Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Brentwood Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
Facility Maintenance and Housekeeping Deficiencies: Surveyors observed missing Whirlpool room tiles, frayed and stained carpeting, marred walls, and other maintenance issues across multiple units. Additional findings included a missing hand sanitizer cover, an exposed wall heater, nonworking overbed lights, a hole in a bathroom wall, a stained divider curtain, a urinal and bed pan left on a bathroom floor, a broken night stand hinge, heavy dust on a TV arm, and damaged ceiling tiles in the dining room.
Failure to Hold Required IDT Care Plan Meetings The facility failed to review and revise care plans by an IDT, including resident and/or representative participation to the extent possible, after required MDS assessments for three residents. Records lacked evidence that IDT meetings were held within 7 days of quarterly, annual, and admission MDS completion, and both the Regional Director of Operations and the social worker confirmed the meetings were not done within the required timeframe. One resident also stated he/she had not met with the care team and had concerns to discuss.
Broken floor heaters exposed piping and sharp metal fins in resident areas, including rooms [ROOM NUMBER] and the TV room on the Passport Unit. The condition was observed by surveyors and confirmed with the Maintenance Director and the DCO.
Insufficient weekend staffing was identified after review of the PBJ staffing report showed Excessively Low Weekend Staffing for the quarter. During interview with the Facility Administrator, it was confirmed that the facility did not have enough staff to meet resident needs on the shifts when staffing was short, affecting residents needing ADL assistance.
Incomplete controlled substance shift count documentation was identified across multiple med cart narcotic bound books. On Eagle, Passport, Short Hall, and Kitchen Hall, the oncoming and/or offgoing med pass staff failed to sign the Shift Count page confirming the narcotic count at shift change on numerous occasions, and the RDCO confirmed the findings during interview.
Expired and undated medications were found in several medication carts, a medication room, and the Pixis machine. Observations with an RN, LPN, and CNA-M identified expired tablets, insulin pens without open dates, and other medications kept available for use despite manufacturer instructions for dating and disposal after opening.
Infection control failures were observed involving EBP, PPE, and urinal handling. A resident with an indwelling catheter and another resident with a catheter had no EBP signage posted, an LPN performed trach care for a resident with chronic respiratory failure and a tracheostomy without face protection, and two unlabeled urinals were found hanging in a shower room.
A resident's call bell was not kept within reach on two observed occasions. The resident was seen in bed with the call bell wrapped around the bed rail and later on the floor, and both a CNA and an RN confirmed the call bell was not reachable.
Respiratory care and the oxygen care plan were not followed for a resident with COPD. Staff observed the resident receiving O2 by NC at 1.5 LPM even though the current provider order was for 2 LPM continuously for SOB, and the resident was unsure of the correct setting. The care plan still listed oxygen as PRN at 1-2 L to keep O2 sat at or above 90%, and the RN and Regional Director confirmed the plan had not been updated to match the current order.
The facility failed to complete an annual performance evaluation for a CNA within the required 12-month period. The CNA was hired in December 2023, and the employee file lacked evidence of a 2025 evaluation; the DCO confirmed the missing evaluation during interview.
The facility failed to ensure that one CNA completed the required annual dementia, abuse and neglect, and resident rights training. Review of the CNA’s employee record showed no evidence of the 2025 in-service training, and the missing training was confirmed by the DCO during interview.
A resident was admitted with a pressure-related skin issue on the left buttock, documented on the nursing admission evaluation and in early skilled notes as a pressure ulcer. Despite this, numerous subsequent daily skilled notes and a skin check documented the skin as intact or without issues. Later documentation identified the wound as a stage 3 pressure ulcer with full-thickness skin loss. The DON confirmed that the ulcer was present on admission, was never thoroughly assessed, was not reported to a physician, and was not appropriately cared for.
A resident was admitted with a documented pressure-related skin issue on the left buttock, and subsequent skilled notes confirmed the presence of a pressure ulcer requiring pressure ulcer care and rehab services. However, there is no indication that the physician was notified, that specific physician orders were obtained, or that an individualized interdisciplinary care plan was implemented for this existing pressure ulcer as required by facility policy. Later, a CNA reported concerns about a wound on the buttocks to the Wound Care Nurse, who stated this was the first time he became aware of the issue, and a new in-house–acquired Stage 3 pressure ulcer on the left sacrum was documented.
A resident had a physician’s order for JP (Jackson Pratt) drain monitoring every shift for prophylaxis, but the Treatment Administration Record for one month showed multiple missing entries where this monitoring was not documented as completed on evening and night shifts. Record review identified specific shifts with no documentation of the ordered JP drain checks, and the DON confirmed these omissions during an interview with surveyors.
The facility experienced repeat deficiencies when QAPI/QAA processes failed to prevent ongoing problems in wound care and clinical documentation. Previously cited issues with pressure ulcer management and incomplete or inaccurate wound care records recurred, including a resident admitted with a pressure ulcer without any MD orders for wound treatment and another resident whose record lacked complete and accurate wound care information. These findings showed that earlier corrective efforts did not resolve the underlying quality of care and record-keeping problems.
A resident was admitted with a documented pressure-related skin issue on the left buttock, identified on the NSG admission/readmission evaluation completed the day of admission. Despite this documented condition, the clinical record lacked a baseline care plan within 48 hours that included the instructions necessary to properly care for the skin issue. The DON confirmed to surveyors that there was no baseline care plan addressing this pressure-related problem.
Two residents requiring wound care did not have care plans developed to address their wounds, including the absence of documented goals and interventions. One had a chronic abscess with new antibiotic orders and wound packing, while the other had wounds on both feet, including an unstageable pressure ulcer. These deficiencies were confirmed by record review and staff interviews.
Two residents did not have documented physician orders for wound care interventions. One resident with a chronic thigh abscess returned from the ER with wound care instructions, but no wound care orders or documentation were present for nearly two weeks. Another resident with a malfunctioning NPWT device had their wound packed with VASHE-soaked gauze based on a reported verbal order, but no such order was documented in the medical record.
The facility did not maintain complete and accurate clinical records for two residents receiving wound care, as the TAR lacked documentation of wound vac dressing changes and wound care on multiple occasions, despite physician orders specifying required care.
Two residents experienced deficiencies in medication administration and documentation. One RN delayed administering Miralax against physician orders, while another left medication unattended with a resident and documented a pain scale without asking the resident. These actions violated the facility's medication pass policy.
The facility failed to maintain accurate records for controlled substances, as staff did not consistently sign the Shift Count pages at shift changes. This issue was observed across multiple units, with instances of staff either failing to sign or pre-signing the narcotic books, contrary to facility policy. The deficiency was confirmed by staff and discussed with the DON.
Expired medications were found on the Sebago unit medication cart, including Naproxen Sodium, Vitamin D, and Oyster Shell Calcium, which were past their expiration dates. These were confirmed and removed by a nurse. Additionally, an unlocked and unattended medication cart was observed on the Eagle unit, with residents nearby. A surveyor intervened to alert a nurse about the unsecured cart. Both issues were discussed with the DON.
The facility's kitchen was found to be unsanitary, with undated and unlabeled meat, stained ceiling tiles, and dirty equipment, including an ice machine, food slicer, and mixer. These issues were confirmed by staff and the Administrator.
The facility was found to have several maintenance and cleanliness issues, including dust and debris on laundry dryers, a broken closet door hinge, a protruding cable outlet, stained ceilings, a red liquid stain on an air handling unit, and dead bugs on light covers. These deficiencies were confirmed by the facility's Administrator and other staff during a survey.
A facility failed to limit a PRN order for Lorazepam to 14 days, as required by regulations. A resident had a PRN order for Lorazepam 0.5 mg for anxiety, prescribed for 3 months without a 14-day limit or supporting documentation for the extended duration. This deficiency was identified during a surveyor's review and discussed with the Administrator.
A facility failed to accurately document the removal of a Lidocaine patch for a resident. A physician's order required the patch to be applied daily and removed nightly. However, a surveyor observed a nurse applying a new patch without removing the old one, which should have been removed the previous evening. This was confirmed by the nurse and discussed with the DON and Regional Director of Clinical Operations.
A registered nurse on the Eagle unit failed to perform hand hygiene between administering medications to multiple residents. The nurse handled medications for three residents consecutively without sanitizing her hands, citing the absence of hand sanitizer on the medication cart when questioned by a surveyor.
The facility failed to conduct annual performance evaluations for CNAs as required. Two CNAs, one hired in 2021 and another in 2009, did not receive their annual evaluations. The employee file for the CNA hired in 2021 showed an annual review signed only by the Division Head, with no employee signature, and lacked any annual review since hire. Both CNAs confirmed they had not received an annual review since being hired. This was confirmed with the Regional Director of Operations.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Facility Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to adequately maintain the building in good repair and sanitary condition across 4 of 4 units, including Passport, LTC both Long Hall and Short Hall, Eagle, and Sebago. Surveyors observed missing tiles in the Whirlpool room near the Sebago and Eagle units, multiple areas of frayed and dirty carpeting throughout the facility, and marred walls in the Eagle Unit Dining Room. Additional observations included a marred wall in room [ROOM NUMBER]A, a hand sanitizer dispenser missing its cover in room [ROOM NUMBER], and a wall heater in room [ROOM NUMBER]A missing its cover with exposed components and unpainted sheet rock. During later rounds with the Administrator, surveyors confirmed badly worn and stained carpeting in both hallways, a nonworking overbed light and a hole in the bathroom wall in room [ROOM NUMBER]A, a stained divider curtain in room [ROOM NUMBER], a urinal and bed pan left on the bathroom floor behind the toilet in room [ROOM NUMBER], a night stand door that could not be closed because of a broken hinge in room [ROOM NUMBER], heavy dust on a TV arm in room [ROOM NUMBER], a nonworking overbed light in room 105A, and tape on the ceiling in the Common Dining Room with a torn ceiling tile in front of the clock.
Failure to Hold Required IDT Care Plan Meetings
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team, including resident and/or representative participation to the extent possible, after required assessments for 3 of 24 residents reviewed. Resident #7 had a Quarterly MDS dated 1/14/26, but the clinical record lacked evidence that an IDT meeting was held within 7 days of completion of that assessment. Resident #66 had a Quarterly MDS dated 12/30/25, and the record also lacked evidence of an IDT meeting within 7 days of completion of the quarterly assessment. Resident #68 stated during interview on 3/2/26 that he/she had not met with the care team and had concerns to bring to them; the record contained an annual MDS dated 2/11/26, quarterly MDSs dated 8/13/25 and 5/13/25, and an admission MDS, but lacked evidence that IDT meetings were held within 7 days of completion of those assessments. The Regional Director of Operations and the social worker confirmed that the meetings were not held within the required timeframe.
Broken Floor Heaters Exposed Piping and Sharp Metal Fins
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards related to broken floor heaters. On 3/2/26 at 10:15 a.m., floor radiators were observed missing coverings, exposing piping and sharp metal fins in rooms [ROOM NUMBER]. This was confirmed with the Maintenance Director at 10:37 a.m. On 3/3/26 at 7:02 a.m., a broken radiator exposing piping and sharp metal fins was also observed in the TV room on the Passport Unit, and this was observed with the Director of Clinical Operations.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of all residents in the facility. Review of the Payroll Based Journal staffing report showed the facility triggered for Excessively Low Weekend Staffing during the fourth quarter 4, covering July 1, 2025 through September 30, 2025. During review of weekend staffing with the Facility Administrator, it was confirmed that the facility did not have enough staff to meet resident needs on the shifts when staffing was short. The deficiency was identified based on record review and interview and was noted to affect all residents needing assistance with ADLs.
Incomplete Controlled Substance Shift Count Documentation
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to allow an accurate reconciliation. Record review showed that controlled substance shift counts were expected at each change of shift, approximately three times per day, but the required documentation was incomplete on multiple medication cart narcotic bound books. On Eagle unit, Passport unit, Short Hall, and Kitchen Hall, the person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty did not sign the Shift Count page confirming the controlled substance count on numerous dates across the reviewed books. The missing signatures were identified in Controlled Substance Book #2 on Eagle unit, Book #8 on Passport unit, Book #5 on Short Hall, and Book #5 on Kitchen Hall. During an interview on 3/3/26 at 8:46 a.m., the Regional Director of Clinical Operations confirmed the findings.
Expired and Undated Medications Found in Multiple Storage Areas
Penalty
Summary
Drugs and biologicals were not consistently labeled, dated, or removed from use when expired in multiple medication storage areas. During observation of the Sebago medication room with an RN, expired Lactaid tablets, Vitamin B6 tablets, and Aspirin 325 mg were found available for use. In the Eagle unit medication cart, expired Naproxen 220 mg tablets were present, along with opened and undated Lantus Solostar pens and an opened and undated Novolog insulin pen, despite manufacturer instructions requiring dating and timely disposal after opening. In the Passport medication cart, an opened and undated Tresiba flex pen was available for use, and in the Kitchen Hall medication cart, an opened bottle of Naproxen Sodium 220 mg tablets with an expired date was observed. A review of the facility's Pixis machine also identified expired medications available for use, including Amiodarone 200 mg tablets, Cefepime 1 gram for injection, fentanyl 25 mcg patches, and Ropinirole 1 mg tablets. These findings were observed by the surveyor with facility staff present, including RNs, an LPN, and a CNA-M, and were discussed with the Regional Director of Clinical Operations.
Infection Control Failures With EBP, PPE Use, and Urinal Storage
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent cross contamination and infection development for residents requiring Enhanced Barrier Precautions (EBP), including residents with indwelling medical devices. On 3/2/26, Resident #7 was observed in his/her room with an indwelling catheter, and there was no evidence of appropriate EBP signage. On 3/2/26, Resident #73 was interviewed and stated he/she had a catheter; the surveyor observed no EBP signage posted in the room at 8:25 a.m. and again at 11:38 a.m. The Infection Preventionist confirmed there was no signage and stated there should be. The facility policy reviewed on 3/2/26 stated EBP applies to residents with indwelling medical devices and requires gown and glove use for certain high-contact care activities. The facility also failed to use correct PPE during tracheostomy care and failed to properly label and store urinal collection devices. On 3/3/26, an LPN performed routine tracheostomy care for Resident #9, who had diagnoses including stroke, persistent vegetative state, chronic respiratory failure with hypoxia, and tracheostomy; the LPN wore a disposable gown and gloves but did not wear face protection during the procedure. The resident’s record showed a December 2025 sputum culture with MDROs including ESBL Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Also on 3/3/26, two unlabeled urinals were observed hanging on the side rail by the toilet in the Passport Unit shower room, and the Director of Clinical Operations confirmed the observation.
Call Bell Not Kept Within Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not keeping the resident's call bell within reach. Resident #59 was observed on 3/2/26 lying in bed with the call bell wrapped around the bed rail facing outside the bed rail, making it unreachable. During an interview shortly after the observation, CNA #5 confirmed the resident could not reach the call bell. The same resident was again observed on 3/3/26 lying in bed with the call bell on the floor and not within reach. RN #1 later confirmed this finding during an interview with the surveyor.
Respiratory Care and Oxygen Care Plan Not Followed
Penalty
Summary
The facility failed to provide respiratory care as ordered for one resident with COPD and failed to keep the plan of care updated for oxygen therapy. On 3/2/26 at 7:47 a.m., the resident was observed receiving oxygen via nasal cannula with the concentrator set at 1.5 LPM, and the resident stated he/she uses oxygen all the time but was not sure what the LPM should be set at. The medical record showed a current provider order dated 5/10/25 for oxygen at 2 liters per minute continuously every shift for shortness of breath. Review of the oxygen saturation documentation for 3/1/26 stated the resident's oxygen saturation was 94% on room air and that the resident was not utilizing oxygen as ordered. The care plan for COPD, initiated on 3/13/24 with a target date of 5/24/26, instructed nursing staff that oxygen settings were O2 via nasal cannula at 1-2 liters as needed to maintain oxygen saturation at or above 90% and noted the resident had intermittent oxygen therapy related to ineffective gas exchange secondary to COPD. On 3/3/26 at 9:10 a.m., the surveyor and RN observed the resident again receiving oxygen at 1.5 LPM, and the RN reviewed the order and confirmed the resident should have 2 LPM, stating, "I'm gonna bump it up. I believe (he's/she's) always been on 2, even when (he/she) was up front." The Regional Director of Clinical Operations later reviewed the findings and confirmed the care plan was not revised to reflect the current oxygen order.
Missing Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete an annual performance evaluation, at least every 12 months, for 1 of 5 sampled employees, CNA #4. CNA #4 was hired in December 2023, and the employee file lacked evidence of a completed annual performance evaluation for 2025. During an interview on 3/4/26 at 9:12 a.m., the Director of Clinical Operations confirmed that CNA #4 did not have an annual performance evaluation in 2025.
Missing Required Annual CNA Training
Penalty
Summary
The facility failed to monitor and ensure that one CNA attended the mandatory yearly dementia, abuse and neglect, and resident rights training for 2025. A surveyor reviewed CNA #2’s employee file and found that the in-service/attendance record lacked evidence of the required annual training. CNA #2 was hired in February 2021, and the missing training was confirmed during an interview with the Director of Clinical Operations.
Failure to Accurately Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess, coordinate care with a physician, and document a resident’s pressure-related wound. A nursing admission/readmission evaluation completed on the day of admission in November 2025 identified a skin issue on the resident’s left buttock that was described as pressure related. Daily Skilled Note/Evaluation entries on 11/30/25 and 12/7/25 documented that the resident’s skin was not intact and that there was a pressure ulcer on the left buttock. However, multiple subsequent Daily Skilled Note/Evaluation entries dated between 12/2/25 and 1/1/25 stated that the resident’s skin was intact, and a skin check note on 1/5/26 at 11:02 a.m. documented that no skin issues were identified. On 1/5/25 at 2:06 p.m., a skin issue note documented that the resident had a stage 3 pressure ulcer/injury with full thickness skin loss. In an interview on 1/6/26, the Director of Nursing Services confirmed, in the presence of two surveyors, that the pressure ulcer had been present upon admission, was never thoroughly assessed, was not reported to a physician, and was not cared for appropriately.
Failure to Notify Physician and Care Plan for Existing Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician, obtain physician orders, and implement a care plan for a resident admitted with a pressure-related skin issue. On admission in November 2025, the Nursing Admission/Readmission Evaluation documented that the resident had a pressure-related skin issue on the left buttock. Subsequent Daily Skilled Notes/Evaluations dated 11/30/25 and 12/7/25 indicated that the resident was receiving daily skilled care for pressure ulcer care and rehab services, and that the skin was not intact with a pressure ulcer on the left buttock. Despite this, there is no documentation in the report that a physician was notified, that specific physician orders were obtained for this existing pressure ulcer, or that an individualized care plan addressing this pressure ulcer was implemented upon admission as required by facility policy. On 1/5/26, a wound care nursing note documented a new skin issue on the left sacrum, identified as a Stage 3 pressure ulcer with full-thickness skin loss that was acquired in-house. During an interview on 1/6/25, the Wound Care Nurse stated that a CNA first brought concerns about a wound on the resident’s buttocks to his attention on 1/5/26, and that this was the first time he had heard of this wound. The facility’s Pressure Injury Prevention Management Program policy requires that, based on the resident evaluation process, an individualized comprehensive care plan be implemented by the interdisciplinary team, including a preventive care plan upon admission and a care plan for any actual pressure injury identified on admission/readmission. The Director of Nursing Services confirmed the above information during an interview, supporting the finding that the facility did not follow its policy to ensure appropriate physician notification, orders, and care planning for the resident’s pressure ulcer present on admission.
Incomplete Documentation of JP Drain Monitoring in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with a physician’s order to monitor a Jackson Pratt (JP) drain every shift starting on 11/22/25. Review of the resident’s clinical record confirmed the standing order to monitor the JP drain each shift for prophylaxis. However, review of the Treatment Administration Record (TAR) for December showed missing documentation of the ordered JP drain monitoring on the 3 p.m. to 11 p.m. shift for 12/30/25, and on the 11 p.m. to 7 a.m. shifts for 12/1/25, 12/3/25, 12/10/25, 12/14/25, 12/15/25, 12/16/25, and 12/22/25. These gaps in the TAR indicate that the required monitoring was not documented as completed on multiple shifts. In an interview on 1/6/25 at 1:48 p.m. with the Director of Nursing Services and two surveyors present, the missing documentation findings were confirmed. The incomplete TAR entries for the JP drain monitoring demonstrate that the facility did not ensure the resident’s clinical record was complete and accurate in accordance with accepted professional standards, as required for safeguarding and maintaining resident-identifiable medical records.
Repeat Deficiencies in Wound Care Management and Clinical Record Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective quality assurance and performance improvement (QAPI/QAA) oversight of wound care and clinical record accuracy, resulting in repeat deficiencies. During a prior recertification survey, deficiencies were cited for quality of care related to wound care for two of three residents reviewed, and for incomplete and inaccurate clinical records for two of three residents reviewed for wound care. Despite having a written plan and a stated completion date, the facility’s quality assurance committee did not ensure that these issues were effectively corrected, as the same areas of noncompliance were identified again during a subsequent complaint survey. During the complaint survey, a resident was found to have had a pressure ulcer upon admission, with no physician orders for care and treatment of the wound documented in the clinical record, demonstrating a continued failure in quality of care for pressure ulcers. In addition, another resident’s clinical record lacked complete and accurate information related to wound care, showing that the facility did not maintain accurate, identifiable clinical records as previously cited. At the exit interview, the Administrator and DNS acknowledged that the facility’s prior plan of correction for these areas had not been effective, and that deficient practices persisted beyond the anticipated date of compliance.
Failure to Develop Baseline Care Plan for Resident With Pressure-Related Skin Issue
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included necessary instructions for wound care for one resident. The resident was admitted in November 2025, and the Nursing Admission/Readmission Evaluation completed on the day of admission documented a pressure-related skin issue on the left buttock. Despite this identified pressure-related skin issue, review of the resident’s medical record showed no evidence of a baseline care plan addressing this condition or providing the instructions needed to properly care for it. On 1/6/25 at 2:15 p.m., the Director of Nursing Services confirmed to surveyors that the above information was accurate. This deficiency centers on the absence of a required baseline care plan for a newly admitted resident with a documented pressure-related skin issue, as confirmed through record review and interview with facility leadership.
Failure to Develop Care Plans for Residents Requiring Wound Care
Penalty
Summary
The facility failed to develop and implement care plans for two residents who required wound care. One resident had a chronic abscess on the right lateral thigh, returned from the emergency room with new antibiotic orders for cellulitis, and required wound packing to remain in place for 48-72 hours. Despite these needs, there was no evidence of a care plan addressing the wound, including goals and interventions, as of the date reviewed. Another resident had a wound on the left foot and an unstageable pressure ulcer on the right foot, both requiring wound care, but similarly lacked a documented care plan with goals and interventions. These findings were confirmed through record review and interviews with the Director of Nursing and the Director of Clinical Operations.
Failure to Obtain and Document Physician Orders for Wound Care
Penalty
Summary
The facility failed to obtain and document physician orders for wound care for two residents with significant wounds. For one resident with a chronic right lateral thigh abscess, the clinical record showed that after returning from the emergency room with instructions for wound packing and antibiotics, there was no evidence of wound care orders or documentation of wound care provided from the date of return until nearly two weeks later. Nursing staff acknowledged having the ER discharge summary but were unable to locate it in the medical record, and could not provide documentation of wound care orders or provider instructions during this period, except for a single wound assessment. For another resident requiring negative pressure wound therapy (NPWT), a malfunction in the wound vac led to the wound being packed with VASHE-soaked gauze. Although nursing staff reported obtaining a verbal order from the provider for this alternative dressing, there was no documentation of such an order in the resident's medical record. These lapses resulted in the absence of required provider orders for wound care interventions as specified in the residents' care plans and clinical needs.
Incomplete Documentation of Wound Care in Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents who were receiving wound care. For one resident, the Treatment Administration Record (TAR) did not show evidence that wound vac dressings were changed as ordered on specific dates, despite physician orders specifying the frequency and timing of these changes. For another resident, the TAR lacked documentation that wound care for both the right heel and left foot was completed on several dates, even though there were clear orders for daily wound care and dressing changes. These deficiencies were identified through review of medical records and confirmed in discussion with the Director of Nursing and the Director of Clinical Operations.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of quality in medication administration for two residents. In the first instance, a registered nurse (RN) did not administer Miralax to a resident as per the physician's order, which specified that the medication should be given in the morning. The RN decided to delay the administration until the afternoon without the resident having refused the medication at the scheduled time. This deviation from the prescribed schedule was not based on the resident's immediate needs or preferences at the time of administration. In the second instance, another RN left a medication cup with a resident without observing the resident take the medication, which is against the facility's policy. Additionally, the RN documented a pain scale for the resident without first asking the resident about their pain level. The RN later corrected the documentation after realizing the error. These actions demonstrate a failure to follow the facility's medication pass policy and proper documentation procedures, potentially compromising the quality of care provided to the residents.
Failure to Maintain Accurate Controlled Substances Records
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, as evidenced by the lack of signatures from authorized personnel on the Shift Count pages of the Controlled Substances Book. This deficiency was observed across multiple units, including the Sebago Unit, Eagle Unit, Short Hall, Kitchen Hall, and Passport Unit, during the period from September 25, 2024, to December 3, 2024. The facility's policy requires that two licensed clinicians conduct a physical inventory of controlled medications at each shift change and document it on an audit record. However, the surveyor found that on several occasions, the licensed nursing staff either coming on duty or going off duty failed to sign the Shift Count page, indicating that the controlled substances count was not properly documented. Specific instances of non-compliance were noted, such as RN #2 and RN #1 failing to sign the shift count book upon accepting the narcotic keys, and LPN #1 pre-signing the nurse going off duty before the end of her shift. These actions were confirmed by the respective staff members during the surveyor's review. The Director of Nursing was informed of these concerns, highlighting a systemic issue in the facility's process for managing controlled substances, which could potentially lead to discrepancies in drug reconciliation.
Expired and Unsecured Medications Found in Facility
Penalty
Summary
The facility failed to remove expired medications from the supply available for use on the Sebago unit medication cart. During an observation, a registered nurse confirmed the presence of expired medications, including Naproxen Sodium, Vitamin D, and Oyster Shell Calcium, which were past their expiration dates of July, November, and October 2024, respectively. These expired medications were subsequently removed by the nurse. Additionally, on the Eagle unit, a medication cart was found unlocked and unattended in the hallway for approximately two minutes, with residents nearby. A surveyor intervened to alert a registered nurse about the unsecured cart. Both incidents were discussed with the Director of Nursing.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. On December 2, 2024, a surveyor noted two trays of meat in the walk-in refrigerator that were undated and unlabeled, along with seventeen ceiling tiles that were stained or dirty. A staff member, who has been with the facility for several years, confirmed that the ceiling had not been addressed during her tenure. On December 4, 2024, further observations revealed a moderate level of dirt on the inside lid of an ice machine in the Passport Unit kitchen, a small amount of dried debris on a food slicer, and a moderate amount of dried dirt and debris on a large mixer. These findings were confirmed with the Administrator.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several maintenance and cleanliness issues observed during a survey. On December 4, 2024, a surveyor noted a significant accumulation of dust and debris on top of all dryers in the laundry area, which was confirmed by the Director of Maintenance. Further environmental rounds with the Administrator, Director of Maintenance, and Director of Housekeeping revealed additional deficiencies: a closet door hinge in need of repair, a cable outlet protruding from the wall, stained ceilings in the Cafe Sun Room and entry, a red liquid stain on the air handling unit near the Nurses Station, four stained ceiling tiles in the Eagle Unit Dining Room, and dead bugs on light covers in the Sebago Unit hallway. These observations were confirmed with the Administrator.
Non-compliance with PRN Psychotropic Medication Order Limits
Penalty
Summary
The facility failed to ensure compliance with the regulation that limits as needed (PRN) psychotropic medication orders to 14 days. During a review of a resident's physician orders, a surveyor identified an order for Lorazepam, a psychotropic medication, prescribed at 0.5 mg by mouth every 24 hours as needed for anxiety. This order, dated November 18, 2024, was set for a duration of 3 months without a 14-day limit or stop date. Additionally, there was no provider documentation justifying the extension of the PRN order beyond the 14-day limit. This deficiency was noted during a surveyor's review on December 3, 2024, and discussed with the facility's Administrator.
Failure to Remove and Document Lidocaine Patch
Penalty
Summary
The facility failed to ensure accurate documentation of the Medication Administration Record (MAR) for a resident receiving a Lidocaine patch. A physician's order dated December 1, 2024, instructed nursing staff to apply a 5% Lidocaine patch to the affected area once daily for pain and to remove it nightly. However, on the morning of December 3, 2024, a surveyor observed a registered nurse administering a new Lidocaine patch to the resident's lower back without having removed the old patch from the previous day. The nurse confirmed that the old patch should have been removed the previous evening, indicating a lapse in following the physician's order and proper documentation in the MAR. This issue was discussed with the Director of Nursing and the Regional Director of Clinical Operations.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
During a medication administration observation on the Eagle unit, a registered nurse failed to perform proper hand hygiene between administering medications to multiple residents. The nurse prepared and administered medications to three residents consecutively without sanitizing her hands between each administration. This lapse in protocol was noted when the nurse discarded used medicine and drink cups and continued to handle medications for the next resident without using hand sanitizer. Upon intervention by the surveyor, the nurse acknowledged the oversight and mentioned the absence of hand sanitizer on the medication cart.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to conduct annual performance evaluations for Certified Nursing Assistants (CNAs) at least every 12 months, as required. Specifically, two CNAs with employment durations exceeding one year did not receive their annual evaluations. CNA #1, hired on February 17, 2021, had an employee file that showed an annual review filled out and signed only by the Division Head, with no evidence of the employee's signature, and lacked any annual review since the date of hire. CNA #1 confirmed during a phone interview that they had not received an annual review since being hired. Similarly, CNA #2, hired on July 13, 2009, had no evidence of an annual review in their employee file since their date of hire. CNA #2 also confirmed in an interview that they had not received an annual review since being hired. This information was confirmed with the Regional Director of Operations.
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 209 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Yarmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coastal Manor | 1.1 mi | ★★★★★ | 36 | 0 |
| Sedgewood Commons | 3.9 mi | ★★★★★ | 0 | 0 |
| Hawthorne House | 4 mi | ★★★★★ | 1 | 0 |
| Fallbrook Commons | 7.5 mi | ★★★★★ | 0 | 0 |
| Cedars Nursing Care Center | 7.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.