Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Pinnacle Health & Rehab At N Berwick during CMS and state inspections, most recent first.
A resident with dementia and behavioral health diagnoses had a care plan that was not accurately revised to reflect current needs. Records showed impulsive behavior, poor decision making, and wandering risk, including attempts to leave the facility and unsafe outdoor activity, but the care plan did not include specific interventions such as boundary setting or other safety approaches.
The facility was found to have deficiencies in maintaining kitchen cleanliness and proper food storage. The kitchen floor was dirty and worn, and the food slicer had dried food particles. The walk-in refrigerator and freezer contained open, undated, or expired food items, including moldy cheese and various other foods. These issues were acknowledged by the Food Service Director and discussed with the Administrator.
The facility did not adhere to its Legionella Water Management Program, failing to implement measures to control and monitor the spread of Legionella and other waterborne pathogens. The Administrator confirmed the absence of necessary controls and monitoring systems, potentially affecting all 59 residents.
The facility failed to maintain a sanitary and comfortable environment due to inadequate housekeeping and maintenance services. A surveyor observed black tape on floors at the entrance of several resident rooms and in hallways, creating uncleanable surfaces. Gaps in the flooring were also noted, further contributing to the unsanitary conditions. These findings were confirmed with the Maintenance Director.
The facility failed to maintain sanitary conditions for oxygen therapy, as observed in four residents. Oxygen concentrators had dusty intake filters, and one resident's oxygen tubing was stored unsanitarily, touching the floor. Interviews with the ADON/Infection Preventionist and an LPN confirmed these unsanitary conditions.
The facility failed to implement its pneumococcal immunization policy for three residents. Despite having signed consent forms, there was no evidence that the residents were offered or administered the pneumococcal vaccine as per CDC recommendations. This deficiency was confirmed during an interview with the Infection Preventionist/ADON.
Care Plan Not Updated for Wandering and Boundary-Setting Needs
Penalty
Summary
The facility failed to ensure a resident’s care plan was accurately revised to reflect current needs for a resident with Vascular Dementia, Obsessive Compulsive Disorder, Major Depressive Disorder, and Anxiety Disorder. Nursing documentation showed the resident was observed outside shoveling snow in the walkway without a coat or gloves, and another note stated the resident wanted a phone card, attempted to leave the facility to help him/herself after being told to wait for office staff, and was redirected by staff. Additional progress notes described a history of poor decision making and difficulty understanding the rationale for safety instructions. The resident’s record also showed a Wandering Risk Assessment identifying high risk for wandering, while the quarterly MDS noted a BIMS score of 13 indicating intact cognition. The care plan, last revised on 1/13/26, included interventions for mood and behaviors such as wandering and a need to keep busy, but it did not include specific approaches such as boundary setting. During interview, the social worker stated the resident had impulsive behaviors and difficulty making safe decisions and required staff to set boundaries. The ADON stated the resident had an agreement with staff to remain only in the fenced-in area outside the front door, was continually monitored, and staff had set boundaries that the resident agreed to follow; however, the current care plan did not reflect these behavioral concerns or safety approaches.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, as observed during a surveyor's initial kitchen tour. The kitchen floor was found to have a significant amount of visible crumbs, dirt debris, and was discolored and worn in appearance. The Food Service Director acknowledged that the flooring was porous and difficult to clean. Additionally, the food slicer had dried food particles on the blade and blade protector, and the dry storage room floor had excessive dirt debris and food particles. In the walk-in refrigerator, several food items were found to be open, undated, or expired, including a 6 lb. block of moldy cheese and a 5 lb. block of moldy Swiss cheese. The walk-in freezer also contained numerous open, undated, or expired food items, such as garlic bread, chicken tenders, chicken breast, various loaves of bread, waffles, sausage, turnovers, muffins, and other prepared foods. These findings were discussed with the Administrator, highlighting the facility's failure to adhere to professional standards for food storage and cleanliness.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to maintain an effective Infection Control Program specifically related to Legionella prevention and control. The Legionella Water Management Program, which was initiated on October 18, 2019, outlined specific measures to control the introduction and spread of Legionella, including temperature and disinfectant controls, acceptable control limits, a diagram of control measure applications, and a system for monitoring these measures. However, during an interview on October 30, 2024, the Administrator confirmed that the facility was not following its own policy. There were no measures in place to control, assess, and monitor areas where Legionella and other opportunistic waterborne pathogens could grow and spread, nor was there a diagram indicating where these measures should be applied. This deficiency has the potential to affect all 59 residents in the facility.
Deficiency in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. During a facility environment tour, a surveyor observed black tape on the floors at the entrance of several resident rooms, including Rooms 19, 20, 21, 22, 23, 25, 27, 28, 31, 32, and 34. Additionally, the hallway floor near the B unit nursing station had black tape that was scuffed, torn, and worn, creating an uncleanable surface. Furthermore, the hallway floors on A, B, and C units, with a concentration at the end of the hallway on D unit, had gaps in the flooring, also creating uncleanable surfaces. These observations were confirmed during an interview with the Maintenance Director, indicating a failure to maintain the building in a sanitary and comfortable manner, as required to honor the residents' right to a safe, clean, and homelike environment.
Unsanitary Oxygen Therapy Practices
Penalty
Summary
The facility failed to provide oxygen therapy in a sanitary manner for four residents using oxygen. Observations revealed that the oxygen concentrators for these residents had intake filters coated in dust and debris. Specifically, Resident #29 and Resident #9 had dusty filters, with Resident #9's oxygen tubing stored unsanitarily, coiled on top of the concentrator and touching the floor. Similarly, Resident #22 and Resident #6 were observed with dusty concentrator filters while using oxygen via nasal cannula. Interviews with the Assistant Director of Nursing/Infection Preventionist and an LPN confirmed the unsanitary conditions of the oxygen concentrator filters for these residents.
Failure to Implement Pneumococcal Immunization Policy
Penalty
Summary
The facility failed to implement its pneumococcal immunization policy for three residents whose immunization records were reviewed. According to the facility's policy revised on February 1, 2020, residents should be assessed for eligibility to receive the pneumococcal vaccine series upon admission and offered the vaccine within 30 days unless medically contraindicated or previously vaccinated. However, the records for three residents showed a lack of evidence that the facility offered or administered the pneumococcal vaccine as per CDC recommendations. Resident #4, admitted with a signed consent form dated January 11, 2024, did not have evidence of being offered or administered the vaccine by October 29, 2024. Similarly, Resident #25, with a consent form signed on April 27, 2023, and Resident #48, with a consent form signed on August 31, 2023, also lacked documentation of receiving the vaccine by the same date. These findings were confirmed during an interview with the Infection Preventionist/Assistant Director of Nursing.
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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 North Berwick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinnacle Health & Rehab At Sanford | 8.5 mi | ★★★★★ | 0 | 0 |
| Dover Center For Health & Rehabilitation | 9.8 mi | ★★★★★ | 0 | 0 |
| Summer Commons | 10 mi | ★★★★★ | 18 | 0 |
| Langdon Place Of Dover | 10.3 mi | ★★★★★ | 0 | 0 |
| Rochester Manor | 10.8 mi | ★★★★★ | 4 | 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.