - Bed A privacy curtain had missing hooks and was hanging in disrepair. > Resident room [ROOM NUMBER] - Bed A privacy curtain had missing hooks and was hanging in disrepair. > The hallway wall mounted fan, by resident room [ROOM NUMBER], was dusty/dirty. > The Arjo Patient Lift had gauze and cloth wrapped around the sling arm creating an uncleanable surface. 200 unit > The hallway floor-carpet hard numerous large brownish stains and was heavily soiled. > Resident room [ROOM NUMBER] - The ceiling above bed A had two large brown stains on it. The left armrest of the wheelchair was cracked/ripped. > Resident room [ROOM NUMBER] - Bed A floor mat was ripped and had frayed edges. The wall fan was heavily soiled with dust/dirt. The bathroom exhaust fan was dusty/dirty. The floor around the base of the toilet was dirty. > Resident room [ROOM NUMBER] - The bathroom exhaust fan was dusty/dirty. > The hallway wall mounted fan, by resident room [ROOM NUMBER], was dusty/dirty. > The hallway wall mounted fan, at end of the hall by the laundry room door, was dusty/dirty. The cloth chair, under this fan in hallway was soiled with dried liquid residue. > The sit-to-stand lift had ripped/missing non-skid tape on the foot area and chipped/missing paint on base legs. 300 Unit > The hallway floor-carpet hard numerous large brownish stains and was heavily soiled. >Broda chair #3, in the hallway by resident room [ROOM NUMBER], had ripped material on the right side. > The tilt back blue Geri-chair, in the hallway by resident room [ROOM NUMBER], had a ripped/ton left armrest > Resident #11's wheelchair had rips/tears in both the left and right armrests. > Resident #40's wheelchair had duct tape on the right hand grip and on the back creating uncleanable surfaces. > Resident room [ROOM NUMBER] - The ceiling tile, above the sink area, had a large brown stain. > Resident room [ROOM NUMBER] - Bed A privacy curtain had missing hooks and was hanging in disrepair. > The hallway wall mounted fan, by resident room [ROOM NUMBER], was dusty/dirty. > Resident #23's wheelchair had rips/tears in both the left and right armrests. > Resident #62's wheelchair had rips/tears on the right arm rest with foam exposed. Additionally, the wheelchair had dried food and liquid residue all over it. > Resident #43's wheelchair had rips/tears on the left arm rest. Additionally, the wheelchair had dried food and liquid residue on the frame. > Resident #24's wheelchair had dried food and liquid residue on the frame. > The Dining room wall had a large area, approximately 3 feet by 3 feet of patched wall with joint compound, which was un-sanded and unpainted. Laundry: > The ceiling vent, above the dryers, was heavily soiled with dust/dirt. On 12/8/22 at 9:15 a.m., in an interview, the Environmental Services Director confirmed the findings.
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 interview 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 an...

Read full inspector narrative →
Based on interview 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 after each assessment for 2 of 25 sampled residents (#7, #60). Findings: 1. During review of Resident 7's medical record, the surveyor noted a IDT Social Services Progress note dated 9/19/22 which stated, [Resident #7] was not invited r/t her dx. On 12/8/22 at 9:58 a.m., during an interview, the Licensed Social Worker (LSW) stated Resident #7 was not invited the IDT meeting due to the resident's cognitive status stating, I did not extend an invitation to him/her. The surveyor asked if all residents with cognitive deficits were not invited to their IDT meeting. she stated, it really depends, we look at the level of cognitive loss or understanding she then stated, she recently had a discussion with Resident #7 regarding his/her money and where Resident #7 wanted it to be distributed. At this time, the surveyor asked, why the resident can make decisions about where his/her money is distributed but did not have the cognitive capability to making decisions about his/ her plan of care. The LSW agreed confirming the above. 2. During review of Resident #60's medical record, the surveyor noted a IDT Social Services Progress note dated 11/21/22 which stated, Email wasn't sent to Father & Step-Mom/Co-guardians or [NAME] r/t Covid +. No one attended on behalf of (Resident #60). Team didn't meet with (Resident #60) r/t him being quarantined (Covid+). Further review of Resident #60's clinical record noted Resident #60 tested positive for Covid on 11/10/22 and precautions were removed on 11/21/22. On 12/8/22 at 10:38 a.m., during an interview, the Licensed Social Worker (LSW) confirmed that no one was invited and no one was given the opportunity to attend using precautions or via video conference.
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 interview, the facility failed to maintain adequate pharmaceutical services to ensure that outdated m...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interview, the facility failed to maintain adequate pharmaceutical services to ensure that outdated medications, and medication no longer in use be removed from availability as discovered in 2 of 3 medication carts and 1 of 3 medication storage rooms. Findings: 1. On [DATE], at 7:30 a.m. a surveyor observed in medication cart B for Unit 200, 1 bottle of Vitamin C with an expired date of 11/22. At this time, this was confirmed with the Licensed Practical Nurse. 2. On [DATE], at 8:00 a.m. a surveyor observed in the medication cart on Unit 300, a box of liquid Morphine Sulfate with strips of paper tape across the open box with writing that said, Do not use. This bottle corresponds to page 37 in the narcotic book. The page in the indicates that there should be around 7.5 ml there and with observation it appears to be less than 5ml. The last date of use of the narcotic was [DATE] and should have been removed from the medication cart and taken to the Director of Nursing to be locked and stored until the medication could be destroyed. At this time, this was confirmed by Registered Nurse #1. 3. On [DATE], at 8:10 a.m. on Unit 100, a surveyor discovered a unopened box of Liquid Lorazepam with the expiration date of [DATE] in the locked refrigerator available for use. At this time, this was confirmed with the Nurse Manager. On [DATE], at approximately 3:00 p.m., the above were confirmed with the Director of Nursing.
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 wall mounted fans, a window fan, the hood system, ceiling lights, ceil...

Read full inspector narrative →
Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall mounted fans, a window fan, the hood system, ceiling lights, ceiling tiles and the dry storage room. Additionally, the facility also failed to ensure products in the walk-in refrigerator and walk-in freezer were labeled and dated. Further, the facility failed to label whipped topping with a thaw date. Findings: On 12/5/22 from 9:10 a.m. to 9:40 a.m., a kitchen tour was conducted with the Certified Dietary Manager in which the following findings were observed: > The wall mounted fan, by a food storage shelf, was dusty/dirty. > Two wall mounted fans, in the dish room, were dusty/dirty and were blowing on clean dishes. > The window fan, in the dish room, was dusty/dirty and was blowing on a clean dish area. > The hood system filter was heavily soiled with dust/dirt. > Two ceiling lights had dust/dirt and debris in and on the lenses. > One ceiling light, in the dish room, had dust/dirt and debris in and on the lens. Additionally, the lens was cracked. > Four ceiling tiles, to the right of the hood system, were soiled with large brown stains. > The dry storage room had one ceiling light with a cracked lens and one ceiling light with a lens that had dust/dirt and debris in it. > The walk-in freezer had one previously opened package of small brown food chunks, five pie shells, one previously opened package of sliced pepperoni and one package of meat balls that was full of ice crystals, that were not labeled and dated. > The walk-in refrigerator had five packages of thawed whipped topping that did not have a thaw date on them. The package noted that the product was good for two weeks after thaw date. On 12/5/22 at 9:40 a.m., the Certified Dietary Manager confirmed the findings. On 12/5/22 at 10:00 a.m., the findings were discussed with the Administrator.
MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

Based on record reviews and interviews, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 1 of 3 resi...

Read full inspector narrative →
Based on record reviews and interviews, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 1 of 3 residents sampled for hospitalizations. (Resident #27) Findings: Documentation in Resident #27's clinical record indicated that the resident was transferred to an acute care hospital on 9/16/22 and again on 10/7/22 and subsequently admitted . The clinical record lacked evidence that Resident #27 and/or the resident representative were provided with a written transfer/discharge notice upon transfer. On 2/7/22 at 12:40 p.m., in an interview, the Nurse Manager for the 200 Unit confirmed that written transfer/discharge notices were not provided to the residents and/or resident representatives in writing for either transfer.
Dec 2019 2 deficiencies
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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility staff failed to develop a care plan to address behaviors and the use of an ...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility staff failed to develop a care plan to address behaviors and the use of an antipsychotic medication for 1 of 6 residents reviewed for unnecessary medications (Resident #10). Finding: On review of Resident #10's most recent signed medication orders, dated 12/3/19, the surveyor noted an order for an antipsychotic medication, Risperdal Tablet 0.5 MG (milligrams) - Give 0.5 mg by mouth in the afternoon for agitation/anxiety related to psychotic disorder with delusions due to known physiological condition, with an original date of 6/7/19. A review of Resident #10's quarterly Minimum Data Sets 3.0 (MDS), dated [DATE] and 9/16/19, revealed the resident received antipsychotic medication for 7 days during each of the assessments' look back period. The surveyor reviewed Resident #10's care plan. The care plan did not address any behaviors nor the use an antipsychotic medication. On 12/05/19 at 9:19 a.m., in an interview with the Director of Nursing, the surveyor confirmed a care plan was not developed to reflect Resident #10's behaviors and use of an antipsychotic medication.
CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews the facility failed to ensure as needed (PRN) psychotropic medications met the required 14-day limit for 2 of 6 residents reviewed for unnecessary medications (R...

Read full inspector narrative →
Based on record reviews and interviews the facility failed to ensure as needed (PRN) psychotropic medications met the required 14-day limit for 2 of 6 residents reviewed for unnecessary medications (Resident #2 and #14). Findings: 1. A review of Resident #2's Physician Orders, revealed Resident #14 with an order, signed 9/6/19, for Hydroxyzine (an antianxiety medication) 25 milligrams (mg), give by mouth (PO) every 6 hours as needed (PRN) for anxiety with no stop date. The medical record lacked evidence of clinical rational to continue the (PRN) medication. A review of Resident #2's Physician Orders, revealed that Resident #2 with an order, signed 11/8/19, for Lorazepam intensol (an antianxiety, liquid medication) 2 mg/milliliters (ml) concentrate 3 mg/1.5 ml PO/sublingual (sl) every 4 hours as needed for agitation/anxiety with no stop date. The medical record lacked evidence of clinical rationale to continue the as needed (PRN) medication. On 12/04/19 at 11:32 a. m., in an interview with the Nurse Manager, the surveyor confirmed the above findings. 2. A review of Resident #14's Physician Orders, and Medication Administration Record (MAR), revealed Resident #14 with a verbal order, received from the practitioner on 11/14/19, for an antipsychotic medication, Seroquel 12.5 milligrams (mg), to be given by mouth every 24 hours PRN for agitation without a stop date. Further review of the medical record indicated that Resident #14 remains on the PRN antipsychotic to date with a lack of evidence of clinical rationale to continue the as needed medication. In an interview with the Director of Nursing on 12/5/19 at approximately 10:00 a. m., the finding was discussed and the surveyor confirmed the finding.
Oct 2018 1 deficiency
MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Requirements (Tag F0622)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility lacked evidence of a written transfer notice for a Resident on 3 of 3 facilit...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility lacked evidence of a written transfer notice for a Resident on 3 of 3 facility-initiated transfer/discharges (#13, #65 & #117). Findings: 1. Documentation in Resident #65's clinical record indicated that he/she was transferred to an acute care hospital on an emergent basis and was subsequently admitted on [DATE]. Review of Resident #65's clinical record lacked evidence of a written transfer notice indicating rationale for the facility-initiated transfer. In addition, the clnical record did have evidence of a discharge form completed dated 8/30/18. On 10/16/18 at 12:43 p.m. in an interview with the Nurse Manager, he/she stated that the Notificiation for Transfer/Discharge/Room Change is only completed for residents who are being discharged . On 10/17/18 at 2;50 p.m. in an interview with the Administrator, Director of Nursing and Business Office Manager the Surveyor confirmed that the clnical record lacked evidence of a written transfer notice. 2. Documentation in Resident #13's clinical record indicated that he/she was transferred to an acute care hospital on an emergent basis and was subsequently admitted on [DATE] and 9/7/18 for changes in respiratory status. Review of Resident #13's clinical record lacked evidence of a written transfer notice. The Surveyor confirmed the findings with the Director of Nursing on 10/17/18 at 10:52 a.m. 3. Documentation in Resident #117's clinical record indicated that he/she was transferred to an acute care hospital on an emergent basis and was subsequently admitted on [DATE]. Review of Resident #117's clinical record lacked evidence of a written transfer notice indicating rationale for the facility- initiated transfer. In an interview with the surveyor and the unit manager on 10/18/18, at 09:24 a. m., the finding was discussed. The unit manager indicated a copy of a transfer form is filled out and sent with the Resident at the time of transfer but he/she does not retain copies. In an interview with the surveyor and the administrator on 10/18/18, at 10:24 a. m., the finding was discussed and the surveyor confirmed the finding for a lack of transfer information on the clinical record.
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+ (85/100). 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.
Concerns
  • • 14 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 South Portland's CMS Rating?

CMS assigns PINNACLE HEALTH & REHAB AT SOUTH PORTLAND an overall rating of 5 out of 5 stars, which is considered much 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 South Portland Staffed?

CMS rates PINNACLE HEALTH & REHAB AT SOUTH PORTLAND's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 53%, compared to the Maine average of 46%.

What Have Inspectors Found at Pinnacle Health & Rehab At South Portland?

State health inspectors documented 14 deficiencies at PINNACLE HEALTH & REHAB AT SOUTH PORTLAND during 2018 to 2024. These included: 12 with potential for harm and 2 minor or isolated issues.

Who Owns and Operates Pinnacle Health & Rehab At South Portland?

PINNACLE HEALTH & REHAB AT SOUTH PORTLAND 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 73 certified beds and approximately 57 residents (about 78% occupancy), it is a smaller facility located in SO PORTLAND, Maine.

How Does Pinnacle Health & Rehab At South Portland Compare to Other Maine Nursing Homes?

Compared to the 100 nursing homes in Maine, PINNACLE HEALTH & REHAB AT SOUTH PORTLAND's overall rating (5 stars) is above the state average of 3.1, staff turnover (53%) is near 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 South Portland?

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 South Portland Safe?

Based on CMS inspection data, PINNACLE HEALTH & REHAB AT SOUTH PORTLAND 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 5-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 South Portland Stick Around?

PINNACLE HEALTH & REHAB AT SOUTH PORTLAND 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 Pinnacle Health & Rehab At South Portland Ever Fined?

PINNACLE HEALTH & REHAB AT SOUTH PORTLAND 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 South Portland on Any Federal Watch List?

PINNACLE HEALTH & REHAB AT SOUTH PORTLAND 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 SOUTH PORTLAND

42 ANTHOINE ST, SO PORTLAND, ME 04106 | (207) 799-8561

B+
Trust Grade (85/100)
5.0
CMS Rating
14
Deficiencies

Strengths

  • 4-star staffing
  • 5-star quality

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025