Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Odd Fellows Health Care Center during CMS and state inspections, most recent first.
A resident with severe dementia and agitation had a PRN order for Seroquel 25 mg twice daily that was written without a stop date and remained in effect beyond the required 14‑day limit. Record review showed no documented clinical rationale to support continuation of this PRN antipsychotic beyond 14 days or to justify an extended time frame, and the DON confirmed that the order did not meet the 14‑day requirement.
Surveyors found that the facility failed to develop, update, and implement accurate care plans for multiple residents. Two residents were repeatedly transferred by CNAs using manual stand-pivot techniques under the arms, despite existing ADL care plans and CNA assignment sheets requiring use of a mechanical lift, sit-to-stand device, or specified assistive equipment and staffing levels. In addition, a resident receiving hospice/palliative care had no corresponding hospice or palliative care plan or interventions in place, and another resident who was always incontinent of bowel and bladder per the MDS had no care plan addressing incontinence. The DON confirmed that these care plans did not reflect the residents’ current needs.
A resident with cerebral palsy and a documented need for extensive ADL assistance, including an oral care routine, was observed on multiple occasions with a white, thick coating at the gum line and reported not receiving staff help with tooth brushing. Review of CNA records showed no documentation of personal hygiene care, and an LPN stated that after a switch to an online documentation system, personal hygiene items were not added for CNAs to record care or assistance levels, resulting in a lack of documented oral hygiene services.
Surveyors found that the facility failed to remove expired medications and biologicals from active stock in both a medication cart and the medication room. During an observation with an LPN, multiple opened and unopened products, including ibuprofen, aspirin, calcium carbonate, vitamin D, vitamin B complex, multivitamins, a Fleets enema, and bisacodyl suppositories, were noted with past expiration dates yet remained stored as available for use in the cart, medication room, and medication refrigerator. These findings were discussed with the DON.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen and did not follow its own policies for food labeling, dating, and dish machine temperature monitoring. During a kitchen tour with the FSD, dust and dirt were observed on metal ductwork above food prep areas, food debris and trash were present on floors under equipment and shelving, and dried food residue was found on the cook stove, a solid floor pad with chipped paint, a food mixer, a food processor and its table, and a dish room food disposal unit, along with a heavily soiled wall-mounted fan. In the reach-in refrigerator, pizza dough and multiple bags of whipped topping were unlabeled and undated, and in the walk-in freezer, large bags of popcorn chicken were also unlabeled and undated, despite policies requiring labeling, dating, and disposal of expired items, and documentation of daily dish machine temperatures.
A resident receiving Duloxetine for alcohol abuse and Trazodone for anxiety-related behaviors had psychoactive medications administered without documented informed consent. Physician orders directed routine and PRN dosing, but the medical record contained no evidence that the resident or representative was informed of the risks and benefits of these treatments or that consent was obtained. The Administrator and DON confirmed the absence of this documentation during surveyor interviews.
Surveyors found that housekeeping and maintenance services were inadequate to maintain sanitary, orderly, and comfortable conditions on two wings, a hallway, and the laundry room. Observations included stained ceiling tiles, chipped and missing paint on baseboard and wall heaters creating uncleanable surfaces, a dining room television stand with missing sealant exposing untreated wood, and a dusty floor fan. In a resident room, surveyors noted dirty, yellow-stained caulking around the toilet base, a dirty glove and soiled towel on the floor under the sink, and a baseboard heater with chipped paint. In the laundry room, the painted cement floor and metal floor drain cover had chipped paint, the drain cover was heavily rusted, and multiple ceiling tiles were stained, all of which were confirmed by the Administrator and Maintenance Director during the tour.
The facility failed to implement and support an effective infection prevention and control program when a resident on contact precautions for ESBL in the urine was cared for by an LPN who entered and exited the room to administer medications without donning required PPE, despite posted instructions and available supplies. Staff interviews revealed misunderstanding of when gowns and gloves were required and lack of familiarity with EBP, with a CNA stating the facility does not use EBP and that PPE is not needed if direct care is not provided. Review of the infection control manual showed no written EBP policies, and the DON acknowledged she had assumed EBP were in place but was unaware they were not included in the manual.
The facility did not ensure that a qualified Infection Preventionist (IP) was in place to oversee the infection prevention and control program. After the previous IP left, another staff member was asked to assume the IP role without having completed the required infection prevention training. Documentation showed that this staff member did not finish the necessary training until several weeks later, and the facility could not provide evidence of required training prior to the staff member taking on IP responsibilities. This lapse had the potential to affect all residents.
The facility failed to maintain and post current daily nurse staffing information. On two separate survey days, the only posted staffing data was more than a month old, and it did not reflect the current day’s breakdown of RNs and LPNs responsible for direct resident care or the shifts covered. The DON confirmed that there was no current staffing posting available at the time of the survey.
The facility failed to maintain an effective infection control program, as staff did not consistently use or provide PPE, did not implement or document transmission-based precautions during a GI illness outbreak, and did not maintain comprehensive infection surveillance records. The Legionella water management policy was incomplete, and there were additional lapses such as a nurse administering eye drops without gloves and facility cats being allowed on food preparation and dining surfaces without proper cleaning.
The facility did not assign a qualified staff member to serve as a dedicated Infection Preventionist (IP) for at least 24 hours per week. Instead, the DON was performing both her full-time duties and the IP role, despite having completed IP training, and was unaware that both roles could not be held simultaneously.
Surveyors found that the facility did not include necessary goals and interventions in the care plans for residents with COPD, congestive heart failure, cardiac pacemaker, and those requiring pain management. Despite updated care plans and active medication orders, the plans lacked documentation addressing these specific medical needs, as confirmed by nursing leadership.
A resident who required substantial assistance with personal hygiene was repeatedly observed over several days with a pinky ring coated in white dried debris, despite receiving help from CNAs. Assessment and documentation confirmed the resident's dependence on staff for personal hygiene, but the issue persisted and was noted by surveyors.
The facility did not ensure that staff maintained current CPR certification as required by its own policy, resulting in multiple shifts where no certified personnel were present. Interviews with the DON and ADON confirmed that only nurses were required to be certified, and staffing records showed repeated gaps in coverage. Four residents were identified as Full Code and could require CPR, while all residents were at risk for choking.
Two residents requiring continuous oxygen therapy were observed using nasal cannulas and tubing that were either discolored, undated, or not changed according to the facility's policy, which requires tubing changes every two weeks. Documentation and staff interviews confirmed that tubing was being changed monthly instead, resulting in a failure to maintain a sanitary environment and adhere to infection control procedures.
Surveyors found that medications were not properly labeled, dated, or disposed of according to manufacturer instructions. An LPN was observed with an opened, unlabeled vial of Tuberculin Purified Protein Derivative in the medication room refrigerator, and two opened bottles of Lumigan eye drops with different expiration dates in the medication cart. Additionally, a medicine cup containing a pill for the facility's house cat and the cat's Phenobarbital tablets were stored with resident medications, contrary to policy.
Surveyors found the kitchen and food service areas to be unsanitary, with dirty floors, walls, and equipment, and observed staff failing to wear required hair and beard coverings or perform proper hand hygiene while serving and preparing food. These deficiencies were confirmed by facility leadership and were not in accordance with facility policy.
Surveyors found that clinical records were incomplete and inaccurate for two residents. An LPN documented daily application and removal of a resident's hearing aids in the MAR, but admitted this was not done unless requested by family, contrary to physician orders. Additionally, ADL documentation for another resident was missing for several days. These issues were confirmed through interviews, observations, and record reviews.
Four residents did not have documentation showing they received, were offered, or refused the pneumococcal vaccine as required by facility policy. The ADON confirmed that assessments and vaccine offers had not occurred due to the absence of a clinic, despite policy requiring timely assessment and offering of the vaccine upon admission.
A review of CNA employee education records showed that several CNAs did not complete the required 12 hours of annual in-service education or the mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. The DON confirmed the lack of documentation for these trainings.
A resident's MDS assessments were not accurately coded to reflect their active diagnoses of HTN, hyperlipidemia, and diabetes. Review of the medical record and interview with the DON confirmed that these conditions were omitted from the Active Diagnosis section of the MDS.
A resident with a documented history of PTSD was not assessed for trauma triggers, and their care plan lacked trauma-informed interventions. The facility's staff confirmed that no assessment for PTSD or trauma-informed care was conducted.
Staff did not consistently ensure resident dignity during care, as evidenced by multiple residents being observed with their incontinence briefs exposed or not fully dressed during daily activities such as ambulation and meals. Some staff acknowledged the lapses but did not take immediate action to address them, and at least one resident expressed discomfort with the situation.
Noncompliant PRN Antipsychotic Order Exceeding 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a PRN psychotropic medication order complied with the required 14‑day limit. Record review on 2/17/26 showed that Resident #9, who had severe dementia with agitation, had a current physician order dated 1/19/26 for Seroquel 25 mg twice daily PRN for agitation, with no stop date. The medical record did not contain documentation of clinical rationale to support continuation of this PRN antipsychotic medication beyond the 14‑day period or to justify an extended time frame. In an interview on 2/17/26 at 2:20 p.m., the Director of Nursing confirmed that the PRN Seroquel order initiated on 1/19/26 did not meet the required 14‑day limit. This lack of a stop date and absence of documented clinical justification for extending the PRN psychotropic medication order led to the cited deficiency for unnecessary medications for 1 of 5 residents reviewed.
Failure to Develop and Implement Accurate Care Plans for Transfers, Incontinence, and Hospice Care
Penalty
Summary
The deficiency involves the facility’s failure to develop, update, and implement comprehensive care plans that accurately reflected residents’ transfer, incontinence, and hospice/palliative care needs. For one resident, surveyors observed CNAs transferring the resident between a wheelchair and recliner by lifting under the arms and performing a pivot transfer, with one CNA needing to grab the resident’s pants to assist with weight support. The resident’s ADL care plan stated the resident may use a hemi-walker to transfer and may use a stand/pivot lift when weak, and the falls care plan indicated use of a hemi-walker and stand/pivot lift as needed. The current CNA assignment sheet listed the resident as a sit-to-stand transfer, but CNAs reported using 1–2 person stand-pivot transfers, sometimes with a walker and sometimes without a sit-to-stand lift, indicating that the care plan and assignment sheet were not being followed or consistently implemented. Another resident, admitted in January 2026, was repeatedly observed being transferred by CNAs using a manual pivot transfer under the arms from wheelchair to recliner and from bed to wheelchair, despite the ADL care plan requiring a mechanical lift with two staff assistance for transfers and the CNA assignment sheet listing the resident as a two-assist with walker. The facility also failed to develop care plans for specific clinical conditions identified in residents’ assessments. One resident’s quarterly MDS documented that the resident was receiving hospice care, and the medical record showed the resident had started palliative care on 1/16/26, yet as of 2/17/26 there was no evidence of a care plan or interventions addressing palliative care needs; the DON confirmed the care plan did not reflect this resident’s current needs. Another resident’s annual MDS indicated the resident was always incontinent of bowel and bladder, but as of 2/17/26 there was no care plan or interventions addressing bowel and bladder incontinence, and the DON similarly confirmed that the care plan did not reflect the resident’s current needs.
Failure to Provide and Document Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate ADL care in the area of personal hygiene, specifically oral care, for one resident over two days of survey. On two separate observations, the resident’s teeth were noted to have a visible white, thick coating at the gum line. The resident, who has a self-care deficit related to cerebral palsy and is care planned to need extensive assistance with ADLs, including set-up with a basin each morning and assistance as needed, stated that staff do not help with tooth brushing and that the resident performs this independently. The resident’s care plan also included an intervention for an oral care routine to brush teeth. Review of CNA documentation for the month showed no evidence that personal hygiene care was being completed. During an interview, an LPN reported being unable to locate documentation of personal hygiene and explained that the facility had recently transitioned to an online documentation system but failed to add personal hygiene items for CNAs to document the care provided and the level of assistance needed. This concern was subsequently discussed with the Director of Nursing.
Expired Medications and Biologicals Left Available for Use in Medication Cart and Room
Penalty
Summary
Surveyors identified a failure to ensure that medications and biologicals available for use were free of expired products during an observation of one medication cart and the medication storage room with an LPN. On the medication cart, surveyors observed an opened bottle of ibuprofen 200 mg tablets with an expiration date of 12/2025, an opened bottle of calcium carbonate 500 mg tablets with an expiration date of 1/2026, an opened bottle of aspirin 325 mg with an expiration date of 10/2025, and an opened bottle of vitamin D 10 mcg with an expiration date of 12/2025, all still available for use. In the medication storage room, surveyors found one Fleets enema with an expiration date of 8/2024, two bottles of aspirin 325 mg with expiration dates of 4/2025 and 5/2025, one bottle of calcium carbonate 500 mg tablets with an expiration date of 1/2026, one bottle of vitamin D 10 mcg with an expiration date of 11/2024, three bottles of vitamin B complex with expiration dates of 11/2025, and two bottles of multivitamins with expiration dates of 11/2025, all stored as available stock. The medication room refrigerator also contained one opened box of bisacodyl suppositories with an expiration date of 11/2025. These findings were discussed with the DON on the same day. The deficiency centers on the facility’s failure to remove expired medications and biologicals from active stock in both the medication cart and medication room, despite their continued availability for use as observed by surveyors.
Failure to Maintain Sanitary Kitchen Conditions and Proper Food Labeling/Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen in a clean and sanitary condition and to follow its own policies for labeling, dating, and monitoring food and dishwashing temperatures. During a kitchen tour with the Food Service Director, surveyors observed dust and dirt buildup on metal ductwork above food preparation areas, food debris and trash on the kitchen floor including under equipment and shelving, and dried food particles and liquid residue on the cook stove surfaces. The solid floor pad under the stove had chipped and missing paint, creating an uncleanable surface. Additional equipment, including a food mixer, a food processor and the table it sat on, and the dish room food disposal unit, had dried food particles and dried liquid residue. A wall-mounted fan in the dish room was heavily soiled with dust and dirt. Surveyors also found that the facility did not follow its Labeling & Dating Procedure and Temperature Log Policy. In the reach-in refrigerator, there was a large plastic container of pizza dough balls that was unlabeled and undated, and four bags of whipped topping without thaw dates, despite manufacturer directions that the product was good for two weeks after thawing. In the walk-in freezer, two large bags of popcorn chicken were unlabeled and undated. The facility’s policies required all items to be labeled and dated when opened or prepared, with expiration dates and disposal of expired items, and required dish machine temperatures to be reviewed and recorded on each shift. Daily dishwasher temperatures were not monitored or documented as required. The Food Service Director confirmed these findings during the surveyor interview.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to obtain informed consent for psychoactive medications for one resident. The resident was admitted in May 2025 and had physician orders dated 12/16/25 for Duloxetine HCl delayed-release capsules 60 mg once daily related to alcohol abuse, and for Trazodone HCl 50 mg, with instructions to give 0.5 tablet at bedtime and 0.5 tablet every 12 hours as needed for aggressive or "on edge" behavior related to an anxiety disorder. Review of the resident’s medical record showed no evidence that the resident or the resident’s representative had been informed of the risks and benefits of these psychoactive medications and no documentation that consent to treatment with these medications had been obtained. On 2/18/26 at 8:20 a.m., during an interview with a surveyor, the Administrator and the Director of Nursing confirmed that the medical record lacked documentation of informed consent and discussion of risks and benefits for the prescribed psychoactive medications.
Environmental and Housekeeping Deficiencies in Resident Care Areas and Laundry
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment during an environmental tour of the East and [NAME] Wings, an inter-unit hallway, and the laundry room. In the hallway between units, three ceiling tiles had brown stains and the baseboard heating unit had chipped and missing paint, creating uncleanable surfaces. On the [NAME] Wing, the wooden television stand in the dining room had missing surface sealant exposing untreated wood, the large standing floor fan in the corner was dusty and dirty, and in one resident room the caulking around the base of the toilet was yellowish and dirty, with a dirty glove and soiled towel on the floor under the sink and a baseboard heater with chipped and missing paint. On the East Wing, the solarium baseboard heater and the dining room wall heating unit also had chipped and missing paint, creating uncleanable surfaces. In the laundry room, the painted cement floor had chipped and missing paint in many areas, the large metal floor water drain cover had chipped and missing paint and was heavily rusted, and five ceiling tiles had brown stains, all contributing to uncleanable and unsanitary conditions. These conditions were observed by the surveyor during the tour and were confirmed in an interview with the Administrator and the Maintenance Director at the time of the survey.
Failure to Implement Contact Precautions and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to establish and implement written infection prevention and control policies and procedures consistent with nationally recognized guidelines, including Enhanced Barrier Precautions (EBP), and to prevent transmission of communicable diseases. A Contact Precautions sign was posted on the door of a resident’s room instructing staff to perform hand hygiene before entering and exiting, don gloves and gown prior to room entry, discard them before exiting, and use dedicated or disposable equipment with appropriate cleaning and disinfection of reusable equipment. A PPE cart was present outside the room. Despite these posted instructions, an LPN was observed entering the room to administer medication without donning any PPE and exiting the room without wearing a gown or gloves. When questioned, the LPN stated that the sign was for staff providing care and that she was only giving medication, acknowledged not wearing PPE, and described contact precautions as requiring gloves and gowns only when providing personal care for residents with colostomies or Foley catheters. She also stated she was not familiar with EBP. Further interviews showed inconsistent understanding and implementation of infection control practices among staff. A CNA reported having received infection control training, including contact precautions and EBP, but stated the facility does not utilize EBP and only uses contact precautions, and that gowns and gloves are not required if staff are not providing direct care. The resident in the room had a documented history of ESBL in the urine and required extensive assistance with activities of daily living, including personal care. Review of the facility’s Infection Control Manual, last updated in April 2025, showed no written policies or procedures addressing EBP. In an interview, the DON stated she assumed EBP were implemented in the facility and was unaware they were not included in the facility’s infection control manual.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to be responsible for the Infection Prevention and Control Program for the period from 8/8/25 to 8/29/25. During an interview on 2/18/26 at 1:57 p.m., the DON reported that the previous IP left employment on 8/7/25 and that another staff member was asked to assume the IP role starting 8/8/25. Review of training documentation showed that the newly designated IP did not complete the required infection prevention training until 8/29/25, and the facility could not provide any documentation that this individual had completed the required IP training before assuming responsibility for the Infection Prevention and Control Program. On 2/25/26 at 3:00 p.m., the Administrator confirmed these findings. This failure to have a qualified, trained individual in place as the IP during that time frame had the potential to affect all residents in the facility.
Failure to Maintain Current Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post the current daily nurse staffing information as required, including the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care, and the shifts to which those numbers corresponded. On two separate survey days, the only posted nurse staffing information available was dated more than a month earlier. On the first survey day at 8:36 a.m., the surveyor observed that the posted nurse staffing information was for 1/7/26. On the second survey day at 8:10 a.m., the surveyor again observed that the posted nurse staffing information was for 1/7/26. Later that morning, at 10:04 a.m., the DON confirmed to the surveyor that there was no current posting of the staffing.
Infection Control Program Deficiencies and Lapses in Policy Adherence
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple lapses in infection surveillance, implementation of transmission-based precautions, and adherence to established policies. During a gastrointestinal illness outbreak affecting both residents and staff, staff interviews revealed inconsistent use and availability of personal protective equipment (PPE), lack of transmission-based precaution signage, and failure to consistently isolate symptomatic individuals. Staff reported that gowns were not readily accessible on the units, and that residents with only diarrhea were not always kept in their rooms. Documentation of the outbreak was incomplete, with the infection preventionist unable to provide comprehensive tracking forms, line lists with symptom onset and resolution dates, or evidence of interventions taken. Medical records for affected residents lacked documentation of symptoms, physician or family notification, and implementation of precautions. The facility's Legionella Water Management Program was found to be inadequate, consisting only of a brief policy referencing bi-weekly water temperature checks without a detailed water system flow diagram, control measures, monitoring protocols, or documentation of testing results and corrective actions. When requested, the administrator was unable to provide additional documentation or evidence of a comprehensive water management plan, relying instead on city testing and a single-page policy. Additional infection control deficiencies were observed, including a nurse administering eye drops to a resident without wearing gloves, contrary to facility policy, and repeated observations of facility cats on kitchenette countertops and dining room tables. Staff acknowledged that cats frequently accessed these surfaces, which were not cleaned after each incident, despite the facility's pet policy requiring removal and disinfection when pets violate these boundaries. These lapses in infection control practices and policy adherence had the potential to affect all residents in the facility.
Lack of Dedicated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the Infection Preventionist (IP) responsible for the infection prevention and control program. During an interview, the Director of Nursing (DON) confirmed that she was functioning as both the full-time DON and the IP, despite having completed her IP training. The surveyor determined that the facility did not have a dedicated IP working at least 24 hours per week in that role, as required. The DON stated she was unaware that she could not fulfill both roles simultaneously, which resulted in the absence of a staff member dedicated to infection prevention and control.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Medical Needs
Penalty
Summary
Surveyors observed that the facility failed to develop and implement complete care plans addressing all identified needs for several residents. Specifically, one resident with COPD requiring continuous oxygen and peripheral neuropathy managed with Gabapentin did not have documented goals or interventions for COPD or pain management in their care plan, despite recent updates. Another resident with congestive heart failure, respiratory failure requiring continuous oxygen, and a cardiac pacemaker also lacked care plan goals and interventions for both heart failure and the presence of the pacemaker, even though regular pacemaker checks were ordered. Additionally, a third resident with an active order for Tramadol for pain management did not have any documented goals or interventions related to pain management in their care plan. These deficiencies were confirmed through observations, medical record reviews, and interviews with facility nursing leadership, indicating a failure to update and implement individualized care plans for residents with significant medical needs.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) in the area of personal hygiene for a resident who required substantial to maximal assistance. Over a three-day period, the resident was repeatedly observed with a pinky ring coated in white dried debris, despite being offered and receiving assistance with dressing and personal care. Documentation and assessment records confirmed the resident's need for significant help with personal hygiene, yet the issue with the soiled ring persisted across multiple observations by surveyors. The deficiency was discussed with facility leadership during the survey.
Failure to Maintain CPR Certification Among Staff
Penalty
Summary
The facility failed to ensure that all staff maintained current certification in cardiopulmonary resuscitation (CPR) for Healthcare Providers, as required by facility policy. During interviews, the DON and ADON stated that only nurses were required to have CPR certification, and a review of employee records confirmed that only two full-time and two per-diem staff members were CPR certified. Staffing records for the month of March revealed multiple shifts, including day, evening, and night shifts, where no staff members present held current CPR certification. The facility's own Cardiopulmonary Policy requires that key clinical staff, including non-licensed personnel, maintain CPR/BLS certification and that each shift have a designated CPR team consisting of at least one nurse, one LPN, and two CNAs, all with current certification. Despite this policy, there were numerous shifts with no certified staff available. At the time of the review, four out of twenty-four residents were identified as Full Code, meaning they could potentially require CPR, and all residents were noted to be at risk for choking.
Failure to Follow Oxygen Tubing Change Policy for Residents on Continuous Oxygen
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to its own policy regarding the frequency of oxygen tubing changes for two residents requiring continuous oxygen therapy. Observations revealed that one resident with COPD was using a nasal cannula with discolored prongs and undated tubing, despite a physician order and documentation indicating monthly tubing changes. The facility's policy, however, required oxygen tubing to be changed at least every two weeks. Another resident with congestive heart failure and respiratory failure was observed with an undated nasal cannula on one occasion and tubing dated nearly a month prior on another, also in contradiction to the facility's two-week change policy. Review of the Treatment Administration Records for both residents showed documentation of monthly tubing changes, which did not align with the facility's updated policy. During an interview, the Director of Nursing confirmed that oxygen tubing should be changed every two weeks as per policy, acknowledging the discrepancy between practice and policy. These findings demonstrate a failure to follow established infection control procedures related to respiratory care for residents requiring continuous oxygen supplementation.
Improper Medication Storage, Labeling, and Disposal
Penalty
Summary
Surveyors observed that the facility failed to properly label, date, and dispose of medications in accordance with manufacturer specifications and professional standards. In the medication room, an opened and unlabeled vial of Tuberculin Purified Protein Derivative was found in the refrigerator, despite manufacturer instructions to discard the vial 30 days after opening. On the medication cart, two opened bottles of Lumigan eye drops were present, one with an expiration date of 2024/08 and the other with an expiration date of 2025/02, and an unlabeled medicine cup containing a small white pill was also found. Further investigation revealed that the pill was medication intended for the facility's house cat, and the cat's Phenobarbital tablets were stored in a cabinet in the medication room. The LPN stated that it was the nurse's responsibility to administer the cat's medication, and the pill was left in the cart because the cat could not be located at the time. These findings indicate that expired and unlabeled medications were not removed from use, and non-resident medications were stored alongside resident medications.
Sanitation and Staff Hygiene Deficiencies in Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation and hygiene deficiencies in the facility's kitchen over a three-day period. The kitchen floor, walls, and dishwasher were found to be dirty, with food debris and trash present throughout the area, including under equipment and shelving. Additionally, the stand mixer and food processor were also covered with dirt and debris. These findings were confirmed with both the Director of Food Services and the Facility Administrator during the survey. Staff were also observed failing to follow proper hygiene protocols. A Certified Nursing Assistant was seen serving food trays without wearing required hair protection and did not perform hand hygiene after touching her hair and clothing until prompted by the surveyor. Further observations included a kitchen staff member prepping food without beard protection and a dietary aide working in the kitchen without a hair net. Facility policy requires continuous use of hair and beard restraints and handwashing after touching any part of the body or clothing, but these protocols were not followed as observed and confirmed by supervisory staff.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For one resident, an LPN documented in the Medication Administration Record (MAR) that bilateral hearing aids were applied each morning and removed at night, as per physician orders, but stated during observation that the hearing aids were not actually put in unless requested by the family, despite daily documentation indicating otherwise for two months. Additionally, review of another resident's Activities of Daily Living (ADL) documentation revealed that Certified Nurses Aides did not complete ADL care documentation for 3 out of 19 days reviewed. These findings were confirmed through interviews, observations, and record reviews, and discussed with facility leadership.
Failure to Implement Pneumococcal Immunization Policy
Penalty
Summary
The facility failed to implement its pneumococcal immunization policy for four out of nine residents whose immunization records were reviewed. Specifically, the medical records for these residents either lacked evidence that the pneumococcal vaccine had been administered, offered, or refused, as required by facility policy. For example, one resident had documentation of receiving the Pneumococcal conjugate vaccine 13 several years prior, but there was no record of subsequent vaccination, offer, or refusal. Another resident, admitted in March 2023, had no documentation of receiving, being offered, or refusing the pneumonia vaccine, and the Assistant Director of Nursing (ADON) confirmed that there was no proof of vaccination and that the resident had not been offered the vaccine. Similar documentation gaps were found for two other residents, including one whose only record of vaccination dated back to 1998. Interviews with the ADON confirmed that the required assessment and offering of the pneumococcal vaccine had not occurred for these residents, with the ADON stating that vaccines had not been offered because a clinic had not been held. The facility's own policies, updated in February 2025, require that all residents be assessed for vaccination status upon admission and be offered the pneumococcal vaccine series within thirty days unless medically contraindicated or already vaccinated. The lack of documentation and failure to offer or assess for the vaccine as outlined in policy led to the identified deficiency.
Failure to Ensure Required CNA Annual Training and Mandatory In-Services
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training, as well as mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. A review of employee education records for five CNAs employed for more than one year revealed that none had documentation of completing the required 12 hours of continuing education for the year 2024. Additionally, three of these CNAs lacked evidence of having attended the mandatory yearly training in dementia care, resident rights, and abuse and neglect prevention. These findings were confirmed during a review of employee files, which showed missing or incomplete in-service attendance records for each CNA. The Director of Nursing verified the absence of documentation for the required trainings. The deficiency was identified through record review and staff interview, with no evidence provided to show that the CNAs had met the annual training requirements.
Inaccurate Coding of Active Diagnoses on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Version 3.0 Assessments were accurately coded for one resident. Record review showed that the resident had documented diagnoses of Hypertension, Hyperlipidemia, and Diabetes. However, the resident's Quarterly MDS assessments did not include these diagnoses under the Active Diagnosis section. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the MDS assessments did not accurately reflect the resident's current medical status.
Failure to Assess and Care Plan for PTSD/Trauma-Informed Care
Penalty
Summary
The facility failed to identify and assess a resident's history of Post-Traumatic Stress Disorder (PTSD) to determine potential triggers and methods to prevent re-traumatization. Record review showed that the resident's medical history included a diagnosis of PTSD, as documented in multiple provider progress notes. However, there was no evidence in the medical record that the facility conducted an assessment to identify specific trauma triggers or developed interventions to prevent re-traumatization. Additionally, the resident's care plan did not include trauma-informed approaches or interventions related to their PTSD. During interviews, both the Licensed Social Worker and the Director of Nursing confirmed that the facility does not assess residents for PTSD or trauma-informed care.
Failure to Maintain Resident Dignity During Care Activities
Penalty
Summary
Staff failed to maintain resident dignity and respect during daily care activities, as evidenced by multiple observations. On one occasion, a resident was assisted in ambulating from the dining room to their room with their clothing open, exposing their incontinence brief. The staff member assisting the resident acknowledged the situation but continued to allow the resident to walk with their brief exposed. In another instance, a resident was observed eating breakfast in the dining room while only partially dressed, wearing a [NAME] and a zip-up sweatshirt. When asked, the resident expressed discomfort with not being fully dressed and stated a preference to be dressed daily before meals. Additionally, another resident was seen walking in the dining room with assistance from a CNA, with their clothing open and incontinence brief exposed. The CNA stated that she typically covers residents to prevent exposure but did not do so in this instance, as she was taking the resident to the bathroom. These incidents were observed and discussed with facility leadership, highlighting a pattern of staff not consistently ensuring residents' privacy and dignity during care and daily routines.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 97 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clover Health Care | 0.3 mi | ★★★★★ | 7 | 1 |
| St Mary's D'youville Pavilion | 2.3 mi | ★★★★★ | 3 | 1 |
| Russell Park Rehabilitation & Living Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Montello Manor | 3.4 mi | ★★★★★ | 2 | 0 |
| Marshwood Center | 4 mi | ★★★★★ | 12 | 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.