Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Sanford during CMS and state inspections, most recent first.
The facility failed to develop comprehensive care plans for several residents, lacking specific interventions for ADLs such as eating, hygiene, and mobility. Changes in assessments and a new EMR system contributed to the oversight, as confirmed by staff interviews.
The facility failed to ensure that two authorized staff members signed the Shift Count page for controlled substances at shift changes, as required by policy. This deficiency was observed in both the Second and First Floor Medication Rooms, with missing signatures on multiple dates, indicating a lack of adherence to the established procedure for controlled substance counts.
The facility failed to store vaccines according to CDC guidelines, using a dormitory-style refrigerator in the First Floor Unit's Medication Room. This refrigerator, which is not recommended for vaccine storage, contained vials of purified protein derivative and unit dose syringes of pneumococcal and influenza vaccines. The issue was confirmed by the charge nurse and Infection Preventionist.
The facility was found to have environmental deficiencies, including a need for wall repair in a resident's room, tape hanging from the dining room ceiling, dark spots on ceiling strapping in a common area, and an unpainted repaired area in the Spa room on the first floor. Additionally, a stained ceiling tile was observed outside a resident's room on the second floor. These issues were noted during a survey and discussed with the Administrator.
A facility failed to maintain complete and accurate clinical records for a resident with Parkinson's disease, who requires total care for ADLs. The care plan specified oral hygiene after meals and toileting every 3-4 hours, but documentation showed these tasks were not consistently performed. Staff interviews confirmed the resident's dependency, and the administrator acknowledged the findings.
A facility failed to implement the care plan for a resident with Parkinson's disease, who is dependent on staff for all ADLs. The care plan included interventions such as assistance with ADLs, oral hygiene, toileting, and repositioning, but the clinical record lacked evidence of these being completed. A CNA confirmed the resident's need for total care and the protocol for refusals, while the administrator acknowledged the deficiency during a record review.
The facility failed to maintain a sanitary environment in a shared room, where personal hygiene items were found unlabeled and available for use on a shared sink. A resident confirmed using these items without knowing their ownership, while another resident's family retrieves items for them. An LPN and a surveyor confirmed the presence of these unlabeled items during an inspection.
Deficiency in Comprehensive Care Plans for ADLs
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for several residents, specifically in the area of Activities of Daily Living (ADLs). The care plans for six residents lacked specific interventions needed to assist them in various ADL areas such as eating, personal hygiene, transfers, dressing, bathing, toileting, bed mobility, and ambulating. This deficiency was identified during a review of the residents' care plans, which did not include personalized assistance required for each resident to attain or maintain their highest practicable quality of life. The issue was partly attributed to changes in the Minimum Data Set assessments for GG - Functional Abilities, which were not properly updated in the residents' care plans. Additionally, the transition to a new Electronic Medical Record system failed to automatically transfer necessary information, requiring manual updates that were not completed. These oversights were confirmed through interviews with the Licensed Practical Nurse Manager, the Director of Nursing, and the Unit Director, who acknowledged the deficiencies in the care plans.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, as required by their Shift Count policy and procedure. The policy, dated 2/3/2000, mandates that all Schedule II-V medications be counted at the change of each shift by both the off-going and on-coming nurse, with both required to sign the shift count sheet if the count is correct. However, during a survey conducted on 2/11/25, it was observed that on multiple occasions, neither the nurse coming on duty nor the nurse going off duty signed the Shift Count page of the Controlled Substances Book, indicating that the controlled substances count was completed. This issue was identified on both the Second Floor and First Floor Medication Rooms. The surveyor confirmed these findings with the Unit Manager and Charge Nurse, noting that the lack of signatures occurred on several dates across both units. The specific dates where signatures were missing include 6/16/24, 9/13/24, 10/2/24, 10/3/24, 11/3/24, 11/6/24, 11/16/24, 11/23/24, 12/2/24, 12/12/24, 12/29/24, 1/3/25, 1/18/25, 1/24/25, 1/25/25, 1/26/25 (both units), 1/27/25, 2/9/25, and 2/10/25. This failure to adhere to the established procedure for controlled substance counts was confirmed through record reviews, observations, and interviews with facility staff.
Improper Vaccine Storage in Dormitory-Style Refrigerator
Penalty
Summary
The facility failed to ensure proper storage of vaccines in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. During an observation of the First Floor Unit's Medication Room, a surveyor identified a dormitory-style refrigerator being used to store vaccines, which is against CDC recommendations. The refrigerator contained vials of purified protein derivative for tuberculosis testing and unit dose syringes of pneumococcal and influenza vaccines. This finding was confirmed by the charge nurse and the Infection Preventionist, and later discussed with the Administrator.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on both the first and second floors. On the first floor, a resident's room had a wall behind a chair that required repair, and the main dining room had many pieces of tape hanging from the ceiling. Additionally, the first-floor common area had several dark spots on the ceiling strapping, and there was an unpainted repaired area on the wall in the Spa room. On the second floor, a stained ceiling tile was observed just outside a resident's room. These observations were made during a survey conducted on February 12, 2025, and were discussed with the facility's Administrator at approximately 10:00 a.m. on the same day.
Incomplete Clinical Records and ADL Care Deficiency
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as required by professional standards. During a complaint investigation, it was found that the facility did not document the provision of oral hygiene and denture cleaning for a resident with Parkinson's disease, who is dependent on staff for all activities of daily living (ADLs). The care plan specified that oral hygiene should be performed after each meal and at bedtime, but there was a lack of documented evidence that this care was provided on numerous occasions throughout September 2024. Additionally, the facility did not adhere to the care plan's requirements for toileting and repositioning the resident. The care plan indicated that the resident should be toileted every 3-4 hours and turned or repositioned every two hours. However, records showed that the resident was toileted and repositioned far less frequently than required. Interviews with staff confirmed the resident's need for total care with ADLs, and the facility administrator acknowledged the findings during a review of the clinical record.
Failure to Implement ADL Care Plan for Resident with Parkinson's
Penalty
Summary
The facility failed to implement the interventions outlined in the care plan for a resident with Parkinson's disease who is dependent on staff for all Activities of Daily Living (ADL) needs. The resident's care plan, updated on August 27, 2024, included specific interventions such as staff assistance with ADLs, oral hygiene and denture cleaning after each meal and at bedtime, toileting or changing every 3-4 hours, and turning and repositioning every two hours. However, a review of the resident's clinical record revealed a lack of evidence that these interventions were completed as written. A complaint was received by the Department of Licensing on September 13, 2024, indicating that ADL care was not being provided as stated in the care plan. During an interview, a Certified Nursing Assistant (CNA) confirmed that the resident requires total care for all ADLs and mentioned the protocol for handling resident refusals, which includes reapproaching and documenting refusals. The facility's administrator confirmed the findings during a review of the resident's clinical record with a surveyor, highlighting the deficiency in implementing the care plan interventions.
Inadequate Labeling of Personal Hygiene Items in Shared Room
Penalty
Summary
The facility failed to maintain a sanitary environment in room [ROOM NUMBER], as observed during a survey. The shared sink in the room contained multiple personal hygiene items that were unlabeled and available for use, including deodorant bottles, body wash, mouthwash, shaving cream, an opened can of ginger ale, an electric razor, several razors held together with a rubber band, a soiled basin, and a toothbrush in a paper cup. Resident 3 confirmed that they use the items on the sink but are unsure of ownership due to the lack of labeling. Resident 2 mentioned that their family retrieves personal items for them from the shared sink. An LPN, along with a surveyor, confirmed the presence of these unlabeled items during an inspection. The deficiency was discussed with the Administrator.
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What surveyors actually found near you
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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 Sanford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summer Commons | 1.5 mi | ★★★★★ | 18 | 0 |
| Pinnacle Health & Rehab At N Berwick | 8.5 mi | ★★★★★ | 5 | 0 |
| Kennebunk Center For Health & Rehabilitation, Llc | 10.7 mi | ★★★★★ | 15 | 0 |
| River Ridge Center | 10.9 mi | ★★★★★ | 0 | 0 |
| Rochester Manor | 13 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.