North Berwick, ME

Pinnacle Health & Rehab At N Berwick

4-star overall rating with 4-star inspections with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

47 Elm St, North Berwick, ME

(207) 676-2242

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1993-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.67

Registered nurse staffing

LPN hours / resident day

0.74

Licensed practical nurse staffing

Aide hours / resident day

2.47

Nurse aide staffing

Weekend hours

3.43

Weekend nurse staffing

RN turnover

38%

Annual RN turnover

Total nurse turnover

34%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.4 0.3 pts worse	1.9 0.2 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	2.1 1.7 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.3%	90.7% 1.6 pts better	93.4% 1.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	85.2%	95.5% 10.3 pts worse	95.5% 10.3 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	5.4%	4.3% 1.1 pts worse	3.3% 2.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	2.9%	10.7% 7.8 pts better	11.4% 8.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	6.2%	5.5% 0.7 pts worse	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	53.8%	17.0% 36.8 pts worse	19.6% 34.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	41.0%	21.0% 20 pts worse	16.7% 24.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.5%	0.0% 0.5 pts worse	0.1% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	33.3%	29.6% 3.7 pts worse	16.3% 17 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	30.6%	25.7% 4.9 pts worse	14.9% 15.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	1.3% 0.5 pts better	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	3.3%	2.7% 0.6 pts worse	1.7% 1.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	30.1%	29.8% 0.3 pts worse	19.8% 10.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	3.2%	4.4% 1.2 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	73.1%	71.2% 1.9 pts better	81.7% 8.6 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	3.9%	15.6% 11.7 pts better	12.0% 8.1 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	4.5%	1.4% 3.1 pts worse	1.6% 2.9 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.8%	20.5% 6.7 pts better	23.9% 10.1 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-30 · Fire 2024-10-30

5 health deficiencies

Top issue: Infection Control (2 deficiencies)

11 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 2 Health 2023-08-23 · Fire 2023-08-23

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2021-05-06 · Fire 2021-05-06

5 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-30

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-10-30

F · Potential for more than minimal harm 2024-10-30

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-10-30

F · Potential for more than minimal harm 2024-10-30

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-10-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-13

F · Potential for more than minimal harm 2024-10-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-12-02

F · Potential for more than minimal harm 2024-10-30

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-11-15

F · Potential for more than minimal harm 2024-10-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-04

E · Potential for more than minimal harm 2024-10-30

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 2024-11-08

D · Potential for more than minimal harm 2024-10-30

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 2024-11-08

D · Potential for more than minimal harm 2024-10-30

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 2024-11-04

D · Potential for more than minimal harm 2024-10-30

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2024-10-29

F · Potential for more than minimal harm 2023-08-23

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-10-13

F · Potential for more than minimal harm 2023-08-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-10-13

F · Potential for more than minimal harm 2023-08-23

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-10-13

F · Potential for more than minimal harm 2023-08-23

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2023-10-13

E · Potential for more than minimal harm 2023-08-23

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2023-10-13

D · Potential for more than minimal harm 2023-08-23

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-10-13

D · Potential for more than minimal harm 2023-08-23

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2023-10-13

D · Potential for more than minimal harm 2023-08-23

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2023-10-13

D · Potential for more than minimal harm 2023-08-23

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-10-13

D · Potential for more than minimal harm 2023-08-23

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-10-13

L · Immediate jeopardy 2021-05-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-07-01

L · Immediate jeopardy 2021-05-06

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2021-06-21

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-10-30

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 2024-11-19

F · Potential for more than minimal harm 2024-10-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-25

E · Potential for more than minimal harm 2024-10-30

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 2024-11-29

E · Potential for more than minimal harm 2024-10-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-11-25

E · Potential for more than minimal harm 2024-10-30

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-11-25

E · Potential for more than minimal harm 2023-08-23

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 2023-09-29

E · Potential for more than minimal harm 2023-08-23

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 2023-09-29

D · Potential for more than minimal harm 2023-08-23

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 2023-09-29

D · Potential for more than minimal harm 2023-08-23

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-09-29

D · Potential for more than minimal harm 2023-08-23

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 2023-09-29

D · Potential for more than minimal harm 2023-08-23

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-09-29

E · Potential for more than minimal harm 2021-05-06

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 2021-06-19

E · Potential for more than minimal harm 2021-05-06

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 2021-06-19

D · Potential for more than minimal harm 2021-05-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2021-06-19

D · Potential for more than minimal harm 2021-05-06

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2021-06-19

D · Potential for more than minimal harm 2021-05-06