Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Maine average
Maine average: 5.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 8
Date: Jun 25, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, facility environment, care planning, staff performance, infection control, and education.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate housekeeping and maintenance, lack of baseline and comprehensive care plans, incomplete staff performance evaluations and education, unsanitary kitchen conditions, and inadequate staff competency in infection prevention and control.
Deficiencies (8)
Failed to promote care for residents in a manner that maintained dignity when staff failed to groom a resident on 1 of 3 days of survey (Resident #34).
Failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 Wings and common areas.
Failed to ensure a baseline care plan was developed and implemented within 48 hours for a new admission (Resident #281).
Failed to review and revise the care plan by an interdisciplinary team including resident participation for 1 of 25 residents reviewed (Resident #65).
Failed to complete annual performance evaluations at least every 12 months for 5 sampled CNAs.
Failed to maintain the kitchen and kitchenettes in a clean and sanitary manner, including sticky floors, stained ceiling tiles, dust and grease buildup, and open unlabeled food containers.
Failed to demonstrate staff competency for Infection Control in Transmission Based Precautions and Enhanced Barrier Precautions across 3 units, with confusion about PPE use and lack of signage.
Failed to ensure CNAs attended mandatory yearly Resident Rights training and required annual in-service education hours for 2 of 5 CNAs reviewed.
Report Facts
Days of survey: 3
Number of sampled residents reviewed for care planning: 25
Number of sampled CNAs reviewed for performance evaluations: 5
Number of sampled CNAs reviewed for education: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Discussed grooming deficiency, housekeeping issues, care planning, and staff performance evaluation deficiencies |
| Food Service Manager | Food Service Manager | Confirmed kitchen sanitation deficiencies and cleaning schedules |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding PPE use and infection control practices |
| Registered Nurse #2 | Registered Nurse | Observed and interviewed regarding PPE use on Black/Wolf Unit |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Reviewed for missing annual performance evaluations and training |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reviewed for missing annual performance evaluations and training |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Reviewed for missing annual performance evaluations and training |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Reviewed for missing annual performance evaluations and training |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Reviewed for missing annual performance evaluations and training |
| Environmental Services Worker #1 | Environmental Services Worker | Interviewed regarding PPE use and infection control knowledge |
| Infection Preventionist | Infection Preventionist | Discussed staff competency concerns related to infection control |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Apr 3, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey of Cedars Nursing Care Center to assess compliance with regulatory requirements related to resident care, environment, medication management, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including inadequate housekeeping and maintenance, failure to implement and revise care plans appropriately, failure to follow physician orders, improper medication administration via feeding tubes, unsanitary respiratory care equipment, improper medication storage and labeling, food safety violations, lack of annual review of infection prevention policies, and failure to offer pneumococcal vaccination to a resident as per CDC guidelines.
Deficiencies (10)
Failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 3 of 3 residential units, including stained ceiling tiles, cobwebs, debris on floors, and sticky residue on doors.
Failed to implement a care plan in the area of nutrition for 1 of 1 sampled resident for tube feedings (#36), including failure to verify tube placement and check gastric residual volume prior to medication and feeding administration.
Failed to revise care plans to reflect current resident status for 1 of 3 residents reviewed for skin conditions and 1 of 1 resident reviewed for limited range of motion.
Failed to ensure nursing obtained new orders for wound care and followed physician orders for 2 of 3 residents reviewed for skin conditions and failed to follow physician orders to obtain a urine sample for 1 of 2 residents reviewed for falls.
Failed to provide appropriate treatment to prevent risk of complications related to enteral feeding for 1 of 1 resident reviewed for tube feeding (#36), including failure to confirm feeding tube placement and check gastric residual volume.
Failed to provide a sanitary environment to prevent disease and infection related to nebulizer and oxygen tubing for 2 of 2 residents reviewed for respiratory care, including improper storage and handling of equipment.
Failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from supply on 3 of 3 neighborhoods observed.
Failed to ensure the kitchen was maintained in a clean and sanitary manner, including unlabeled and undated food items, staff with uncovered hair, and dust on kitchen ceiling.
Failed to conduct an annual review of the Infection Prevention and Control Program (IPCP), with multiple policies lacking review or revision dates.
Failed to ensure 1 of 5 residents reviewed for immunizations was reviewed and offered pneumococcal vaccination in accordance with CDC recommendations.
Report Facts
Residents reviewed for skin conditions: 3
Residents reviewed for tube feeding: 1
Residents reviewed for limited range of motion: 1
Residents reviewed for immunizations: 5
Days without refrigerator temperature monitoring: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Confirmed housekeeping and maintenance deficiencies during facility tour | |
| Registered Nurse (RN#1) | Observed failing to confirm G-tube placement and check gastric residual volume | |
| President of Nursing | Interviewed regarding multiple deficiencies including tube feeding, wound care, medication storage, and infection control | |
| Registered Nurse (RN#3) | Interviewed regarding care plan and splint use for Resident #8 | |
| Rehabilitation Manager | Interviewed regarding Resident #8's contractures and splint use | |
| Certified Nursing Assistants (3 CNAs) | Interviewed regarding Resident #8's care and splint use | |
| Wound Nurse | Interviewed regarding wound care for Resident #21 | |
| Certified Medication Technician | Observed medication storage deficiencies | |
| Unit Manager | Interviewed regarding unsafe medication storage at bedside for Resident #47 | |
| Dietary Director | Observed with hair uncovered in kitchen | |
| Food Service Director | Aware of kitchen sanitation findings | |
| Director of Nursing | Confirmed lack of annual IPCP policy review and other deficiencies |
Inspection Report
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
The inspection was conducted to ensure that the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents.
Findings
The facility failed to ensure that a resident was free from an avoidable accident hazard by not removing a hot pack timely for 1 of 1 residents reviewed for accidents, resulting in a dime-sized blister on the resident's lower back.
Deficiencies (1)
Failure to remove a hot pack timely as per facility procedure, leading to a blister on Resident #1's lower back.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interview confirmed the avoidable accident hazard related to Hot Packs |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 22, 2023
Visit Reason
The inspection was conducted following an anonymous complaint alleging emotional/mental abuse by a staff member (CNA #1) toward Resident #1, including harsh treatment, rough care, and lack of privacy, causing the resident to feel embarrassed, humiliated, and fearful to ask for assistance.
Complaint Details
The complaint was anonymous and alleged that Resident #1 experienced emotional/mental abuse by CNA #1, including harsh treatment, rough care with hot water, and lack of privacy leading to embarrassment. The complaint was substantiated by interviews and review of facility communications. The facility failed to report the abuse to the State Survey Agency and did not conduct a thorough investigation. The LCSW and Rehab Unit Nurse Manager did not report the allegations, and the DON acknowledged the failures.
Findings
The facility failed to protect Resident #1 from emotional/mental abuse by staff, failed to timely report the abuse allegations to the State Survey Agency, and did not conduct a thorough investigation. The Licensed Clinical Social Worker and Rehab Unit Nurse Manager did not report the allegations, and the Director of Nursing acknowledged the failure to report and investigate. The facility removed the alleged staff member from Resident #1's care but did not suspend or investigate properly. The LCSW had not completed required annual abuse/neglect training.
Deficiencies (3)
Failed to protect Resident #1 from emotional/mental abuse by staff causing embarrassment, humiliation, and fear to ask for assistance.
Failed to timely report an allegation of abuse to the Division of Licensing and Certification (State Survey Agency) for Resident #1.
Licensed Clinical Social Worker did not complete annual training for abuse/neglect/reporting as required.
Report Facts
Residents affected: 1
Date of survey completed: Aug 22, 2023
Last LCSW training date: Jul 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Alleged to have emotionally/mentally abused Resident #1 |
| Licensed Clinical Social Worker | LCSW | Did not report abuse allegations and had not completed required annual training |
| Director of Nursing | DON | Acknowledged failure to report and investigate abuse allegations |
| Rehab Unit Nurse Manager | Nurse Manager | Knew of allegations but did not report to State Survey Agency |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 1, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to medication management, food safety, infection control, and overall facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure PRN antipsychotic medication orders met required time limits, expired medications not removed from medication rooms and carts, unsafe and unsanitary storage of frozen foods, failure to monitor chemical sanitizer levels in kitchen, and inadequate infection prevention and control program including lack of water management for Legionella.
Deficiencies (4)
Failed to ensure an as needed (PRN) antipsychotic medication order met the required 14-day time limit or provided rationale to extend beyond 14 days for 1 of 5 residents reviewed.
Failed to ensure expired medications were removed from supply in 1 of 2 medication rooms and 1 of 4 medication carts observed.
Failed to store frozen foods in a safe and sanitary manner on 2 of 3 days of kitchen observations and failed to monitor chemical sanitizer levels for sanitizing buckets.
Failed to maintain an infection prevention and control program including personal equipment storage and failed to assess and monitor for Legionella and other waterborne pathogens.
Report Facts
Residents reviewed for unnecessary medications: 5
Medication rooms observed: 2
Medication carts observed: 4
Days of kitchen observations: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding expired medications and infection control deficiencies |
| Informatics Nurse | Informatics Nurse | Confirmed no evidence of PRN order renewal after 14 days |
| Licensed Practical Nurse | Licensed Practical Nurse | Observed medication room and infection control concerns |
| Registered Nurse | Registered Nurse | Observed medication cart with expired medication |
| Executive Chef | Executive Chef | Confirmed unsafe food storage and sanitizer monitoring deficiencies |
| Maintenance | Maintenance | Interviewed about water management program absence |
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