Cedars Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Maine.
- Location
- 630 Ocean Avenue, Portland, Maine 04112
- CMS Provider Number
- 205003
- Inspections on file
- 17
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cedars Nursing Care Center during CMS and state inspections, most recent first.
Surveyors found that housekeeping and maintenance services were inadequate, resulting in dust-coated fans, exposed sheetrock, gouged walls, broken fixtures, and torn carpets throughout all wings and common areas. These conditions were observed and confirmed by facility leadership, indicating a failure to provide a clean, safe, and comfortable environment for residents.
The facility did not complete required annual performance evaluations for five CNAs, with no evidence of evaluations for the year 2024 for staff hired in various years. This was confirmed by the DON during the survey.
Surveyors found that staff across three units were unable to consistently identify or implement correct Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). PPE was present on resident doors without clear signage, and staff interviews revealed confusion about when and how to use PPE, as well as misunderstanding of color-coded indicators. The facility's EBP improvement plan had not been updated or used to assess staff competency since its initiation, and the Infection Preventionist confirmed ongoing issues with staff understanding of these protocols.
A review of CNA education records revealed that several CNAs did not complete mandatory annual Resident Rights training, and two did not meet the required 12 hours of annual in-service education. These deficiencies were confirmed by the DON.
A resident with limited mobility and an ADL self-care deficit was not assisted by staff with shaving, despite a care plan indicating the need for help with personal hygiene. The resident had not been offered assistance and expressed discomfort with the lack of grooming.
A resident admitted with a closed fracture and requiring daily anticoagulant injections did not have a baseline care plan developed and implemented within 48 hours of admission. The medical record lacked necessary instructions for proper care, and this deficiency was confirmed with the DON.
A resident was not invited to or involved in their interdisciplinary team (IDT) care plan meetings, despite documentation of multiple meetings. The resident stated they were unaware of care plan meetings, and the medical record lacked evidence of their participation.
Surveyors identified multiple sanitation issues, including sticky substances on the walk-in fridge and freezer floors, stained and dust-laden ceiling tiles above clean dish areas, and heavy dust and grease on kitchen surfaces. In a kitchenette, a black powdery substance was found on a freezer shelf and an open, unlabeled, undated fruit container was present in the refrigerator. The Food Service Manager confirmed that ceiling cleaning was infrequent and acknowledged the presence of removable dust and debris.
The facility failed to maintain adequate housekeeping and maintenance services, resulting in stained ceiling tiles, cobwebs, debris on the floor, and an IV pole with stains and debris. These deficiencies were confirmed with the Maintenance Supervisor during a facility tour.
The facility failed to update care plans for two residents with changing medical needs. One resident's care plan did not reflect current treatment for edema, and another resident's care plan did not align with current recommendations for limited range of motion due to pain and ill-fitting splints.
The facility failed to follow physician orders for wound care for two residents and did not obtain a required urine sample or conduct neurological checks for a resident after a fall. One resident did not receive updated wound care after their ulcer healed, and another did not have moisturizer applied as ordered. Additionally, post-fall protocols were not followed for a resident exhibiting increased confusion and urinary frequency.
The facility failed to properly date and dispose of open medications and ensure expired medications were removed from use. Observations revealed expired and improperly stored medications, including an unlabeled Tuberculin Purified Protein vial and medications left unsafely on a resident's nightstand without proper assessment.
The facility failed to maintain kitchen sanitation and proper food handling. Observations included an unlabeled pan of green beans, a Dietitian with uncontained hair, a food server improperly wearing a hair net, and dust on the kitchen ceiling. These issues were confirmed with the DON.
A facility failed to implement a nutrition care plan for a resident receiving tube feedings. An RN administered medication and a feeding bolus via gastrostomy tube without confirming tube placement or checking gastric residual volume, stating there were no orders to do so. This was discussed with the President of Nursing.
A facility failed to confirm G-tube placement and check gastric residual volume before administering a feeding bolus and medication to a resident. The nurse stated there were no orders to perform these checks, and the resident confirmed that these procedures were not followed.
The facility failed to maintain a sanitary environment for respiratory care equipment for two residents. A nebulizer pipe was improperly stored with other items, and an oxygen concentrator's nasal cannula was not stored in a plastic bag. The facility lacked a policy for proper storage of these items.
The facility failed to conduct an annual review of its IPCP. Various policies within the program lacked dates indicating a review and/or revision was completed. The DON confirmed that while the facility reviews its policies and procedures, the policies were unsigned and there was no evidence to show that the policies related to the IPCP were reviewed and revised annually.
The facility failed to ensure that a resident was reviewed and offered a pneumococcal vaccination in accordance with CDC recommendations. The resident's immunization record lacked evidence of review or offer of the vaccine, which was confirmed by the DON.
Failure to Maintain Sanitary and Orderly Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment across all three wings and common areas over a three-day period. Specifically, multiple fans in the hallways were found coated with thick layers of dust, and this was acknowledged by the Director of Nursing. During an environmental tour, several resident rooms were found with uncleanable surfaces due to exposed joint compound and sheetrock, gouged walls, chipped paint exposing metal flashing, and a broken lamp. Some rooms had makeshift repairs, such as a plastic wall protector attached with medical tape and a gouged laminate plank creating a hole in the floor. Additionally, stained and torn carpets were observed in the common area hallways near the elevators. These conditions were directly observed by surveyors and discussed with facility leadership, including the Chief Operating Officer and the Director of Nursing. The findings indicate that housekeeping and maintenance services were not adequately provided, resulting in unsanitary and disordered conditions throughout the facility. No specific residents' medical histories or conditions were mentioned in relation to the observed deficiencies.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for five sampled Certified Nursing Assistants (CNAs), as required. Specifically, there was no evidence of completed annual performance evaluations for the year 2024 for CNAs hired in April 2023, June 2005, March 2017, November 2003, and October 2020. This deficiency was identified through performance evaluation reviews and interviews, and was confirmed with the Director of Nursing on 6/24/25 at 2:07 p.m. No information regarding the medical history or condition of any residents was provided in relation to this deficiency.
Staff Lacked Competency in Infection Control Precautions
Penalty
Summary
The facility failed to ensure staff competency in Infection Control, specifically regarding Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP), across three units. Surveyors observed that PPE was present on resident doors without appropriate signage indicating when or what PPE should be used. Multiple staff members, including RNs, CNAs, and Environmental Services workers, were unable to correctly identify the type of precautions in place or the correct use of PPE. Some staff relied on verbal reports or care plans for information, but there was confusion and inconsistency in understanding the difference between TBP and EBP. In several instances, staff either did not know the reason for PPE placement or misunderstood the requirements for donning PPE, with some believing PPE was only necessary for certain activities or misinterpreting color-coded indicators. Record review revealed that the facility's Enhanced Barrier Precautions Performance Improvement Plan had not been reviewed or revised since its last update, and there was no evidence of ongoing staff competency assessments or knowledge checks since the plan's initiation. The Infection Preventionist acknowledged ongoing issues with staff understanding of TBP and EBP, despite the implementation of the improvement plan. These findings demonstrate a lack of effective implementation and staff education regarding infection control protocols, as evidenced by direct observations and staff interviews.
Failure to Provide Required CNA Training on Resident Rights and Annual In-Service Education
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) received mandatory annual training on Resident Rights, as evidenced by a review of employee education records for five CNAs. None of the five CNAs reviewed had documentation of completing the required Resident Rights training for the current year. Additionally, two of these CNAs did not have evidence of completing the required 12 hours of annual in-service education for the year. These findings were confirmed through record review and interview with the Director of Nursing.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
Staff failed to maintain a resident's dignity by not assisting with personal grooming, specifically shaving, despite the resident's care plan indicating a need for assistance with personal hygiene due to limited mobility. On one of the survey days, the resident was observed with long facial hair on the chin and upper lip and reported not having shaved since admission because he did not have a shaver. The resident stated that staff had not offered or asked if he would like assistance with shaving, and expressed that the facial hair bothered him. The care plan in place required staff to assist with personal hygiene, but this intervention was not implemented prior to surveyor intervention.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was newly admitted with a closed fracture of the upper and lower end of the left fibula and required daily Enoxaparin injections. Record review showed that as of June 25, 2025, the resident's medical record did not contain evidence of a baseline care plan that included the necessary instructions to provide minimum healthcare information for proper care in this area. This deficiency was confirmed during an interview with the Director of Nursing on the same day. The lack of a baseline care plan meant that essential instructions for the resident's care, particularly regarding the administration of anticoagulant therapy, were not documented or available to staff within the required timeframe after admission.
Failure to Involve Resident in Interdisciplinary Care Plan Review
Penalty
Summary
The facility failed to ensure that the care plan was reviewed and revised by an interdisciplinary team (IDT) with the participation of the resident, as required. One resident reported never having heard of care plan meetings, and a review of the medical record showed that while IDT meetings were held on several occasions, there was no evidence that the resident was invited to or participated in these meetings. The deficiency was confirmed through interviews and record review, and the lack of resident involvement in care planning was discussed with the Director of Nursing.
Sanitation Deficiencies in Kitchen and Kitchenette Areas
Penalty
Summary
Surveyors observed and confirmed multiple sanitation deficiencies in the facility's kitchen and kitchenette areas. In the main kitchen, the floor of the walk-in refrigerator and freezer was found to have a sticky substance, and several ceiling tiles were stained with a heavy concentration of dust buildup above the clean dish area, exit, and dish machine. A flat surface near the kitchen entrance was covered in a thick layer of dust and grease. In a kitchenette, a black powdery substance was found on the top shelf of the freezer door, and an open, unlabeled, and undated container of fruit was present in the refrigerator. The Food Service Manager acknowledged that ceiling cleaning was scheduled only annually and agreed that this frequency was insufficient, as demonstrated when dust and debris were easily wiped off the ceiling during the surveyor's inspection. No specific residents were directly involved or affected as described in the report, and no medical history or resident condition was mentioned in relation to the deficiency.
Inadequate Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to maintain adequate housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment for residents in three residential units. During a facility tour with the Maintenance Supervisor, several deficiencies were observed, including stained ceiling tiles in various locations, cobwebs attached to light fixtures, debris stuck to the floor, and an IV pole with stains and debris. Additionally, a unit exit door had a buildup of sticky material from glue residue. These findings were confirmed with the Maintenance Supervisor during the tour.
Failure to Update Care Plans for Residents with Changing Medical Needs
Penalty
Summary
The facility failed to revise the care plan to reflect the current status of two residents. For Resident #21, the care plan initiated on 2/22/21 for edema did not reflect the current treatment of compression wraps with kerlix and coban, as observed on 4/1/24. The resident's medical record indicated a new wound identified on 2/21/24 and a provider order for wound care, but the care plan was not updated to include these changes. The Registered Nurse confirmed that the resident was no longer using ted hose, which was still listed in the care plan, indicating a lack of updates to reflect the resident's current needs and treatment for edema. For Resident #8, the care plan last revised on 3/9/24 did not reflect the resident's current condition regarding limited range of motion. The resident reported that splints for the arm and leg no longer fit due to weight loss, and staff interviews confirmed that the resident was not wearing the splints or receiving passive range of motion (PROM) as prescribed. The Rehabilitation Manager and Director of Nursing confirmed that the care plan was outdated and did not reflect the current recommendations to avoid using the splints and performing PROM due to the resident's pain and risk of pressure ulcers. The care plan failed to be revised to align with the resident's current needs and therapy recommendations.
Failure to Follow Physician Orders for Wound Care and Post-Fall Protocol
Penalty
Summary
The facility failed to ensure proper wound care and adherence to physician orders for two residents with skin conditions and one resident with a fall incident. For Resident #21, the wound nurse did not update the treatment orders after the venous ulcer on the right foot healed, leading to the continued use of outdated wound care procedures. The wound nurse confirmed that the wound was documented as healed on 2/29/24, but the orders were not updated to reflect the current treatment needs. Additionally, Resident #30 had extremely dry, scaly skin on their arms, and despite having a physician order to apply moisturizer twice daily, the staff failed to follow this order. The Treatment Administration Record inaccurately documented that the moisturizer was applied, and the RN responsible was unaware of the existing order, leading to the resident not receiving the necessary skin care treatment. For Resident #3, the facility did not follow the physician's order to obtain a urine sample and conduct neurological checks after the resident experienced a fall and exhibited increased confusion and urinary frequency. The medical record contained an order dated 3/30/24 to obtain a urine sample to rule out a urinary tract infection and to perform neurological checks. However, during an interview on 4/3/24, the President of Nursing confirmed that the urine sample was not obtained, and the neurological checks were not completed, indicating a failure to follow through with the prescribed post-incident actions.
Improper Medication Storage and Expired Medications
Penalty
Summary
The facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and ensure expired medications were removed from the supply available for use. During an observation of medication storage on the [NAME] Neighborhood, a Certified Medication Technician was found to have an opened bottle of multivitamins with minerals that had expired in 3/24, and the medication room refrigerator contained an influenza vaccine with a temperature log showing recordings only once daily and 11 days without monitoring. Additionally, on the [NAME] Neighborhood, an opened bottle of Tuberculin Purified Protein was found unlabeled without an opened date, contrary to manufacturer instructions that it should be discarded after 30 days. These findings were discussed with the President of Nursing on 4/2/24 at 10:02 a.m. Furthermore, a surveyor observed medications left unsafely on top of a resident's nightstand, including a Spiriva inhaler, two Combivent inhalers, and a Flonase inhaler. The resident confirmed that the nurses left the medications there. An interview with the unit manager revealed that the resident had not been assessed to safely keep medications at the bedside, nor were those medications being stored safely. This indicates a failure to ensure proper medication storage and safety protocols were followed in the facility.
Kitchen Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner. During an initial tour of the kitchen, a surveyor observed a pan of green beans in the refrigerator that was unlabeled and undated. Additionally, the Dietitian was seen walking through the kitchen with her hair uncontained and uncovered. The Food Service Director was present and aware of these findings. On a subsequent observation, a food server with long hair was seen wearing a hair net improperly, as her hair was not fully contained. The staff member stated she worked in Medical Records and was trained to serve meals. Later, a return observation to the kitchen revealed a light amount of dust on and hanging from approximately one-quarter of the kitchen ceiling. These findings were confirmed with the Director of Nursing.
Failure to Implement Nutrition Care Plan for Tube Feeding
Penalty
Summary
The facility failed to implement a care plan in the area of nutrition for a resident receiving tube feedings. The resident's nutrition care plan, revised on 3/2/24, instructed nursing staff to verify the tube placement before administering any medications, tube feedings, or flushing the tube. On 4/1/24 at 12:01 p.m., a Registered Nurse (RN) was observed administering medication and a feeding bolus via gastrostomy tube (GT) without confirming the placement of the G-Tube or checking the gastric residual volume (GRV). During an interview, the RN stated that she did not check the placement or residual because there were no orders to do so. This issue was later discussed with the President of Nursing at 4:11 p.m. on the same day.
Failure to Confirm G-Tube Placement and Check Residuals
Penalty
Summary
The facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding for one resident reviewed for tube feeding. During an observation, a registered nurse administered a feeding bolus and medication via a gastrostomy tube without confirming the placement of the G-tube or checking the gastric residual volume (GRV) prior to administration. The nurse stated that there were no orders to perform these checks. The resident confirmed that nursing staff did not ensure the G-tube was in the correct place or check residuals before administering feedings or medications. This deficiency was discussed with the President of Nursing.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
The facility failed to provide a sanitary environment to prevent the development and transmission of disease and infection related to respiratory care for two residents. For Resident #21, a nebulizer pipe with tubing was observed stored in a basin along with an exercise band and socks. The resident mentioned that the nebulizer had not been used for a long time. The Registered Nurse (RN#1) later discarded the nebulizer pipe. The President of Nursing confirmed that the last nebulizer order for Resident #21 was in March 2020 and stated that nebulizers should be rinsed, dried, and stored in a bag when not in use. For Resident #170, an oxygen concentrator with a nasal cannula tubing was observed unlabeled and hanging off the knob of the concentrator. The resident stated that oxygen was only used at night. The next day, the nasal cannula was dated but still improperly stored. RN#1 could not explain the discrepancy and mentioned that oxygen tubing is often wrapped up and not stored in bags. The President of Nursing confirmed that nasal cannulas should be stored in plastic bags when not in use. The facility was unable to provide a policy and procedure for the storage of oxygen tubing and nebulizer supplies when used intermittently.
Failure to Conduct Annual Review of IPCP
Penalty
Summary
The facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP). During a review of the facility's IPCP policy and procedures, a surveyor noted that various policies within the program lacked dates indicating a review and/or revision was completed. The undated policies included Infection Control, Pneumococcal Immunization for Resident with Prevnar 13 and Prevnar 23, Infection Control: Influenza Vaccination for Residents, Administration of Covid-19 Vaccine, Coronavirus Pandemic Strategies to Mitigate Healthcare Personnel Staffing Shortages, Influenza Protocol, and Transmission Based Precautions. The Director of Nursing confirmed that while the facility reviews its policies and procedures, the policies were unsigned and there was no evidence to show that the policies related to the IPCP were reviewed and revised on an annual basis.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was reviewed and offered a pneumococcal vaccination in accordance with CDC recommendations. During a review of the resident's immunization record, the surveyor found no evidence that the resident, who is over the age of [AGE], was reviewed, offered, or received a pneumococcal conjugate vaccination. This was confirmed by the Director of Nursing during an interview, who acknowledged the lack of documentation in the resident's record.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
