Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 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.
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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.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seaside Healthcare Llc | 0.6 mi | ★★★★★ | 13 | 0 |
| Fallbrook Commons | 1.2 mi | ★★★★★ | 0 | 0 |
| Barron Center | 3.1 mi | ★★★★★ | 34 | 0 |
| Pinnacle Health & Rehab At South Portland | 3.9 mi | ★★★★★ | 36 | 0 |
| Sedgewood Commons | 4 mi | ★★★★★ | 0 | 0 |
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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.