Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Saint Vincent Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A resident was prescribed Sertraline and Seroquel for depression and delusions, but there was no evidence of a gradual dose reduction (GDR) attempt or documentation of clinical necessity for continued use. Facility policy requires GDRs for psychotropic medications unless contraindicated, but this was not followed, as confirmed by a corporate nurse.
A resident with bilateral heel wounds did not receive the required weekly wound assessments, as documentation was inconsistent and missing key details such as measurements and wound stage. Staff interviews confirmed that weekly monitoring was not performed, contrary to facility policy.
A resident with respiratory conditions was observed receiving continuous oxygen therapy via nasal cannula and portable tank, but review of clinical records and confirmation from the unit manager revealed that no physician order for oxygen had been obtained.
A resident on contact precautions for C. diff continued to have loose, uncontained bowel movements, yet staff failed to follow required infection control procedures. A laundry staff member entered and exited the resident's room without proper hand hygiene and was unaware of the contact precautions, while other staff were unclear about the resident's status. Facility policy required use of gowns, gloves, and handwashing, but these were not consistently followed.
Four residents who previously received a COVID-19 booster were not documented as having been offered or educated about the next recommended vaccine dose, as required by CDC guidelines and facility policy. This was confirmed by record review and staff interview.
Two residents who remained in the facility after Medicare coverage ended were not given written notice of the specific services and charges they could be liable for, as required. Instead, the SNF ABN forms provided to them stated 'No cost estimate available' rather than a good faith estimate of costs, which was confirmed as standard practice by a Social Services staff member.
The facility did not maintain the required RN staffing levels, failing to have an RN on duty for 8 consecutive hours a day, 7 days a week, for 7 days within a 92-day period. Specific days lacked RN coverage, as confirmed by staffing reports and interviews with HR staff.
The facility did not follow its antibiotic use protocols, failing to monitor, track, and review antibiotic use for six months. Despite having residents on antibiotics, there was no documentation of monthly monitoring or adherence to criteria. The facility's policy assigns the Infection Preventionist and DON to oversee the Antibiotic Stewardship Program, but they could not provide evidence of regular reporting on antibiotic use and resistance to staff.
The facility failed to provide adequate activities for residents, impacting their well-being. A resident with vascular dementia was often left without activities, leading to decreased participation. Another resident with dementia had limited engagement due to cognitive impairments, despite a care plan indicating interests. A third resident with Alzheimer's expressed boredom and agitation, with no individualized activity program in place. Staff confirmed infrequent activities and lack of tailored plans.
The facility failed to offer and document influenza and pneumococcal vaccinations for two residents. One resident was not offered the influenza vaccine for the 2023/2024 season, and another resident, admitted in June 2023, did not receive the pneumococcal vaccine despite signing a consent. These deficiencies were confirmed by interviews with the Regional Clinical Director and the DON.
The facility failed to timely inform two residents of the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). The NOMNC and ABN were signed on the last covered day of Medicare Part A Skilled Services, and the facility lacked a policy for issuing beneficiary notices.
The facility did not ensure that required members attended the Quality Assessment and Assurance group meetings quarterly. In Quarter 2, the Medical Director and Infection Preventionist were absent, and in Quarter 3, another staff member was missing. This was confirmed by the DON.
Failure to Attempt or Document Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications underwent a gradual dose reduction (GDR) or had documentation supporting the clinical necessity for continued use of these medications. Record review showed that the resident had physician orders for Sertraline, an antidepressant, and Seroquel, an antipsychotic, both prescribed for depression and delusions. However, there was no evidence in the medical record of any attempts to perform a GDR or documentation indicating a contraindication to GDR for either medication. This was confirmed during an interview with the corporate nurse, who acknowledged the absence of required documentation. Facility policy requires that residents on psychotropic medications receive GDRs unless clinically contraindicated, but this was not followed in this case.
Failure to Complete Required Weekly Pressure Ulcer Assessments
Penalty
Summary
A deficiency was identified when a resident with two heel wounds did not receive the required weekly assessments, including measurements and descriptions of the pressure ulcers. Review of the resident's medical record showed inconsistent documentation, with wound assessments recorded on non-weekly intervals and some assessments missing key information such as wound stage and measurements. Interviews with the Director of Nursing and the Unit Manager confirmed that weekly wound monitoring was not performed as required. Facility policy mandates completion of weekly pressure ulcer documentation immediately after skin rounds, but this was not followed for the resident in question, who had an unstageable pressure ulcer on the right heel.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
A resident who returned from the hospital with diagnoses including acute bronchitis, urinary tract infection, early pneumonia, and reactive airway disease was observed on multiple occasions using oxygen via nasal cannula, both in bed and in a wheelchair with a portable oxygen tank. Clinical notes indicated the resident was on 1 liter of oxygen via nasal cannula and that orders would be initiated with the physician notified. However, review of the resident's physician orders revealed that no orders for oxygen had been obtained. This was confirmed by the unit manager, who acknowledged that the resident was receiving continuous oxygen without a physician's order.
Failure to Implement Contact Precautions for Resident with C. diff
Penalty
Summary
The facility failed to implement its policies and procedures for Transmission Based Precautions (TBP) for a resident on contact precautions for Clostridioides difficile (C. diff). Observation revealed that a staff member from the laundry department entered and exited the resident's room, which was clearly marked for Enteric Contact Isolation, without washing hands with soap and water as required. The staff member was unaware that the resident was on contact precautions. Additionally, another staff member, a Licensed Nursing Assistant, believed that the contact precautions had been removed, while a Registered Nurse confirmed that the resident was still on contact precautions due to ongoing loose and/or watery bowel movements that were difficult to contain. Interviews with the Director of Nursing and the Infection Preventionist confirmed that the resident had completed treatment for C. diff but remained on contact precautions because of persistent symptoms. Facility policy required all staff and visitors to wear gloves and a disposable gown upon entering the room and to wash hands before entering and exiting. The failure to follow these procedures was confirmed through observation, staff interviews, and review of facility policy.
Failure to Offer and Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine. Specifically, for four residents reviewed for immunizations, there was no documentation that they were offered or educated about the next recommended dose of the COVID-19 vaccine, despite having previously received the COVID-19 Bivalent Booster (Pfizer) in the prior year. This lack of documentation was confirmed through record review and interview with the Infection Preventionist. Facility policy required that all residents be considered eligible for COVID-19 vaccination per CDC guidelines and that ongoing updates be monitored to adjust vaccination schedules accordingly. However, the records for the four residents did not reflect any offer or education regarding the updated CDC recommendations for additional COVID-19 vaccine doses. The deficiency was identified through review of vaccination records and staff interview, which confirmed the absence of required documentation.
Failure to Provide Required Cost Estimates on SNF ABN Forms
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the specific items and services offered by the facility, the charges for those services, and the amount of potential liability for services not covered by Medicare. For two residents who were discharged from Medicare services but remained in the facility, the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) forms did not include the required estimated costs for ongoing care and services. Instead, the forms stated 'No cost estimate available' for the per day/item or service, which did not meet the requirement for a good faith cost estimate as outlined in the SNF ABN form instructions. Interview with a staff member from Social Services confirmed that it was their practice to write 'No cost estimate available' rather than providing an estimated cost. Review of the official SNF ABN form instructions indicated that while it is permissible to state that no cost estimate is available in rare circumstances, this should not be a routine or frequent practice. The deficiency was identified through record review and staff interview, and it affected two residents who remained in the facility after their Medicare coverage ended.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 7 out of 92 days reviewed between October 1, 2023, and December 30, 2023. A review of the facility's Payroll Based Journal Staffing Data Report for Quarter 1 2024 revealed that there were no RN hours for specific days, including October 7, October 21, December 16, and December 17, 2023. Additionally, the facility's daily nursing time sheets indicated that on October 7, only 6 RN hours were worked, and on October 8, October 21, October 22, December 16, December 17, and December 31, there were either no RN hours documented or significantly fewer hours worked than required. Interviews with Staff J from Human Resources confirmed these findings.
Failure in Antibiotic Use Monitoring and Reporting
Penalty
Summary
The facility failed to adhere to its antibiotic use protocols, specifically in monitoring, tracking, and reviewing antibiotic use for six out of the twelve months reviewed. From December 2023 through April 2024, the facility did not track antibiotic use, as confirmed by the Director of Nursing during an interview. The facility had residents with infections who were on antibiotics during this period, yet there was no documentation of monthly antibiotic monitoring, tracking, or review, nor evidence that antibiotics met the criteria for use. The facility's policy on Antibiotic Stewardship, revised in February 2022, outlines that the Infection Preventionist, along with the Director of Nursing, is responsible for overseeing the Antibiotic Stewardship Program. This includes tracking antibiotics, ensuring adherence to evidence-based criteria, and reviewing antibiotic resistance patterns. However, the facility could not provide documentation or evidence of regular reporting on antibiotic use and resistance to relevant staff, such as prescribing clinicians and nursing staff, as confirmed by the Director of Nursing.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities that meet the interests and support the well-being of residents, as evidenced by observations and interviews. Resident #45 was frequently observed sitting in a wheelchair in the hallway with no activities occurring on the unit. Despite having a history of being active in activities, Resident #45's participation had significantly decreased, with no documented activities attended in May 2024. Staff interviews revealed that activities on the Second Floor Unit were infrequent, occurring only once every other week, and residents needed to be transported to other floors for activities. Resident #55, who has dementia, was observed sitting in a wheelchair with no engagement in activities. Although the resident's care plan indicated an interest in music, arts, and crafts, among other activities, there was no documentation of participation in May 2024. The resident's representative expressed concerns about the lack of engaging activities, noting that Resident #55 was unable to operate an iPad purchased for music due to cognitive impairment. Staff confirmed that Resident #55 attended activities primarily when accompanied by a spouse. Resident #63, diagnosed with Alzheimer's disease and dementia with agitation, was observed expressing boredom and agitation, with no activities documented in April or May 2024. Despite a leisure interest assessment indicating preferences for activities such as fishing, chess, and religious services, there was no individualized activity program in place. Staff acknowledged the resident's behaviors and lack of participation in group activities but could not provide a tailored activity plan.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and provided education on the risks and benefits of the Pneumococcal and Influenza vaccinations. For Resident #29, a review of the medical record revealed no documentation that the influenza vaccination had been offered for the 2023/2024 flu season. This was confirmed by an interview with the Regional Clinical Director, Staff G. The facility's policy, dated 2015, stated that all residents, staff, and volunteers should be offered the influenza vaccine from October through the end of March each year. For Resident #59, the medical record review showed that the resident was admitted in June 2023 and had signed a consent for the pneumococcal vaccine upon admission. However, there was no documentation that the vaccine had been administered. The Quarterly Minimum Data Set (MDS) indicated that the pneumococcal vaccination was not up to date. This was confirmed by an interview with the Director of Nursing, Staff A, who acknowledged that the resident had not received the pneumococcal vaccine. The facility's policy, revised in 2022, required informed consent and administration of the vaccine according to standing orders, which was not followed in this case.
Failure to Timely Inform Residents of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed in a timely manner about the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN). This deficiency was identified for two residents. For one resident, the last covered day of Medicare Part A Skilled Services was documented, and the facility initiated the discharge from Medicare Part A Services before benefit days were exhausted. The NOMNC and ABN were signed on the last covered day. Similarly, for another resident, the last covered day of Medicare Part A Skilled Services was noted, and the facility initiated the discharge before benefit days were exhausted, with the NOMNC signed on the last covered day. Interviews with facility staff, including a social worker, regional clinical director, and director of clinical reimbursement, confirmed the findings. It was revealed that the facility did not have a policy for issuing beneficiary notices. According to the instructions for the NOMNC, the notice must be delivered at least two calendar days before Medicare-covered services end, which was not adhered to in these cases.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assessment and Assurance group attended meetings at least quarterly. Specifically, during the review of the Quality Assurance Performance Improvement (QAPI) meeting attendance sheets, it was found that in Quarter 2, the Medical Director and Infection Preventionist were not in attendance. Additionally, in Quarter 3, another required member of the facility's staff was absent. These findings were confirmed through an interview with the 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 Berlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coos County Nursing Home | 1.4 mi | ★★★★★ | 5 | 0 |
| Country Village Center, Genesis Healthcare | 20.4 mi | ★★★★★ | 8 | 0 |
| Morrison Nursing Home | 23.7 mi | ★★★★★ | 7 | 0 |
| Merriman House | 30 mi | — | 0 | 0 |
| Rumford Community Home | 30 mi | ★★★★★ | 0 | 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.