Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gorham House during CMS and state inspections, most recent first.
Housekeeping and maintenance services were not maintained to keep multiple unit areas sanitary and orderly. Surveyors found dirty kitchen floors, heavy dust on surfaces and hand sanitizer dispensers, food debris in a resident room, stained and damaged ceiling and wall surfaces, peeling paint, exposed raw wood and sheetrock, broken floor tiles, and dust-coated vents. A resident also reported missing eyeglasses for several weeks, and staff confirmed the facility was not using personal belongings inventory sheets and the resident's chart lacked one.
Psychotropic medication management was deficient for multiple residents. One resident’s PRN trazodone order remained active beyond the ordered duration, another resident’s Seroquel and trazodone were linked to an inappropriate diagnosis, and two residents receiving multiple psychotropic medications had no documented MAR/TAR monitoring for side effects despite care plan instructions and staff acknowledgment that no monitoring order was in place.
Unsafe flooring and exposed hazards in Cottage Unit. The facility had ripped, curled, lifting, and bowed flooring in multiple resident rooms, a bathroom floor hole with exposed subflooring, a loose tile in the whirlpool shower, a heater missing its cover with exposed piping and sharp metal fins, and a broken electrical outlet in an unlocked staff breakroom. An RN reported repeated work orders and emails to Maintenance, but the issues were deferred as not part of phase one, and the MD confirmed the flooring was an accident hazard and that no audits were being done to monitor floor safety.
Failure to follow up on consultant pharmacy recommendations for two residents. One resident remained on Mirtazapine for depression/anxiety without documented MD review of a recommendation to consider dose reduction, and another resident remained on Seroquel for delusions/hallucinations without documented MD response to a recommendation to taper to the lowest effective dose. Subsequent DRR notes stated no new irregularities despite the unresolved recommendations, and the RDO confirmed there was no provider follow-up.
Binding arbitration terms were not clearly communicated to residents or their representatives, and the agreement was included in the admission packet as part of the admission process. An LSW described electronically clicking through the packet with residents or POAs, including the arbitration section, while being unsure how revocation worked. The Administrator and LSW later confirmed the electronic packet contained a DO box to enter arbitration and a DO NOT box to opt out.
A resident’s record showed new orders for Seroquel and Trazodone, but there was no evidence that the RR consented to the medications or was informed in advance of the risks, benefits, and alternatives for these psychotropic drugs. The DON confirmed the finding during interview.
Failure to provide required transfer/discharge and bed-hold notices for two residents transferred to an acute care hospital. The record showed no written notice with appeal rights or Ombudsman contact information, and no written bed-hold notice specifying the bed-hold duration for either resident; the DON and Administrator confirmed the missing documentation.
A resident with Alzheimer’s disease, depression, DM2, a left foot ulcer, toe amputations, and PAD had a care plan that was not updated to match current wound care orders, including changes from a PICO dressing to other wound dressings and the fact that the wound vac was no longer in use. The care plan also was not revised after new psychotropic meds, Seroquel and Trazodone, were ordered, and it did not reflect the resident’s specific dementia-related activity preferences or interventions for mood and behaviors. The DON confirmed the care plan had not been revised to reflect the resident’s current needs.
QAPI program failed to address reported unsafe conditions in The Cottage. Surveyors observed multiple environmental safety concerns, and record review showed the QAPI agenda did not include the Cottage issues despite multiple emails reporting them. The Administrator and Regional Director of Operations stated Cottage repairs were deferred to Phase 2 of renovations, while Phase 1 focused on foyer upgrades and expanding the memory care unit by 10 beds, and acknowledged that appearance-related work was given a higher priority than resident safety concerns.
Infection control failed when a resident's fabric chair was observed with dark brown and light brown substances on the seat, and brown spots were also seen on the bathroom floor. A CNA stated the resident often is incontinent with diarrhea, and the observations were confirmed by the Maintenance Director and Regional Director of Operations.
An LPN spoke to a resident with severe cognitive impairment in a loud, verbally inappropriate manner, including statements such as “nobody wants to talk to you” and “shut up,” while the resident was agitated on a secure dementia unit. The resident had dementia with behavioral problems, anxiety, and depression, and staff witnesses reported hearing the comments directed at the resident.
Two CNAs verbally abused a resident with severe dementia by making inappropriate and threatening statements, including giving false information and instructing the resident to go to the bathroom in their pants. The CNAs admitted to these actions, which violated professional standards and the resident's right to dignity and safety.
Housekeeping, Maintenance, and Personal Property Deficiencies
Penalty
Summary
The facility failed to maintain adequate housekeeping and maintenance services to keep the interior sanitary, orderly, and comfortable on Windsor I, Windsor II, and Cottage. On Windsor II, a surveyor observed the kitchen floor to be excessively dirty with debris built up in the corners, and all flat surfaces were covered with a heavy layer of dust. The Housekeeping Supervisor later observed and confirmed dust behind the hallway hand rail, a stain on the front of the nurses station, dust on the top of the cabinet holding the floor plan, and dust on two wall hand sanitizer dispensers that was heavy enough to form a ball and fall to the floor when touched. Additional observations on Windsor II included food debris and wrappers on the floor in a resident room, a stained ceiling tile above one bed, a cracked rail behind a bed headboard, peeling paint on a heater, a window sill with a large chunk of wood splintered off exposing raw wood, a missing mirror above the sink with a gouged wall, and peeled and rolled linoleum at a closet threshold. The Cottage unit also had multiple maintenance and housekeeping issues, including broken floor tiles in a resident room, marred and chipped paint exposing sheetrock in a resident room and in the hallway by the kitchenette, chipped paint along a door frame, and a whirlpool room vent above the shower coated with dust and debris. In addition, the facility failed to ensure a resident's personal belongings were kept safe and secure. A resident and spouse reported that the resident's eyeglasses had been missing for several weeks. The medical record did not contain a personal belongings inventory sheet, and a Social Worker note documented that dietary staff did not have the eyeglasses. Staff interviews confirmed that inventory sheets were not being used, that a blank inventory sheet was found in a file cabinet, and that the resident's chart did not contain one. The DON stated that resident personal items are to be inventoried on admission and documented in the medical record, but the admission director stated she had not seen the inventory process used on the skilled/long-term care side and that it was not in the admission packet.
Psychotropic Medication Orders, Diagnoses, and Monitoring Deficiencies
Penalty
Summary
The facility failed to follow a physician order for a resident prescribed trazodone for insomnia and as needed for anxiety. The resident’s record showed the PRN trazodone order was written for 90 days, but the medication administration record from October 2025 through February 2026 still showed the PRN medication as available. During interview, the Regional Director of Operations and the DON confirmed the PRN order should have ended on September 25, 2025, and the order had been transcribed with an indefinite end date. The facility also failed to ensure that psychotropic medications were tied to a specific, diagnosed, and documented condition for another resident. That resident had diagnoses including Alzheimer’s disease and depression, and physician orders dated 10/10/25 listed Seroquel and trazodone as related to Cognitive Communication Deficit. During discussion with the surveyor, the DON confirmed that Cognitive Communication Deficit was not an appropriate diagnosis for the use of those medications. For two residents receiving multiple psychotropic medications, the MAR and TAR for February 2026 lacked evidence of monitoring for side effects. One resident had active orders for several psychotropic medications, including antidepressants, antipsychotics, antianxiety medications, and clozapine, and the care plan called for monitoring and reporting adverse reactions such as unsteady gait, tardive dyskinesia, EPS, falls, swallowing difficulty, and other symptoms. Another resident had active orders for fluoxetine, olanzapine, and sertraline, and the care plan also called for monitoring for psychotropic medication complications. RN #1 stated there was no place in the MAR or TAR to monitor side effects, and the DON confirmed there was no order to monitor for side effects of psychotropic medications, stating there should be.
Unsafe flooring and exposed hazards in Cottage Unit
Penalty
Summary
The facility failed to ensure the Cottage Unit environment was free of accident hazards. During observation, the flooring in rooms 5 and 9 was ripped up and curled, the flooring in rooms 2 and 6 was lifting and bowed, and the bathroom floor in one resident room had a hole in front of the toilet with exposed subflooring and flooring that sank when stepped on. A chipped and loose tile was also observed in the Whirlpool room shower. In addition, a resident room heater was missing its cover, exposing piping and sharp metal fins, and the staff breakroom, which was unlocked and kept open, had a broken electrical outlet. RN #1 stated she had submitted multiple work orders and emails to Maintenance about the flooring and tile concerns, but the issues had not been fixed and had been deferred because they were not part of phase one. Review of maintenance work orders and emails showed repeated reports over several months for peeling, ripped, and unsafe flooring in the Cottage apartments, the Whirlpool room, and resident rooms, as well as exposed radiators. During the tour with the Maintenance Director and Regional Director of Operations, the same hazards were observed, and the Maintenance Director confirmed the flooring was an accident hazard and posed a risk of falling or tripping. He also stated no audits were being done to monitor whether the floor was safe for residents.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up timely on Consultant Pharmacist recommendations and failed to ensure the Consultant Pharmacist reported ongoing irregularities for 2 of 5 residents reviewed for unnecessary medications. For one resident, the clinical record showed an order for Mirtazapine 15 mg at bedtime for depression/anxiety, and a Pharmacy Drug Regimen Review dated 12/18/25 recommended evaluating the current dose and considering a gradual taper to the lowest possible effective dose, including an attempt to reduce Mirtazapine to 7.5 mg as tolerated. By 2/11/26, there was no evidence in the record that the recommendation had been reviewed or responded to by the medical provider, and a later monthly review dated 1/21/26 stated there were no new irregularities even though the earlier recommendation remained unanswered. For another resident, the clinical record showed orders for Seroquel 25 mg twice daily for delusions and 75 mg in the evening for hallucinations and delusions. A Pharmacy Drug Regimen Review dated 10/24/25 recommended evaluating the dose and considering a gradual taper to the lowest possible effective dose, including reducing Seroquel to 25 mg twice daily and 50 mg at bedtime. By 2/11/26, there was no evidence that the recommendation had been reviewed or responded to by the medical provider, and subsequent monthly reviews dated 11/24/25, 12/18/25, and 1/21/26 all stated there were no new irregularities despite the unresolved recommendation. During interview on 2/11/26, the Regional Director of Operations confirmed there was no medical provider follow-up to the pharmacy recommendations for both residents and that the consultant pharmacy should have noted this failure in future reviews.
Binding Arbitration Agreement Not Clearly Communicated
Penalty
Summary
The facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly communicated to residents or their representatives and failed to ensure the agreement was not required as a condition of admission. The deficiency involved 3 of 3 residents reviewed for arbitration, with residents 77, 56, and 76 electronically signing the binding arbitration agreement as part of the admission packet. The report also references resident 63 in the scope statement. During the entrance conference, the Acting Administrator stated there were no residents with a binding arbitration agreement. However, a surveyor later reviewed the admission packet and found a binding arbitration form included in the packet. The EMR showed that three residents had electronically signed the agreement. When this was brought to the Acting Administrator’s attention, she stated she had not known it was part of the admission packet and said she would contact the corporate office and review the admission agreements. The LSW stated she was new in her role and had received very little orientation. She described going through the admission packet with the resident or POA, filling in information before the meeting, and electronically clicking through the document so the resident would not sign a blank form. She stated the arbitration section was part of the admission packet and that she explained it as a lifelong agreement involving lawyer and mediation services, but she was unsure of the exact revocation process. In a later interview, the Administrator and LSW confirmed that the electronic packet included a page with a DO box to enter into binding arbitration and a DO NOT box to opt out, and that the document would proceed to the next section depending on which box was selected.
Failure to Inform Resident Representative About Psychotropic Medication Use
Penalty
Summary
The facility failed to inform a Resident Representative in advance of the treatment risks and benefits, options, and alternatives related to the use of psychotropic medications for one sampled resident, R67. Record review showed that on 10/10/25, new orders were entered for Seroquel, an antipsychotic, and Trazodone, an antidepressant, to begin in the evening. The medical record did not contain evidence that the Resident Representative gave consent for these medications or that the Resident Representative was informed of the risks and benefits of treatment with these psychoactive medications or of alternative options. During an interview on 2/11/26 at 1:00 p.m., the DON confirmed the finding.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to issue written transfer/discharge notices and written bed-hold notices for 2 of 4 sampled residents transferred or discharged to an acute care hospital, Resident #67 and Resident #69. For Resident #67, the clinical record showed transfer to the hospital on [DATE], but there was no evidence that the resident or the resident's representative received a written transfer/discharge notice with appeal rights and the name and address of the Office of the State Long-Term Care Ombudsman, or a written bed-hold notice specifying the duration of the bed-hold. For Resident #69, the clinical record also showed transfer to the hospital on [DATE], but there was no evidence that the resident or the resident's representative received the required written transfer/discharge notice with appeal rights and Ombudsman information, or a written bed-hold notice specifying the duration of the bed-hold. The Director of Nursing and the Administrator confirmed the lack of documentation during interviews.
Care Plan Not Updated for Wound Care, Psychotropic Meds, and Dementia Needs
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident with Alzheimer’s disease, depression, type 2 diabetes mellitus, a left foot ulcer with 4th and 5th toe amputations, and peripheral arterial disease. The resident’s wound clinic orders changed over time, including use of Grafix, a PICO negative pressure dressing with specific tubing and battery placement instructions, later a return to Hydrofera Blue Ready Transfer Foam and ABD pad with rolled gauze, and then a subsequent order for Prisma and Hydrofera Blue with skin barrier protection. The resident’s care plan still reflected a focus area for a wound vac related to the left foot wound and included general interventions to follow wound center instructions, monitor the wound vac, and attend follow-up appointments, but it was not revised to reflect the current wound care regimen or the fact that the wound vac was no longer in use. The resident also had new psychotropic medications ordered, including Seroquel and Trazodone, but the care plan was not revised to include the addition of these medications or the need to monitor for side effects and efficacy. In addition, the resident’s care plan for impaired cognitive function/dementia, last revised on 7/14/25, continued to list general interventions such as breaking tasks into one step, asking yes/no questions, and providing simple structured activities, but it was not updated to include the resident’s specific preferences for activities and interventions to address mood and behaviors associated with dementia. The DON confirmed in interview that the care plan had not been revised to reflect the resident’s current needs.
QAPI Program Failed to Address Reported Unsafe Conditions in The Cottage
Penalty
Summary
Failure to have a plan describing the process for conducting QAPI and QAA activities was identified when the facility did not make a good faith effort to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program focused on outcomes of care and quality of life. Based on interviews and record review, the facility did not follow up on multiple emails reporting unsafe conditions in The Cottage unit. On 2/9/26, surveyors observed significant concerns about the environment at The Cottage and found multiple safety concerns. On 2/10/26, review of QAPI documentation showed QAPI meeting attendance for the past year with required members present, but the QAPI agenda did not include the environmental concerns reported from The Cottage. During an interview on 2/11/26, the Administrator and Regional Director of Operations stated that the Cottage repairs were planned as part of Phase 2 of renovations, while Phase 1 consisted of upgrading the foyer and expanding the memory care unit by 10 beds. They stated that this was a corporate decision and acknowledged that the facility environmental observation for appearance was given a higher priority than the safety of residents in The Cottage.
Infection Control Program Failure Related to Unsanitary Resident Seating
Penalty
Summary
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 clean and sanitary seating for a resident. During an observation in the resident's room, a dark brown and a light brown substance were seen on the seat of a fabric chair, and brown spots were also observed on the bathroom floor. A CNA stated that the resident often is incontinent with diarrhea. The observations were later confirmed by the Maintenance Director and the Regional Director of Operations.
Dignified Communication Failure Toward Resident With Dementia
Penalty
Summary
The facility failed to ensure staff spoke to a resident in a dignified manner for 1 of 29 residents reviewed for abuse. On 1/30/26, staff observed an LPN speak in a verbally inappropriate manner to R10, who was exhibiting agitation and behaviors typical for the resident. Two staff members entered the resident’s unit and observed the LPN speaking in a loud voice and saying, “I don't want to talk to you. Nobody wants to talk to you. I don't want to talk to you (R10), Nobody wants to talk to you. Shut up. Nobody is talking to you, nobody is listening to you.” The resident and nurse were separated, and staff removed the resident from the unit to distract and check in with him/her. R10’s record showed diagnoses of dementia with behavioral problem, anxiety disorder, and depression, and an MDS assessment dated 11/4/25 indicated a BIMS score of 3, consistent with severe cognitive impairment. R10 lived on the secure dementia unit and required partial to moderate assistance with activities of daily living. The care plan identified behavioral problems related to dementia and included interventions to anticipate needs and provide positive interaction and attention. Nursing and physician notes documented mood lability, irritability, and agitation, and the resident could be difficult to calm or redirect when highly agitated. During the facility’s investigation, the LPN denied saying “shut up,” but 3 of 4 staff who observed the incident reported hearing the LPN’s statements directed to R10.
Verbal Abuse of Resident by CNAs
Penalty
Summary
Two CNAs verbally abused a resident with severe dementia and a history of behavioral disturbances. The incident was reported by a non-facility member who overheard the interactions via a video and audio communication app. During the incident, the CNAs made inappropriate and threatening statements to the resident, including telling the resident that their spouse was dead, giving a false year when asked, and instructing the resident to go to the bathroom in their pants. The CNAs admitted to these actions during interviews conducted as part of the facility's investigation. The facility's investigation confirmed that the CNAs' behavior violated professional standards, the resident's dignity, the right to feel safe, and the expectation of compassionate care. The resident was unable to recall the interactions and a review of the clinical record did not reveal any negative outcomes resulting from the incident. The facility's abuse prohibition policy, which includes information on verbal abuse, was in place at the time of the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gorham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springbrook Center | 3.9 mi | ★★★★★ | 3 | 0 |
| Barron Center | 5.4 mi | ★★★★★ | 34 | 0 |
| Maine Veterans Home - Scarborough | 7.3 mi | ★★★★★ | 0 | 0 |
| Fallbrook Commons | 7.7 mi | ★★★★★ | 0 | 0 |
| Pine Point Center | 8.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.