Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southridge Rehab & Living Ctr during CMS and state inspections, most recent first.
Care plans were missing key resident-specific needs for hospice comfort care, pain management, wandering/elopement risk, and dialysis care. A resident on hospice lacked comfort-focused interventions, a resident receiving oxycodone had no pain plan, a resident with documented wandering and exit-seeking had no wander/elopement care plan, and a resident on dialysis had no plan details for the dialysis schedule, access sites, or emergency procedures.
The facility failed to maintain required CNA training on abuse, neglect, exploitation, misappropriation of resident property, and dementia care. Record review showed one CNA lacked mandatory abuse, neglect, and dementia training upon hire, another lacked mandatory dementia training upon hire, and a third had no evidence of the required annual abuse/neglect and dementia training in the following year. The surveyor confirmed the findings with the Senior VP of Development and Operations.
A resident with COPD, chronic respiratory failure, and a tracheostomy self-administered nebulizer treatments, but the current provider orders did not reflect self-administration and the record lacked evidence of a current assessment for safe self-administration of meds. The care plan stated the resident could self-administer respiratory meds, while the ADON confirmed the last assessment was 2 years old and the current orders did not specify self-administration.
A resident’s quarterly MDS was incomplete in the hospice section even though the chart included a physician order to admit the resident to hospice if appropriate due to suspected 6 months or less. The MDS coordinator confirmed the incomplete coding with surveyors.
A facility failed to provide appropriate care for a resident with a gastrostomy tube when an RN administered meds via the tube without checking placement. The facility policy required placement verification before feeding or med administration, and the RN later stated placement was only checked if something seemed wrong, despite an order to check placement each shift.
PPE use was not followed for a resident on Contact Precautions for ESBL in the urine. An RN entered the room wearing gloves, placed a diabetic testing supply caddy on the resident’s bed, and obtained a blood glucose reading before exiting and removing gloves. The Contact Precautions sign directed staff to wear gloves and gown for all care and resident contact, and the Unit Manager confirmed PPE was required during blood glucose checks and that the supply caddy should not have been placed on the bed.
A facility failed to ensure residents received mail on Saturdays, one of the scheduled delivery days. During a group interview, four residents reported concerns about not getting mail on Saturdays, and the Senior [NAME] President of Development and Operations confirmed mail was not routinely delivered on weekends because mail had previously been lost.
A Transportation Aid transported a resident with multiple fractures without securing the required seatbelt and shoulder harness due to a malfunction, and did not report the issue to maintenance staff who were present. During the trip, the resident slid from the wheelchair and sustained a new femur fracture. Facility policy required safety belts to be worn and signage to be posted, but no sign was observed in the van during the survey.
A C.N.A.-M failed to properly identify a resident before administering medications, resulting in the resident receiving another individual's medications, including an anticoagulant, antipsychotic, and other prescription drugs. The resident became lethargic and was transported to the hospital for evaluation, where they were found to be stable and later returned to the facility.
A resident with dementia and a known history of exit-seeking was inadequately supervised despite being identified as a high elopement risk. The resident was able to access and open a second-floor window, exit the building, and was later found outside in a snowbank with injuries and hypothermia. Staff were unaware the resident was missing until notified by others, and facility documentation and environmental safeguards were lacking.
A resident experienced ineffective PRN medication for anxiety and was later found missing and subsequently outside after an elopement, resulting in hospitalization for hypothermia and frostbite. The facility failed to notify the physician of the ineffective interventions, missing status, and elopement, and did not document required details of the search, as confirmed by the Administrator and DON.
A resident's baseline care plan required behavior monitoring and documentation every shift, but this was not completed for five consecutive days. CNAs reported the resident exhibited wandering, exit seeking, and distress, yet were not informed of the resident's prior elopement history. The Administrator and DON could not provide evidence or explanation for the lack of documentation.
A resident with dementia and anxiety received antipsychotic and antianxiety medications without required documentation of behavior monitoring or justification for as needed medication administration. Nursing staff did not follow physician orders for monitoring or document nonpharmacological interventions prior to administering psychotropic medications.
The facility failed to maintain a safe and clean environment, with issues such as stained curtains, chipped laminate surfaces, and cobwebs observed in resident rooms across two units. Additionally, a continuously running toilet and rough wall surfaces were noted, posing potential hazards. These deficiencies were confirmed with a Corporate Quality Improvement Nurse.
The facility failed to follow its Falls Management Policy for eight residents, resulting in incomplete documentation and lack of updated fall prevention interventions in care plans. Despite conducting post-fall observations, the necessary follow-up documentation was missing, and the Director of Nursing acknowledged the inconsistency in documentation. This deficiency indicates a systemic issue in handling fall incidents, potentially impacting resident safety.
The facility failed to maintain a clean and sanitary kitchen, with unlabeled desserts, soiled ceiling tiles, and dirty fans blowing on the cooking area. Temperature logs for meals were missing for several days. Additional unsanitary conditions were found in unit refrigerators, and employee drinks were improperly stored in kitchen fridges.
The facility failed to adequately screen and document Pneumococcal and Influenza vaccinations for two residents. One resident's records lacked documentation of receiving, being offered, or refusing the Pneumococcal vaccine upon admission. Another resident's records did not show documentation for both Pneumococcal and Influenza vaccinations. The facility's policy requires offering these vaccinations unless contraindicated or previously immunized, with documentation of vaccination, contraindication, or refusal.
The facility failed to document COVID-19 vaccination status for two residents, as required by CDC guidelines. The absence of documentation was confirmed during a survey, revealing that the facility lacked a Resident Immunization policy for COVID-19 and did not follow CDC recommendations for screening LTC residents.
A resident at high risk for falls, admitted with respiratory failure and hypoxia, experienced a fall after being left on a bedside commode without a call bell within reach. The resident attempted to reach for the call bell, resulting in a fall to her knees and back. The incident was documented, and the DON acknowledged the oversight.
Incomplete care plans for hospice, pain, wandering, and dialysis needs
Penalty
Summary
Care plans were not developed to address several identified resident needs. Resident #22 had a hospice follow-up note stating comfort-focused hospice management and a preference for minimal intervention, but the current care plan did not identify comfort care or include interventions for hospice needs. Resident #25 had orders for scheduled and PRN oxycodone for pain, but the care plan contained no documentation addressing pain management. The charge nurse stated that unit nurses do not create the care plan and that it is done by the MDS coordinator. Resident #4’s admission MDS coded wandering behavior and indicated the behavior placed the resident at risk for entering a potentially dangerous area, including outside the facility. The admission assessment also identified elopement risk and noted that a wander bracelet was applied. Nursing progress notes documented repeated wandering and exit-seeking behaviors, including attempts to leave the unit through secured doors, but the care plan lacked evidence of a wander/elopement risk focus, goals, or interventions. Resident #6 was admitted with ESRD and hemodialysis, had a left arm AV fistula and a right chest central line, and received dialysis Monday-Wednesday-Friday at an outside dialysis center, but the care plan did not include the dialysis days, location of the dialysis center, the presence of the central line, monitoring instructions for the site before and after dialysis, or emergency procedures.
Missing Required CNA Abuse and Dementia Training
Penalty
Summary
The facility failed to implement and maintain an effective training program that included required education on abuse, neglect, exploitation, misappropriation of resident property, and dementia care for nurse aides. Review of staff education records on 4/29/26 showed that CNA #1, hired on 6/20/25, had no evidence of completing mandatory abuse, neglect, and dementia training upon hire. CNA #2, hired on 10/14/25, also had no evidence of completing mandatory dementia training upon hire. CNA #3, hired on 10/16/24, had completed abuse, neglect, and dementia training in 2024, but the record lacked evidence of the required abuse and neglect and dementia training in 2025. On 4/30/26 at 1:05 p.m., the surveyor confirmed these findings with the Senior [NAME] President of Development and Operations.
Self-Administration Orders and Assessment Not Current
Penalty
Summary
The facility failed to ensure current provider orders reflected a resident’s self-administration of respiratory medication and failed to complete an assessment of the resident’s ability to safely self-administer medication for one resident with COPD, chronic respiratory failure, and a tracheostomy. The resident’s current orders included ipratropium nebulization twice daily for COPD and sodium chloride 3% nebulization via tracheostomy every 4 hours to help clear tracheal secretions, and the care plan stated the resident was able to self-administer medications/treatments and self-administer respiratory medications, with medications stored in the Nurse Treatment Cart. However, the clinical record did not contain evidence that an assessment had been completed for the resident’s ability to safely self-administer medications. During interview, the ADON confirmed the resident self-administered nebulizer treatments and stated staff and the physician meet with the resident and a form is completed, but she was unable to locate evidence of an annual assessment. The ADON later provided the last assessment, dated 3/22/24, along with older provider orders from 2/23/24 that stated the resident could self-administer budesonide and ipratropium/albuterol via nebulizer. The ADON confirmed the current orders did not specify the resident may self-administer nebulizer treatments and that the last assessment for safe self-administration had been completed 2 years ago. The facility policy stated the self-administration screen is to be completed initially, quarterly, and with a change in the resident’s medical condition.
Inaccurate MDS Hospice Coding
Penalty
Summary
The facility failed to ensure the MDS Version 3.0 assessment was accurately coded for hospice for one sampled resident. The resident had a physician order dated 8/27/25 to admit the resident to hospice if appropriate due to suspected 6 months or less, but the resident’s quarterly MDS Version 3.0 assessment had Section O, Special Treatments, Procedures, Programs, incomplete in the hospice area. On 4/29/26 at 3:30 p.m., the MDS coordinator confirmed the finding with three surveyors.
Failure to Verify Gastrostomy Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding for 1 of 1 resident reviewed for tube feeding, Resident #8. The facility’s Enteral Tube Policy, last revised 7/22, states that enteral feeding tube placement must be verified prior to the initiation of feeding and/or medication administration, and that x-ray is the only way to verify placement. On 4/28/26 at 11:05 a.m., a surveyor observed RN #1 administer medications via a gastrostomy tube for Resident #8 without checking tube placement. During an interview later that day, RN #1 stated they only check tube placement if they feel something is wrong and confirmed that the order states to check placement each shift.
PPE Use Not Followed for Resident on Contact Precautions
Penalty
Summary
The facility failed to follow professional standards of practice for PPE use for a resident on Contact Precautions for ESBL in the urine. During an observation, an RN entered the room wearing gloves, greeted the resident, and placed a diabetic testing supply caddy on the resident’s bed next to the resident’s legs while obtaining a blood glucose reading. After completing the blood glucose check, the RN exited the room and removed the gloves. The Contact Precautions sign on the door instructed staff to wear gloves and gown for all care and resident contact and to remove PPE before exiting the room. In an interview, the RN stated gowns and gloves were to be worn during personal care, but said personal care was not being provided at the time. The Unit Manager stated staff were required to wear appropriate PPE when providing care to any resident on Contact Precautions, including while obtaining a blood glucose reading, and confirmed the diabetic testing supply caddy should not have been placed on the resident’s bed because it would require disinfection due to potential contamination.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when mail was not delivered to all residents on Saturday, one of the six scheduled delivery days. During a group interview on 4/27/26 at 2:15 p.m., four residents stated they were concerned about not receiving mail on Saturdays. On 4/30/26 at 1:05 p.m., the Senior [NAME] President of Development and Operations confirmed that mail was not routinely delivered on Saturdays because mail had previously been lost, and stated that the weekend supervisor would be delivering the mail as needed on Saturdays.
Failure to Secure Resident During Transport Results in Injury
Penalty
Summary
A Transportation Aid failed to ensure the safe transport of a resident by not securing the shoulder harness strap and seat belt during a van ride to a medical appointment. The resident, who had a history of multiple fractures including a left distal femur fracture that was not healing well, was loaded into the van with the wheelchair secured, but the seatbelt system was not fastened because it was not functioning. The Transportation Aid was aware that the safety belts were not working but did not report the issue to maintenance staff, who were present at the facility at the time. Instead, the Transportation Aid proceeded with the transport, believing the short distance would not pose a problem. During the transport, the resident slid from the wheelchair onto the floor of the van, resulting in a comminuted fracture of the left femur. The facility's policy required that safety belts be worn at all times, and a visible sign to that effect was supposed to be present in the van, but no such sign was observed during the survey. The Transportation Aid had only recently begun driving the van and had received training through videos and orientation from the Maintenance Director. The failure to secure the resident and to report the malfunctioning safety equipment directly led to the resident's injury.
Failure to Identify Resident Results in Significant Medication Error and Hospitalization
Penalty
Summary
A significant medication error occurred when a Certified Nurse Assistant-Medication (C.N.A.-M) failed to properly identify a resident prior to administering medications, resulting in the resident receiving another individual's prescribed medications. The medications administered in error included Eliquis, Metformin, Flexeril, Lyrica, Furosemide, Potassium chloride, Risperidone, and Vitamin B. This action was not in accordance with the facility's General Dose Preparation and Medication Administration policy, which requires verification of the correct medication, dose, route, rate, time, and resident identity each time medication is administered. Following the administration of the incorrect medications, the resident exhibited lethargy and poor oxygen perfusion, necessitating transport to the emergency room for evaluation. Clinical documentation indicated that the resident was initially stable with mild drowsiness, but later became unresponsive, prompting emergency services to be called. The resident was evaluated at the hospital, where all laboratory results and blood sugar levels were within normal limits, and was subsequently returned to the facility while still lethargic, as expected by the hospital physician.
Failure to Supervise High Elopement Risk Resident Resulting in Fall from Second-Story Window
Penalty
Summary
A facility failed to provide adequate supervision and a safe environment for a resident with dementia who was identified as a high risk for elopement and had a history of exit-seeking behaviors. After being transferred to a secured unit due to increased safety concerns, the resident continued to exhibit wandering and exit-seeking behaviors, including being found in another resident's closet with an open window. Despite being on 1:1 supervision at times and wearing a Secure Care anklet, the resident was able to access a second-floor window and exit the building without staff knowledge. Staff were unaware the resident was missing a second time until alerted by another staff member who found the resident outside in a snowbank under an open window. The resident was found outside at approximately 1:00 a.m. in freezing temperatures, having fallen from a second-story window. The resident sustained scrapes, a bump on the head, and was diagnosed with hypothermia, metabolic encephalopathy secondary to hypothermia and hypoxia, and frostbite. Documentation revealed that staff did not follow the facility's elopement policy regarding updating the care plan and documenting search times. The windows in the unit were easily opened and accessible, contributing to the resident's ability to exit the building. This series of failures resulted in an immediate jeopardy situation.
Failure to Notify Physician After Ineffective Interventions and Resident Elopement
Penalty
Summary
The facility failed to notify the physician when interventions for a resident's distress were ineffective and did not inform the physician after the resident was missing and required a search, or when the resident experienced a life-threatening elopement. Documentation showed that a PRN medication for anxiety was administered on two occasions without effect, but there was no evidence that alternative interventions were attempted or that the physician was notified of the lack of response. Additionally, clinical notes indicated the resident was found missing from their bed and later located in another room's closet with an open window, but the records did not document the time the search began or ended, nor was there evidence of physician notification regarding these incidents. Subsequently, the resident was found outside in a snowbank beneath an open second-story window and was transferred to the hospital with hypothermia and frostbite. The medical record lacked documentation that the facility physician was notified of this event. During an interview, the Administrator and DON confirmed that the physician had not been notified of the resident's behaviors and elopement, as required by facility policy.
Failure to Document and Monitor Resident Behaviors per Baseline Care Plan
Penalty
Summary
The facility failed to follow the baseline care plan for a resident in the area of behavior monitoring during the first five days of admission. The baseline care plan required documentation of behaviors in the Treatment Administration Record (TAR) or on a behavior monitoring form every shift. However, a review of the resident's electronic medical record showed no documentation of behaviors for every shift between 2/12/25 and 2/17/25. Certified Nursing Assistants (CNAs) who worked with the resident during this period reported that the resident exhibited wandering, exit seeking, refusal of care, and frequent distress, but were not informed of the resident's history of elopement. During interviews, the Administrator and Director of Nursing were unable to provide additional evidence or an explanation for the lack of adherence to the care plan.
Failure to Monitor and Document Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor and document targeted behaviors to support the use of antipsychotic and antianxiety medications for a resident with dementia and generalized anxiety disorder. The resident had physician orders for sertraline, clonazepam, and lorazepam, with specific instructions for behavioral and physical monitoring three times daily, as well as documentation of all behaviors, effectiveness of interventions, and any psychoactive side effects. The care plan also required monitoring and documentation of changes in mentation and the use of distraction techniques if the resident became agitated or restless. Between the specified dates, there was no documentation on the Treatment Administration Record (TAR) that nursing staff followed the required behavior monitoring as directed by the physician order. The Medication Administration Record (MAR) indicated that as needed psychotropic medication was administered four times, but for three of those instances, there was no documentation explaining why the medication was given. Additionally, progress notes did not support the required behavior monitoring or explain the rationale for administering as needed medications, nor did they document any nonpharmacological interventions attempted prior to medication administration.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents in two units, as observed during an environmental tour. On the second floor B-2 unit, several deficiencies were noted, including stained window curtains, a window curtain off track, a stained ceiling tile, and a large chip in the laminate on a sink, creating an uncleanable surface. Additionally, a resident bathroom toilet was continuously running, and a hand sanitizer dispenser near the nurses' station had a missing drip catch cup, leaving rough screw holes in the wall. The second-floor hallway ceiling tile was also observed to have hanging dirt and debris. On the first floor B-1 unit, deficiencies included missing hooks on bed curtains, chipped paint on the ceiling, a chipped laminate drawer under a sink, and cobwebs along a wall. These observations were confirmed with the Corporate Quality Improvement Nurse at the time of the tour.
Failure to Follow Falls Management Policy
Penalty
Summary
The facility failed to adhere to its Falls Management Policy for eight residents reviewed for falls in 2024. The policy requires comprehensive documentation and follow-up after a fall, including updating fall prevention interventions in the care plan and completing documentation for three shifts post-fall. However, the records for these residents showed incomplete documentation, with missing updates in care plans and lack of follow-up by the Director of Nursing (DON) as stipulated by the policy. Resident #13 experienced six falls, Resident #30 had one fall, Resident #35 had one fall, Resident #36 had two falls, Resident #39 had three falls, Resident #1 had eight falls, and Resident #41 had nine falls. In each case, the facility did not complete the required documentation or update the care plans with new interventions. The post-fall observations were conducted, but the necessary follow-up documentation was not present, indicating a systemic issue in the facility's handling of fall incidents. The Director of Nursing acknowledged the lack of consistent documentation during a meeting with surveyors, despite regular discussions about falls. This deficiency highlights a significant gap in the facility's implementation of its Falls Management Policy, potentially affecting the quality of care and safety of the residents involved.
Unsanitary Kitchen and Inadequate Food Temperature Logging
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during two initial kitchen inspections. On the first observation, two unlabeled and undated pans of desserts were found in the fridge, and the Food Service Director confirmed they were for the day's dessert. The ceiling tiles were soiled, and a wall-mounted fan with light to moderate dirt was blowing on the cooking area. Additionally, a cart-mounted fan with moderate to heavy dirt was also blowing on the cooking area. The cook was unable to provide a temperature log for the meals being prepared, revealing a lack of documentation for several meals over the past week. Further observations revealed unsanitary conditions in other areas of the facility. A refrigerator in the B-2 Unit Common Dining area had a heavy layer of dust on top, with dirt and dried food inside both the freezer and refrigerator compartments. The resident refrigerator on the B-1 Unit was found with a heavy amount of dirt and rust on the base plate. Additionally, three employee drinks were discovered in the reach-in fridges in the kitchen, and a half-eaten ice cream sandwich was found in the walk-in freezer. These findings were confirmed with the unit charge nurse and the Corporate Food Service Consultant.
Failure to Document Vaccination Status for Residents
Penalty
Summary
The facility failed to perform adequate screening and documentation for Pneumococcal and Influenza vaccinations for two residents. Resident #1's electronic medical record and physical medical record lacked documentation of receiving, being offered, or refusing the Pneumococcal vaccination upon admission. Similarly, Resident #6's records did not show any documentation of receiving, being offered, or refusing both Pneumococcal and Influenza vaccinations since their admission. The facility's policy requires that each resident be offered these vaccinations unless medically contraindicated or previously immunized, with proof of vaccination, contraindication, or refusal documented. These deficiencies were confirmed by a surveyor through interviews with the facility's Infection Preventionist and the Corporate Quality Improvement Nurse.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to adequately screen and document COVID-19 vaccination status for two residents, leading to a deficiency in compliance with CDC guidelines. Resident #1, who was admitted to the facility on an unspecified date, had no recorded COVID-19 vaccination status in either the electronic or physical medical records. Similarly, Resident #6, admitted on October 26, 2023, also lacked documentation of having received, been offered, or refused the COVID-19 vaccination. The deficiency was confirmed during a survey conducted on June 25, 2024, when a surveyor reviewed the residents' medical records and found the absence of necessary documentation. Further discussions with the facility's Infection Preventionist and Corporate Quality Improvement Nurse revealed that the facility did not have a Resident Immunization policy for COVID-19 and failed to follow CDC recommendations for screening LTC residents for COVID-19 vaccinations. This lack of policy and adherence to guidelines contributed to the oversight in documenting the vaccination status of the residents.
Failure to Provide Call Bell Leads to Resident Fall
Penalty
Summary
The facility failed to provide a call bell for a resident assessed to be at high risk for falls while using the bedside commode. The resident, admitted with respiratory failure and hypoxia, had experienced eight unwitnessed falls since admission. On March 22, 2024, a nurse's note indicated that the resident was assisted to the bedside commode, but the CNA left the call bell out of reach. As a result, the resident attempted to reach for the call bell, fell to her knees, and then onto her back. This incident was documented in the facility's Resident Incident Reporting Form, confirming the fall occurred when the resident was reaching for the call bell. The Director of Nursing acknowledged that the call bell should have been within reach for a resident at high risk for falls.
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 138 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 Biddeford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seal Rock Healthcare | 2.3 mi | ★★★★★ | 20 | 0 |
| St Andre Health Care Facility | 2.9 mi | ★★★★★ | 0 | 0 |
| Pine Point Center | 6.9 mi | ★★★★★ | 4 | 0 |
| Kennebunk Center For Health & Rehabilitation, Llc | 7.7 mi | ★★★★★ | 16 | 0 |
| Maine Veterans Home - Scarborough | 8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Southridge Rehab & Living Ctr.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.