Deficiencies (last 3 years)
Deficiencies (over 3 years)
25.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
344% worse than Maine average
Maine average: 5.7 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's refusal to readmit a resident with known behavioral issues and concerns about psychotropic medication management and consent.
Complaint Details
The complaint investigation focused on Resident #1, who exhibited aggressive behaviors and was refused readmission by the facility until a safety plan was established. The investigation found the facility did not have physician documentation justifying the refusal and failed in medication management and consent procedures.
Findings
The facility was found to have violated a resident's right to be free from discrimination and coercion by refusing readmission without a safety plan. The facility failed to ensure proper physician orders for psychotropic medications, obtain written informed consent for psychotropic and opioid medications, and monitor behaviors related to medication use.
Deficiencies (3)
F 0550: The facility violated a resident's right to a dignified existence and freedom from discrimination by refusing to readmit a resident with behavioral issues without a safety plan in place.
F 0605: The facility failed to ensure physician orders for PRN antipsychotic medication contained a duration/stop date and failed to renew orders every 14 days as required.
F 0757: The facility failed to obtain written informed consent for psychotropic medications for 2 residents and opioid medication for 1 resident, and failed to monitor behaviors to support psychotropic medication use for 1 resident.
Report Facts
Hospital stay duration: 11
PRN antipsychotic order date: Oct 31, 2025
Psychotropic medication consent dates: Nov 6, 2025
Medication start dates: Nov 7, 2025
Medication start date: Nov 21, 2022
Medication start date: Oct 17, 2025
Medication start date: Nov 15, 2025
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 13, 2025
Visit Reason
The inspection was conducted following a complaint and facility-reported incident regarding a resident fall with injury and concerns about staff not following care plans.
Complaint Details
The complaint investigation was substantiated. The facility reported an incident where Resident #1 fell from bed and was transferred to the Emergency Department, later dying. The investigation found failures in care plan implementation, supervision, and safety protocols.
Findings
The facility failed to implement a resident's care plan for falls, resulting in a resident falling from bed and later dying. The facility also failed to provide adequate supervision and safety measures, including leaving a resident unattended in a high bed without rails. Additionally, the facility lacked behavioral health training for multiple Certified Nursing Assistants.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions, resulting in a resident fall.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision, resulting in immediate jeopardy when a resident fell from a high bed without rails.
F 0949: The facility failed to provide behavior health training consistent with requirements for 6 of 8 reviewed Certified Nursing Assistants.
Report Facts
Residents affected: 1
Certified Nursing Assistants lacking behavioral health training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in fall incident and failure to follow care plan |
| LPN on duty | Licensed Practical Nurse | Instructed CNA #1 and responded to fall incident |
| Interim Director of Nursing | Interim Director of Nursing | Confirmed lack of behavioral health training and absence of bed safety policy |
| Administrator | Facility Administrator | Discussed facility efforts post-fall and confirmed training deficiencies |
Inspection Report
Annual Inspection
Census: 6
Deficiencies: 20
Date: May 9, 2025
Visit Reason
Annual Long Term Care Survey Process for Federal Recertification conducted to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including resident dignity during meals, failure to provide written information on advance directives, inadequate housekeeping and maintenance, failure to monitor PASRR evaluations, incomplete baseline and comprehensive care plans, failure to follow physician orders and monitor residents after falls, unsafe hot water temperatures creating immediate jeopardy, improper medication storage and self-administration procedures, unsanitary kitchen conditions, inadequate infection control practices, incomplete documentation of resident care, and lack of staff training on quality assurance.
Deficiencies (20)
F 0550: The facility failed to create a homelike environment and promote resident dignity during the evening meal by serving meals on trays in the dining room.
F 0578: The facility failed to provide written information concerning the right to formulate an advance directive to 13 of 14 residents reviewed.
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment due to multiple housekeeping and maintenance deficiencies across all units.
F 0645: The facility failed to ensure a resident with a specialized mental health diagnosis was referred for PASRR Level II evaluation after the expected 30-day exemption period.
F 0655: The facility failed to develop and implement a baseline care plan within 48 hours for a resident, lacking goals and interventions for activities of daily living.
F 0656: The facility failed to develop and implement comprehensive care plans addressing smoking and respiratory needs for two residents.
F 0657: The facility failed to hold interdisciplinary team meetings within 7 days following Minimum Data Set assessments for 5 residents.
F 0684: The facility failed to follow physician orders for urine collection prior to surgery and failed to adequately assess and monitor a resident after unwitnessed falls.
F 0689: The facility failed to ensure hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit, creating an immediate jeopardy to resident safety.
F 0689: The facility failed to provide supervision and safety equipment for a resident who smokes, despite assessment indicating need for supervision and protective apron.
F 0695: The facility failed to provide sanitary respiratory care by leaving a resident's nebulizer mask and tubing unbagged and failing to maintain documentation of CPAP cleaning.
F 0698: The facility failed to provide safe and appropriate dialysis care by not monitoring a resident's dialysis access site or performing pre- and post-dialysis assessments.
F 0730: The facility failed to complete annual performance evaluations for 5 sampled Certified Nursing Assistants hired in 2023.
F 0761: The facility failed to ensure medications were stored properly, including ice buildup in a medication refrigerator, and failed to obtain physician orders and safety assessments for resident self-administration of medications.
F 0812: The facility failed to maintain a clean and sanitary kitchen environment, including unclean ceiling tiles, vents, fans, dusty walls, improperly dated food, and an ice machine without an air gap.
F 0814: The facility failed to maintain a garbage storage area in a sanitary condition, with trash on the ground and an open dumpster exposing waste.
F 0842: The facility failed to maintain complete and accurate clinical documentation for activities of daily living care for a resident.
F 0867: The facility's Quality Assurance Committee failed to ensure effectiveness of corrective plans of action, resulting in re-citation of deficiencies during follow-up survey.
F 0880: The facility failed to maintain an infection control program by not using proper personal protective equipment during high contact care for a resident on Enhanced Barrier Precautions.
F 0944: The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement Program to 5 sampled employees.
Report Facts
Residents affected: 6
Residents affected: 13
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 1
Hot water temperature: 129.5
Hot water temperature: 131.1
Hot water temperature: 127.2
Employees: 5
Missing dish washer temperature logs: 40
Missing refrigerator/freezer temperature logs: 70
Missing resident care documentation: 30
Employees: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Lacked annual performance evaluation and QAPI training |
| Certified Nursing Assistant #2 | CNA | Lacked annual performance evaluation and QAPI training |
| Certified Nursing Assistant #3 | CNA | Lacked annual performance evaluation and QAPI training |
| Certified Nursing Assistant #4 | CNA | Lacked annual performance evaluation and QAPI training |
| Certified Nursing Assistant #5 | CNA | Lacked annual performance evaluation and QAPI training |
| Registered Nurse #1 | RN | Failed to wear PPE when providing high contact care to resident on Enhanced Barrier Precautions |
| Licensed Practical Nurse #1 | LPN | Confirmed failure to follow pre- and post-dialysis assessment policies |
| Director of Nursing | DON | Confirmed multiple care and monitoring deficiencies |
| Food Service Director | FSD | Confirmed kitchen sanitation and temperature monitoring deficiencies |
| Administrator | Facility Administrator | Confirmed multiple findings including hot water temperature and kitchen sanitation |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 9, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with healthcare regulations and facility policies at Clover Health Care.
Findings
The facility failed to follow physician orders for urine collection prior to surgery, resulting in surgery cancellation for one resident. Neurological monitoring was not adequately performed after unwitnessed falls for another resident. Medication storage and self-administration procedures were not properly followed, and clinical records for one resident were incomplete.
Deficiencies (3)
F 0684: The facility failed to ensure physician orders were followed for urine collection for urinalysis/culture prior to surgery for Resident #24, resulting in surgery cancellation. The facility also failed to adequately assess and monitor neurological status after unwitnessed falls for Resident #77.
F 0761: The facility failed to ensure medications were stored properly in a refrigerator and failed to obtain physician orders and complete a safety assessment for medication self-administration for Resident #24.
F 0842: The facility failed to ensure clinical records were complete and accurate for Resident #67, with multiple missing documentation entries for activities of daily living and elimination.
Report Facts
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Confirmed failure to follow preoperative urine collection orders and medication self-administration safety assessment. |
| Director of Nursing | DON | Confirmed lack of neurological monitoring documentation and medication storage issues. |
| Assistant Director of Nursing/Infection Preventionist | ADON/IP | Confirmed facility did not fill lab paperwork correctly leading to surgery cancellation. |
| Area Director of Clinical Operation | Confirmed lab paperwork error and neurological monitoring deficiencies. |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 22, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory standards related to resident dignity, environment maintenance, staffing, food service, and infection control at Clover Health Care.
Findings
The facility was found deficient in maintaining resident dignity, environmental cleanliness and safety, adequate staffing levels, proper food temperature and dietary management, and infection control practices related to linen handling. All deficiencies were assessed as causing minimal harm or potential for actual harm.
Deficiencies (6)
F 0550: The facility failed to maintain resident dignity when a maintenance staff member entered a resident's room without knocking or announcing themselves for 1 of 4 residents reviewed.
F 0584: The facility failed to maintain a safe, clean, and homelike environment as evidenced by heavily soiled sit-to-stand patient lifts and broken window shades in multiple resident rooms.
F 0689: The facility failed to ensure the residents' environment was free from accident hazards due to loose, unsecured linoleum flooring causing a trip hazard in 1 of 4 units.
F 0725: The facility failed to provide sufficient direct care staff to meet resident needs, resulting in delayed assistance with activities of daily living and incomplete care.
F 0812: The facility failed to ensure food served was maintained at proper hot temperatures and residents' nutritional needs were assessed before meal service, resulting in cold, unpalatable meals.
F 0880: The facility failed to maintain an infection control program related to linen handling, including carrying soiled linen improperly and carrying clean linen against the body.
Report Facts
Days under minimum staffing: 19
Temperature of meal items: 90
Number of residents reviewed for dignity issue: 4
Number of units with environmental issues: 2
Number of sit-to-stand lifts soiled: 3
Number of resident rooms with broken window shades: 4
Size of linoleum flooring hazard: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Confirmed soiled patient lifts and discussed staffing shortages and food temperature issues. |
| RN #2 | Registered Nurse | Reported facility often staffed under required state staffing ratios. |
| CNA #1 | Certified Nursing Assistant | Reported staffing shortages affecting resident care and meal delays. |
| CNA #3 | Certified Nursing Assistant | Reported staff feel rushed and some care might not get completed due to short staffing. |
| CNA #4 | Certified Nursing Assistant | Observed carrying soiled linen improperly, confirming infection control issue. |
| CNA #5 | Certified Nursing Assistant | Observed carrying clean linen against body, confirming infection control issue. |
| CNA #7 | Certified Nursing Assistant | Reported inadequate staffing on weekends and need for multiple staff for lifts. |
| LPN | Licensed Practical Nurse | Reported short staffing and incomplete resident care. |
| Kitchen Supervisor | Kitchen Supervisor | Confirmed food temperature monitoring issues and staffing cuts in kitchen. |
| Maintenance Staff | Maintenance Staff | Entered resident room without knocking, causing dignity issue. |
| Administrator | Facility Administrator | Confirmed findings related to dignity, environment, staffing, food service, and infection control. |
Inspection Report
Routine
Deficiencies: 19
Date: Feb 9, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements across multiple areas including resident care, medication management, infection control, dietary services, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to serve residents meals simultaneously, inadequate accommodations for resident needs, improper notification of Medicare coverage changes, privacy violations, poor housekeeping and maintenance, incomplete investigations of medication diversion, failure to provide timely bed hold notices, incomplete care plans, improper respiratory equipment maintenance, failure to post nurse staffing information, inadequate pharmaceutical record keeping, expired medications in use, failure to provide dental care, dietary deficiencies, infection control lapses, and incomplete nurse aide training.
Deficiencies (19)
F 0550: The facility failed to serve all residents seated at the same table at the same time during one of four meals observed, causing some residents to wait 36 minutes before being served.
F 0558: The facility failed to reasonably accommodate the needs of Resident #449 by not providing requested bed side rails and a bed extender in a timely manner.
F 0582: The facility failed to provide Notice of Medicare Provider Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice with correct dates and timely for multiple residents.
F 0583: The facility failed to ensure privacy for Resident #302 due to lack of bed curtains and inadequate bathroom access.
F 0584: The facility failed to maintain the building in good repair and sanitary condition across multiple units and the laundry room, including torn furniture, missing curtain hooks, soiled equipment, and missing ceiling tiles.
F 0610: The facility failed to thoroughly investigate an allegation of medication diversion by not documenting staff interviews and timely reporting.
F 0625: The facility failed to issue a complete bed hold notice including daily bed hold cost for Resident #55 transferred to hospital.
F 0656: The facility failed to document Enhanced Barrier Precautions in the clinical record for Resident #56 on infection control measures.
F 0657: The facility failed to review and revise care plans by an interdisciplinary team including resident participation for Residents #67 and #10, resulting in contradictory and incomplete care plans.
F 0695: The facility failed to maintain respiratory equipment properly for residents receiving oxygen therapy, including unlabeled nasal cannulas on the floor and dusty oxygen concentrator filters.
F 0732: The facility failed to post nurse staffing information in a prominent, accessible, and visible location for residents and visitors for the entire survey period.
F 0755: The facility failed to maintain accurate and complete records of receipt and disposition of controlled drugs, failed to ensure two authorized staff signed shift counts, and failed to ensure two signatures on pharmacy delivery entries for controlled substances.
F 0761: The facility failed to adequately date and properly dispose of open and expired medications on multiple units, including insulin pens and various medications past expiration date.
F 0790: The facility failed to assist Resident #3 in obtaining routine and emergency dental care within 3 days after loss of dentures and lacked documentation of dental services.
F 0800: The facility failed to provide Resident #302 with a diet reflecting increased protein requirements as ordered and documented in the clinical record.
F 0812: The facility failed to serve and store food in a sanitary manner, including unlabeled and undated food containers, lack of temperature logs, and inadequate cleaning documentation in the kitchen and unit kitchens.
F 0842: The facility failed to document Enhanced Barrier Precautions in the clinical record and care plan for Resident #56 despite signage indicating use of EBP.
F 0880: The facility failed to maintain an infection prevention and control program to prevent cross contamination, including uncovered linens, unlabeled toileting items, improper glove use during food service, and unsanitary whirlpool rooms.
F 0947: The facility failed to ensure 5 of 5 Certified Nursing Assistants completed required annual training on abuse, resident rights, and dementia care.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 5
Missing ceiling tiles: 13
Missing ceiling tiles stained: 5
Controlled substance count missing signatures: 6
Expired medications: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of investigation and training deficiencies |
| Licensed Practical Nurse #3 | LPN | Interviewed about dentures and whirlpool room |
| Licensed Social Worker #1 | Licensed Social Worker | Confirmed lack of dental records and IDT invitations |
| Assistant Dietary Manager | Assistant Dietary Manager | Confirmed dietary program issues and food safety concerns |
| Nurse Manager | Nurse Manager | Observed medication cart and controlled substance record deficiencies |
| Registered Nurse #2 | RN | Counted narcotic drawer and involved in medication administration |
| Laundry Aide #3 | Laundry Aide | Observed delivering uncovered linens |
| Director of Clinical Operations | Director of Clinical Operations | Confirmed nurse staffing posting and dietary issues |
Inspection Report
Routine
Deficiencies: 19
Date: Feb 9, 2024
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, accommodation of resident needs, notification of Medicare coverage, privacy, housekeeping and maintenance, medication diversion investigation, bed hold notices, care planning, respiratory care, nurse staffing posting, pharmaceutical services, dental care, dietary services, infection control, and nurse aide training.
Deficiencies (19)
F 0550: Facility failed to serve all residents seated at the same table at the same time during one of four meals observed, causing some residents to wait 36 minutes before being served.
F 0558: Facility failed to reasonably accommodate needs of resident #449 by not providing requested bed side rails and bed extender in a timely manner.
F 0582: Facility failed to provide Notice of Medicare Provider Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice timely and with correct dates for multiple residents.
F 0583: Facility failed to ensure privacy for resident #302 due to lack of bed curtain and inadequate bathroom access.
F 0584: Facility failed to maintain building and environment in good repair and sanitary condition across multiple units and laundry room.
F 0610: Facility failed to thoroughly investigate an allegation of medication diversion for one staff member, lacking evidence of staff interviews and timely reporting.
F 0625: Facility failed to issue a complete bed hold notice including daily bed hold cost for resident transferred to hospital.
F 0656: Facility failed to document Enhanced Barrier Precautions (EBP) in clinical record for resident #56 on EBP list.
F 0657: Facility failed to review and revise care plans by interdisciplinary team including resident participation for residents #67 and #10, resulting in contradictory and outdated care plans.
F 0695: Facility failed to maintain respiratory equipment and follow infection control procedures for oxygen therapy for residents #21, #22, and #26.
F 0732: Facility failed to post nurse staffing information in a prominent, accessible, and visible location for residents and visitors for all survey days observed.
F 0755: Facility failed to maintain accurate controlled substance records, failed to ensure two-person shift counts and signatures, and failed to properly document pharmacy deliveries for controlled substances.
F 0761: Facility failed to properly date and dispose of expired or opened medications and failed to remove expired medications from supply on multiple units.
F 0790: Facility failed to assist resident #3 in obtaining routine and emergency dental care within 3 days after loss of dentures; no documentation of dental services or replacement.
F 0800: Facility failed to provide resident #302 with increased protein portions as ordered; dietary system change caused omission of diet modification.
F 0812: Facility failed to serve and store food in a sanitary manner, failed to maintain accurate temperature logs in main and unit kitchens, and failed to ensure kitchen staff wore hair coverings.
F 0842: Facility failed to document Enhanced Barrier Precautions (EBP) in clinical record including care plan for resident #56.
F 0880: Facility failed to maintain infection prevention and control program to prevent cross contamination related to personal toileting items, transmission based precautions, linen handling, and sanitary environment in multiple units.
F 0947: Facility failed to ensure 5 of 5 Certified Nursing Assistants completed required annual training on abuse, resident rights, and dementia care.
Report Facts
Residents affected: 4
Residents affected: 5
Missing ceiling tiles: 13
Missing ceiling tiles stained: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failure to investigate medication diversion and lack of reconciliation documentation |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed dentures missing and whirlpool room usage |
| Licensed Social Worker #1 | Licensed Social Worker | Confirmed lack of dental records and IDT invitations |
| Assistant Dietary Manager | Assistant Dietary Manager | Confirmed dietary system change caused diet order omission |
| Nurse Manager | Nurse Manager | Observed medication cart and controlled substance record deficiencies |
| Infection Preventionist | Infection Preventionist | Confirmed lack of Enhanced Barrier Precautions documentation |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 9, 2022
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for nursing home care, including resident care plans, food safety, staff training, and facility sanitation.
Findings
The facility was found deficient in developing complete care plans for residents at risk of wandering, maintaining kitchen sanitation and proper food labeling, monitoring dishwasher rinse temperatures, and ensuring mandatory training for nurse aides in dementia care and abuse prevention.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan addressing the risk of wandering/elopement for one resident, lacking interventions and goals from 8/18/20 through 2/8/22.
F 0812: The kitchen was not maintained in a clean and sanitary manner, with dirty equipment and unlabeled, undated, or unsealed food items. The facility also failed to monitor dishwasher rinse cycle temperatures adequately.
F 0947: The facility failed to ensure that 2 of 5 Certified Nursing Assistants completed mandatory training in dementia care and abuse prevention, with missing documentation for required education.
Report Facts
Dishwasher rinse cycle temperature failures: 30
Certified Nursing Assistants missing training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed findings related to care plan deficiencies and staff training | |
| Food Service Director | Confirmed findings related to kitchen sanitation and dishwasher temperature monitoring | |
| Administrator | Confirmed findings related to kitchen sanitation and staff training |
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