Windward Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Camden, Maine.
- Location
- 105 Mechanic Street, Camden, Maine 04843
- CMS Provider Number
- 205180
- Inspections on file
- 33
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Windward Gardens during CMS and state inspections, most recent first.
A resident with dementia and a history of falls had an unwitnessed fall in their room, after which initial assessment noted no injuries and indicated neuro checks were completed and passed, but the medical record contained no documentation of ongoing neuro checks following the event. A later, witnessed fall in a hallway was documented with normal ROM and vital signs and no head impact. During interview, the DON stated that neuro checks are required for every unwitnessed fall and produced a neuro check sheet dated for a different day, which she believed corresponded to the unwitnessed fall, yet no neuro check documentation for that unwitnessed fall was present in the medical record, resulting in the cited deficiency.
Several newly admitted residents did not have baseline care plans developed and implemented within 48 hours, as required. The care plans lacked necessary goals and interventions for conditions such as alcohol abuse, mental health disorders, malnutrition, dementia, recent surgery, and dietary allergies. Additionally, the plans did not specify the type or level of assistance needed for ADLs, and dietary instructions were missing or delayed.
Surveyors identified that two residents' clinical records were incomplete and lacked accurate documentation. For one resident, required assessments and interventions such as diabetic foot checks, respiratory assessments, and monitoring for medication side effects were not consistently documented. For another resident, records did not show whether blood sugar checks and sliding scale insulin administration were performed as ordered. These omissions were confirmed during record review and staff interviews.
A resident reported being physically abused by a staff member, resulting in ongoing pain. Despite being made aware of the allegation, facility leadership did not notify the State Agency, failed to conduct an investigation, and did not submit required documentation within the mandated timeframe.
A resident with dementia and anxiety suffered a leg fracture, but the care plan was not updated with new goals or interventions following the injury. Review of records showed the care plan had not been revised to address the resident's new needs after the incident.
A resident with multiple wounds did not receive care according to provider orders or the facility's wound management policy. Nursing staff failed to initiate updated wound care orders from a wound care consult and continued previous treatments, while documentation lacked evidence of proper wound monitoring and description. The resident was later sent to the ER with pressure sores reportedly due to lack of repositioning.
The facility did not provide enough nursing staff on weekends for a significant portion of a reviewed quarter, as confirmed by payroll records and facility leadership. The Administrator acknowledged that adequate staffing was not maintained for most weekend days during the period in question.
Surveyors identified widespread deficiencies in housekeeping and maintenance, including uncovered trash bins, stained ceiling tiles, torn window screens, soiled floors, damaged furniture, chipped paint, loose grab bars, and missing privacy curtain hooks. These issues were observed throughout all wings, the laundry room, and common areas, and were confirmed by the Senior Maintenance Director and the Administrator.
A resident who is bedbound and cognitively intact, with a care plan emphasizing the importance of participating in activities and religious services, was not consistently invited to or offered scheduled activities. Activity participation records lacked documentation of invitations, refusals, or one-on-one sessions, and the activity calendar was not posted within the resident's view. Staff interviews confirmed that required documentation and offers of activities were not made.
Surveyors found unsecured chemicals accessible to residents, sharp and splintered laminate on doors in multiple rooms, and instances of oxygen tanks left unsecured. Facility leadership and staff confirmed these hazards and acknowledged that proper storage and maintenance procedures were not followed.
Surveyors identified multiple sanitation and maintenance issues in the kitchen, including dusty and dirty equipment, missing or stained ceiling tiles, uncleanable surfaces, and improper food storage practices such as unsecured, undated, and unlabeled food items in the walk-in freezer. These deficiencies were confirmed by kitchen staff during the inspection.
The facility did not complete required neurological assessments after unwitnessed falls for a resident, failing to follow its own policies for post-fall monitoring. Another resident did not receive timely wound care orders or consistent catheter care and output monitoring, with documentation missing for both wound management and Foley catheter interventions.
The facility failed to ensure complete and accurate clinical documentation for several residents, including missing evidence of family communication regarding goals of care, lack of documentation of required neurological checks after a fall, and incomplete records of daily weights and catheter care for a resident with CHF. Additionally, there was no documentation that palliative or hospice consults were obtained for a resident with failure to thrive, despite multiple notes indicating these were planned.
A resident with a specialized mental health diagnosis was re-admitted for permanent LTC placement and had a PASRR Level I Screen completed for a change in condition. However, the facility failed to forward the PASRR Level I to the State Mental Health Authority to determine if a PASRR Level II evaluation was needed.
A resident experienced an unwitnessed fall and was assessed for low back pain, but the family was not notified of the incident until the following day, contrary to facility policy requiring immediate notification of the resident's representative after such events.
Nurse staffing information was not posted in a visible and accessible area for three consecutive days, as confirmed by surveyor observation and staff interview. The posted information was outdated, and the required daily updates were not made.
A resident with an existing care plan for risk of skin breakdown developed a Stage 3 pressure ulcer, but the care plan was not updated to address the new wound care needs. This lapse was confirmed through record review and staff interview, indicating a failure to revise the care plan after a significant change in the resident's condition.
A physician order for a wound clinic consultation was not carried out for a resident with a Stage 3 pressure ulcer. After returning from the hospital with instructions for a wound clinic referral, the order was signed by the primary physician and noted by nursing staff, but the referral was not completed, as confirmed by the Nurse Manager.
A physician did not review and sign a resident's medication and treatment orders within the required timeframe, resulting in the orders being eight days overdue at the time of discharge. This lapse was confirmed by facility staff.
A resident did not receive the required physician visit and progress note within the mandated timeframe. The attending physician's last documented visit was over a month before discharge, resulting in the required review and documentation being overdue.
A resident experienced a fall and sustained an acute right humeral neck fracture. Despite the incident, there was no evidence that the resident's representative was immediately notified. The Administrator confirmed the lack of documentation regarding the notification during an interview.
A resident who sustained a fractured right humerus after a fall did not have a care plan developed to address the injury and decreased functional ability. Despite the fracture being confirmed by an x-ray, the facility did not create a care plan with interventions from the time of the injury until the resident's discharge. The Administrator confirmed the lack of a care plan during an interview with the surveyor.
The facility failed to maintain accurate clinical records for residents, including incomplete documentation of weights, meal intakes, and palliative care follow-up. A resident with heart failure and dementia did not have daily weights recorded as ordered, and another resident with Alzheimer's had missing meal intake records. Additionally, required neurological checks after a fall were not completed, and documentation for routine care tasks was lacking.
A resident experienced significant weight loss and decreased meal intake, but the facility failed to notify the physician of these changes. Despite orders for daily weight monitoring, weights were recorded only three times over 13 days. Interviews revealed that medical staff were not informed of the resident's nutritional concerns, contributing to the deficiency.
A facility failed to implement a baseline care plan within 48 hours for a resident admitted with heart failure. The care plan lacked goals and interventions for nutrition and diuretic medication use, despite provider orders for Furosemide. The DON confirmed the care plan was incomplete during a complaint investigation.
A resident experienced significant weight loss and reduced meal intake, which the facility failed to address according to its Nutrition/Hydration Care and Services policy. Despite multiple provider visits, there was no evidence of addressing the resident's nutritional concerns. The resident was later admitted to the emergency department in critical condition due to severe dehydration and renal failure, which could have been prevented with proper care.
A facility failed to monitor a resident for side effects of psychotropic medications, despite the resident's care plan indicating a risk for complications. The resident, with severe anxiety, depression, and delirium, was prescribed multiple psychotropic medications, but there was no documentation of monitoring for side effects. The DON confirmed the lack of monitoring during an interview.
The facility failed to assess a resident after a pacemaker surgery and did not complete an admission assessment for another resident. A resident returned with specific wound care orders, but the facility did not conduct a skin assessment or obtain wound care orders. Another resident's admission assessment lacked documentation of a pacemaker, despite family notification. The DON confirmed these deficiencies.
The facility failed to update and implement care plans for three residents, leading to deficiencies in monitoring and addressing their medical needs. A resident with a pacemaker was not monitored for complications, another's care plan was not updated after a hip replacement, and a third resident's care plan lacked goals for a pacemaker and communication needs. The Acting DON confirmed these findings.
A facility failed to assess and obtain wound care orders for a resident after pacemaker surgery. The cardiology department's attempts to contact the facility for post-op care were unsuccessful for five days, and the nurse was unaware of the resident's two wound sites. The clinical record lacked evidence of wound assessment and care orders, violating the facility's wound management policy.
The facility failed to provide residents and/or their representatives with written information concerning their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for 14 out of 17 residents reviewed. The Senior Director of Nursing confirmed these findings, indicating a systemic issue in the facility's admission process and record-keeping practices.
The facility failed to provide adequate housekeeping and maintenance services, resulting in unsanitary and uncomfortable conditions across multiple units, including dirty toilets, running toilets, holes in walls, stained carpets, and broken fixtures. These deficiencies were confirmed by facility staff during tours.
The facility failed to provide a continuous resident-centered activities program, as scheduled activities were not conducted, and proper documentation was lacking. A resident who expressed a strong preference for group activities was not informed about the activity schedule, and observations revealed that activities were either not started on time or not conducted as planned.
The facility failed to maintain a safe environment by not securing baseboard heating unit covers, exposing sharp edges and hot pipes, and by leaving hazardous chemicals unsecured in a resident room. These deficiencies were confirmed by the Administrator during the survey.
The facility failed to maintain a sanitary environment for respiratory care equipment for two residents. Unlabeled oxygen tubing and outdated nebulizer masks were observed, and there was no documentation of weekly changes as required.
The facility failed to complete annual performance evaluations for five CNAs, with the last evaluations conducted in 2021. The Market Clinical Advisor confirmed the lack of documentation for evaluations since 2021.
The facility failed to ensure proper vaccine storage temperatures for two medication storage room refrigerators. Observations revealed that the Spring Garden medication room refrigerator lacked evidence of temperature monitoring, and the Penobscot House medication room had incomplete temperature logs. The DON and RN were unaware of the requirement to document these temperatures.
The facility failed to label and date products in the walk-in refrigerator and freezer, and did not remove expired foods. Additionally, the facility did not accurately monitor and document freezer and dish machine temperatures, leading to discrepancies in recorded temperatures. These issues were confirmed by the Dietary Manager and the Market Clinical Advisor.
The facility failed to maintain complete and accurate clinical records for two residents. One resident's records lacked behavior monitoring for side effects of prescribed medications, while another resident did not receive scheduled doses of Lorazepam due to unavailability and lack of emergency kit access.
The facility failed to maintain an Infection Control Program, with surveyors observing improper storage of personal toileting items and medical supplies across three units. Bedpans and wash basins were found on the floor, and soiled hospital gowns, used gloves, and unlabeled urinals were noted in shared bathrooms. These findings were confirmed by the Administrator, Senior Director of Nursing, and Corporate Nurse Educator.
The facility failed to ensure that four out of five CNAs completed mandatory annual training in abuse prevention, resident rights, and dementia care. A review of personnel records revealed that the CNAs lacked evidence of completing the required training within the last twelve months, which was confirmed by the Market Clinical Advisor.
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which includes appeal rights and liability of payment, at least 2 days prior to the last covered day for two residents whose Medicare Part A services were discontinued. Both residents remained living in the facility, and the Administrator confirmed the notices were not provided.
The facility failed to refer two residents with specialized mental health diagnoses for a PASRR Level II evaluation when their stays extended beyond the expected 30 days. Both residents had initial PASRR Level I determinations for short-term stays, but the facility did not forward these to the State Mental Health Authority for further evaluation when their stays became long-term.
A facility failed to update and implement goals and interventions for a resident's antipsychotic medication use. The resident, diagnosed with dementia and major depressive disorder, had an active order for Risperdal, but the care plan lacked specific goals, interventions, and side effect monitoring. This was confirmed by the Senior DON during a record review.
The facility failed to revise the care plan for a resident who had fallen while using a walker. The resident's care plan indicated the need for extensive assistance with a wheelchair, but therapy notes and an interdisciplinary meeting confirmed the resident's use of a two-wheeled walker. The care plan was not updated to reflect this change.
The facility failed to follow physician orders for two residents. One resident did not receive prescribed Lorazepam for anxiety on two consecutive days. Another resident, admitted with benign non-nodular prostatic hyperplasia, had a urinalysis ordered but the results were not documented or available. Both deficiencies were confirmed by the Senior Director of Nursing.
A facility failed to follow treatment plans and maintain accurate records for a resident with pressure and venous ulcers. Dressings were not changed daily as required, and records inaccurately indicated compliance with physician's orders. The issue was confirmed by the Senior Director of Nursing.
The facility failed to ensure that two authorized individuals signed the Narcotic Bound Book Shift Count page at the change of shift for multiple shifts on the North Wind unit. The review revealed that the oncoming nurse failed to sign on three occasions, and the outgoing nurse failed to sign on two occasions. The LPN unit manager acknowledged that signatures are not currently audited but should be. The DON and Senior DON confirmed the findings.
A facility failed to document the justification for psychotropic medications prescribed to a resident with dementia and depression. The clinical record lacked psychotropic assessment, signed consents, and behavior monitoring, contrary to facility policy.
The facility failed to notify the resident, family, and/or the resident's representative in writing of transfers/discharges to an acute care hospital for two residents. Documentation lacked evidence of written transfer/discharge notices, confirmed during interviews with the Licensed Social Worker and the Senior Director of Nurses.
Failure to Document Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure neurological checks were completed according to orders and facility practice for a resident reviewed for falls. The resident, who had dementia and a history of falls, experienced an unwitnessed fall in their room on 12/12/25 at 6:30 a.m., where they were found lying on their right side on the floor and reported having gotten up and slid on the floor. The incident report documented that the resident was assessed with no injuries and that initial neuro checks were completed and passed, but the medical record contained no evidence that ongoing neuro checks were performed after this unwitnessed fall. A subsequent, witnessed fall in the hallway on 12/16/25 was documented with no head impact, no injuries, normal ROM and vital signs, and transfer back to a chair near the nurses’ station for close monitoring. During an interview, the DON stated that neuro checks are done for every unwitnessed fall and provided a neuro check sheet dated 12/16/25, which she believed was intended for the 12/12/25 fall, but at the time of review there was no documentation of neurological checks in the medical record for the 12/12/25 unwitnessed fall, confirming the deficiency.
Failure to Develop and Implement Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several newly admitted residents, as required by facility policy. Specifically, the baseline care plans for five residents did not include necessary goals and interventions related to their individual healthcare needs. For example, one resident with alcohol abuse did not have corresponding goals and interventions documented, and another resident with multiple mental health diagnoses and a Level II PASRR also lacked timely care planning. Additionally, a resident with severe protein-calorie malnutrition did not have dietary orders and instructions included in the baseline care plan until nine days after admission. Further deficiencies were noted for residents with dementia and repeated falls, as well as those with recent orthopedic surgery and specific dietary allergies. In these cases, the baseline care plans failed to specify the type and level of assistance required for activities of daily living (ADLs) and did not address dietary needs or allergies. These findings were confirmed through record reviews and interviews with the Market Lead Clinical Specialist, who acknowledged the absence of required care plan elements for the affected residents.
Incomplete and Inaccurate Clinical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For one resident, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2025 showed missing documentation for several required assessments and interventions, including diabetic foot checks, head of bed elevation for shortness of breath, encouragement of deep breathing for cough, and monitoring for side effects of psychotherapeutic medications during specific shifts. Additionally, documentation of the evening meal was missing on two dates in the resident's eating record. For another resident, the clinical record included a physician order for sliding scale insulin administration based on finger stick blood sugar (FSBS) results four times daily. However, the TAR for November 2025 lacked evidence of FSBS results and whether sliding scale insulin was administered or needed for several morning treatments. The Market Lead Clinical Specialist was unable to locate the missing documentation elsewhere in the record, and the surveyor confirmed these findings.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to comply with its abuse prohibition policy by not notifying the State Agency after potential abuse concerns were identified, not investigating allegations of potential abuse, and not submitting the results of any investigation within the required five business days. According to the facility's policy, any suspected or alleged abuse, mistreatment, or neglect must be reported to the appropriate authorities within two hours if serious bodily injury is involved, and an investigation must be initiated within 24 hours. However, documentation and interviews revealed that these steps were not followed after concerns were raised about a staff member being rough with a resident and causing pain to the resident's shoulder. A resident, who was found to be cognitively intact based on a Brief Interview for Mental Status (BIMS) score of 12 out of 15, reported being physically abused by a staff member, resulting in ongoing pain. The resident's representative and an Adult Protective Case Worker confirmed that the facility administrator was made aware of the allegations. Despite this, there was no evidence in the clinical record or incident reports that an investigation was conducted or that the incident was reported to the State Agency as required. The Market Lead Clinical Specialist also confirmed these failures during the survey.
Failure to Update Care Plan After Resident Leg Fracture
Penalty
Summary
The facility failed to update the care plan with appropriate goals and interventions after a resident sustained a left leg fracture. The resident, who had a history of dementia with psychotic disturbance and anxiety, was admitted in September and suffered a left leg fracture in October. Review of the clinical record showed that the care plan, last reviewed in August, did not reflect any updates or evidence of new goals and interventions following the fracture. This deficiency was identified during an annual survey and confirmed through interview and record review.
Failure to Follow Wound Care Orders and Policy for Pressure Ulcer Management
Penalty
Summary
Facility staff failed to follow provider orders and the facility's Skin Integrity and Wound Management policy for a resident with multiple wounds. The resident was admitted with a right heel that was pink and boggy and an open wound on the dorsal right foot. Provider orders directed staff to apply skin prep to both heels, ensure heels were offloaded, monitor skin integrity every shift, and perform specific wound care to the right dorsal/lateral foot. Despite these orders, documentation showed that nursing staff did not consistently monitor or describe the wounds as required, and weekly skin checks lacked adequate detail about the resident's wounds. A wound care consult later provided new daily care orders for three wounds, including cleansing with wound cleanser, applying Betadine, and leaving the wounds open to air. However, review of the Treatment Administration Records revealed that nursing staff did not initiate these new orders and continued with the previous wound care regimen. The resident was subsequently sent to the emergency room after being found with pressure sores on the heels, reportedly due to not being moved by staff. Nursing documentation did not reflect changes in the resident's wound condition, and daily monitoring as required by policy was not evident.
Failure to Maintain Adequate Weekend Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff on weekends during the first quarter reviewed, as evidenced by the Center for Medicare & Medicaid Services Payroll Based Journal (PPJ) Report. The report showed that the facility triggered for low weekend staffing for the period from 10/1/24 through 12/31/24. During an interview and review of staffing records with the Administrator and Scheduler, it was confirmed that the facility was not adequately staffed for 32 out of 39 weekend days reviewed. This deficiency was identified through record review, interviews, and analysis of the PPJ report, with the Administrator acknowledging the staffing shortfall during the specified period.
Failure to Maintain Sanitary and Comfortable Environment Facility-Wide
Penalty
Summary
Surveyors observed multiple failures in housekeeping and maintenance services across all facility wings, the laundry room, and a hallway. Specific findings included an uncovered outdoor trash bin with exposed garbage, stained ceiling tiles, a torn window screen in the laundry room, and a soiled laundry room floor. In resident rooms, issues included marred bathroom walls, ripped wheelchair armrests, hanging heater covers, chipped paint, missing sealant on furniture, dirty floors, and liquid around toilets. Additional observations included loose grab bars, broken and missing laminate on counters and cabinets, and missing or damaged privacy curtain hooks. Common areas and entrance doors were noted to have chipped or missing paint and black marks, creating uncleanable surfaces. The environmental tour also revealed food debris and dirt on patient lift equipment and marred walls in communal areas. These deficiencies were confirmed by both the Senior Maintenance Director and the Administrator during the survey. The report does not mention any specific residents' medical histories or conditions at the time of the deficiency, nor does it detail any immediate harm, but it documents the facility's failure to maintain a sanitary, orderly, and comfortable environment as required.
Failure to Provide Resident-Centered Activities and Document Participation
Penalty
Summary
The facility failed to provide a continuous, resident-centered activities program as required by its own policy and the care plan of a resident who is bedbound, cognitively intact, and has diagnoses including schizoaffective disorder and major depression. The resident's care plan and MDS indicated that it was very important for them to keep up with news, attend favorite activities, listen to preferred music, and participate in religious services. Despite these documented preferences, reviews of the activity calendars and participation records for two consecutive months showed no evidence that the resident was invited to, refused, or participated in scheduled activities such as BINGO, live music, or church services. The activity calendar was posted in a location not visible to the resident, and the resident reported being unaware of activities, expressing a desire to have been informed about them. Interviews with the Activity Director confirmed that bedbound residents or those not interested in group activities should receive one-on-one engagement at least twice a month and should still be invited to activities of their choice. However, there was no documentation that the resident was offered or refused such activities or one-on-one sessions. The Market Clinical Advisor also stated that offers and refusals should be documented daily, but this was not done for the resident in question. This lack of documentation and failure to invite or offer activities as per the resident's preferences and care plan constituted the deficiency.
Unsecured Chemicals, Environmental Hazards, and Improper Oxygen Tank Storage
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision within the facility. Chemicals including air freshener, hand sanitizer, and pre-toilet spray were found unsecured in an unlocked office on the administrative wing, an area accessible to residents. Safety Data Sheets for these chemicals indicated the need for immediate medical attention in case of exposure, and the Clinical Lead confirmed that residents had access to these unsecured chemicals. Additionally, a container of laundry detergent was found stored on the floor in a resident bathroom, also accessible to residents. Environmental hazards were observed on two units, where room, closet, and bathroom doors had chipped and splintered laminate with sharp edges, creating unsafe conditions. These hazards were present in multiple resident rooms and common areas, as confirmed by the Administrator and Senior Maintenance Director. In one instance, a toilet was found loose and not secured to the floor, further contributing to the unsafe environment. Oxygen tanks were not stored securely on at least one occasion. An LPN was observed placing an unsecured oxygen tank on the floor behind a resident’s wheelchair, and another unsecured tank was found standing upright against a wall in a resident room. Staff interviews confirmed that oxygen tanks should not be left unsecured and that empty tanks should be stored in a designated storage closet. These findings were acknowledged by facility leadership during interviews.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
Surveyors observed multiple sanitation and maintenance deficiencies in the facility's kitchen during an inspection. The hood over the dishwashing machine was found to be dusty with rust build-up, and the dish room contained a wall-mounted fan, ceiling vent, and ceiling grid system that were all dusty or dirty. Two ceiling lights in the dish room had visible dirt and debris in their lenses. The floor in front of the dish machine had a large section of missing laminate, exposing untreated cement, and the 3-bay pot sink had a chemical hose hanging down into the center bay. Additional issues included two stained ceiling tiles in the kitchen hallway, two heavily soiled kitchen ceiling vents, and a food slicer with dried food particles on the blade and shroud. The cement floor in front of the stove and one kitchen exit door had chipped or missing paint, creating uncleanable surfaces. The kitchen office was missing nine ceiling tiles. In the walk-in freezer, a package of fish patties and an open bag of pizza crusts were found unsecured, undated, and unlabeled. Trash and debris were also observed scattered across the freezer floor. These findings were confirmed by the Head and a kitchen aide during the inspection, and later discussed with the Food Service Director. The facility's failure to maintain a clean and sanitary kitchen environment, as well as to properly store and label food items, was documented based on these direct observations.
Failure to Complete Post-Fall Neurological Assessments and Timely Wound Care
Penalty
Summary
The facility failed to properly assess and monitor a resident following unwitnessed falls, as well as failed to follow its own Fall Management and Neurological Evaluation policies. Specifically, after two separate unwitnessed falls, the resident did not receive the required neurological assessments for the full 72-hour monitoring period. Documentation showed that only a portion of the required neurological checks were completed, with significant gaps in monitoring after the initial hours post-fall. The facility's policies required frequent neurological checks after any unwitnessed fall or head injury, but these were not consistently performed or documented. Additionally, the facility did not ensure that another resident received appropriate wound care for pressure ulcers upon admission. Despite a hospital wound care note recommending specific wound care orders and a follow-up appointment, there was no evidence that these orders were implemented or that new orders were obtained in a timely manner. Wound care orders were not entered until 13 days after admission, and there was no documentation that the resident was taken to the recommended wound care follow-up appointment. The same resident also required monitoring and care for an indwelling Foley catheter, including regular output measurement and catheter care as outlined in the care plan. However, the clinical record lacked evidence that output was consistently measured and recorded, and there was no documentation of catheter care being performed as required. These deficiencies were confirmed through record review and staff interviews.
Incomplete Clinical Documentation and Communication Failures
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents, resulting in deficiencies related to documentation and communication. For one resident with severe vascular dementia and a history of frequent falls, the clinical record did not contain evidence that the family was contacted to discuss goals of care after a significant change in condition, as indicated in the provider's note. Additionally, after the resident experienced an unwitnessed fall, there was no documentation that neurological checks were performed, despite facility policy and staff acknowledgment that such checks are required and should be recorded. Another resident with congestive heart failure and an indwelling Foley catheter had provider orders for daily weights and output monitoring, as well as catheter care and monitoring for signs of infection. The clinical record lacked evidence that daily weights were consistently obtained or documented, and there were multiple shifts where output measurements were not recorded. Staff interviews confirmed that these required assessments and documentation were not completed as ordered. A third resident, recently admitted with severe protein calorie malnutrition and adult failure to thrive, had multiple progress notes indicating that palliative and hospice consults were discussed and planned with the family. However, the clinical record did not contain evidence that these consults were actually obtained or ordered prior to the resident's death. Staff interviews revealed uncertainty about whether referrals were made and indicated that the resident's participation in skilled services delayed the hospice referral, which was not documented clearly in the progress notes.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
A deficiency was identified when a resident with diagnoses of generalized anxiety and bipolar disorder was re-admitted to the facility for permanent LTC placement. The resident's clinical record included a PASRR Level I Screen, which was completed for a change in condition and indicated the intent for permanent placement. However, the record did not contain evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority to determine if a PASRR Level II evaluation and determination was necessary. This omission was confirmed through record review and interview with facility staff.
Failure to Timely Notify Family of Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant incident involving a fall. According to the medical record, a resident experienced an unwitnessed fall in the bathroom, was found on the floor with complaints of low back pain, and was assessed for injuries. Nursing documentation indicated that the fall occurred in the evening, but there was no evidence that the family was notified of the incident until the following day, approximately 17 hours later, during an Interdisciplinary Team (IDT) meeting. The family confirmed they had not been informed of the fall until that time. Facility policy requires immediate notification of the resident, physician, and representative in the event of an incident resulting in injury with the potential for requiring physician intervention. The facility's Falls Management Policy also specifies that the resident's representative should be notified of any fall and subsequent follow-up treatment. The lack of timely notification to the family was confirmed through record review and interview, demonstrating noncompliance with both facility policy and regulatory requirements.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent and accessible location for three consecutive days. On the morning of 4/14/25, surveyors observed that the posted nurse staffing information was outdated, displaying the date 4/11/25. During an interview on 4/15/25, the Market Clinical Advisor confirmed that the required nurse staffing information was not posted on 4/12/25, 4/13/25, and 4/14/25.
Failure to Update Care Plan for Newly Discovered Pressure Ulcer
Penalty
Summary
The facility failed to review, revise, and update the care plan for a resident after a new pressure ulcer was discovered. The resident had an admission care plan dated 12/19/24 that addressed risk for skin breakdown. However, after being diagnosed with a Stage 3 pressure ulcer on the sacrum on 1/15/25, there was no evidence that the care plan was updated to reflect the resident's new skin care needs. This deficiency was confirmed during a record review and interview with the Director of Nursing and the Marketing Clinical Advisor.
Failure to Complete Physician-Ordered Wound Clinic Referral
Penalty
Summary
A physician order for a wound clinic consultation was not followed for a resident with a Stage 3 pressure ulcer on the sacrum. After being evaluated in the hospital emergency department for lightheadedness, the resident returned to the facility with instructions from the ED for a referral to the hospital wound clinic. The primary physician signed the order for the wound clinic referral, and a facility nurse noted the order. However, the referral was not completed, as confirmed by the Nurse Manager during an interview with the surveyor. This deficiency was identified through record review and staff interview, and it specifically involved the failure to carry out a physician-ordered wound clinic consultation for the resident.
Physician Review and Signature of Orders Not Completed Timely
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care and signed the necessary medication and treatment orders within the required timeframe. Specifically, the resident's clinical record showed that the physician last signed the 30-day block orders on 12/10/24, but did not review or sign the subsequent block order by the required date, even after accounting for a 10-day grace period. As a result, the physician's review and signature were eight days overdue at the time of the resident's discharge. This deficiency was confirmed during an interview with the Marketing Clinical Advisor, who acknowledged the lapse in timely physician review and signature.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the attending physician conducted required visits and documented progress notes for a resident as mandated. Clinical record review showed that the resident was admitted on a specified date and received a physician visit on 12/10/24. However, the subsequent required 30-day physician visit, including the 10-day grace period, was due on 1/20/25 but did not occur. There were no further physician visits or progress notes documented before the resident's discharge. This was confirmed during an interview with the Marketing Clinical Advisor, who acknowledged that the last physician visit was on 12/10/24, resulting in the required review and progress note being 8 days overdue at discharge.
Failure to Notify Resident's Representative of Fall and Fracture
Penalty
Summary
The facility failed to notify the resident's representative of a fall resulting in a fracture. A review of the clinical record for Resident #1 revealed that on December 23, 2024, the resident experienced a fall and subsequently complained of right shoulder pain. A medical provider ordered x-rays, and a radiology report dated December 24, 2024, confirmed an acute right humeral neck fracture. However, there was no evidence that the resident's representative was immediately informed of the fall and the resulting fracture. During an interview on January 22, 2025, the Administrator acknowledged the absence of documentation indicating that the resident's representative was promptly notified of the incident.
Failure to Develop Care Plan for Fractured Humerus
Penalty
Summary
The facility failed to develop a care plan for a resident who experienced a change in condition due to a fractured right humerus. On 12/23/24, the resident had a fall and complained of right shoulder pain, leading to an x-ray order. The radiology report on 12/24/24 confirmed an acute right humeral neck fracture. However, from 12/24/24 until the resident's discharge on 1/19/25, there was no evidence of a care plan with interventions to guide staff in managing the fracture and the resident's decreased functional ability to use the upper extremity. On 1/22/25, during an interview with the surveyor, the Administrator confirmed the absence of a care plan addressing the resident's fractured arm, indicating a lapse in the facility's responsibility to ensure comprehensive care planning for the resident's needs.
Deficiencies in Clinical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for several residents, leading to deficiencies in the areas of weight monitoring, meal intake documentation, palliative care follow-up, fall management, and resident positioning. For Resident #1, who was diagnosed with heart failure, dementia, and severe anxiety, the facility did not consistently document daily weights as ordered, with only three weights recorded over a 13-day period. Additionally, there were multiple instances of missing meal intake documentation throughout December 2024. Despite a hospital discharge summary indicating a referral for palliative care, there was no evidence in the clinical record that this was followed up on by the facility. Resident #1 also experienced an unwitnessed fall on December 28, 2024, but the required neurological checks were not completed according to the facility's policy. The Director of Nursing confirmed that the neurological evaluation flow sheet was incomplete and had been improperly discarded. There was no documentation of an order to discontinue the neurological checks, indicating a lapse in following the facility's fall management policy. For Resident #2, who has Alzheimer's disease, dementia, and heart failure, the facility failed to document weights on two specified dates and did not provide reasons for these omissions. The resident's meal intake records were also incomplete, with several missing entries for breakfast, lunch, and dinner throughout December 2024. Additionally, there was a lack of documentation for the task of checking and changing the resident every two hours, as required. The Unit Manager acknowledged these documentation issues, indicating an ongoing problem within the facility.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced a change in meal intakes and significant weight loss. The resident, who was admitted with diagnoses including urinary tract infection, congestive heart failure, dementia, severe anxiety, and delirium, had orders for daily weight monitoring due to congestive heart failure. However, daily weights were only recorded three times over a 13-day period, and the resident experienced a 23-pound weight loss. Despite these changes, there was no evidence that the provider was notified of the significant weight change or the resident's decreased meal intake. Interviews with facility staff, including a medical doctor, unit manager, nurse practitioner, and registered dietitian, revealed that none were adequately informed of the resident's nutritional concerns or weight loss. The medical doctor expected to be notified within 24-48 hours if weights were not being recorded as ordered, and the registered dietitian was not aware of the resident's inadequate eating until reviewing the clinical record. The lack of communication and failure to notify the appropriate medical providers of the resident's condition changes contributed to the deficiency identified during the complaint investigation.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, as required by their policy. The policy, dated 10/24/22, mandates that a baseline person-centered care plan must be created within 48 hours of admission, including necessary healthcare information to provide effective care. However, for one resident admitted for skilled care services with a diagnosis of heart failure, the baseline care plan lacked goals and interventions related to nutrition and the use of diuretic medications. The deficiency was identified during a complaint investigation, where it was found that the resident's provider orders included a prescription for Furosemide, a diuretic, to be administered daily for fluid overload. Despite this, the baseline care plan did not address the use of this medication or include relevant nutritional goals. The Director of Nursing confirmed during an interview that the care plan was incomplete and did not meet the facility's expectations for timely completion within the 48-hour window.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to adequately address significant weight loss and reduced meal intake for Resident #1, as identified during a complaint investigation. The facility's policy on Nutrition/Hydration Care and Services requires staff to provide nutritional and hydration care consistent with the patient's comprehensive assessment, including consulting with a dietitian and obtaining necessary orders. However, Resident #1 experienced a 12.20% weight loss, with meal intakes recorded at 25% or less for a significant number of meals. Despite being seen by a provider on multiple occasions, there was no evidence that weight loss or nutrition concerns were addressed during these visits. Additionally, the admission Dietary Screening for Malnutrition was delayed, and the nutritional assessment lacked a complete evaluation and plan. Interviews with facility staff revealed a lack of communication and follow-up regarding Resident #1's nutritional status. The Medical Doctor and Nurse Practitioner were not informed of the resident's weight loss or decreased intake, and the Registered Dietitian was unaware of these issues until conducting an initial record review. The resident was later admitted to the emergency department in a critical state, with severe dehydration and renal failure, which was attributed to inadequate nutrition and hydration management. The emergency room doctor noted that the resident's condition could have been prevented with proper care.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor for side effects of psychotropic medications for a resident during a complaint investigation. The resident, who was admitted for skilled care services, had diagnoses including severe anxiety, depression, and delirium. The care plan for the resident, initiated on December 19, 2024, indicated a risk for complications related to the use of psychotropic drugs, with a goal to maintain the smallest effective dose without side effects. The intervention required monitoring for changes in mental status and functional level, with reporting to the medical doctor as needed. Despite these requirements, a review of the resident's clinical record showed a lack of evidence that the resident was monitored for side effects of the prescribed psychotropic medications. The active orders for December 2024 included multiple anti-anxiety and antipsychotic medications, yet there was no documentation of monitoring for side effects. During an interview, the Director of Nursing confirmed that the resident was not being monitored for side effects of the psychotropic medications, indicating a deficiency in the facility's medication management practices.
Failure to Assess Residents Post-Surgery and Upon Admission
Penalty
Summary
The facility failed to properly assess a resident after returning from a surgical procedure and did not complete an admission assessment for another resident. Resident #1 returned to the facility after a pacemaker battery replacement surgery with specific wound care orders for the right groin area and left chest wall. However, the facility did not conduct a skin assessment or obtain wound care orders upon the resident's return. The cardiology department attempted to contact the facility multiple times regarding post-operative wound care but was unable to reach the staff until five days later. During this time, the nurse was unaware of the surgical site on the resident's left chest, indicating a lack of communication and documentation. Resident #3 was admitted with a history of peripheral vascular disease and hypertension, and was observed with a pacemaker monitor on the bedside table. Despite this, the resident's clinical record did not include any information about the pacemaker, and the admission assessment was incomplete. The resident's family confirmed that the facility was informed about the pacemaker during admission. The RN interviewed was unaware of the pacemaker and acknowledged that a skin check and treatment orders should have been completed during the admission assessment. The Acting Director of Nursing confirmed the deficiencies in both cases.
Failure to Update and Implement Care Plans for Residents
Penalty
Summary
The facility failed to update and implement care plans for three residents, leading to deficiencies in monitoring and addressing their medical needs. Resident #1, who was admitted with heart failure, hypertension, and a complete atrioventricular block requiring a pacemaker, had a care plan initiated on 2/2/24. However, the clinical record lacked evidence of monitoring for pacemaker complications such as shortness of breath, weakness, syncope, fatigue, cyanosis, and bradycardia, as outlined in the care plan. Resident #2, admitted with osteoarthritis and a recent total right hip replacement, had a care plan initiated on 11/15/23. The care plan was not updated following a left total hip replacement on 3/13/24, despite the discharge summary indicating the need for dressing changes at the first post-op appointment. Resident #3, with peripheral vascular disease and significant hearing loss, had a care plan initiated on 5/22/24 that lacked goals and interventions for a pacemaker and communication needs. The resident's family had informed the nurse of the pacemaker upon admission, but this was not reflected in the care plan. The Acting Director of Nursing confirmed these findings during an interview.
Failure to Assess and Obtain Wound Care Orders
Penalty
Summary
The facility failed to adequately assess and obtain wound care orders for a resident who underwent a surgical procedure for pacemaker battery replacement. The cardiology department made multiple attempts to contact the facility for post-operative wound care instructions but was unable to reach the facility staff until five days later. Upon contact, the nurse was unaware of the resident's two wound sites, indicating a lack of proper communication and documentation. The resident's clinical record lacked evidence of surgical wound assessment upon return to the facility, and there were no orders obtained or entered for wound care for the pacemaker insertion site on the left upper chest. The facility's policy on skin integrity and wound management requires following specific orders from the surgeon and implementing special wound care treatments as indicated. However, the facility did not adhere to this policy, as confirmed by the Acting Director of Nursing. The Licensed Practical Nurse (LPN) reviewed the resident's clinical record and confirmed the absence of a nurse-to-nurse report, skin assessment, and wound care orders. This deficiency highlights a significant lapse in communication and adherence to wound care protocols, resulting in inadequate care for the resident's surgical wounds.
Failure to Provide Written Information on Medical Rights and Advance Directives
Penalty
Summary
The facility failed to provide residents and/or their representatives with written information concerning their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for 14 out of 17 residents reviewed for advance directives. The facility's policy mandates that residents be informed and provided with written information about their rights upon admission, but this was not adhered to in multiple cases. For instance, Resident #5, Resident #14, Resident #19, Resident #21, Resident #22, Resident #26, Resident #27, Resident #34, Resident #44, Resident #49, Resident #52, Resident #54, Resident #58, and Resident #219 all had clinical records that lacked evidence of receiving the required written information. In one specific case, Resident #27, who was cognitively intact, indicated during an interview that they believed they had provided an advance directive upon admission, but no such document was found in their clinical record. The Senior Director of Nursing confirmed these findings during an interview, acknowledging that the facility did not comply with its policy to inform residents about their rights and document advance directives. This oversight indicates a systemic issue in the facility's admission process and record-keeping practices, affecting the residents' ability to make informed decisions about their medical care.
Inadequate Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across four units, the laundry room, and hallways. During a tour of the Spring Gardens Unit, surveyors observed a shower room with personal items left on the sink, multiple resident rooms with visibly dirty toilets, running toilets, holes in the walls, dirty and cluttered floors, and stained sinks. These observations were confirmed by the Corporate Nurse Educator (CNE) during the tour. On a subsequent environmental tour, additional deficiencies were noted in the laundry room, North Wind, Penobscot House, and Windward Center units. The laundry room had cracked tiles and chipped paint, while North Wind had uncleanable surfaces, stained carpets, and broken bathroom fixtures. Penobscot House had missing countertop edging and dirty wheelchairs, and Windward Center had dirty floors, marked walls, and missing toilet tank lids. These findings were confirmed by the Senior Maintenance Director, the Administrator, and the Housekeeping/Laundry Supervisor.
Failure to Provide Continuous Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide a continuous resident-centered activities program, as evidenced by the lack of scheduled activities being conducted and the absence of proper documentation. Resident #10, who is cognitively intact and expressed a strong preference for participating in group activities such as BINGO, was not informed about the activity schedule and did not have an activity calendar in their room. Despite BINGO being scheduled multiple times in April 2024, there was no evidence that Resident #10 was invited or declined to join these activities. Observations on 4/22/24 and 4/23/24 revealed that no activities were held as scheduled, and the Activities Director confirmed that they had been out for 10 days and were catching up on assessments instead of conducting activities. Further observations on 4/24/24 and 4/25/24 showed that scheduled activities were either not started on time or not conducted as planned. The activity room was often empty or had minimal participation, and staff did not actively encourage residents from other units to join. Interviews with the Senior Director of Nursing and the Director of Nursing indicated that the expectation was for activities to be offered daily and documented, and for residents to be in the activity room when activities start. However, these expectations were not met, leading to a failure in providing a continuous resident-centered activities program for all residents.
Failure to Ensure Safe Environment and Secure Chemicals
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards relating to baseboard hot water heating units and unsecured chemicals. During observations on the Penobscot House Unit, surveyors noted that in multiple resident rooms, baseboard heating unit covers were either partially off or missing sections, exposing sharp metal edges and hot pipes. These deficiencies were confirmed by the Administrator during the survey. Additionally, in one resident room, surveyors found unsecured containers of disinfectant wipes, fabric softener, and laundry detergent, which pose potential health risks as outlined in their respective Safety Data Sheets (SDS). The SDS for these chemicals indicated various first aid measures for exposure, including skin and eye contact, inhalation, and ingestion, highlighting the potential hazards of having these chemicals unsecured in resident areas. The observations and interviews conducted during the survey revealed that the facility did not maintain a safe environment for its residents. The exposed hot pipes and sharp metal edges from the baseboard heating units present a risk of burns and cuts, while the unsecured chemicals pose risks of skin irritation, eye damage, and respiratory issues. These findings indicate a failure to provide adequate supervision and hazard prevention measures, as confirmed by the Administrator during the survey.
Failure to Maintain Sanitary Respiratory Care Equipment
Penalty
Summary
The facility failed to provide a sanitary environment to prevent the development and transmission of disease and infection related to oxygen and nebulizer mask/tubing for two residents. For Resident #19, the surveyor observed unlabeled oxygen tubing on two occasions, and the clinical record lacked an order or documentation for weekly tubing changes. The Senior Director of Nursing confirmed that the tubing had not been changed weekly. For Resident #49, the surveyor observed a nebulizer mask stored on the nightstand with a date of 4/1/24, and the resident stated they used the nebulizer twice daily. The medical record lacked evidence of an order or documentation for weekly changes of the nebulizer mask and tubing. The Senior Director of Nursing confirmed that the nebulizer masks should be rinsed, air-dried, and stored in a plastic bag, and all oxygen-related tubing should be changed weekly.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations at least every 12 months for five sampled Certified Nursing Assistants (CNAs). Specifically, CNA #1, hired on 2/4/2019, had their last evaluation in 2021, with no evaluations for 2022 and 2023. CNA #2, hired on 2/4/2020, also had their last evaluation in 2021, with no evaluations for 2022 and 2023. CNA #3, hired on 4/5/2021, had no evaluations for 2022 and 2023. CNA #4, hired on 10/12/2021, had no evaluations for 2022 and 2023. CNA #5, hired on 7/2/2018, had their last evaluation in 2021, with no evaluations for 2022 and 2023. The Market Clinical Advisor confirmed the lack of documentation for these evaluations since 2021 during an interview on 4/25/24 at 9:30 a.m.
Failure to Monitor Vaccine Storage Temperatures
Penalty
Summary
The facility failed to ensure proper vaccine storage temperatures for two medication storage room refrigerators, specifically in Spring Harbor and Penobscot House. During an observation on April 23, 2024, surveyors and the Director of Nursing (DON) noted that the Spring Garden medication room refrigerator, which contained three vials of influenza vaccine, lacked evidence of temperature monitoring. The DON confirmed that refrigerator temperatures should be monitored daily, but this was not being done at the time of the observation. Additionally, during an observation of the Penobscot House medication room, a surveyor found that the Temperature Log for Medication/Vaccine Refrigerators lacked entries for the period from April 1, 2024, through April 15, 2024. The Registered Nurse (RN#1) indicated that she was unaware of the requirement to document these temperatures. The Senior Director of Nursing was unable to provide temperature logs for the period from January 1, 2024, through April 15, 2024, confirming that the facility did not start monitoring vaccine storage temperatures until April 16, 2024.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure that products in the walk-in refrigerator and freezer were labeled and dated, and did not remove expired foods. During a kitchen tour, several expired items were found in the walk-in refrigerator, including an opened bottle of horseradish, a container of lobster base, a container of Gochujang red pepper paste, and a bottle of kiwi lime flavored dessert sauce. Additionally, the walk-in freezer contained two bags of patties and one bag of pizza dough crust that were not labeled or dated. The Dietary Manager confirmed these findings and removed the expired and unlabeled items. The facility also failed to accurately monitor and document freezer and dish machine temperatures. Temperature logs for the freezer showed consistent readings of 0 degrees for several months, despite the freezer being out of order for a period. The Dietary Manager admitted that the documented temperatures were not accurate. Furthermore, the dish machine's wash cycle temperatures were consistently recorded as 155 degrees, and rinse temperatures as 180 degrees, which was not reflective of actual observed temperatures. The Senior Maintenance Director identified an issue with the dishwasher screen, which affected the wash cycle temperatures. These inaccuracies in temperature monitoring and documentation were confirmed by the Dietary Manager and the Market Clinical Advisor.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. Resident #10, who was admitted with diagnoses including dementia and major depressive disorder, had active orders for Risperdal and Zoloft. However, the clinical record lacked evidence of behavior monitoring for side effects for both medications. This deficiency was confirmed during a review of the resident's entire clinical record with the Senior Director of Nursing. For Resident #219, there was an order for Lorazepam to be administered twice daily for anxiety. However, the medication was not available when scheduled, and the resident did not receive the medication on two occasions. The facility has an emergency kit for such situations, but there was no documentation that the emergency kit was accessed, nor was there a call to the pharmacy for an override code. The Senior Director of Nursing confirmed that the MAR documentation was inaccurate and that the resident did not receive the medication as required.
Infection Control Deficiency Due to Improper Storage and Sanitation
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to prevent cross-contamination and infection. On multiple occasions, surveyors observed improper storage of personal toileting items and medical supplies across three units: Windward Gardens, Penobscot, and Spring Gardens. Specifically, bedpans and wash basins were found on the floor in shared bathrooms, which does not support good infection control practices. These observations were confirmed by the Administrator and the Senior Director of Nursing during interviews. Additionally, surveyors noted soiled hospital gowns, used gloves, and unlabeled urinals in shared bathrooms on the Spring Gardens unit. A bariatric commode containing urine and a bedpan with an emergency call bell string resting inside were also observed. These findings were confirmed during a tour with the Corporate Nurse Educator. The facility's failure to maintain a sanitary environment and properly store medical supplies and personal items contributed to the deficiency in their infection control program.
Failure to Provide Mandatory Training for CNAs
Penalty
Summary
The facility failed to implement and maintain an effective training program for its Certified Nursing Assistants (CNAs), specifically in the areas of abuse prevention, resident rights, and dementia care. During a review of employee personnel records, it was found that four out of five CNAs did not complete the required annual training. CNA #1, hired on 2/4/2019, lacked evidence of resident rights education and dementia training within the last twelve months. CNA #2, hired on 2/4/2020, lacked evidence of abuse education, resident rights education, and dementia training within the last twelve months. CNA #4, hired on 10/12/2021, lacked evidence of resident rights education within the last twelve months. CNA #5, hired on 7/2/2018, lacked evidence of abuse education, resident rights education, and dementia training within the last twelve months. The Market Clinical Advisor confirmed these deficiencies during an interview.
Failure to Provide SNFABN Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form 10055, which includes appeal rights and liability of payment, at least 2 days prior to the residents' last covered day for two residents whose Medicare Part A services were discontinued. Resident #274's Medicare Part A coverage for skilled services ended on 11/24/23, and the medical record lacked evidence that the resident or their legal representative was provided a SNFABN. Similarly, Resident #276's Medicare Part A coverage for skilled services ended on 3/14/24, and there was no evidence that the resident or their legal representative received a SNFABN. Both residents remained living in the facility. The Administrator confirmed during an interview that the SNFABN notices were not provided to these residents.
Failure to Refer Residents for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that two residents with specialized mental health diagnoses, whose stays extended beyond the expected 30 days, were referred to the appropriate state-designated authority for a PASRR Level II evaluation and determination. Resident #34 was admitted with a diagnosis of Bipolar Disorder and had a PASRR Level I determination letter indicating no further evaluation was required for a short-term stay. However, when Resident #34's stay extended to long-term, the facility did not forward the PASRR Level I to the State Mental Health Authority for a Level II evaluation. Similarly, Resident #52 was admitted with diagnoses of Bipolar Disorder and Borderline Personality Disorder and also had a PASRR Level I determination letter for a short-term stay. When Resident #52's stay extended to long-term, the facility again failed to forward the PASRR Level I to the State Mental Health Authority for a Level II evaluation. The Market Clinical Advisor confirmed that the necessary referrals were not made for both residents after their stays changed from short-term to long-term.
Failure to Update and Implement Antipsychotic Medication Care Plan
Penalty
Summary
The facility failed to update and implement goals and interventions for the use of antipsychotic medication for a resident diagnosed with dementia and major depressive disorder. The resident was admitted to the facility with an active order for Risperdal, an antipsychotic medication, to be administered twice daily for mood stabilization and agitation. However, a review of the resident's clinical record revealed that the care plan lacked specific goals, interventions, and monitoring for side effects related to the antipsychotic medication. This deficiency was confirmed by the Senior Director of Nursing during the review.
Failure to Revise Care Plan for Resident's Current Ambulation Status
Penalty
Summary
The facility failed to revise the care plan to reflect a resident's current status for one of the residents reviewed for falls. During an interview, the resident stated that they lost their balance and fell, hitting their head while attempting to use their walker to go to the dining room. The resident's care plan, initiated on 2/22/24, indicated the need for extensive assistance with ambulation using a wheelchair. However, therapy notes from 3/7/24 showed that the resident had met goals for safely ambulating on level surfaces using a two-wheeled walker with contact guard assist. An interdisciplinary meeting on 3/13/24 confirmed the resident's use of a two-wheeled walker for short distances with contact guard assist. Despite these updates, the care plan was not revised to reflect the resident's current ambulation status, as discussed during an interview with the Senior Director of Nursing on 4/24/24.
Failure to Follow Physician Orders for Medication and Laboratory Tests
Penalty
Summary
The facility failed to follow physician orders for two residents. Resident #219 had a medication order for Lorazepam to be administered twice daily for anxiety, but did not receive the medication on two consecutive days. This was confirmed by the Senior Director of Nursing. Resident #269, who was admitted with a diagnosis of benign non-nodular prostatic hyperplasia with lower urinary tract symptoms, had a provider's order for a urinalysis culture and sensitivity test. Although the urinalysis was obtained and signed off, there were no records of the laboratory results in the resident's medical record or available through the laboratory used by the facility. This was also confirmed by the Senior Director of Nursing.
Failure to Follow Wound Care Treatment Plans and Maintain Accurate Records
Penalty
Summary
The facility failed to ensure that treatment plans were followed and resident records were accurate for a resident with pressure and venous ulcers. The resident was admitted with a pressure ulcer on the right hip and venous ulcers on both shins. Provider orders specified daily wound care for these ulcers, including cleansing and applying specific dressings. However, during an observation, it was found that the dressings on all three wounds were dated two days prior, indicating they had not been changed as required. The treatment administration record inaccurately indicated that the dressings had been changed daily, as per the physician's orders. The Senior Director of Nursing confirmed the failure to follow the physician's orders and the treatment plan, as well as the inaccuracy in the resident's records. The care plan for the pressure ulcer also specified that wound care should be provided per treatment order, which was not adhered to. This discrepancy was observed and confirmed by both the surveyor and the registered nurse performing the dressing change.
Failure to Sign Narcotic Bound Book Shift Count
Penalty
Summary
The facility failed to ensure that two authorized individuals signed the Narcotic Bound Book Shift Count page at the change of shift for multiple shifts between 4/11/24 and 4/22/24 on the North Wind unit. According to the Genesis HealthCare policy, a complete count of all Schedule II-IV controlled substances is required at the change of shifts, and the count must be performed by two licensed nurses or authorized personnel. However, the review of the bound medication book revealed that the oncoming nurse failed to sign the shift count page on three occasions, and the outgoing nurse failed to sign on two occasions. During an interview, the LPN unit manager demonstrated the shift change process and acknowledged that signatures are not currently audited but should be. The Director of Nursing and Senior Director of Nursing confirmed the findings.
Lack of Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide documentation justifying the use of psychotropic medications for a resident diagnosed with dementia, depression, and major depressive disorder. The resident was prescribed Risperdal and Zoloft, but the clinical record lacked evidence of psychotropic assessment, signed consents, or side effect/behavior monitoring for these medications. This deficiency was identified during a review of the resident's clinical record by the Senior Director of Nursing (Corporate). The facility's policy on psychotropic medication use requires that all medications used to treat behaviors must have a clinical indication, be used in the lowest dose to achieve the desired therapeutic effect, and be monitored for efficacy, risks, benefits, and adverse consequences. Additionally, antipsychotic medications used to treat behavioral or psychosocial symptoms of dementia must be clinically indicated and supported by adequate rationale. The facility did not adhere to these policies, as there was no documentation of a comprehensive assessment, informed consent, or behavior monitoring for the resident receiving psychotropic medications.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to notify the resident, family, and/or the resident's representative in writing of transfers/discharges to an acute care hospital for two residents. Documentation in Resident #5's clinical record indicated transfers to the hospital on 11/22/23 and 11/24/23, but there was no evidence of written transfer/discharge notices provided to the resident or their representative. Similarly, Resident #49 was transferred to the hospital on 4/17/24, and the clinical record lacked evidence of a written transfer/discharge notice. These findings were confirmed during interviews with the Licensed Social Worker and the Senior Director of Nurses.
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Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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