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

64

Certified beds

Average residents

57

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

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

0.67

Registered nurse staffing · state 1.03 · national 0.68

LPN hours / resident day

0.74

Licensed practical nurse staffing · state 0.47 · national 0.87

Aide hours / resident day

2.47

Nurse aide staffing · state 2.86 · national 2.35

Total nurse hours

3.88

All reported nurse hours · state 4.35 · national 3.89

Licensed hours

1.41

RN + LPN hours · state 1.49 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.91 · national 3.43

Weekend RN hours

0.35

Weekend registered nurse coverage · state 0.73 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.72

CMS adjusted RN staffing hours

Adjusted total hours

4.16

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

38%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

34%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,094

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

46.06

Composite VBP score used to determine payment impact.

Payment multiplier

0.9994

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

5.53

Baseline 63.79% · Performance 41.10% · Measure score 5.53 · Achievement 5.53 · Improvement 5.33

Adjusted total nurse staffing

3.69

Baseline 4.07 hours · Performance 4.13 hours · Measure score 3.69 · Achievement 3.69 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.05%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 6.23%
Discharge to community	25.48%	50.57% 25.1 pts worse	Worse than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 14.78%
Medicare spending per beneficiary	1.21	1.02 0.2 pts worse
Drug regimen review with follow-up	62.5%	95.27% 32.8 pts worse	Numerator 15 · Denominator 24
Falls with major injury	4.17%	0.77% 3.4 pts worse	Numerator 1 · Denominator 24
Discharge self-care score	30%	53.69% 23.7 pts worse	Numerator 6 · Denominator 20
Discharge mobility score	25%	50.94% 25.9 pts worse	Numerator 5 · Denominator 20
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 24 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	8.93%	8.2% 0.7 pts better	Numerator 10 · Denominator 112
Staff flu vaccination coverage	100%	42% 58 pts better	Numerator 122 · Denominator 122
Discharge function score	35%	56.45% 21.5 pts worse	Numerator 7 · Denominator 20
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.

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 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star
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 · Adjusted 0.4 · Observed 0.5 · Expected 1.8 · Used in QM five-star
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 · Q1 89.5% · Q2 96.6% · Q3 88.9% · Q4 94.2% · 4Q avg 92.3%
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 · 4Q avg 85.2%
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 · Q1 5.3% · Q2 5.2% · Q3 5.6% · Q4 5.8% · 4Q avg 5.4% · Used in QM five-star
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 · Q1 3.8% · Q2 0.0% · Q3 5.9% · Q4 1.9% · 4Q avg 2.9%
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 · Q1 2.1% · Q2 2.3% · Q3 8.9% · Q4 11.9% · 4Q avg 6.2%
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 · Q1 59.6% · Q2 54.2% · Q3 57.4% · Q4 42.9% · 4Q avg 53.8%
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 · Q1 40.0% · Q2 36.8% · Q3 38.9% · Q4 50.0% · 4Q avg 41.0% · Used in QM five-star
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 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5%
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 · Q1 46.7% · Q2 31.0% · Q3 34.5% · Q4 18.2% · 4Q avg 33.3% · Used in QM five-star
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 · Q1 35.6% · Q2 30.4% · Q3 39.5% · Q4 15.4% · 4Q avg 30.6% · Used in QM five-star
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 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.8% · Used in QM five-star
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 · Q1 1.8% · Q2 1.9% · Q3 1.9% · Q4 7.7% · 4Q avg 3.3% · Used in QM five-star
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 · Q1 25.4% · Q2 41.4% · Q3 32.1% · Q4 21.2% · 4Q avg 30.1%
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 · Q1 4.0% · Q2 0.0% · Q3 6.5% · Q4 2.5% · 4Q avg 3.2% · Used in QM five-star
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 · Q3 70.0% · Q4 80.0% · 4Q avg 73.1%
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 · Adjusted 3.9% · Observed 4.2% · Expected 12.1% · Used in QM five-star
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 · 4Q avg 4.5% · Used in QM five-star
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 · Adjusted 13.8% · Observed 12.5% · Expected 21.6% · Used in QM five-star

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

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 2021-06-19

Penalties and ownership