Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Kennebunk Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
Housekeeping and maintenance services were not adequately provided in the laundry room and medication storage room. Surveyors observed chipped wood, broken floor tiles, rusted and damaged surfaces, dirt and debris behind washers, and stained, lifting wall and trim materials in the laundry area. In the medication room, dust and debris and a dried pink substance were found on the floor, and later observations still showed debris plus chipped, missing paint and stains on the wall; the DON and an RN confirmed the findings.
Failure to hold IDT meetings within the required timeframe after MDS assessments. Record reviews showed multiple residents had quarterly, annual, or Significant Change MDS assessments without evidence of an IDT meeting within 7 days, and several meetings were held 11 to 19 days after the assessment. The DOSS confirmed the facility was scheduling care plan reviews after the MDS process and was using a 2-week timeframe instead of the required 7 days.
The facility failed to follow FSBS-before-meals orders for two residents, as blood sugar checks were completed after breakfast instead of before meals. The facility also failed to follow its insulin administration policy for a resident ordered Glargine in the morning, and the DON confirmed another resident’s Glargine had been given outside the expected liberalized med pass time frame.
The facility failed to maintain adequate weekend staffing after the CMS PBJ Report showed low weekend staffing during the quarter reviewed. During surveyor interview, the Administrator confirmed the facility was not adequately staffed for 5 of 39 reviewed day shifts.
Expired blood collection tubes were found available for use on multiple units, including blue top, yellow top, and red tubes past their expiration dates. Surveyors also observed an unlocked, unattended treatment cart on the Windmere Unit containing resident meds and treatments such as Compound W, Nystatin, Diclofenac, hydrocortisone cream, ammonium lactate, and SaniCloth wipes while staff walked past it.
Kitchen sanitation, food labeling, and emergency food supply failures: The facility failed to keep the kitchen and dish room clean and sanitary, with debris, buildup, dust, uncleanable wall surfaces, and staff personal items observed in food prep areas. Multiple foods in dry storage, refrigerators, and the freezer were left open, unlabeled, or undated, including meat, produce, dairy items, and condiments. The facility also lacked a current emergency food supply during part of the survey period, and staff reported the supply had been expired and used for routine meal prep.
Failure to Inspect Bed Frames and Mattresses for Entrapment Hazards: Surveyors observed a resident asleep with the head at the foot end of the bed and later found a large gap between the mattress and footboard. Surveyors also found similar gaps on multiple beds across several units. The facility’s policy required annual bed entrapment checks, but records showed only limited mattress/bed measurements and no evidence of annual inspections.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
Dining room meal service failed to maintain resident dignity when three residents seated at the same table were not served together. One resident received a meal while two tablemates waited, and staff continued serving other tables first. A CNA said she was waiting for the rest of the trays, and a resident later asked when the meals would arrive. A staff member said the facility was busy, and the remaining meals were delivered several minutes later. The DON/Administrator said weekend dining room meal delivery had only recently been implemented and some trays were ending up on the wrong carts.
A resident was transferred to an acute care hospital twice, but the facility did not provide the legal representative with the required written transfer/discharge notice or bed hold notice, including the cost of care and appeal rights. The BOM confirmed that these notices are not issued to resident representatives.
Failure to Follow Oxygen Order: A resident receiving O2 had a physician order for continuous oxygen at 2 L/min via NC, but surveyors observed the concentrator set above the ordered rate on multiple occasions and later observed the resident without O2 and the concentrator powered off. The resident stated staff provide the tubing and adjust the concentrator, while the DON said the resident often removes the O2 and that the record did not reflect the frequent removal in progress notes or the care plan.
A facility failed to evaluate and document the self-administration of medications for four residents, who were found with various creams and medications at their bedside without proper orders or evaluations. The facility's policy requires a self-administration evaluation, a physician's order, and a care plan, which were not completed, as confirmed by the DON.
The facility failed to properly store and label medications and treatments on two units. Several residents had unlabeled creams on their bedside tables, with some applying them independently. Medical records showed discrepancies in provider orders for these treatments. The DON confirmed the improper storage and removed the items.
A resident was found with a can of disinfectant spray on their bedside dresser, which they used for odor control. The DON was unaware of its presence and confirmed it should not have been accessible to the resident, indicating a failure to ensure the environment was free from accident hazards.
A resident was found with an unknown cream and applesauce on their bedside table, stating they applied the cream for arthritis pain themselves. The facility's records inaccurately documented that a nurse applied Voltaren Gel, which the resident confirmed they used independently. This discrepancy highlights a failure in maintaining accurate clinical records.
The facility failed to maintain a sanitary and comfortable environment across all units and the Laundry Room. Observations revealed black and brown substances around toilets, peeled caulking, and improperly stored items in shared bathrooms. The Laundry Room had significant dust and debris on fans, heaters, and pipes, with stained sinks and cobwebs. These issues indicate a widespread failure in housekeeping and maintenance services.
The facility failed to provide adequate ADL care for several residents, including bathing and oral hygiene. A resident with COPD did not receive proper ADL care, and documentation was lacking. Another resident was observed with poor oral hygiene despite care plan instructions. Additional residents reported not receiving regular showers, with missing or infrequent documentation in their EMRs. The DON confirmed the lack of documentation and care provided.
The facility failed to maintain sanitary conditions for respiratory care, with two residents' nebulizer equipment improperly stored and maintained. One resident's equipment was not changed per physician orders, and there was no record of filter changes. Another resident's equipment was unbagged and unlabeled. These issues were confirmed by the Regional Director of Clinical Operations.
The facility was found to have insufficient direct care staff on weekends, as confirmed by the Administrator and a review of staffing reports. This deficiency, identified during the fourth quarter of 2024, potentially affects all residents needing assistance with ADLs.
The facility's kitchen was found to be unsanitary, with debris and expired food items present. Staff failed to follow personal hygiene protocols, such as wearing hair restraints, and did not change gloves between handling different food items. Additionally, food temperatures were not monitored before serving.
The facility failed to ensure residents and their representatives were clearly informed about the terms and conditions of a binding arbitration agreement, which was included in the admission paperwork. The Admissions and Marketing Director did not adequately explain that signing the agreement was not mandatory for admission and that it would remain in effect unless rescinded within 30 days. Interviews revealed that residents and their representatives were unaware of the agreement's implications, leading to a deficiency in the facility's admission process.
The facility did not maintain adequate pharmaceutical services, as an expired medication card for Ondansetron HCL 4 mg was found in a medication cart on Eagle Wing. This expired medication was intended for a resident and was confirmed by an LPN. The issue was discussed with the DON.
A resident's choice to keep a sweater on was disregarded by staff, leading to a cracked tooth during its removal. Despite the resident's clear objection and physical resistance, staff removed the sweater, causing the injury. The incident was reported to the Department of Licensing and Certification, and the Director of Nursing confirmed the resident's rights were not respected.
A resident with a history of falls and diagnoses of COVID-19 and orthostatic hypotension experienced multiple unwitnessed falls without proper neurological monitoring as per facility policy. The facility's documentation showed repeated vital signs and incomplete evaluations, and the Director of Nursing confirmed these deficiencies.
The facility failed to document that Advance Directives were offered or reviewed with residents and/or their representatives, affecting 11 out of 14 residents reviewed. Interviews with staff confirmed the deficiency, with the social worker admitting to inconsistent documentation and follow-up, and the DON acknowledging missing documentation in residents' charts.
The facility failed to document controlled substance counts at shift changes in the Sagamore Unit, as required by policy. Over a period, multiple shifts lacked evidence of proper documentation by two authorized individuals, leading to an incident where a 30ml bottle of Ativan was unaccounted for. Interviews confirmed the lack of adherence to the correct process.
The facility failed to provide a separately locked compartment for controlled drugs, as required by regulations. This was discovered when a surveyor observed the absence of a separate locked box in the medication room's refrigerator. The issue was confirmed by the DON, following an incident where a bottle of Ativan was reported missing during a shift change.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Housekeeping and Maintenance Deficiencies in Laundry and Medication Storage Areas
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in the medication storage room and the laundry room. During a tour of the laundry room with the Director of Operations and the Director of Housekeeping, surveyors observed chipped wood on the folding table door, broken floor tiles by the door between the clean and dirty sides, a rusted door frame, missing sheet rock, chipped paint on the dirty-side windowsill, dirt and debris behind all three washers, broken floor tiles exposing untreated cement, and a wall by the sink stained with an unknown substance with lifting wall material and lifting rubber floor trim. In the medication storage room, a surveyor observed dust and debris under the counter on the right side at the back of the room, along with a dried pink substance on the floor. The DON confirmed the unclean floor and stated housekeeping would clean it. When the room was observed again the next morning, the pink substance had been removed, but dust and debris remained in the corner and other areas of the floor, and the wall between the refrigerator and cabinet had chipped and missing paint with stains creating an uncleanable surface. An RN confirmed these findings during interview.
Failure to Hold IDT Meetings Within Required Timeframe After MDS Assessments
Penalty
Summary
The facility failed to review and revise care plans through an interdisciplinary team (IDT) meeting within 7 days of the comprehensive MDS 3.0 assessment for 7 of 21 residents reviewed. Record reviews showed that Resident #2 had quarterly MDS assessments dated 1/16/26 and 10/16/25 with no evidence of an IDT meeting within 7 days of either assessment. Resident #35 had quarterly MDS assessments dated 3/4/26, 1/13/26, 10/2/25, and 7/3/25 with no evidence of an IDT meeting within 7 days of the quarterly assessments. Resident #79 had an annual MDS dated 2/25/26 with no evidence of an IDT meeting within 7 days of the assessment. Additional record reviews showed Resident #8 had a Significant Change MDS completed on 1/21/26 with no evidence of an IDT meeting within 7 days of that assessment. Resident #7 had a quarterly MDS completed on 3/27/26, but the IDT meeting was scheduled for 4/15/26, 19 days after the assessment. Resident #23 had a quarterly MDS completed on 2/5/26, and the IDT meeting was held on 2/16/26, 11 days after the assessment. Resident #40 had a quarterly MDS completed on 3/26/26, and the IDT meeting was held on 4/13/26, 17 days after the assessment. During interviews, the Director of Social Services confirmed the findings and stated the facility was having care plans first and then the MDS assessment, and that the facility schedules IDT meetings within 2 weeks following the care plan review date rather than within 7 days following the MDS assessments.
Failure to Follow FSBS Orders and Long-Acting Insulin Timing
Penalty
Summary
The facility failed to follow physician orders for fingerstick blood sugar checks before meals for two residents. The Medication Admin Audit Report for one resident showed an order for FSBS before meals and at bedtime with notification of the HCP for FSBS 70 or greater than 350 unless otherwise indicated, but the resident’s blood sugar was checked at 9:29 a.m. after breakfast. A second resident had the same type of FSBS order, but the blood sugar was checked at 9:47 a.m. after breakfast. These findings were identified during surveyor review of the medication administration records and observation of medication administration timing. The facility also failed to follow its policy for administering long-acting insulin for one resident. During medication administration observation, the surveyor saw that the resident had not yet received the ordered Glargine 15 units subcutaneously once daily in the morning, with a start date of 4/6/26. The MedTech stated that injections are done by the nurse. In a separate interview, the DON reviewed another resident’s MAR and confirmed that the Glargine had been given at 11:47 p.m.; when questioned about the timing, the DON stated the resident was under liberalized medication administration times and then stated, “well an hour before and an hour after and all we can do is follow provider orders.” The DON later confirmed the findings.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure it was sufficiently staffed on weekends for 1 of 1 quarters reviewed. Review of the CMS PBJ Report showed the facility triggered for low weekend staffing during the first quarter reviewed. During an interview on 4/15/25 at 12:00 p.m. with a surveyor, the Administrator confirmed the facility was not adequately staffed for 5 of 39 days reviewed on day shifts.
Expired Lab Supplies and Unlocked Treatment Cart
Penalty
Summary
Expired lab supplies were found available for use on 4 of 4 units when surveyors observed blood collection tubes that had passed their expiration dates. At 7:50 a.m., surveyors identified 95 blue top blood collection tubes, 3 yellow top blood collection tubes, and 29 red blood collection tubes with expired dates. At 7:59 a.m., the ADON confirmed the expired blood collection tubes with the surveyors and removed them from use. Later, the Regional Director of Operations confirmed that the facility sometimes performs its own blood draws. The facility also failed to ensure a treatment cart was locked when unattended. At 9:37 a.m., two surveyors observed an unlocked and unattended treatment cart on the Windmere Unit. The cart contained resident medications and treatments, including Compound W, Nystatin, Diclofenac, Asperflex, hydrocortisone cream, ammonium lactate, and individually packaged SaniCloth disinfecting wipes. Several staff members walked past the cart during the observation, and the Administrator later stated that the nurse assigned to the cart was doing wound rounds on the unit and then locked the cart.
Kitchen sanitation, food labeling, and emergency food supply failures
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition during an initial kitchen tour. In the main food preparation area, the sanitizer solution hose was immersed below the water in the sink, cracks were observed on the wall behind the sink, and a dedicated handwashing sink was present between the dish room and food prep area. The surveyor interviewed the kitchen staff member, who stated he sometimes used the handwashing sink to rinse vegetables as a last resort, and the surveyor observed there was no air gap separation under that sink. Personal items, including staff water bottles, an energy drink, an ID badge, and a charger, were stored on a food prep surface, and crumbs, food debris, and a heavily soiled radio were also present on the countertop. Food debris and buildup were noted on the floors and baseboards throughout the kitchen, and the tray on top of the microwave was covered with crumbs, dried liquid, and a staff water bottle. The facility also failed to ensure foods were sealed, labeled, and dated in multiple storage areas. In dry storage, an opened box of baking soda was unlabeled and undated. In the cook’s refrigerator, a container of bacon grease was labeled only with the cook’s name and was undated, and an opened package of whipped topping was undated. In the walk-in refrigerator, an open bag of spinach was unlabeled and undated, cabbage was stored uncovered on a tray without labels or dates, and an open bag of shaved cheese had an open date but no discard date. In the walk-in freezer, an open box of ground beef patties was undated with the inner bag open and exposed to air, two meat items were unlabeled and undated, and the floor contained debris, trash, and residue buildup. The dish room was also observed to be unclean, with significant food debris in the grate under the dish machine, unpainted spackled wall areas creating an uncleanable surface, and two wall-mounted oscillating fans covered in dust, with one blowing toward clean dishes. In addition, the facility failed to maintain an emergency food supply for part of the survey period. During interviews, the Food Services Director stated the emergency food supply was expired when he started, and the Administrator stated the facility had been using the emergency food supply for routine meal prep because it was nearing expiration, but replenishment had not occurred due to miscommunication. The interim Food Services Director later stated the facility did not have an emergency food supply list and that a replacement supply was being delivered.
Failure to Inspect Bed Frames and Mattresses for Entrapment Hazards
Penalty
Summary
The facility failed to conduct regular inspection of bed frames and mattresses as part of its maintenance program to ensure mattress and bed frame compatibility and to identify possible entrapment areas for 4 of 4 units observed: Eagle, [NAME], Sagamore, and Windmere. The facility policy, revised 5/2/25, states that entrapment zones will be checked with the bed in the flat position, that Zone #7 between the head and foot board and the mattress end will not exceed 4 3/4 inches, and that all beds will be checked annually using the Bed Assessment Tool to Prevent Entrapment and when there is a change in side rail status. On 04/12/26, a surveyor observed Resident #7 asleep in bed with the head at the foot end of the bed, and on repeat observation later that day a large gap was seen between the mattress and the footboard, creating an area of possible entrapment. During additional observations, surveyors identified large gaps between the mattress and footboard on multiple beds in Windmere Unit rooms 100 D, 106 D, 107 W, 108 W, and 109 W; Eagle Unit room [ROOM NUMBER] W; Sagamore Unit room [ROOM NUMBER] W; and [NAME] Unit rooms 18 D and 20 D. The Administrator stated the improperly fitting mattresses had been identified and audited, and the Regional Engineering Director stated the facility inspects zones 1-4 annually, but the facility was unable to provide evidence of the original audit. The provided Bed System Measurement Device Test Results Worksheet showed only 10 beds measured in 2024 and 6 beds measured on 9/25/25, with no evidence of annual measurements.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Dining Room Meal Service Did Not Serve Tablemates at the Same Time
Penalty
Summary
The facility failed to provide care in a manner that maintained residents’ dignity by not serving all residents seated at the same table at the same time during lunch meal service in the dining room. On 4/12/26 between 12:07 p.m. and 12:18 p.m., Residents #7 and #48 were seated at a table with Resident #29. Resident #29 had already received a meal, while Residents #7 and #48 had not yet received theirs. Staff continued delivering meals to other tables in the dining room instead of serving the residents seated together at the same table at the same time. At 12:10 p.m., Resident #7 asked CNA #1 where the meals were and stated that Resident #29 was waiting to begin eating until the other two residents received their meals. CNA #1 said she was waiting for the rest of the meal trays to be delivered to the dining room and continued delivering meals to other residents. At 12:16 p.m., Residents #7 and #48 still had not received their meals, and Resident #48 asked a staff member when they would receive their meals; the staff member replied, "It's going to come out. They're really busy today." Resident #48 then received a meal at 12:17 p.m., followed by Resident #7. CNA #2 stated that the facility had recently started a new weekend meal-passing process and that there was supposed to be one meal cart specifically for residents seated in the dining room, but some residents’ meals ended up on carts designated for delivery to the units. The Administrator stated that until recently all residents were eating in their rooms except those requiring special assistance with meals, and that this was only the second day of implementing weekend meal delivery in the dining room.
Failure to Provide Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to issue a written transfer and discharge notice and a bed hold notice that included the cost of care and a statement of the resident's appeal rights to the legal representative for Resident #77, who was transferred to an acute care hospital on 1/15/26 and again on 4/12/26. Review of the resident's clinical record found no evidence that the required written transfer/discharge notice or bed hold notice was provided for either transfer. During an interview on 4/15/26 at 2:19 p.m. in the presence of four surveyors, the Business Office Manager confirmed that she does not issue a written transfer/discharge notice and bed hold notice to resident representatives.
Failure to Follow Oxygen Order
Penalty
Summary
The facility failed to follow a physician order for continuous oxygen therapy for one resident receiving O2. On 4/12/26, a surveyor observed the resident asleep in bed wearing oxygen via nasal cannula while the concentrator was set between 3.5 and 4 liters per minute, although the active order was for oxygen at 2 liters per minute continuous via nasal cannula every shift for shortness of breath. On 4/14/26, the resident was again observed asleep in bed with the concentrator set to 2.5 liters per minute. On 4/15/26, the resident was observed lying in bed without oxygen and with the concentrator powered off, and stated that he/she did not need to wear oxygen that day. During interview, the resident stated that staff hand him/her the tubing and that he/she puts it on and takes it off, but staff make all adjustments to the concentrator settings. The DON stated that providers definitely do not want the resident's oxygen to be worn as needed, but that the resident often removes it, and the resident's clinical record did not reflect the frequent removal of oxygen in nursing progress notes or the care plan.
Failure to Evaluate and Document Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to determine if it was clinically appropriate for four residents to self-administer medications, as observed during a survey. Residents were found with various creams and medications at their bedside without proper documentation or orders for self-administration. Specifically, Resident #2 had an unknown cream, Resident #3 had Biofreeze and Voltaren gels, Resident #4 had Biofreeze and Triad Hydrophilic wound dressing paste, and Resident #5 had an unknown cream for arthritis pain. None of these residents had a documented physician order for self-administration, a self-administration evaluation, or a care plan for self-administration in their medical records. The facility's policy requires a self-administration evaluation by a licensed nurse, a physician's order for self-administration, and a person-centered care plan for residents who self-administer medications. However, these steps were not followed for the residents in question. The Director of Nursing confirmed that there should be an MD order and evaluation completed if a resident is self-administering medications. This oversight indicates a failure to adhere to the facility's policy and ensure the safe self-administration of medications by residents.
Improper Storage and Labeling of Medications and Treatments
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatments on two of the four units observed during the survey. On the Sagamore and [NAME] units, several residents had medicine cups with unknown and unlabeled creams on their bedside tables or dressers. Resident #5 had a medicine cup with an opaque cream left on the bedside tray table, which the resident stated was for arthritis pain and applied independently. Similarly, Resident #2 had an unlabeled cream for itching, and Resident #3 had an unlabeled cream on the bedside dresser. Resident #4's bedside dresser was cluttered with treatment supplies, including a pump bottle of Biofreeze and a tube of Triad Hydrophilic wound dressing paste. The review of medical records revealed discrepancies in the documentation of provider orders for the creams observed. Resident #2's record lacked evidence of a provider order for any cream treatment other than house stock lotions. Resident #3 had documented orders for Biofreeze and Voltaren gels, while Resident #4 had an order for Biofreeze but lacked documentation for the Triad Hydrophilic wound dressing paste. Resident #5's record contained an order for Voltaren gel. The Director of Nursing confirmed the improper storage of these unknown and unlabeled creams and removed them from the residents' rooms.
Improper Storage of Disinfectant Spray in Resident's Room
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards due to improper storage of a chemical. During the survey, it was observed that a resident had a can of Great Value Disinfectant Spray Linen Scent on their bedside dresser. The resident mentioned using the spray for odor control, indicating it was their personal can. The Director of Nursing (DON) was unaware of the disinfectant's presence in the room and confirmed that it should not have been accessible to the resident. This oversight occurred on the day of the survey, as noted in the findings.
Inaccurate Clinical Records for Medication Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for medications. During an observation, a resident was found with a medicine cup containing an unknown cream and two cups of applesauce on a bedside tray. The resident stated that the nurse was giving medications but had to cut them in half due to their size. The resident also mentioned that the cream was for arthritis pain and that they applied it themselves. Later, the Director of Nursing (DON) and the surveyor observed the cream still on the bedside table, and the DON removed it. A review of the resident's provider order indicated that Voltaren External Gel was to be applied to the resident's hips twice daily. However, the Treatment Administration Records (TAR) inaccurately documented that the gel was applied at a time when the surveyor and DON were conducting a walkthrough, and the resident stated they applied the gel independently to their neck and groin. The resident confirmed that they only used the Voltaren when needed and that nursing staff did not apply it. This discrepancy between the TAR and the resident's account indicates a failure in maintaining accurate clinical records.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment across all four units, including Windermere, Eagle, Sagamore, and Regena, as well as the Laundry Room. Observations revealed multiple deficiencies in housekeeping and maintenance services. In the Sagamore unit, shared bathrooms were found with black and brown substances around the base of toilets, peeled caulking strips, and various items improperly stored on the floor, such as commode buckets and basins. These observations were made over several days, indicating a persistent issue with cleanliness and maintenance. In the Laundry Room, surveyors noted significant dust and debris accumulation on fans, heaters, air vents, and pipes. The sink and eye wash station on the dirty linen side were heavily stained and soiled, with additional dust and cobwebs observed on windows and behind the hot water tank. Similar issues were found in other rooms, with heavy staining around toilets, dusty wall fans, stained heating units, chipped floor tiles, and basins stored on the floor. These findings highlight a widespread failure to provide a safe, clean, and homelike environment for residents.
Failure to Provide Adequate ADL Care and Documentation
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for six residents, as observed through a series of interviews, observations, and record reviews. Resident #126, admitted for skilled services following a Chronic Obstructive Pulmonary Disease exacerbation, did not receive appropriate ADL care, including bathing, dressing, and oral hygiene. Documentation for Resident #126 was lacking, with no evidence of ADL care being provided on specific shifts in March 2024. The Director of Nursing confirmed the absence of documentation, which could not suggest that the resident received the necessary care. Resident #6 was observed multiple times with thick debris on their teeth, indicating a lack of proper oral hygiene care. Despite the care plan instructing staff to monitor and provide mouth care, the CNA documentation inconsistently recorded oral care as completed. The Director of Nursing acknowledged the resident's need for assistance with oral hygiene during a joint observation with the surveyor. Additional residents, including Resident #230, Resident #64, Resident #226, and Resident #19, reported not receiving regular showers or baths. Documentation in their Electronic Medical Records (EMR) was either missing or showed infrequent bathing activities, with some residents expressing a desire for showers that were not accommodated. The Director of Nursing stated that CNAs are expected to document bathing activities and refusals, but the records did not reflect this practice.
Failure to Maintain Sanitary Respiratory Care Practices
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, specifically concerning the use and maintenance of nebulizer equipment for two residents. For one resident, the nebulizer machine was observed with the mouthpiece and tubing improperly stored and not changed according to physician orders. The tubing was dated from a previous month, and the facility's records showed inconsistencies with the scheduled changes. Additionally, there was no evidence of the nebulizer filter being changed as recommended by the manufacturer. The Director of Nursing was unable to provide a record of filter changes, indicating a lapse in following the manufacturer's maintenance guidelines. Another resident's nebulizer equipment was found unbagged and unlabeled on their bedside table during multiple observations. This lack of proper storage and labeling further demonstrates the facility's failure to adhere to sanitary practices for respiratory care equipment. The Regional Director of Clinical Operations confirmed these observations, highlighting the facility's oversight in maintaining a clean and safe environment for residents requiring respiratory care.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly on weekends. This deficiency was identified through a review of the Payroll Based Journal staffing report, which revealed excessively low weekend staffing during the fourth quarter of 2024. During an interview on January 15, 2025, the Administrator confirmed that the facility did not have enough staff to meet resident needs on weekends. This staffing shortfall has the potential to affect all residents requiring assistance with Activities of Daily Living (ADLs).
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. The kitchen floor around and under the prep sink and the 3-bay sink was littered with crumbs, food, dirt, and debris. The air gaps for the kitchen prep sink and ice machine were not plumbed according to code requirements, risking food contamination. The tray line table, shelving unit, and dish washer hood exhaust were heavily soiled with dirt and debris. The walk-in freezer had a large brown ice puddle, a cookie wrapper, crumbs, and debris on the floor, while the walk-in refrigerator's fan was coated with dust, and contained expired food items. Additionally, the food mixer safety shield and cage were visibly soiled. During meal service, kitchen staff failed to adhere to personal hygiene standards. Several staff members, including cooks and dietary aides, were observed without proper hair restraints, despite having facial hair. One cook was seen handling multiple food items with the same pair of gloves, without changing them between tasks, which included handling grilled cheese sandwiches, steak, soup, fish, and chicken salad sandwiches. Furthermore, the facility did not monitor food temperatures prior to serving, as evidenced by the absence of recorded temperatures for several food items on the Kitchen Production Report.
Failure to Clearly Communicate Arbitration Agreement Terms
Penalty
Summary
The facility failed to ensure that the terms and conditions of a binding arbitration agreement were clearly communicated to residents or their representatives, and that signing such an agreement was not a condition of admission. During a survey, it was discovered that the arbitration agreement was included in the admission paperwork for all five residents reviewed. The Admissions and Marketing Director was responsible for having residents or their representatives sign the admission packet, which included the arbitration agreement. However, she did not adequately explain the agreement's terms, including the fact that it was not mandatory for admission and that it would remain in effect even after discharge and readmission unless rescinded within 30 days. Interviews with residents and their representatives revealed that they were not properly informed about the arbitration agreement. One resident's representative stated that she signed the paperwork under pressure and was not aware that the arbitration agreement was not a requirement for admission. Another resident did not recall signing the agreement and expressed that they would not have signed it had they understood its implications. The Admissions and Marketing Director admitted to not fully understanding the agreement's permanence and mistakenly believed a new agreement could be made with each admission. The facility's failure to clearly communicate the arbitration agreement's terms and conditions resulted in residents and their representatives signing the agreement without fully understanding its implications. The Administrator and the Admissions Coordinator were unaware that residents did not understand they had signed a binding agreement that limited their rights to choose a dispute resolution method. This oversight highlights a significant deficiency in the facility's admission process and communication with residents and their families.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to maintain adequate pharmaceutical services by not removing outdated medications from one of the three medication carts. During an observation, a surveyor found that a medication card for Ondansetron HCL 4 mg, intended for a resident, had expired. This expired medication was still present in the medication cart on Eagle Wing. The finding was confirmed with an LPN present at the time of the observation. The issue was subsequently discussed with the Director of Nursing.
Resident's Clothing Choice Ignored, Resulting in Injury
Penalty
Summary
The facility failed to respect a resident's choice regarding clothing, leading to an incident where a resident's tooth was cracked. On the night of April 12, 2024, two staff members attempted to remove a sweater from a resident who had expressed a desire to keep it on. Despite the resident's clear communication and physical resistance by biting down on the sweater, the staff proceeded with the removal, resulting in the resident's tooth breaking. This incident was reported to the Department of Licensing and Certification by Adult Protective Services, and the Director of Nursing confirmed the resident's rights were not upheld in this situation.
Failure to Conduct Neurological Monitoring After Falls
Penalty
Summary
The facility failed to adequately evaluate a resident after an unwitnessed fall and complete neurological assessments as per facility policy for a resident reviewed for falls. The facility's Fall Prevention Program and Neurological Evaluation Policy require monitoring of a resident's status for 72 hours after a fall and performing neurological evaluations whenever there is a possibility of a head injury, change in mentation, or an unwitnessed fall. However, the medical record of the resident, who was admitted with diagnoses of COVID-19 and orthostatic hypotension, showed a lack of evidence of neurological monitoring per policy after multiple unwitnessed falls. The resident experienced four unwitnessed falls during their stay, with documentation indicating incomplete or incorrect neurological monitoring. For instance, after a fall on 9/24/24, the medical record lacked evidence of neurological monitoring. On 10/6/24, the neurological evaluations recorded the same vital signs repeatedly, and some evaluations were not completed. After a fall on 10/13/24, the resident was sent to the emergency department for a CT scan, but the medical record lacked evidence of neurological monitoring upon their return. The Director of Nursing confirmed the deficiencies in neurological monitoring and documentation during a review with the surveyor.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to provide evidence that Advance Directives were offered or reviewed with residents and/or their representatives, and that written information concerning the right to formulate an Advance Directive was provided. This deficiency was identified for 11 out of 14 residents reviewed, including Residents #8, #3, #35, #17, #18, #19, #37, #64, #226, and #230. The electronic and paper medical records for these residents lacked documentation of the facility's compliance with these requirements. Interviews with facility staff, including the Administrator, social worker, and Director of Nursing, confirmed the deficiency. The social worker acknowledged that while they ask about Advance Directives upon admission, they do not always document or follow up. The Director of Nursing admitted that if documentation is not found in the chart, it is considered non-existent, and mentioned that calls were made to families for missing documentation. This lack of documentation and follow-up indicates a systemic issue in ensuring residents' rights to formulate Advance Directives are upheld.
Failure to Document Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that two authorized individuals signed the Narcotic Bound Book Shift Count page, indicating that they counted all controlled substances at the change of shift for multiple shifts. This deficiency was identified in one of the four units reviewed for drug diversion, specifically the Sagamore Unit. The facility's policy on Controlled Substances requires a physical inventory of controlled medications by two licensed clinicians at each shift change, documented on an audit record. However, between 8/14/24 and 9/3/24, there was a lack of documented evidence that a shift change count was conducted by two qualified staff for 56 shifts. The issue came to light when a 30ml bottle of Ativan could not be located during a shift change on 8/16/24. Further review of the shift count log revealed that the status of the count was left blank for 42 of the 56 shifts. Interviews with the Director of Nursing (DON) and several nursing staff confirmed the lack of documentation and adherence to the correct change of shift count process. The DON acknowledged that it is a common issue to find missing signatures and incomplete entries in the narcotic count logs.
Failure to Securely Store Controlled Drugs
Penalty
Summary
The facility failed to provide a separately locked, permanently affixed compartment for the storage of controlled drugs, specifically those listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976. This deficiency was identified during an observation on September 3, 2024, when a surveyor noted that the locked refrigerator in the locked Medication Room did not have a separate, locked box attached for the storage of controlled substances. This observation was confirmed during an interview with the Director of Nursing, who stated that there had never been a separate locked box in that refrigerator. The issue came to light following a facility-reported incident on August 16, 2024, when a 30ml bottle of Ativan could not be located during a shift change at 16:00.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 183 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kennebunk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Ridge Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Southridge Rehab & Living Ctr | 7.7 mi | ★★★★★ | 0 | 0 |
| St Andre Health Care Facility | 8.7 mi | ★★★★★ | 0 | 0 |
| Seal Rock Healthcare | 9.3 mi | ★★★★★ | 20 | 0 |
| Pinnacle Health & Rehab At Sanford | 10.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.