Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Cedar Crossings during CMS and state inspections, most recent first.
Medication carts were repeatedly observed unlocked and unattended, including one with the narcotic drawer key left in place and a cup of pills sitting on top of the cart. An open vial of tuberculin in the med room refrigerator was also found without an open date, and staff acknowledged the labeling issue.
A resident admitted with schizophrenia had a closet with a broken bottom drawer that was unsecured and no longer attached to the frame. A CNA said the damage had been present for about six weeks, while the Maintenance Director was unaware of the issue and confirmed the closet was in disrepair and the drawer needed to be removed. The Administrator confirmed the damage was not reported to maintenance or repaired in a timely manner.
A resident with depression and insomnia received trazodone 50 mg at HS after the order was changed from insomnia to depression. An IDT psychoactive drug review recommended a GDR to reduce the dose to 25 mg and update the diagnosis, and the physician verbally agreed, but the GDR was not completed and documentation of implementation could not be found.
Delayed Baseline Care Plan Completion: A resident admitted with muscle weakness and a need for assistance with personal care did not have a baseline care plan completed within the required timeframe. The care plan, which should have included ADLs, nutrition, skin, pain, and fall risk, was not completed until 13 days after admission. An LPN stated the charge nurse initiated the plan on admission, and the DNS acknowledged the delay.
Failure to obtain prescribed eyeglasses for a resident with a vision deficit. The resident, who had DM and HTN, had an eye exam showing cataracts and blurry vision with glasses prescribed, but the glasses were not received for months. The resident reported barely being able to see out of the current glasses and needing to get very close to the TV, while staff acknowledged no follow-up had been done on the invoice and the facility did not assist with obtaining the glasses in a timely manner.
Controlled substance records were not kept in order for 1 of 4 med carts reviewed. An LPN did not complete or sign the shift count with another staff member, and another LPN did not count controlled meds before leaving a shift. A discrepancy was also found for Norco, where the Controlled Substance Book and med card did not match, and the prior shift LPN stated he administered Norco but did not record it in the controlled substance book.
Pharmacist recommendations were not addressed for two residents. One resident with COPD and depression had Abilify-related AIMS monitoring recommendations that were not documented as completed, and another resident with type 1 DM had a Venlafaxine order clarification issue that remained unresolved for an extended period despite MAR documentation showing once-daily administration.
An unattended medication cart on [NAME] Hall was observed twice with the computer screen open and displaying resident information. An LPN and an RN acknowledged the cart was left unattended, and the DNS stated staff were expected to lock the screen when the computer was unattended.
A resident with dementia, anxiety, sensory impairments, frequent falls, and documented high elopement risk had care plan interventions for frequent monitoring and staff awareness of wander risk, and was listed in the facility’s elopement records. Progress notes described ongoing exit-seeking behavior and a prior elopement in which the resident left through the front door with belongings and was later found in the community. Despite this, multiple staff members, including CNAs, a CMA, and an RN, reported they did not know the resident was an elopement risk or that elopement interventions were in place, while only an LPN recognized the resident as an exit seeker who dressed neatly and sat near the exit. Observations showed the resident fully dressed, making the bed, cleaning the room, and repeatedly stating an intention to go home, while leadership acknowledged staff were not following the care plan or aware of the elopement risk.
The facility failed to provide a safe and homelike environment, with tripping hazards in the dining room and damaged flooring and walls in resident areas. A resident with a history of stroke experienced discomfort due to cold room temperatures, which staff struggled to regulate. Other residents reported similar temperature issues, highlighting a broader problem within the facility.
The facility failed to enforce smoking policies and conduct timely assessments for three residents, leading to potential hazards. A resident with chronic heart failure kept smoking materials unsecured, contrary to policy. Another resident with kidney disease had delayed assessments and also kept materials unsecured. A third resident with schizoaffective disorder had no initial assessment or care plan, and staff were unclear about the policy. The facility acknowledged these issues, indicating a systemic problem in policy enforcement.
The facility failed to provide adequate nursing staff, resulting in prolonged call light response times for residents with conditions such as morbid obesity, diabetes, and cancer. Staff interviews confirmed that response times were longer during short-staffed periods, and the facility did not meet state minimum CNA and bariatric staffing ratios on several occasions.
The facility did not complete annual performance reviews for five CNAs, as confirmed by the DNS and Administrator. This oversight was identified during an interview and record review, where it was found that the personnel profiles lacked the necessary documentation, potentially compromising resident care.
The facility failed to properly store, label, and dispose of medications, as observed in three out of four medication carts. Expired and improperly labeled medications, including insulin and Naloxone, were found, and a medication cart was left unlocked and unattended. Additionally, Lorazepam tablets for a resident without an order and multiple opened medicated creams without open dates were discovered. Staff was uncertain about labeling requirements, and the DNS expected adherence to the facility's policy.
A resident with severe cognitive impairment and dysphagia was not provided with necessary dental services since admission, despite having broken and decayed teeth. Observations and family reports indicated poor oral hygiene, and staff confirmed the resident was not seen by a dentist. The facility failed to address the resident's dental needs, as confirmed by the DNS.
A resident with deep vein thrombosis, atrial fibrillation, and high blood pressure experienced leg discomfort due to swelling. Despite a provider's order for compression stockings, the resident did not receive them, and they were not observed on the resident. A progress note indicated an order for Tubigrip, but it was not implemented due to an oversight. The DNS expected orders to be processed and implemented.
A resident with sleep apnea was found to have a dusty BIPAP machine with improperly stored tubing and mask, and no distilled water available. Staff interviews revealed inconsistencies in cleaning responsibilities, and there was no physician's order for the machine. The RNCM acknowledged the lack of proper maintenance and oversight, placing the resident at risk for breathing complications.
A resident with end-stage renal disease did not receive prescribed medications before dialysis, as staff administered only a pain medication prior to departure. The resident's other morning medications were given after returning from dialysis, contrary to physician orders. Additionally, Pre/Post Dialysis Communication forms were often inaccurate or incomplete, with staff acknowledging inconsistencies and lack of proper documentation.
A facility failed to address a pharmacist's recommendation to increase a resident's Melatonin dosage due to insomnia. Despite the pharmacist's suggestion to increase the dosage from 1 mg to 3 mg, the clinical record showed no follow-up action. Staff interviews confirmed that the provider did not respond to the recommendation, leading to delays in addressing the resident's medication needs.
The facility failed to maintain proper waste containment and sanitation in the garbage storage area. Observations revealed uncovered dumpsters with overflowing garbage bags spilling onto the ground. The Dietary Manager acknowledged the issue, noting that garbage collection occurred three times a week, and the overflow had accumulated since the previous week. The Maintenance Director confirmed the facility's policy to keep garbage contained and the area clear of debris, and staff were educated on maintaining closed dumpsters.
The facility failed to follow infection control practices for two residents, one with a PEG tube and another with a Foley catheter. Staff did not adhere to enhanced barrier precautions, such as wearing gowns, during hands-on care, despite the presence of instructions and the need for such precautions due to the residents' medical conditions.
The facility did not ensure that CNAs received the mandatory 12 hours of annual in-service training. A review of records for five staff members showed no completed training hours, which was confirmed by the DNS and Administrator.
The facility failed to provide written transfer notices with appeal rights to two residents and their representatives when they were transferred to the hospital. One resident, admitted with a stroke and swallowing difficulties, and another with gallbladder issues, were both transferred without receiving the required notifications. The DNS confirmed that these notifications were not being provided, despite expectations.
The facility failed to provide two residents with a written bed hold notification, including reserved payment details, when they were transferred to the hospital. One resident with a stroke and swallowing difficulties and another with gallbladder issues did not receive the required notice. The DNS confirmed the oversight.
A resident with chronic kidney disease and requiring dialysis requested bed rails for bed mobility upon admission. Despite being cognitively intact and needing moderate assistance, the resident had to use the headboard to reposition themselves and waited weeks for bed rails. A public complaint and grievance form highlighted the delay. An LPN recalled the request and claimed an assessment was done, but the DNS stated no assessment was completed, although a physician order was initiated. The administrator acknowledged the delay in providing the bed rails.
A facility failed to allow a resident to return after a therapeutic leave, exceeding the bed-hold policy. The resident, with diagnoses including heart failure and homelessness, was out of the facility and upon return, was informed of discharge against medical advice. Despite returning to her/his room, the resident was escorted out, and a complaint was filed alleging belongings were locked up. The administrator confirmed the resident was not permitted to return after being late from leave.
A resident with hypertension was discharged from a facility and transported to another state without a meal for the extended journey. The discharge instructions did not include a meal provision, and staff confirmed that no meal was sent with the resident. The facility administrator acknowledged this oversight.
A resident admitted with cataracts in both eyes did not receive timely optometry services as outlined in their care plan. Despite requests for an eye exam since admission, the facility failed to schedule an ophthalmology appointment until recently. A staff member acknowledged the delay in scheduling the necessary vision appointment.
A resident admitted with congestive heart failure and diabetes had dental care needs due to being edentulous. Despite requesting a dental exam and dentures, the facility failed to schedule any dental appointments from admission in 2022 until new orders in 2023. Observations confirmed the resident was missing most natural teeth, and staff acknowledged the delay in scheduling a dental appointment.
A resident with cognitive impairment and aphasia eloped from the facility due to inadequate re-evaluation of elopement risks and care plan interventions. Despite being identified as an elopement risk, the resident's exit-seeking behaviors were not consistently documented or communicated among staff, leading to an immediate jeopardy situation. The facility's Wandering and Elopement policy was not effectively implemented, resulting in the resident's continued missing status.
The facility did not develop or present a QAPI plan to the SSA and lacked documentation of an ongoing QAPI program. The administrator confirmed the absence of these essential components during the survey.
The facility did not conduct quarterly QAA meetings and failed to involve the Medical Director in quality assurance activities. This was confirmed by the Administrator, who acknowledged the lack of meetings and the Medical Director's absence, putting residents at risk of not receiving optimal care.
Unsecured medication carts and unlabeled tuberculin vial
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles and failed to keep medications and medication carts properly secured. On 5/20/26, a medication cart on one hall was observed unlocked and unattended while containing resident medications, and on 5/21/26 another medication cart on a different hall was also observed unlocked and unattended with resident medications inside. On 5/22/26, a third medication cart was observed unattended with the key hanging out of the narcotic drawer and a medication cup full of pills sitting on top of the cart, and a fourth cart was observed unlocked and unattended while a staff member entered a resident's room. Staff acknowledged each of these observations, and the DNS stated the expectation was for medication carts and medications to be locked when unattended. The facility also failed to properly label biologicals in the medication room refrigerator. On 5/21/26, an open, undated vial of tuberculin was observed in the medication room refrigerator, and the manufacturer's instructions indicated the medication should be discarded 30 days after opening. Staff acknowledged the vial was open and not labeled with an open date, and the DNS stated the expectation was for tuberculin to be labeled with an open date.
Unrepaired Closet Damage in Resident Room
Penalty
Summary
The facility failed to maintain a homelike environment for Resident 44, who was admitted in 3/2025 with diagnoses including schizophrenia. Maintenance requests reviewed from 3/2026 to 5/2026 showed no damaged furniture in the resident’s room that required repair. However, on 5/18/26 the closet in Resident 44’s room was observed to have a broken bottom drawer that was unsecured on the bottom level of the closet and no longer attached to the frame. On 5/21/26, a CNA stated she was aware the closet had a broken bottom drawer and said it had been broken for approximately six weeks. The Maintenance Director stated nursing staff were expected to submit an electronic maintenance request when damaged furniture was identified, but he was unaware of the damage in Resident 44’s room and acknowledged the closet was in disrepair and the broken drawer needed to be removed. The Administrator later confirmed the closet was in disrepair and had not been reported to maintenance staff or repaired in a timely manner.
Failure to Complete Ordered GDR for Trazodone
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was completed when indicated for one resident reviewed for medications. The resident was readmitted with diagnoses including depression and insomnia and had a physician order for trazodone 50 mg at bedtime for insomnia, which was later discontinued and replaced with a new order for trazodone 50 mg at bedtime related to depression. The resident’s MAR showed trazodone was administered from 4/6/26 through 5/21/26. A 4/21/26 psychoactive drug review documented that the IDT recommended a GDR to decrease trazodone from 50 mg to 25 mg and to change the diagnosis for use of trazodone from insomnia to depression, and the review indicated the physician verbally agreed with the plan. On 5/22/26, the DNS stated the GDR for the resident’s trazodone was not completed and that she could not find documentation that the GDR was implemented.
Delayed Baseline Care Plan Completion
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for Resident 40, who was admitted with diagnoses including muscle weakness and the need for assistance with personal care. Record review showed the baseline care plan was not completed until 4/14/26, which was 13 days after admission. Staff 12, the LPN Resident Care Manager, stated that upon admission the charge nurse initiated the baseline care plan, which included the resident's ADLs, and that it was expected to be completed within 72 hours of admission. Staff 2, the DNS, stated that a baseline care plan included information about ADLs, nutrition, skin, pain, and fall risk, and acknowledged that Resident 40's baseline care plan was completed 13 days after admission.
Failure to Obtain Prescribed Eyeglasses for Resident With Vision Deficit
Penalty
Summary
The facility failed to ensure that Resident 48 received an assistive device to maintain vision ability. Resident 48 was admitted with diagnoses including diabetes and hypertension, and the care plan dated 4/21/25 identified a vision deficit related to decreased visual acuity with interventions to ensure eyeglasses were clean, appropriate, and being worn. A provider vision progress note dated 12/9/25 documented an eye exam for cataracts and blurry vision in both eyes, and the evaluation indicated glasses were prescribed and would be shipped to the facility two weeks after payment was received. During interviews on 5/18/26 and 5/21/26, Resident 48 stated the eye doctor visit occurred in January, a new glasses prescription was received, but no glasses had been received yet. The resident reported barely being able to see out of the current glasses and needing to get very close to the TV, and stated the resident had been waiting for months and did not know where the new glasses were. A physician progress note on 5/21/26 documented poor vision and noted the resident had an eye exam in January and ordered glasses but did not receive them. Staff stated the facility received an invoice from the optometrist after glasses were needed, that Social Services gave the invoice to the resident to inform them of the cost, and that no invoice from the 12/9/25 vision exam had been received or followed up on. The Administrator stated on 5/22/26 that the invoice for the new glasses had just been received and the facility did not assist with obtaining glasses in a timely manner.
Controlled Substance Count and Documentation Errors
Penalty
Summary
The facility failed to ensure resident narcotic drug records were in order and that an account of all controlled drugs was maintained for 1 of 4 medication carts reviewed for medication storage. On [NAME] Hall, the Controlled Substance Book was reviewed with an LPN, and there were no signatures for the day shift controlled medication count. The LPN stated she did not count the controlled medications with another staff member before coming on shift, and another LPN stated he worked the prior night shift and did not count controlled medications with staff before leaving the facility. During the same review, a discrepancy was identified between the controlled medication card and the Controlled Substance Book for Norco. The book showed three Norco tablets remaining, while the medication card showed two tablets remaining. The LPN stated the prior shift LPN did not update the Controlled Substance Book, and the prior shift LPN stated he administered Norco to a resident but did not record the administration in the controlled substance book. The DNS stated the expectation was for two staff to count controlled medications between shifts, compare them to the Controlled Substance Book, and sign the signature page after the count was completed.
Pharmacist Recommendations Not Addressed for Two Residents
Penalty
Summary
The facility failed to ensure pharmacist recommendations were addressed for 2 of 5 sampled residents reviewed for unnecessary medications. For Resident 1, who was readmitted with diagnoses including COPD and depression, a pharmacist recommendation on 4/17/26 stated that the resident was receiving Abilify for depression and recommended monitoring for movement disorders such as extrapyramidal side effects and tardive dyskinesia with AIMS testing upon initiation of antipsychotic medications, during dosage changes, and every 6 months. A second recommendation on 5/9/26 repeated the same concern, and although "AIMS Completed" was handwritten on the recommendation, there was no date or signature documented. Review of the medical record found no documentation that an AIMS assessment had been completed for Resident 1 prior to 5/21/26. For Resident 10, who was admitted with diagnoses including type 1 diabetes mellitus with ketoacidosis without coma, a pharmacist recommendation on 4/17/26 asked the facility to clarify the Venlafaxine 75 mg order because the MAR listed both "one tablet once a day" and "one tablet two times a day," while charting showed the medication was being given once daily. Review of the April and May MARs showed the resident had been receiving Venlafaxine 75 mg once daily, but the pharmacist recommendation was not addressed until 5/19/26, when the order was verified and clarified as once daily. Staff stated the facility typically attempted to address pharmacist recommendations within 72 hours, but the recommendation for Resident 10 was not addressed until it was noticed later.
Unattended Medication Cart Exposed Resident Information
Penalty
Summary
The facility failed to ensure resident medical records were kept secured and confidential during two separate observations. On 5/21/26, surveyors observed the medication cart on [NAME] Hall unattended from 1:01 PM to 1:02 PM, with the computer screen open and displaying resident information; an LPN acknowledged the cart had been left unattended and the screen showed resident information. On 5/22/26 at 9:49 AM, the [NAME] Hall medication cart was again observed unattended with the computer screen open and displaying resident information while an RN entered a resident's room; the RN then returned to the cart and acknowledged it had been left unattended with resident information visible. The DNS stated the expectation was for staff to lock the computer screen when the computer was unattended.
Failure to Ensure Staff Awareness of Resident Elopement Risk and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were aware of a resident’s elopement risk and corresponding care plan interventions. The resident was admitted with dementia with anxiety, bilateral hearing loss, cataracts, visual impairment, and a history of frequent falls. A care plan dated 5/21/25 identified the resident as at risk for elopement due to poor cognition, with interventions including frequent monitoring, visual checks, and ensuring staff awareness of the resident’s wander risk. Progress notes on 6/17/25 documented exit-seeking behavior, administration of an anxiety medication for anxiety and exit seeking, and an elopement later that evening when the resident left the facility through the front door with belongings, walked in the community, and was later found by a bystander. Subsequent assessments and documentation, including an elopement assessment on 12/3/25 and an annual MDS on 1/29/26, identified the resident as high risk for elopement with moderate to severe cognitive impairment and functional limitations in ADLs, reduced safety awareness, and impaired sequencing. The resident was also listed in the facility’s Elopement Book as a high elopement risk, and progress notes continued to describe exit-seeking behavior. Despite these documented risks and interventions, multiple staff interviews and observations showed that staff were not aware of the resident’s elopement risk or care plan interventions. On 4/2/26, several staff members, including a SSD assistant, CMA, and CNAs, either were unaware the resident had previously eloped or did not know the resident was an elopement risk or had elopement interventions in place. An RN stated there were no residents in her section who were an elopement risk, while an LPN identified the resident as an exit seeker who dressed nicely and sat by the door, noting visitors could mistake the resident for another visitor. Observations on 4/2/26 and 4/3/26 showed the resident fully dressed, sitting on the side of the bed, making the bed, cleaning the room, and repeatedly stating a desire to go home and intent to go home. The administrator and DNS later acknowledged that staff did not follow the resident’s care plan and were not aware of the resident’s elopement risk.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several deficiencies observed in the dining rooms, hallways, and resident rooms. In the Enhanced Care Unit (ECU) dining room, there were significant tripping hazards due to missing and damaged linoleum flooring. Staff confirmed that these issues had been present for some time and had been reported to maintenance, yet no warnings were in place to alert residents of the hazards. Additionally, various resident rooms and shared spaces exhibited damage such as scrapes on walls and black marks on floors, further detracting from a homelike environment. Resident 68, who was admitted with a diagnosis of cerebral infarction, experienced discomfort due to the inability to regulate the temperature in her/his room. The room was consistently cold, particularly from midnight to 8:00 AM, despite attempts by staff to adjust the thermostat. The Maintenance Director acknowledged the difficulty in maintaining a comfortable temperature and noted that unauthorized adjustments to the thermostat could exacerbate the issue. Other residents in nearby rooms also reported similar temperature concerns, indicating a broader issue with temperature regulation in the facility.
Failure to Enforce Smoking Policies and Timely Assessments
Penalty
Summary
The facility failed to ensure timely smoking assessments and safe storage of smoking materials for three residents, leading to potential accident hazards. Resident 22, admitted with chronic heart failure and diabetes, was assessed as safe to smoke independently. However, observations revealed that Resident 22 kept smoking materials in their pocket, contrary to the facility's policy requiring these materials to be locked up. Staff interviews confirmed that Resident 22 did not comply with the policy, and there was no evidence that the facility enforced the safe storage requirement. Resident 50, with end-stage kidney disease and diabetes, was also assessed as safe to smoke independently. However, the initial smoking assessment was missing, and the quarterly assessment was delayed. Observations showed that Resident 50 kept smoking materials with them, and staff interviews indicated a lack of clarity and enforcement regarding the storage policy. Despite being aware of the policy, staff acknowledged that Resident 50 did not comply with the requirement to lock up smoking materials. Resident 60, diagnosed with schizoaffective disorder and kidney disease, was found to have no initial smoking assessment or care plan related to smoking until months after admission. Observations and interviews revealed that Resident 60 kept smoking materials unsecured, and staff were uncertain about the current smoking policy. The facility's Director of Nursing Services acknowledged the delay in assessment and the absence of a care plan, highlighting a systemic issue in policy enforcement and resident compliance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call light response times for several residents. Resident 26, admitted with morbid obesity and diabetes, reported call light response times of up to 45 minutes, with logs showing multiple instances of delays exceeding 30 minutes. Similarly, Resident 22, with morbid obesity and a right leg amputation, experienced delays of up to an hour, leading to sitting in soiled briefs. Resident 57, diagnosed with lung and brain cancer, also faced extended wait times, prompting attempts to self-manage care. Interviews with staff revealed that call light response times were longer during periods of short staffing, which occurred occasionally. Staff members acknowledged that not all personnel assisted with answering call lights, contributing to the delays. The facility's administrator and director of nursing services confirmed the expectation for call lights to be answered within 20 minutes and recognized the failure to meet this standard for the affected residents. A review of the facility's staffing reports indicated that the facility did not meet mandatory state minimum CNA ratios on several occasions, particularly during the day shift. Additionally, the facility struggled to meet state bariatric staffing ratios on multiple dates. The staffing coordinator admitted difficulties in covering shifts, especially with last-minute call-offs, and the facility's leadership acknowledged the challenges in maintaining adequate staffing levels to meet state requirements.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant (CNA) received annual performance reviews, as evidenced by the lack of completed reviews for five randomly selected CNAs. During an interview and record review, it was discovered that the personnel profile records for these CNAs did not contain any annual performance reviews. Staff 2, the Director of Nursing Services (DNS), confirmed that if the reviews were not in the personnel profile folders, they had not been completed. Both Staff 1, the Administrator, and Staff 2 acknowledged this oversight, which placed residents at risk for receiving care from potentially incompetent staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage, labeling, and disposal of drugs and biologicals, as observed in three out of four medication carts. During an early morning observation, a diabetic/treatment cart was found to contain expired and improperly labeled medications, including Naloxone Nasal Spray and Lantus insulin without an open date. Additionally, an unlabeled bottle of insulin and a Humulin Kwik Pen with an expired open date were found. An unlabeled tube of Solosite Wound Treatment Gel was also discovered with an expired date. Furthermore, the medication cart was left unlocked and unattended outside the dining room, posing a risk to residents as several staff members and a resident walked past it. Further inspection revealed a medication storage card containing Lorazepam tablets for a resident who no longer had an order for the medication, along with three loose tablets of unknown ingredients. Staff confirmed these medications should have been destroyed. Additionally, multiple opened medicated creams and ointments were found without open dates on the labels, and staff was uncertain if open dates were required. The Director of Nursing Services (DNS) stated that staff was expected to adhere to the facility's policy for storing, labeling, and destroying medications and biologicals.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was admitted with diagnoses including dysphagia and pneumonitis. The resident, who had severe cognitive impairment and required substantial assistance for oral hygiene, had not been seen by a dentist since admission. Observations revealed the resident had jagged, broken, and decayed teeth, along with thick accumulations of oral secretions. A family member noticed the buildup on the resident's teeth and reported it to the facility staff, but dental care was not provided. Staff interviews revealed that the resident's teeth were swabbed rather than brushed due to a choking risk, and the resident was not seen by a dentist during the last visit to the facility. The Director of Nursing Services confirmed the inaccuracy of the resident's MDS and acknowledged the need for dental care. The deficiency was identified as a failure to provide timely dental services, placing the resident at risk for unmet dental needs.
Failure to Implement Compression Stocking Order for Resident with Edema
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with edema, as observed during a survey. The resident, admitted in November 2024 with conditions including deep vein thrombosis, atrial fibrillation, and high blood pressure, reported discomfort due to swelling in the legs. Despite a provider's order for compression stockings issued approximately four weeks prior, the resident did not receive them, and they were not observed on the resident's lower extremities. A registered nurse was unaware of the order, but located a progress note from December 6, 2024, indicating an order for Tubigrip, a form of compression dressing. The LPN Resident Care Manager acknowledged that the order had not been followed up on or implemented due to an oversight. The Director of Nursing Services stated that she expected provider orders to be processed and implemented.
Failure to Maintain and Support Resident's BIPAP Machine
Penalty
Summary
The facility failed to ensure proper respiratory care and maintenance of equipment for a resident diagnosed with sleep apnea who utilized a BIPAP machine. The resident was admitted with diagnoses including anxiety and depression, and the care plan indicated the need for a CPAP/BIPAP machine, which required regular cleaning. However, observations revealed that the BIPAP machine was dusty, and the tubing and mask were improperly stored in a drawer under magazines and a cracker box. The resident reported that staff did not clean the device or ensure it had distilled water, and there was no evidence of a physician's order for the BIPAP machine in the clinical record. Staff interviews confirmed that the resident used the BIPAP machine at night, but there was inconsistency in the cleaning responsibilities, with night shift staff reportedly responsible for cleaning. Despite this, the machine remained dusty, and there was no distilled water available. The RNCM acknowledged the lack of orders for the BIPAP machine and the inadequate cleaning of the equipment. This deficiency placed the resident at risk for breathing complications due to the improper maintenance and oversight of the respiratory equipment.
Failure to Administer Medications and Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to administer medications and ensure accurate completion of communication forms for a resident requiring dialysis. The resident, diagnosed with end-stage renal disease and diabetes, was scheduled for dialysis on Tuesdays, Thursdays, and Saturdays. Despite physician orders for specific medications to be administered before dialysis, the resident only received a pain medication prior to leaving the facility. Staff members confirmed that the resident's other morning medications were not administered until after returning from dialysis, which was contrary to the prescribed schedule. Observations and interviews revealed that the resident routinely left for dialysis without receiving the necessary medications, which were intended to be given before the procedure. Staff members, including LPNs and a CMA, acknowledged that the medications were either marked as administered or noted as the resident being out, despite not being given at the correct times. This practice was not known to the RNCM and DNS, who expected staff to seek clarification on medication administration for dialysis days. Additionally, the facility failed to ensure the accuracy and completion of Pre/Post Dialysis Communication forms. The forms were often inaccurate, incomplete, or not returned from the dialysis center. Staff members admitted to inconsistencies in the forms, with two different versions being used, and acknowledged that the forms were not always transcribed or uploaded into the electronic system as required. The RNCM and DNS were unaware of these issues, indicating a lack of oversight in the communication process for dialysis care.
Failure to Address Pharmacist Recommendations for Medication Adjustment
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were addressed for a resident reviewed for unnecessary medications. The resident was admitted with a diagnosis of insomnia and was prescribed Melatonin 1 mg at bedtime. In November, the pharmacist recommended increasing the dosage to 3 mg due to the resident's limited sleep duration of one to four hours per night. However, there was no indication in the clinical record that this recommendation was addressed. Interviews with staff revealed that the facility did not receive a response from the resident's provider regarding the pharmacist's recommendation, and it was noted that the provider did not consistently respond to such recommendations, causing delays in follow-up.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to ensure that waste was properly contained in dumpsters and that the garbage storage area was maintained in a sanitary condition. During an observation, the outside dumpsters adjacent to the kitchen door were found uncovered, with garbage bags full of kitchen and resident care waste spilling over and covering the ground around the dumpsters. A minimum of 20 bags of garbage were piled on the ground in the parking lot in front of the dumpsters. This situation was acknowledged by the Dietary Manager, who noted that the garbage collection usually occurred three times a week, and the overflow had accumulated since the previous week. The Maintenance Director confirmed that the facility's policy required garbage to be contained within the dumpsters with lids closed and the area around the dumpsters to be clear of garbage bags and debris to limit accessibility to pests. He stated that an additional dumpster was being used to contain all of the garbage and that staff had been educated on the importance of keeping the garbage in the dumpsters with the lids closed. The Director of Nursing Services also stated that she expected the facility's garbage to be contained in the dumpsters.
Failure to Follow Infection Control Practices for Residents with Special Needs
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to a risk of cross-contamination. Resident 36, who has severe cognitive impairment and requires significant assistance for toileting hygiene, was observed with a soiled brief. Staff 35, a CNA, entered the resident's room without donning the required personal protective equipment (PPE) such as a gown, despite the posted instructions for enhanced barrier precautions due to the resident's PEG tube. Staff 35 admitted to not wearing a gown while providing care, which included changing the resident's brief and linens. Similarly, Resident 49, who has a Foley catheter, did not have instructions for enhanced barrier precautions posted outside their room. Staff 41, another CNA, provided hands-on care, including a brief change, wearing only gloves and no additional PPE. The facility's infection preventionist and administrator confirmed that enhanced barrier precautions were necessary for Resident 49 due to the presence of the Foley catheter, but these precautions were not followed.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of in-service training annually. This deficiency was identified for five randomly selected staff members. During an interview and record review, it was revealed that the personal profile records for these staff members showed no completed training hours. The Director of Nursing Services (DNS) confirmed that if no records were found in the personal profile folders, the training was not completed. Both the Administrator and the DNS acknowledged the lack of completion of the required training hours for the staff members involved.
Failure to Provide Transfer Notices with Appeal Rights
Penalty
Summary
The facility failed to provide written transfer notices with appeal rights to residents and their representatives when residents were transferred to the hospital. This deficiency was identified for two residents who were hospitalized. Resident 80, admitted in February 2024 with a stroke and swallowing difficulties, was transferred to the hospital on October 5, 2024. A review of Resident 80's health record showed no evidence of a transfer notice with appeal rights being provided in writing to the resident or their representative. Similarly, Resident 81, admitted in October 2024 with gallbladder calculus and abdominal pain, was transferred to the hospital on October 31, 2024. Again, there was no documentation in Resident 81's health record indicating that a transfer notice with appeal rights was provided in writing. Staff 2, the Director of Nursing Services (DNS), confirmed that transfer notifications with appeal rights were not being provided to residents or their representatives upon hospital transfer, despite it being her expectation that such notifications should be given.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide two residents with a written bed hold notification, including information on reserved bed hold payment, at the time of their transfer to the hospital. Resident 80, who was admitted in February 2024 with a stroke and difficulty swallowing, was discharged to the hospital on October 5, 2024, without receiving the required written notice. Similarly, Resident 81, admitted in October 2024 with gallbladder calculus and abdominal pain, was transferred to the hospital on October 31, 2024, without receiving the written bed hold policy. Staff 2, the Director of Nursing Services (DNS), confirmed that the written bed hold policy was not provided to either resident or their representatives at the time of their hospital transfers.
Failure to Provide Bed Rails for Resident Mobility
Penalty
Summary
The facility failed to provide bed rails needed for bed mobility for a resident, which placed the resident at risk of activities of daily living (ADL) decline. The resident, who was admitted with chronic kidney disease and required dialysis, was cognitively intact with a BIMS score of 15 and needed moderate assistance with bed mobility. Upon admission, the resident requested bed rails to assist with bed mobility, as documented in a nursing admission note. Despite this request, the resident had to use the headboard to reposition themselves and waited several weeks before bed rails were installed. A public complaint was filed on 6/28/24, indicating the resident's request for bed rails. A grievance form filed by the resident on 5/29/24 reiterated the request for bed rails. Staff interviews revealed that an LPN recalled the resident's request and stated that an assessment was completed, and a physician's order was requested. However, the Director of Nursing Services (DNS) stated that a bed rail assessment was not completed, although a physician order was initiated on 5/29/24. The facility administrator acknowledged the delay in providing the bed rails, which were not installed until 5/29/24, despite the resident's request at the time of admission.
Failure to Permit Resident Return After Therapeutic Leave
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization or therapeutic leave, exceeding the bed-hold policy, for one of the four sampled residents reviewed for discharge. The resident, who was admitted in December 2023 with diagnoses including absence of the right foot, heart failure, and cocaine abuse, was noted to be homeless and staying in her/his car or motels. On March 4, 2024, a progress note indicated the resident was out of the facility at her/his mother's house, and by March 5, 2024, staff had left a voice message for the resident to return. On March 9, 2024, the resident returned to the facility early in the morning after being out since March 3, 2024, and was informed by a staff RN that she/he was discharged per facility policy. Despite this, the resident went to her/his previous room and went to bed, prompting staff to call the on-call manager. A public complaint filed on May 3, 2024, alleged that upon the resident's return, her/his belongings were locked up, and she/he was informed of being discharged against medical advice (AMA) and was escorted out of the facility. The facility's administrator confirmed that the resident was not permitted to return after being late from therapeutic leave.
Failure to Provide Meal During Resident Discharge
Penalty
Summary
The facility failed to ensure that meals were provided for a resident during discharge, which was identified as a deficiency. Resident 5, who had been admitted to the facility in December 2023 with a diagnosis of hypertension, was discharged on January 11, 2024, to another state. The discharge instructions indicated that the resident was to be transported to a new nursing facility, with an expected travel time from 10:15 AM to 5:30 PM. However, there was no indication that a meal was ordered or provided for the resident during this extended transport. Staff 10, a CNA, confirmed that the resident was sent out by medical transport without a meal. The facility administrator, Staff 1, acknowledged that the staff did not send a meal with the resident for the transport.
Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide timely optometry services for a resident who was admitted in March 2022 with diagnoses including congestive heart failure and diabetes mellitus. The resident's initial care plan, dated April 5, 2022, indicated the presence of cataracts in both eyes and included an intervention to refer the resident for an eye exam. Despite this, a progress note from June 17, 2023, revealed that a staff member had discussed scheduling a vision appointment with the resident, but there was no documentation of any appointments being made. The resident reported on July 9, 2024, that they had requested an eye exam since admission, but the facility only recently scheduled an ophthalmology appointment. A staff member acknowledged on July 17, 2024, that the facility had not made a timely vision appointment for the resident after their admission.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for a resident who was admitted in March 2022 with diagnoses including congestive heart failure and diabetes mellitus. The resident's initial care plan in April 2022 indicated dental care needs due to being edentulous, with an intervention to obtain a dental consult. Despite the resident requesting a dental exam in August 2022, and a progress note in June 2023 indicating a discussion about scheduling a dental appointment, no appointments were documented until new orders were issued in August 2023. Observations in July 2024 confirmed the resident was missing most natural teeth and had requested dentures since admission, but the facility had not scheduled any dental appointments. Staff acknowledged the delay in making a timely dental appointment for the resident.
Failure to Address Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The facility failed to re-evaluate elopement risks and modify care plan interventions for a resident with cognitive impairment and aphasia, leading to an immediate jeopardy situation. The resident, admitted in April 2024 with a history of stroke, dysphagia, and severe cognitive impairment, exhibited wandering and exit-seeking behaviors. Despite being identified as an elopement risk, the resident's care plan did not adequately address these behaviors, and staff failed to consistently document or communicate the resident's exit-seeking tendencies. On June 12, 2024, the resident eloped from the facility, having been last seen at 6:30 AM. Staff initiated a search and contacted law enforcement when the resident was not found. Interviews revealed that staff were aware of the resident's elopement risk but did not consistently chart or communicate these behaviors. The resident had previously been observed unsupervised in the parking lot, and staff had overheard the resident expressing a desire to leave. However, these incidents were not adequately addressed in the care plan or communicated among staff. The facility's failure to re-evaluate the resident's elopement risk and modify care plan interventions resulted in the resident's elopement and placed other residents at risk. Staff interviews indicated a lack of awareness and communication regarding the resident's behaviors, contributing to the deficiency. The facility's Wandering and Elopement policy was not effectively implemented, as staff did not consistently monitor or document the resident's exit-seeking behaviors, leading to the resident's continued missing status.
Removal Plan
- All current residents with cognitive impairment will have an elopement risk assessment completed
- Residents with an identified elopement risk will have care plans reviewed for effective interventions and updated as needed
- Behavior monitors will be created and/or updated to reflect identified elopement risks and interventions
- Weekly audits to be conducted of elopement risks for care plan, interventions and behavior monitor
- Audits will be brought to QAPI for review
- Nursing staff were to update themselves regarding wandering protocol at the start of every shift
- Residents with known elopement/wandering risks observed to be exit seeking would be monitored by staff, who were not to leave the resident and tell other staff to alert the charge nurse
- Nurses were to chart any type of exit seeking behaviors
- At the beginning of each shift, all care staff will do walking rounds and all residents must have visual checks completed by staff
- Elopement risk assessments will be completed on admission, quarterly and with any behavioral changes
Lack of QAPI Plan and Program
Penalty
Summary
The facility failed to develop and present a Quality Assurance and Performance Improvement (QAPI) plan to the State Survey Agency (SSA) and did not provide documentation or evidence of an ongoing QAPI program. This deficiency was identified through interviews and record reviews. The facility's administrator, referred to as Staff 1, acknowledged the absence of a QAPI plan and program during the survey.
Failure to Conduct Quarterly QAA Meetings and Involve Medical Director
Penalty
Summary
The facility failed to conduct quarterly Quality Assessment and Assurance (QAA) committee meetings and did not include the Medical Director in the quality assurance process. This deficiency was identified through interviews and record reviews, which revealed a lack of evidence or documentation supporting the occurrence of these meetings. Staff 1, the Administrator, acknowledged that the QAA committee had not met quarterly and confirmed the absence of the Medical Director's involvement in the quality assurance activities. This oversight placed residents at risk of not receiving the necessary care and services for optimal outcomes.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 513 citations issued within 25 miles in the last 12 months — including the 5 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascade Terrace Post Acute | 1 mi | ★★★★★ | 5 | 0 |
| Avalon Care Center - Portland | 1.2 mi | ★★★★★ | 4 | 0 |
| Gracelen Care Center | 2 mi | ★★★★★ | 5 | 0 |
| Secora Rehabilitation Of Cascadia | 2.1 mi | ★★★★★ | 0 | 0 |
| Village Health Care | 2.2 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.