Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barron Center during CMS and state inspections, most recent first.
Incomplete IDT care plan reviews were documented for multiple residents, with meetings missing required participation from the attending MD, RN, CNA, and nutrition services. One resident and representative stated the resident was never invited or included, and a social worker later confirmed an invitation letter had been created after the fact for a meeting that had already occurred.
A facility failed to maintain sanitary respiratory equipment for two residents. One resident’s oxygen tubing was past due for replacement, the nasal cannula was unlabeled, and the TAR had no documentation of required changes. Another resident’s nasal cannula tubing was found on the floor during care and was placed back on the resident’s face.
Expired and undated meds were found in multiple med rooms and carts, including unopened bottles past exp dates, opened insulin products without dates, and an opened PPD vial kept beyond the manufacturer’s discard timeframe. Staff on 2 South, 3 South, and 2 North confirmed the expired and unlabeled medications during the observations.
Food Storage, Temperature Monitoring, and Equipment Cleanliness Deficiencies: Surveyors found missing and inconsistent temp logs for the main kitchen refrigerator/freezer, dish machine, tray line, and multiple unit kitchenette refrigerators/freezers, along with missed outdated supply checks in several kitchenettes. They also observed food prep equipment, including a meat slicer and mixers, with dried debris, dust, and debris, and the DON/Administrator confirmed the findings.
Failure to Use Required PPE During EBP Care: Staff did not follow EBP instructions for high-contact care. Two RNs provided G-tube care for a resident with an indwelling feeding tube while wearing only gloves, and two CNAs provided hygiene and peri care for a resident with a suprapubic catheter and ESBL history while also wearing only gloves. The posted EBP guidance required both gloves and gowns for device care and hygiene/toileting activities.
A resident's loss of personal property, including two cell phones and identification, was not properly investigated or reported to the State Agency within the required timeframe. The incident was not communicated to facility leadership, and no evidence of an internal investigation or required external reporting was found.
A resident admitted with CVA, right arm flaccid paralysis, DM2, lung mass, a right humerus fracture with delayed healing, dysphagia, and recurrent falls did not have a baseline care plan developed and implemented within 48 hours of admission. The clinical record lacked evidence of the instructions needed to address the resident’s immediate health and safety needs, and the care plan was not started until 3 days after admission. The issue was discussed with the DON during interview.
A facility failed to ensure comprehensive care plans were developed for two residents in the areas of MDRO and PASRR. One resident had a history of ESBL in the urine, a suprapubic catheter, and an EBP sign posted on the door, but the care plan lacked goals and interventions for EBP precautions and ESBL history. Another resident had a Level II PASRR for Alzheimer’s disease, major mental psychotic disorder, and being deaf and mute since childhood, but the care plan lacked PASRR-related goals and interventions. The DON confirmed the omissions.
A facility failed to maintain a COVID-19 vaccination policy and procedure and did not offer the updated 2024-2025 COVID-19 vaccine to an eligible resident. The DON confirmed no current policy could be found, and the resident’s record showed a prior COVID-19 vaccine dose but no evidence the vaccine was offered, received, or refused upon admission.
Inaccurate MDS Coding for Active Diagnosis and PASRR: The facility failed to code MDS 3.0 assessments accurately for two residents. One resident had a history of ESBL/MDRO and was on Enhanced Barrier Precautions, but the MDSs stated no MDRO was present. Another resident had a Level II PASRR for Alzheimer’s disease, major mental psychotic disorder, and deaf and mute since childhood, but the MDSs lacked evidence that PASRR Level II was completed. The DON confirmed the coding errors.
A resident experienced a fall and sustained injuries after a CNA failed to follow the care plan, which required a maximum of two-person assistance for toileting. The CNA attempted to toilet the resident alone, leading to the resident falling past the bed rail. The resident suffered injuries and complained of pain and dizziness.
Incomplete IDT Care Plan Reviews and Missing Resident Participation
Penalty
Summary
The facility failed to have care plans reviewed and revised by an interdisciplinary team after assessments for 6 of 21 residents reviewed, including Resident #6, #3, #5, #91, #99, and #8. The report states that the required team participation was incomplete, with meetings lacking involvement from the attending physician, a CNA responsible for the resident, and a member of nutrition services. For Resident #6, the resident and representative stated the resident was not aware of the meetings and had never been invited, while the representative said the IDTs were done by phone and had been without the resident. For Resident #6, the medical record showed IDT meetings on 2/21/25 and 12/19/24, but there was no evidence the resident was invited or participated, and the invitation letter for the 12/19/24 meeting was handwritten with a future date of 12/18/25. The LSW later confirmed the letter was created that day and stated, "That was on me, I didn't invite her to this meeting. I did sign this today." For Resident #3, the record showed an IDT meeting on 3/19/25 with only the social worker and nutrition services present, and no evidence of an IDT meeting after the Quarterly MDS dated 12/4/24 and the significant Change MDS dated [DATE]. Similar incomplete IDT participation was documented for Resident #5 on 7/9/25, Resident #91 on 7/9/25 and 10/23/24, and Resident #99 on 11/13/24, with only the social worker and nutrition services participating.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for two residents receiving respiratory care. For one resident, oxygen tubing was observed dated 7/17/25 and was past due for replacement under the facility’s policy, while the nasal cannula had no label, no date of change, and no staff initials. Review of the resident’s TAR showed no documentation of tubing or cannula changes as required by policy, and an RN verified that the tubing was past due and the cannula had not been labeled. For another resident, during personal hygiene care, the resident’s oxygen nasal cannula tubing with the prongs lying on the floor under the bed was observed. After hygiene was completed, a CNA picked up the nasal cannula from the floor and placed it back on the resident’s face. The surveyor immediately intervened and discussed that the cannula had been on the floor and that a sanitary environment had not been maintained to prevent transmission of disease or infection.
Expired and Undated Medications Found in Medication Rooms and Carts
Penalty
Summary
Drugs and biologicals were not consistently labeled or stored according to accepted professional principles in the facility’s medication areas. During observation of the 2 South medication room, an unopened bottle of Naproxen Sodium was found available for use with an expiration date of 5/2025. The refrigerator also contained two opened, undated vials of Lantus insulin and one opened, undated Basaglar insulin KwikPen, despite manufacturer directions to discard the medication after 28 days of use. RN #1 confirmed the expired and unlabeled medications at the time of the observation. Additional medication storage issues were identified on 3 South and 2 North. In the 3 South CNA-M medication cart, two bingo cards of Zofran 4 mg were observed with remaining tablets and expiration dates of 5/13/25 and 5/29/25, and the CNA-M confirmed the medications were expired. In the 2 North medication room, an unopened bottle of Calcium 600 with Vitamin D was found with an expiration date of 7/2025, and the refrigerator contained an opened vial of Tuberculin Purified Protein Derivative labeled with an open date of 7/17/25 even though the manufacturer directions stated the vial should be discarded after 30 days. The 2 North nurse medication cart also contained an opened, undated Basaglar insulin KwikPen, and RN #4 confirmed the expired and unlabeled medications.
Food Storage, Temperature Monitoring, and Equipment Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation and storage. During observations and record review, surveyors found that the main kitchen did not have ongoing documentation of refrigerator/freezer temperatures, with the only record provided ending on 5/5/2025. The Director of Food Services confirmed the absence of current documentation. Review of dish machine temperature logs showed that temperatures were not consistently recorded, with 37 of 129 days missing documentation across April through August 2025. Surveyors also found problems with tray line temperature audits, including 4 undated sheets and 110 of 294 meals without temperature documentation. On return visit, the meat slicer had dried debris, and the large floor mixer and countertop mixer were covered in dust and debris; staff confirmed the equipment had been used recently. In unit kitchenettes, temperature logs were incomplete across multiple areas, including the Third Floor Day Room, Second Floor Day Room, 2 North and 2 South Kitchenettes, and the Zolov Unit. Documentation also showed missed outdated supply checks in the 3rd Floor, 2nd Floor, and Zolov Unit kitchenettes. The Administrator confirmed all findings during interview.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to maintain its Infection Control Program for residents on Enhanced Barrier Precautions (EBP) by not using the required gown and gloves during high-contact care activities. The facility policy stated that targeted gown and glove use was required for activities such as dressing, bathing, hygiene, changing linens, toileting, wound care, and care involving indwelling medical devices such as Foley catheters and feeding tubes. On 8/19/25 at 8:30 a.m., Resident #118’s room was posted for EBP and contained gloves and disinfectant wipes on the door, yet two RN managers were observed at the bedside wearing only gloves while providing care related to the resident’s gastrostomy tube. One RN was seen cleansing around the G-tube site and holding a syringe, while the other retrieved gauze from the dresser and brought it to the bedside. When questioned, one RN initially stated only gloves were needed, then later acknowledged that a gown would also be used for G-tube care. Later that day at 2:09 p.m., Resident #6’s room was also posted for EBP with gloves and gowns available on the door, but two CNAs were observed wearing only gloves while providing personal hygiene and peri care to the resident, who had neurogenic bladder, a suprapubic catheter, and a history of ESBL in the urine. During interview, one CNA confirmed catheter care had been provided and stated she believed gowns were only required when emptying the Foley bag. The posted EBP instructions in the room stated that staff must wear gloves and a gown for high-contact resident care activities, including hygiene, toileting, and device care for urinary catheters and feeding tubes.
Failure to Investigate and Report Resident Property Misappropriation
Penalty
Summary
The facility failed to investigate an allegation of potential misappropriation of a resident's personal property and did not ensure that the results of the investigation were reported to the State Agency within 5 business days, as required by facility policy. Specifically, a resident was reported missing two cell phones, a case containing identification, a Medicare card, and a small amount of cash. The resident's son communicated the loss to the facility, expressing doubt that the items could have been accidentally discarded. The social worker responded by searching the resident's room, trash, and notifying the kitchen and laundry departments. An online crime report was filed with the local police, but the report was rejected as the police do not handle missing or lost property cases of this nature. A review of the resident's medical record confirmed the missing items were previously documented in the personal effects inventory. During interviews, the Social Services Director stated there was no evidence that an internal investigation had been completed or that a 5-day report was sent to the State Agency. Both the Administrator and the Director of Nursing confirmed they had no knowledge of the incident, and it had not been discussed in staff meetings. This demonstrates a failure to follow internal and external reporting procedures for suspected misappropriation of resident property.
Baseline Care Plan Not Completed Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #5, who was admitted with cerebrovascular accident with right arm flaccid paralysis, type 2 diabetes mellitus, lung mass, fracture of the right humerus with delayed healing, dysphagia, and recurrent falls. The clinical record lacked evidence that a baseline care plan was completed within 48 hours to include the instructions needed to properly care for the resident’s immediate health and safety needs related to these conditions. The care plan was not initiated until 7/3/25, which was 3 days after admission. On 8/20/25 at 12:31 p.m., the Director of Nursing was interviewed and the issue was discussed.
Incomplete Care Plans for MDRO and PASRR
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed for two residents in the areas of MDRO and PASRR. Resident #6 was re-admitted in April 2025 with neurogenic bladder requiring a suprapubic catheter and a history of ESBL in the urine, and observations on 8/18/25 and 8/19/25 showed an EBP sign posted on the bedroom door; however, the care plan last updated on 6/3/25 lacked goals and interventions related to EBP precautions and the ESBL history. Resident #9 had a Level II PASRR dated 1/22/19 indicating eligibility based on Alzheimer's disease, major mental psychotic disorder, and being deaf and mute since childhood, but as of 8/20/25 the care plan lacked goals and interventions related to PASRR. On 8/20/25 at 12:31 p.m., the DON confirmed that both residents' care plans lacked the required information.
Failure to Offer COVID-19 Vaccination and Lack of Policy
Penalty
Summary
The facility failed to develop a Coronavirus (COVID-19) policy and procedure for COVID-19 vaccination and failed to offer the updated 2024-2025 COVID-19 vaccine to an eligible resident. A review of the facility’s infection control policies and procedures found no evidence of a COVID-19 policy and procedure regarding immunizations, and the Director of Nursing confirmed she was unable to locate a current policy and procedure for COVID-19 vaccinations. Clinical record review showed that Resident #80 was admitted in March 2025 and had a last documented COVID-19 vaccination on 11/3/22. There was no evidence that the resident had received, been offered, or refused the COVID-19 vaccination. The Director of Nursing also confirmed the clinical record did not indicate staff had offered the resident a COVID-19 vaccination upon admission.
Inaccurate MDS Coding for Active Diagnosis and PASRR
Penalty
Summary
The facility failed to ensure that MDS 3.0 assessments were coded accurately for Active Diagnosis and PASRR for 2 of 21 sampled residents. For Resident #6, the clinical record showed a re-admission in April 2025 with neurogenic bladder requiring a suprapubic catheter and a history of ESBL, an MDRO, in the urine, and an Enhanced Barrier Precautions sign was observed posted on the bedroom door on 8/18/25 and 8/19/25; however, the Quarterly MDS, Significant Change MDS, and most recent Quarterly MDS all indicated under Active Diagnosis section I1700 that the resident did not have an MDRO. For Resident #9, the clinical record included a Level II PASRR dated 1/22/19 showing eligibility for services due to Alzheimer's disease, major mental psychotic disorder, and deaf and mute since childhood, but review of the Quarterly MDSs dated 7/31/24, 10/25/24, 1/24/25, 7/17/25 and the Annual MDS showed no evidence in section S0510 that a PASRR Level II had been completed. During interview on 8/20/25 at 12:31 p.m., the DON confirmed both residents' MDSs were coded incorrectly.
Failure to Follow Care Plan Results in Resident Fall
Penalty
Summary
The facility failed to provide care based on the comprehensive assessment and the resident's person-centered care plan, resulting in an avoidable accident. On the night shift of 1/17/25, a Certified Nursing Assistant (CNA) did not adhere to the care plan for a resident who required a maximum of two-person assistance for toileting. Instead, the CNA attempted to toilet the resident alone using a bedpan, which was against the care plan instructions. During this process, the CNA rolled the resident away from her, causing the resident to fall past the bed rail and onto the floor. The bed was positioned at waist level for care, which contributed to the fall. As a result of the fall, the resident sustained visible injuries to her left foot, right toes, and left big toe, and complained of pain in her neck and back. Additionally, the resident experienced dizziness, blurred vision, and lethargy. The incident report and documentation from the Nursing Supervisor confirmed that the injury occurred because the care plan was not followed, emphasizing the requirement for a maximum of two-person assistance for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 175 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springbrook Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Fallbrook Commons | 2.8 mi | ★★★★★ | 0 | 0 |
| Cedars Nursing Care Center | 3.1 mi | ★★★★★ | 1 | 0 |
| Seaside Healthcare Llc | 3.2 mi | ★★★★★ | 13 | 0 |
| Pinnacle Health & Rehab At South Portland | 4.6 mi | ★★★★★ | 36 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Barron Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.