10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Lewiston, ME
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
102 Campus Ave, Lewiston, ME
(207) 777-4200
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
210
Certified beds
Average residents
166
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Health
Operator or chain grouping
Approved since
1984-02-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 5 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
RN hours / resident day
1.19
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.47 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.86 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.35 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.91 · national 3.43
Weekend RN hours
1.25
Weekend registered nurse coverage · state 0.73 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.22
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
49%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
7,231
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.43
Baseline 16.04% · Performance 19.84% · Measure score 3.43 · Achievement 3.43 · Improvement 0
Healthcare-associated infections
5.94
Baseline 5.54% · Performance 6.06% · Measure score 5.94 · Achievement 5.94 · Improvement 0
Total nurse turnover
0
Performance 65.75% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.77
Baseline 3.56 hours · Performance 3.86 hours · Measure score 2.77 · Achievement 2.77 · Improvement 0.87
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 245 · Observed rate 8.16% · Lower 95% interval 7.06% |
| Discharge to community | 54.6% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 259 · Observed rate 48.65% · Lower 95% interval 48.47% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.2% |
95.27%
1.9 pts better
|
Numerator 139 · Denominator 143 |
| Falls with major injury | 1.4% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 143 |
| Discharge self-care score | 56.25% |
53.69%
2.6 pts better
|
Numerator 63 · Denominator 112 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 48 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 0.7% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 143 · Adjusted rate 1.07% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 132 · Observed rate 3.79% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 3.62% |
8.2%
4.6 pts worse
|
Numerator 5 · Denominator 138 |
| Staff flu vaccination coverage | 99.32% |
42%
57.3 pts better
|
Numerator 145 · Denominator 146 |
| Discharge function score | 56.25% |
56.45%
0.2 pts worse
|
Numerator 63 · Denominator 112 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 70 · Denominator 70 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 36.84% |
25.2%
11.6 pts better
|
Numerator 28 · Denominator 76 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.4
1.4 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.4 · Expected 1.6 · 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 1.8 · Expected 1.5 · 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 92.3% · Q2 94.9% · Q3 93.4% · Q4 88.2% · 4Q avg 92.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.5%
0.2 pts worse
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
4.3%
1 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.2% · Q3 4.4% · Q4 3.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
10.7%
6.5 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.5% · Q3 2.8% · Q4 2.6% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.5%
0.1 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.6% · Q3 11.7% · Q4 3.2% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
17.0%
4.5 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 12.8% · Q3 12.6% · Q4 14.9% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
21.0%
3.4 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 15.3% · Q3 18.2% · Q4 21.1% · 4Q avg 17.6% · 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 | 35.8% |
29.6%
6.2 pts worse
|
16.3%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 26.5% · Q3 37.1% · Q4 41.6% · 4Q avg 35.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.7% |
25.7%
10 pts worse
|
14.9%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 29.6% · Q3 41.2% · Q4 33.3% · 4Q avg 35.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.3%
0.1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.5% · Q3 1.4% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.7%
0.9 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.2% · Q3 0.7% · Q4 0.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
29.8%
0.4 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 33.1% · Q3 20.0% · Q4 39.0% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.4%
0.5 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.6% · Q3 4.2% · Q4 3.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.5% |
71.2%
27.7 pts worse
|
81.7%
38.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.4% · Q2 53.6% · Q3 37.8% · Q4 30.0% · 4Q avg 43.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
15.6%
5.8 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.4%
1.2 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.8% |
74.5%
3.7 pts worse
|
79.7%
8.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
20.5%
0.9 pts worse
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 18.9% · Expected 21.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Nutrition and Dietary (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-01
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-01
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-26
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 2025-04-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-01
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-01
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-05-01
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-03-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-04
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-03-04
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-04
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-04
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-04
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-04
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 2024-03-04
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-04
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-04
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-04
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-04
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2024-03-04
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-12
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-05-12
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2022-05-12
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 2022-05-12
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-25
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-04-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-25
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-05-12
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-04-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-25
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-24
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 2025-05-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-01
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-01
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-05-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-01
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 2025-05-01
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-05-01
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
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 2024-04-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-21
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 2024-03-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-21
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 2024-03-21
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-21
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-21
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 2024-03-21
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-21
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-08
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-18
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-04-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-20
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Contracted Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Nearby options
Lewiston, ME
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Lewiston, ME
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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