Cycle 1
Health 2025-05-01 · Fire 2025-05-01
13 health deficiencies
Top issue: Infection Control (4 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Freeport, ME
Hawthorne House
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
6 Old County Rd, Freeport, ME
(207) 865-4782
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
First Atlantic Healthcare
Operator or chain grouping
Approved since
1993-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.47 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.86 · national 2.35
Total nurse hours
4.68
All reported nurse hours · state 4.35 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
4.32
Weekend nurse staffing · state 3.91 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.73 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.94
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,664
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.67% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0.84
Performance 7.58% · Measure score 0.84 · Achievement 0.84 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.87
Baseline 72.63% · Performance 61.32% · Measure score 1.87 · Achievement 0.58 · Improvement 1.87
Adjusted total nurse staffing
7.72
Baseline 5.30 hours · Performance 5.27 hours · Measure score 7.72 · Achievement 7.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 14.75% · Lower 95% interval 7.67% |
| Discharge to community | 47.01% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 41.38% · Lower 95% interval 37.55% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.92% |
95.27%
0.3 pts worse
|
Numerator 56 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 37.84% |
53.69%
15.8 pts worse
|
Numerator 14 · Denominator 37 |
| Discharge mobility score | 37.84% |
50.94%
13.1 pts worse
|
Numerator 14 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 1.72% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 58 · Adjusted rate 2.27% |
| Healthcare-associated infections requiring hospitalization | 7.58% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 4.36% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 87 |
| Staff flu vaccination coverage | 99.65% |
42%
57.7 pts better
|
Numerator 287 · Denominator 288 |
| Discharge function score | 64.86% |
56.45%
8.4 pts better
|
Numerator 24 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 67.74% |
96.28%
28.5 pts worse
|
Numerator 21 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 2.86% |
25.2%
22.3 pts worse
|
Numerator 1 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 33.7% |
90.7%
57 pts worse
|
93.4%
59.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 22.2% · Q3 46.7% · Q4 44.6% · 4Q avg 33.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
95.5%
1.4 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
4.3%
1.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.6% · Q3 1.7% · Q4 3.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
10.7%
4.1 pts better
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.4% · Q3 2.0% · Q4 5.1% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.5%
0.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 10.2% · Q3 7.4% · Q4 1.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
17.0%
11.7 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 31.1% · Q3 27.3% · Q4 31.6% · 4Q avg 28.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.9% |
21.0%
8.9 pts worse
|
16.7%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 27.0% · Q3 27.0% · Q4 34.3% · 4Q avg 29.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.6% |
29.6%
2 pts worse
|
16.3%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q2 56.2% · Q4 20.8% · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.5% |
25.7%
3.8 pts worse
|
14.9%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.8% · Q2 40.7% · Q3 17.6% · Q4 21.8% · 4Q avg 29.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.3%
0.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.1% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.7%
0.3 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.4% · Q4 3.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
29.8%
4.6 pts better
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 24.2% · Q3 19.2% · Q4 26.4% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.4%
2 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.4% · Q3 4.9% · Q4 6.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 23.4% |
71.2%
47.8 pts worse
|
81.7%
58.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 15.4% · Q3 21.2% · Q4 37.4% · 4Q avg 23.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
15.6%
5.2 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 9.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.4%
0.4 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.0% |
74.5%
40.5 pts worse
|
79.7%
45.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.0% |
20.5%
9.5 pts worse
|
23.9%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.0% · Observed 25.8% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-05-05 · Fire 2022-05-05
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-06
F · Potential for more than minimal harm
2024-05-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-06-10
C · Minimal harm
2024-05-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-10
F · Potential for more than minimal harm
2022-05-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-05-19
F · Potential for more than minimal harm
2022-05-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-19
F · Potential for more than minimal harm
2022-05-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-05-19
D · Potential for more than minimal harm
2022-05-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-05-19
D · Potential for more than minimal harm
2022-05-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-19
D · Potential for more than minimal harm
2022-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-19
D · Potential for more than minimal harm
2022-05-05
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-05-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-01-28
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-03-04
E · Potential for more than minimal harm
2024-05-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-07
B · Minimal harm
2024-05-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-06-07
B · Minimal harm
2024-05-08
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-06-07
B · Minimal harm
2024-05-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-07
D · Potential for more than minimal harm
2023-05-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-12
F · Potential for more than minimal harm
2022-05-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-03
E · Potential for more than minimal harm
2022-05-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-05
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-06-03
Penalties and ownership
What sits behind the stars
Ownership
Coffin, Craig
5% Or Greater Indirect Ownership Interest · Individual
Bowden, Kenneth
Operational/Managerial Control · Individual
Bowden, Kenneth
Corporate Officer · Individual
Coffin, Craig
Operational/Managerial Control · Individual
Coffin, Craig
Corporate Officer · Individual
First Atlantic Healthcare
Operational/Managerial Control · Organization
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#2
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2-star overall rating with 2-star inspections with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Sedgewood Commons
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3-star overall rating with 3-star inspections with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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