Average — CMS composite of the measures below.
A standard survey is most likely before 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 South Portland during CMS and state inspections, most recent first.
Meal service did not preserve resident dignity or a homelike dining environment. During observations, staff served residents at different times while moving between tables, and one resident was assisted with feeding before other residents had been served. In addition, trays were placed in front of residents without asking whether they wanted the food removed from the tray. On the dementia unit, staff stated trays were kept in front of residents to prevent them from grabbing each other’s food, and CNA staff reported they had not been told to serve each resident at the table before moving on.
Call Bells Left Out of Reach for Multiple Residents: Four residents were observed with call bells not within reach, including one resident with the call light tucked under a pillow, another with the call bell draped over a recliner chair and blocked by a tray table, a resident with poor vision and hearing whose call bell was hanging off the bed, and another resident whose call bell remained clipped to the wall jack at the foot of the bed. One CNA stated the call light should be within reach, and the DON confirmed residents should have access to their call bells at all times.
Failure to Document Advance Directive Discussions: The facility lacked evidence that Advance Directives were offered, reviewed, or explained in writing to multiple residents or their representatives. Records for several residents admitted between 2022 and 2025 contained no documentation showing the right to formulate an Advance Directive was discussed, and an LPN, the DON, and an RN confirmed the missing documentation; one RN noted that yearly Advance Directive discussions are something the facility just needs to do.
The facility failed to maintain a resident room and a shared bathroom in a sanitary, orderly, and comfortable condition. An LPN observed a bed footboard with missing and peeling luminant that the resident said had been present for at least two years, and surveyors also found stained ceiling tiles in a shared bathroom, including one with blueish gray spotty growth. The Maintenance Director said a recent water leak had been fixed.
The facility failed to hold IDT meetings within 7 days of completed MDS assessments for 6 reviewed residents. Several residents had IDT meetings held well after MDS completion, one resident had an IDT meeting before the MDS was completed, and one resident had no evidence of an IDT meeting within the required timeframe. The findings were discussed with the Administrator and DON during an interview with 2 surveyors.
Respiratory equipment was not maintained in a sanitary condition for 3 residents reviewed. One resident had oxygen tubing dated earlier than expected with no clear order or weekly change documentation, another had oxygen tubing with a date that did not match TAR entries showing weekly replacement, and a third resident’s CPAP machine, tubing, and mask were observed unbagged on a bedside table. The DON and an LPN confirmed the findings.
The facility failed to document targeted behaviors and side effects to support psychotropic medication use for three residents. One resident with anxiety, psychosis, dementia, and a psychotic disorder was receiving Risperdal and Lexapro without behavior or side-effect monitoring orders, while two other residents with diagnoses including dementia with behavioral disturbance, psychosis, anxiety, depression, and bipolar disorder were receiving Seroquel, Lorazepam, Zoloft, and Divalproex without evidence of targeted behavior tracking or side-effect monitoring.
Expired medications were observed in two medication rooms, including unopened liquid acetaminophen, Iron 325 mg tablets, and Vitamin D 25 mcg. In one medication refrigerator, an opened vial of Tuberculin Purified Protein was stored with manufacturer directions to keep it at 35 to 46 degrees F, and refrigerator logs showed missed temperature checks. The DON confirmed the refrigerators should have been monitored twice daily.
A facility failed to complete a smoking assessment for a resident who went off property unsupervised to smoke. An LPN said the resident left with a pager arrangement, and the resident stated staff did not accompany him/her. Record review showed staff were unsure whether the resident was allowed to go out, later learned the resident went across the street to smoke, and noted confusion about self-outings and wheelchair limits; the chart lacked evidence of a smoking assessment.
Failure to address a resident's trauma history in the care plan. A resident with vascular dementia and severe cognitive impairment had a trauma questionnaire showing a significant trauma history and a family-reported trigger that showers by men could cause re-traumatization, with showers to be provided by women only. The record did not show the findings were communicated to the provider, and the care plan did not include trauma history or interventions to prevent re-traumatization during care. The DON confirmed staff had not acted on the questionnaire findings to ensure trauma-informed care.
Kitchen Sanitation Deficiency in Walk-In Refrigerator: The facility failed to keep the walk-in refrigerator clean and sanitary when a surveyor observed a double fan over shelving units containing food with obvious built-up debris. The CDM acknowledged the condition, and the observation was later confirmed by the Administrator and DON.
The facility failed to keep a resident’s record complete and accurate for a resident with a pacemaker. The care plan noted the pacemaker and monitoring for signs of malfunction, but the active chart lacked pacemaker orders and evidence of device checks or follow-up appointments. The UM said no orders or follow-up were made because the resident was on hospice, and the MD confirmed the record had no pacemaker orders.
The facility's Quality Assurance Committee failed to ensure the effectiveness of a Plan of Correction for a previously identified deficiency related to infection control. The deficiency, cited under F880, involved the failure to maintain and implement an infection control program. During a follow-up survey, the same issue was identified, indicating ineffective corrective measures. This was confirmed in an interview with the Administrator and DON.
An LPN failed to follow the facility's COVID-19 PPE protocol by entering a COVID-19 positive resident's room wearing only an N-95 mask, contrary to the policy requiring full PPE. Despite clear signage and available PPE, the LPN believed it was unnecessary for a brief visit. This was confirmed in an interview with the surveyor, and the requirement for full PPE was reiterated by the DON and Infection Preventionist.
Meal Service Did Not Preserve Resident Dignity or a Homelike Dining Environment
Penalty
Summary
The facility failed to promote resident dignity during meal service on the 200 unit by not serving residents in a consistent and respectful manner. During a meal observation, one resident at Table 1 received a tray at 12:24 p.m., while staff served multiple other tables before returning to provide the second resident’s meal at 12:34 p.m. At Table 2, one resident was served at 12:26 p.m. and the second resident was not served until 12:29 p.m. At Table 3, one resident was served at 12:27 p.m., the second resident was served at 12:39 p.m., and staff sat down to provide feeding assistance to that resident while other residents still had not been served; the third resident at that table was not served until 12:43 p.m. The facility also failed to maintain a homelike dining environment during observed meals on the 200 unit and Bayview unit. During the 200 dining room observation, all meal trays were placed in front of each resident and no residents were asked whether they wanted to keep the food on the tray. During the Bayview unit lunch observation, all 9 residents in the dining room were sitting at the table with lunch trays. RN #1 stated that because it is a dementia unit, staff keep the food on the tray to help prevent residents from grabbing each other’s food. CNA #2 stated she had never been told that each resident needed to be served at the table before moving to another table and had always just placed a tray in front of the resident, and that she did not normally ask residents if they wanted the plates placed on the table. The ADON stated that residents should be asked if they want their plates removed from the tray for the meal, and the Administrator and DON confirmed this.
Call Bells Left Out of Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for four sampled residents. On 9/16/25, Resident #5 was observed seated in a Broda chair in the room with the call bell tucked underneath a pillow on the bed and out of reach. The resident stated trying to get into bed and said he/she usually has to holler to get help. When the call bell was pressed, a CNA entered and stated the resident usually likes to go back to bed after breakfast and that the call light should not be under the pillow and should be within reach. Resident #54 was observed with the call bell hanging over a recliner chair at the head of the bed while the resident sat in a wheelchair at the foot of the bed with a tray table in front. The resident was unsure whether the call bell could be accessed and said he/she had not tried and did not know how to move the table. Later, the resident was lying in a low bed with the call bell still draped over the recliner chair and out of reach. Resident #54’s care plan identified confusion, gait/balance problems, incontinence, and being unaware of safety needs, with interventions to keep the call light within reach and encourage use for assistance. Resident #7 was observed lying in bed with the call bell attached to the blankets and hanging off the side of the bed above the floor, and the resident did not know where the call bell was located. Resident #7’s care plan noted poor vision and poor hearing requiring tactile and physical cues, along with a working and reachable call light. Resident #67 was observed lying in a low bed with the call bell clipped to the wall jack at the foot of the bed and not within reach on two separate observations.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to provide evidence that Advance Directives were offered or reviewed with residents and/or resident representatives, and failed to show that written information about the right to formulate an Advance Directive was provided for 8 of 25 residents reviewed. The affected residents were #4, #8, #29, #57, #68, #52, #34, and #50. For Residents #4, #8, #29, and #57, review of the electronic medical record lacked evidence that the facility offered or reviewed Advance Directives or provided written information about the right to formulate one. Resident #4 was admitted in June 2022, Resident #8 in October 2023, and Residents #29 and #57 in August 2025. For Resident #68, admitted in October 2023, the electronic medical record lacked evidence that the facility offered, reviewed, or provided written information concerning the right to formulate an Advance Directive with the resident and/or resident representative. Similar lack of documentation was found for Resident #52, admitted in July 2024, and Resident #34, admitted in August 2025. Resident #50, admitted in July 2024, also had no evidence in the record that the facility offered, reviewed, or provided written information concerning Advance Directives. During interviews, an LPN, the DON, and an RN confirmed the lack of documentation, and RN #4 stated that yearly discussion regarding Advance Directives is something the facility just needs to do.
Maintenance Deficiencies in Resident Room and Shared Bathroom
Penalty
Summary
The facility failed to adequately provide maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on 2 of 3 units, including the 100's and 200's. In one resident room, the footboard on bed B was observed to have missing and peeling areas of luminant, creating an uncleanable surface. During a later observation of the same room with an LPN present and the resident in the room, the LPN stated she had never noticed the condition before and agreed it needed to be fixed, while the resident stated the footboard had been like that for at least two years. In a shared bathroom for two rooms, surveyors observed two stained ceiling tiles near and around the light fixture, including one tile with a blueish gray spotty growth. The Maintenance Director acknowledged a recent water leak had been fixed and stated the tiles would be replaced immediately.
IDT Meetings Not Held Within Required Timeframe After MDS Completion
Penalty
Summary
The facility failed to hold Interdisciplinary Team (IDT) meetings within 7 days of completed MDS assessments for 6 of 6 residents reviewed. For Resident #4, the annual MDS completed on 6/23/25 had an IDT meeting on 7/7/25, the quarterly MDS completed on 3/24/25 had an IDT meeting on 4/14/25, and the quarterly MDS completed on 12/20/24 had an IDT meeting on 1/9/25. For Resident #8, quarterly MDS assessments completed on 7/31/25, 4/29/25, and 1/27/25 had IDT meetings on 8/14/25, 5/12/25, and 2/13/25, respectively. For Resident #13, the quarterly MDS completed on 6/30/25 had an IDT meeting on 7/17/25, the significant change MDS completed on 3/31/25 lacked evidence of an IDT meeting, and the quarterly MDS completed on 12/31/24 had an IDT meeting on 1/16/25. Resident #57 had a quarterly MDS completed on 11/29/24, but the IDT meeting was held on 11/21/24, before the MDS completion date. Resident #5 had a quarterly MDS completed on 8/7/25 with no evidence of an IDT meeting within 7 days after the assessment. Resident #16 had an admission MDS completed on 11/12/24 with an IDT meeting on 11/25/24, a quarterly MDS completed on 5/15/25 with an IDT meeting on 6/5/25, and a quarterly MDS completed on 8/15/25 with an IDT meeting on 8/28/25. On 9/16/25 at 2:29 p.m., the findings were discussed with the Administrator and the DON during an interview with 2 surveyors.
Respiratory equipment not maintained in sanitary condition
Penalty
Summary
The facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 3 residents reviewed for respiratory care. Resident #31 was observed using oxygen nasal cannula tubing dated 9/5/25, and the electronic medical record lacked evidence of an order and/or that the nasal cannula had been changed weekly. Resident #19 was observed using oxygen nasal cannula tubing dated 8/25/25, while the TAR documented oxygen maintenance weekly per protocol, including replacement of the nasal cannula every Monday; the TAR also showed the cannula was replaced on 9/1/25 and 9/8/25, which did not match the date on the tubing. Resident #57 was observed with a CPAP machine on top of the bedside table with the tubing and mask connected and not bagged. The DON confirmed the findings for Resident #31 and Resident #19, and an LPN confirmed the observation for Resident #57.
Lack of Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor and document targeted behaviors and side effects of psychotropic medications to support the use of psychotropic drugs for 3 of 5 residents reviewed for unnecessary medications. Resident #4 had diagnoses including anxiety, psychosis, dementia, and a psychotic disorder and was receiving Risperdal 0.25 mg twice daily and Lexapro 10 mg each morning, but the clinical record lacked evidence of monitoring for side effects and behaviors related to these medications. During record review with an LPN, it was confirmed that there were no orders for monitoring behaviors or side effects, and this was later confirmed with the Administrator and DON. Resident #6 had diagnoses including anxiety, major depressive disorder, dementia with behavioral disturbance, and psychosis and was ordered Seroquel 12.5 mg daily, Lorazepam 0.5 mg three times daily and every 4 hours as needed for agitation, and Zoloft 75 mg daily. Resident #31 had diagnoses including bipolar disorder and dementia with behavioral disturbance and was ordered Seroquel 300 mg at bedtime, Divalproex Sodium 1500 mg at bedtime, and Lorazepam 1.5 mg at bedtime. For both residents, the clinical record lacked evidence and documentation of targeted behaviors and monitoring for side effects of these medications, and the issue was discussed with the LPN during the survey.
Expired Medications and Improper Refrigerator Storage
Penalty
Summary
Expired medications were found in two medication rooms during survey observations, and medication storage practices did not match manufacturer directions in one of the rooms. In the 100 unit medication room, the LPN showed surveyors two unopened bottles of liquid acetaminophen with an expiration date of 8/2025 and an unopened bottle of Iron 325 mg tablets with an expiration date of 8/2025. In the 300 unit medication room, the RN showed surveyors an unopened bottle of Vitamin D 25 micrograms with an expiration date of 8/2025, and the refrigerator contained an opened vial of Tuberculin Purified Protein with manufacturer directions to store it at 35 to 46 degrees Fahrenheit. Review of refrigerator temperature logs from 8/25 through 9/15/25 showed missing temperature monitoring for 18 of 62 opportunities in August and 10 of 29 opportunities in September. The DON confirmed the medication refrigerators should have been monitored twice daily.
Missing Smoking Assessment for Resident Leaving Unsupervised to Smoke
Penalty
Summary
The facility failed to ensure a smoking assessment of resident capabilities and deficits was completed for a resident who went outside to smoke and left the facility property unsupervised. The facility policy stated it was a non-smoking facility and prohibited residents from smoking both inside and outside the facility. During interview, an LPN stated the resident went outside to smoke, had a cell phone and call pendant, and handed a corresponding pager to the nurse because the resident went off facility property unsupervised to smoke. The resident stated he/she went outside to smoke, was not permitted to smoke on facility property, and was not accompanied by staff. The resident also showed a pager and lanyard used when leaving to smoke. Record review showed a nursing progress note stating staff were unsure whether the resident was allowed to go outside, the resident went around the building and down the street out of sight, and staff later learned the resident went across the street to smoke. A care plan team nursing note stated there had been confusion with self-outings and limitations regarding the electric wheelchair and that the resident expressed a need to get out and be alone sometimes to think, smoke, or cry. The clinical record lacked evidence of a smoking assessment. The DON stated the facility was a no-smoking facility for residents and that the resident went outside but was not permitted to smoke on facility premises.
Failure to Address Trauma History in Care Plan
Penalty
Summary
The facility failed to identify a resident's past history of trauma and did not revise the care plan to include trauma-informed interventions for one resident reviewed for trauma. The resident was admitted in May 2025 and had a diagnosis of vascular dementia. A brief trauma questionnaire completed on 6/9/25 indicated a history of significant trauma, including a family-reported trigger that showers provided by men could cause re-traumatization and that showers should be provided by women only. The record did not show that the questionnaire results were communicated to the resident's provider, and the most recent MDS quarterly assessment dated 8/19/25 documented a BIMS score of 7, indicating severe cognitive impairment. The care plan last revised on 9/9/25 did not include the resident's trauma history or interventions to prevent re-traumatization during care, such as having only female staff provide showers. On 9/16/25 at 4:45 pm, the DON was interviewed and the surveyor discussed that staff had not acted on the trauma questionnaire findings to ensure the resident received trauma-informed care.
Kitchen Sanitation Deficiency in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure the kitchen was maintained in a clean and sanitary manner in 1 of 1 walk-in refrigerators observed during the survey. During an observation of the walk-in refrigerator with the Certified Dietary Manager, a surveyor saw a double fan on the right side over shelving units containing food with obvious built-up debris. The CDM stated that she would clean it, and the observation was later confirmed by the Administrator and DON during interview.
Incomplete pacemaker orders and follow-up documentation
Penalty
Summary
The facility failed to ensure that the medical record for one resident with a pacemaker was complete and contained accurate information. Resident 13 was admitted in 2022 for hospice/end-of-life care with diagnoses including heart dysrhythmia and a pacemaker. The care plan updated 7/17/25 stated that the resident had a pacemaker related to dysrhythmias and included monitoring for signs of altered cardiac output or pacemaker malfunction, but the active orders did not contain evidence that pacemaker orders were obtained. During record review, a document dated 4/29/22 was provided showing a pacemaker implant and a scheduled device follow-up with a plan for routine follow-up, but the clinical record lacked evidence that this was done. The UM confirmed there were no orders or follow-up appointments because the resident was on hospice on admission, and the MD stated that a resident with a cardiac pacemaker would be expected to have orders for pacemaker checks and appointments, confirming that no such orders were present in the record.
Recurrent Infection Control Deficiency
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction (POC) for a previously identified deficiency from a Complaint Survey Process dated 7/30/24. The deficiency, cited under federal citation F880, involved the failure to maintain and implement an infection control program to prevent the development and transmission of disease and infection. During a follow-up survey on 9/25/24, the same deficiency was identified, indicating that the corrective measures were not effective. This was confirmed during an interview with the Administrator and Director of Nursing on the same day.
LPN Fails to Follow COVID-19 PPE Protocol
Penalty
Summary
A staff member, identified as LPN#1, failed to adhere to the facility's Infection and Prevention Policy, specifically the update dated 7/18/24, which is designed to prevent the spread of COVID-19 within the facility. On 7/30/24, a surveyor observed LPN#1 entering a room of a COVID-19 positive resident wearing only an N-95 mask, without the full Personal Protective Equipment (PPE) required by the facility's policy. The policy mandates that staff must wear an N-95 mask, eye protection, gown, and gloves when entering the room of a COVID-19 positive resident. Despite a sign on the door indicating respiratory precautions and the availability of PPE in a cabinet nearby, LPN#1 did not don the full PPE, believing it was unnecessary for a brief visit. This was confirmed in an interview with the surveyor after LPN#1 exited the room. The Director of Nursing and the Infection Preventionist confirmed the requirement for full PPE in such situations during an interview with the surveyor.
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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 So Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seaside Healthcare Llc | 3.3 mi | ★★★★★ | 13 | 0 |
| Cedars Nursing Care Center | 3.9 mi | ★★★★★ | 1 | 0 |
| Barron Center | 4.6 mi | ★★★★★ | 34 | 0 |
| Fallbrook Commons | 5 mi | ★★★★★ | 0 | 0 |
| Piper Shores | 5.1 mi | ★★★★★ | 12 | 0 |
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