Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windward Gardens during CMS and state inspections, most recent first.
The facility failed to maintain a clean, sanitary, and orderly environment on one unit, as evidenced by multiple rooms with food debris on floors, overflowing trash cans (some without liners), and unbagged soiled washcloths left on over‑bed tables, floors, sinks, and in wash basins. Additional items such as non‑skid socks, plastic utensils, a sheet, and a trash bag were left on floors, while medical items including nebulizer and oxygen tubing, a tubigrip stocking, and medicine cups with residual substances were improperly stored or discarded. A resident reported that a night shift staff member left an overflowing bathroom trash can unemptied at the end of her shift, and leadership confirmed that environmental concerns had been identified on the affected units.
A resident with atrial fibrillation was receiving Eliquis (apixaban) twice daily as ordered, and the MAR showed doses were given as scheduled. Following two separate falls, staff completed SBAR Communication Forms and progress notes to notify the provider of the change in condition. However, on both occasions, the Background section under Medication Alerts on the SBAR forms did not indicate that the resident was on an anticoagulant, despite the form’s directive to complete relevant sections before contacting the MD/NP/PA. During interviews, facility leadership confirmed that the SBAR documentation for these falls failed to reflect the resident’s anticoagulant therapy, resulting in incomplete and inaccurate clinical records.
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.
Housekeeping and maintenance services were not adequately provided across multiple wings. During an environmental tour, surveyors found dirty and unlabeled items in resident bathrooms, broken and cracked floor tiles, chipped and gouged doors, missing paint and laminate, dust and debris in bathroom light fixtures, and a resident wheelchair with ripped armrests creating uncleanable surfaces.
A facility failed to provide written transfer/discharge and bed hold notices for multiple hospital transfers involving two residents, and it also failed to communicate discharge details and send signed physician orders to an ALF on time for another resident. Record reviews and staff interviews confirmed the missing notices and delayed discharge information.
The facility failed to ensure the pharmacist identified a medication irregularity for a resident receiving oxycodone without a valid order, and failed to ensure timely provider response to a pharmacy MRR recommendation for another resident. One resident continued receiving a scheduled II narcotic despite an order with no duration, and another resident had a pharmacy recommendation to evaluate citalopram dosing and complete an AIMS test, but the record lacked evidence of a timely provider response.
Expired and unlabeled meds were found on a medication cart, including expired tablets and insulin pens without resident identifiers or open dates. Surveyors also found incomplete temp logs for four med/vaccine refrigerators holding flu, COVID, shingles, Prevnar 20, and Hep B vaccines, with many days missing the required twice-daily readings despite the facility stating it follows CDC guidance.
Kitchen sanitation and food storage practices were deficient during a tour. A male kitchen worker with facial hair was not wearing facial hair protection, fans and equipment were dirty, several surfaces had chipped paint or rust, and multiple foods in dry storage, the walk-in refrigerator, and the walk-in freezer were not labeled, dated, sealed, or secured. A pitcher on a prep table was also unlabeled, and the ice machine was not plumbed with an appropriate air gap; the FSD confirmed the findings.
Failure to follow EBP and PPE procedures occurred when a resident with an indwelling urinary catheter had no EBP sign posted and no PPE cart outside the room, despite the facility’s procedure requiring gown and gloves for catheter care. Staff also failed to sanitize hands after removing gloves when setting up a breakfast tray for a resident on EBP, and another CNA entered a contact precaution room for a resident with shingles without fully following gown-and-glove requirements.
Failure to designate a qualified Infection Preventionist. Surveyors found the DON had previously served as the IP but had moved into the DON role and was working full time there, while an LPN hired as the IP was also working on the floor as a Charge Nurse. The LPN had not completed IP training and was only on module 12, and surveyors confirmed the facility did not have a qualified IP working at least 20 hours in the role.
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's PRN antipsychotic order lacked a stop date, and the physician did not evaluate the resident and enter a new order to renew the medication every 14 days as required by facility policy. The record showed Haloperidol ordered PRN, and the finding was confirmed by the Market Lead Clinical Specialist.
Inaccurate MDS Coding for PASRR Status: A resident’s admission MDS 3.0 was coded as “NO” for Level II PASRR status even though the clinical record contained a Level II PASRR uploaded on the day of admission. During interview, the MDS RN confirmed the coding error.
A resident with bipolar disorder and anxiety had a PASRR Level II determination requiring psychiatric services and ongoing counseling, but the care plan did not reflect the Level II specialized services. Review of the record showed the resident had not been set up with a psychiatrist, although counseling with a licensed behavioral health professional was occurring, and the PASRR requirement for psychiatrist services was not being followed.
A resident admitted with a G-Tube had the tube removed, but the care plan meeting that followed did not reflect the change. The Market Lead Clinical Specialist later confirmed the care plan had not been accurately revised.
Failure to supervise a resident during meals. A resident with orders for direct meal supervision, small bites and sips, upright positioning, and continued observation after meals was left unattended in the dining room during breakfast and lunch. A CNA left the area multiple times, and the resident was observed eating while unsupervised, with staff frequently out of eyesight.
Failure to Post Daily Nurse Staffing Information: The facility failed to post nurse staffing information on a daily basis for 1 of 4 survey days. Two surveyors observed staffing sheets posted that were dated several days earlier, and the finding was later discussed with the Administrator, Market Clinical President, and Market Clinical Lead during the exit conference.
Failure to Provide Allergy-Appropriate Meal Options: A resident with documented dairy and pepper-related allergies repeatedly received meal tickets listing 2% milk with breakfast items, and staff were unsure whether the food was prepared without milk. The resident stated meals had to be checked at every meal, had not been able to choose menu options, and had not seen a menu since admission; the FSD said new admissions automatically receive the first menu option until menu review occurs within 72 hours.
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.
Failure to Maintain Clean and Sanitary Resident Environment on One Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, and comfortable environment on one of four units, the North Wind unit. A complaint was received alleging that staff left dirty washcloths in a resident’s room after providing care, and during a telephone interview the complainant reported that staff left soiled washcloths on the resident’s shelves. During an onsite investigation, a surveyor observed multiple housekeeping and maintenance issues across several rooms on the North Wind unit, including food debris such as orange peels and crushed crackers/chips on floors, overflowing trash receptacles, and trash cans without liners containing various refuse. In one room, the bathroom trash can was overflowing with debris and used exam gloves, and an unbagged soiled washcloth was on the floor next to the trash can. Additional observations included unbagged soiled washcloths on over‑bed tables, on floors, and in sinks, as well as a visibly soiled washcloth and a medicine cup with red liquid residue on a sink, and an unbagged wash basin with a soiled washcloth on the floor under the sink. Other items such as a sheet and trash bag were left on the floor outside a shower, non‑skid socks and a plastic spoon were on the floor by a bed, and a tubigrip stocking and a medicine cup with an unknown white cream were left on a nightstand. Nebulizer tubing was observed hanging out of a nightstand drawer, and oxygen tubing was draped over a trash can and extending to the floor. During observation of one resident’s room, the resident reported that a night shift staff member had intended to empty the overflowing bathroom trash can but left it when her shift ended. The Market Clinical Lead confirmed the environmental concerns during the tour and acknowledged that environmental issues had been identified on the North Wind and Spring Gardens units.
Incomplete SBAR Documentation of Anticoagulant Use After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident reviewed for falls. The resident was admitted with atrial fibrillation and was on anticoagulation therapy, with an active physician order for Eliquis (apixaban) 2.5 mg by mouth twice daily, which was administered as scheduled from March 1 through March 18, 2026, per the MAR. However, during two documented fall events on 3/12/26 and 3/17/26, the SBAR Communication Forms and corresponding progress notes used to notify the physician of the resident’s change in condition did not indicate in the Background section under Medication Alerts that the resident was on an anticoagulant, despite the form’s instruction to complete relevant aspects before calling the provider. On 4/1/26, during interviews with the Administrator and the Market Clinical Lead, it was discussed and confirmed that the SBAR communication forms used for the resident’s falls did not reflect the resident’s anticoagulant therapy, demonstrating that the clinical documentation related to these change-in-condition notifications was incomplete and inaccurate.
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.
Housekeeping and Maintenance Deficiencies Across Multiple Wings
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 4 of 4 wings during an environmental tour with the Senior Maintenance Director, the Administrator, and the Housekeeping/Laundry District Manager. In Spring Garden, multiple resident rooms had dirty or unlabeled items in bathrooms and on countertops, including an unlabeled dirty urinal, unlabeled denture cup, unlabeled water pitcher, wash basins, bed pans, and a graduated cylinder on the floor. Several rooms also had broken or cracked floor tiles, chipped or gouged bathroom doors exposing untreated wood, chipped or missing paint, and chipped or missing laminate on sink countertops, creating uncleanable surfaces. Additional findings were observed in North Wind, Penobscot House, and Windward Center. In North Wind, a resident room bathroom contained a bed pan and commode seat parts on the floor under the sink. In Penobscot House, multiple resident room bathroom ceiling light fixtures had visible dust and debris. In Windward Center, Resident #10's wheelchair armrests were both ripped and torn, creating uncleanable surfaces. The Senior Maintenance Director, the Administrator, and the Housekeeping/Laundry District Manager confirmed the observed findings during interview.
Failure to Provide Required Transfer/Discharge Notices and Timely Discharge Information
Penalty
Summary
The facility failed to issue written transfer/discharge notices and bed hold notices to residents and their legal representatives for facility-initiated transfers/discharges to an acute care facility. Resident 9 was transferred to an acute hospital on 9/8/25 and 9/16/25, and Resident 11 was transferred to an acute hospital on 6/30/25, 7/19/25, and 9/11/25. In both records, there was no evidence that written transfer/discharge notices or bed hold notices were provided to the resident and/or legal representative for the transfers. During record review and interview, the Clinical Lead confirmed that Resident 9’s record lacked evidence of written transfer/discharge notices and bed hold notices for both hospital transfers. The Clinical Lead also confirmed that Resident 11’s record lacked evidence that transfer/discharge notices and bed hold notices were provided in writing to the resident’s family/representative for all three transfers to the acute hospital. The facility also failed to ensure communication to an Assisted Living Facility for a resident discharged there after skilled services ended. For Resident 80, the record showed discharge planning discussions and an appeal of the discontinuation of skilled services, but the record lacked documentation that the receiving ALF was notified of the discharge date before discharge or at the time of discharge. Signed physician orders were not faxed to the ALF until the day after discharge, and the ALF stated it needed signed physician orders before it could administer medications to the resident upon return.
Pharmacist Review and Provider Response Deficiencies
Penalty
Summary
The facility failed to ensure that a licensed pharmacist identified and reported medication irregularities during the monthly medication regimen review, including review of the medical chart, for two residents. For Resident R2, the clinical record showed an order for oxycodone 10 mg every 6 hours as needed for pain, entered on an unspecified date with no duration, and still in effect at the time of review. The resident continued to receive the scheduled II narcotic on the November MAR without a valid physician order, and a surveyor confirmed this finding during an interview with the Market Lead Clinical Specialist. For Resident R35, the pharmacy medication regimen review recommendation noted that the resident had been taking citalopram 20 mg since 2023 and asked the provider to evaluate the current dose and consider a dose reduction; it also noted the resident was taking Seroquel 25 mg twice daily and was due for an AIMS test every 6 months. The provider response stated disagreement because the condition was not well controlled, but the clinical record lacked evidence that the provider responded to the recommendation before surveyor intervention. During an interview, the Clinical Marketing Specialist confirmed the findings.
Expired, Unlabeled Medications and Incomplete Vaccine Refrigerator Monitoring
Penalty
Summary
Drugs and biologicals were not properly labeled and stored on the Penobscot Unit medication cart. During observation with an LPN, expired medications were found available for resident use, including Magnesium Oxide 400 mg tablets expired in 11/2025, Calcium 600 and DS tablets expired in 7/2025, and Acidophilus Probiotic tablets expired in 10/2025. The same cart also contained a Lantus insulin pen with a little over 220 units that had no resident identifier and no open date, as well as a Humalog Kiwi pen with no open date. This was confirmed with the Facility Administrator during the survey. The facility also failed to adequately monitor medication and vaccine refrigerators in four medication storage areas. Surveyors observed refrigerators in the Spring Garden, Windward Center, Penobscot, and North Wind medication storage rooms containing vaccines such as shingles, flu, COVID, Prevnar 20, and Hep B. Review of the temperature logs for September, October, and November showed multiple days without evidence of twice-daily temperature readings in each refrigerator, including 21 missed days in September for two units, 14 missed days in September for Penobscot, and 22 missed days in September for North Wind, with additional missed days in October and November across all four logs. During interview, the Market Lead Clinical Advisor stated the facility follows CDC guidance for immunization temperature monitoring, and CDC guidance reviewed stated temperatures should be checked and recorded a minimum of 2 times daily.
Kitchen Sanitation, Food Labeling, and Ice Machine Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and failed to ensure food items were properly labeled, dated, wrapped, or secured during a kitchen tour. Observations identified a male kitchen worker with facial hair who was not wearing facial hair protection, a dusty and dirty wall-mounted fan in the dish room, and a section of cement floor under the dish machine with chipped and missing paint that created an uncleanable surface. Surveyors also observed a food mixer with dried food particles and dried liquid residue on the base and mix arm, with chipped and missing paint on the mix arm, and a food processor with dried food particles on the lid and unit. A round table fan running next to an active food preparation area was missing its front screen guard and was dusty and dirty, and a metal shelf under large storage bins had chipped and missing paint and rust, also creating an uncleanable surface. Additional observations showed multiple food storage and labeling issues in several areas of the kitchen. In the dry storage room, two previously opened packages containing a brown powder-type substance were not sealed and had not been labeled or dated. In the walk-in refrigerator, two fruit cups, a container of chicken salad, a package of cheese slices, and a previously opened package of shredded cabbage were not labeled or dated. In the walk-in freezer, two packages of French toast and two packages of pancakes were not labeled or dated, and a case of pizza dough and a case of biscuit dough had been previously opened and were left open to the air and not secured closed. A clear 2-quart pitcher containing a white powder-like substance on a food preparation table was also not labeled or dated. The ice machine was observed not to be plumbed with an appropriate air gap, and the Food Service Director confirmed the findings during interview.
Failure to Follow EBP and PPE Procedures
Penalty
Summary
The facility failed to follow its Enhanced Barrier Precautions (EBP) procedure for a resident with an indwelling urinary catheter. The resident was admitted with diagnoses including retention of urine, an indwelling urinary catheter, and UTI. The facility procedure stated that the appropriate EBP sign should be posted on the room door and PPE should be readily accessible outside the room, with gown and gloves required for urinary catheter care. On observation, the resident’s urinary catheter was connected to gravity drainage on the bed frame, but there was no EBP sign posted on the door and no PPE cart outside the room. Record review showed the resident had a care plan addressing UTI and risk for MDRO colonization/infection due to indwelling devices, and physician orders included ciprofloxacin for bacterial infection. The resident’s TAR showed the RN performed catheter care and changed the catheter on multiple dates in November and December 2025. The facility also failed to provide a sanitary environment related to PPE use on another unit. A CNA was observed entering the resident’s room to set up a breakfast tray, then exiting the room and walking down the hallway without sanitizing her hands after removing gloves. The CNA stated she had worn gloves because the resident was on EBP and that she usually sanitizes her hands after doffing gloves but forgot. In a separate observation, a CNA caring for a resident on contact precautions for shingles was seen wearing gloves in the room and leaning over the resident while stating she knew the resident should be on gown and gloves and had used both earlier, but only needed to obtain an oxygen saturation quickly. An RN confirmed the observation.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the Infection Preventionist responsible for the Infection Control Program. Surveyors found that since September 2025, the DON had moved from the Infection Preventionist role into the DON position and was working full time as DON, while an LPN was hired as the Infection Preventionist but was also working 20 hours per week on the floor as a Charge Nurse. During interviews, the LPN stated she was only on module 12 of the Infection Preventionist training and had not completed the training yet. The Market Lead Clinical Specialist stated that part time is considered 20 hours per week, and surveyors confirmed the facility did not have a qualified Infection Preventionist who worked at least 20 hours in the role.
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.
PRN Antipsychotic Order Lacked Stop Date and Required Renewal
Penalty
Summary
The facility failed to ensure that physician orders for a PRN anti-psychotic medication included a duration or stop date and failed to ensure the physician evaluated the resident and wrote a new order to renew the PRN anti-psychotic every 14 days for Resident #10. The facility policy, Medication Management, revised 1/25, stated that PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Review of Resident #10's clinical record on 12/3/25 showed a physician order dated 10/9/25 for Haloperidol, an anti-psychotic medication, to administer 2 tablets of 0.5 mg every 8 hours as needed, and the order did not have a stop date. During an interview on 12/2/25 at 12:07 p.m., the Market Lead Clinical Specialist confirmed the finding.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the admission MDS 3.0 was coded accurately to reflect that Resident #2 had a Level II PASARR. Record review showed that the resident’s clinical record contained a PASRR Level II uploaded on the day of admission in the electronic documents section, but the admission MDS 3.0 dated 5/27/25 was coded in Section A1500 as “NO” to the question asking whether the resident was currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. During an interview on 12/2/25 at 9:30 a.m., the MDS RN confirmed this finding.
PASRR Level II Services Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to incorporate recommendations from a resident’s PASRR Level II determination into the resident’s assessment, care plan, and transitions of care for one sampled resident with bipolar disorder and anxiety. The PASRR Outcome Notice, dated 4/22/24, stated that the resident qualified for Level II services and was to receive ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications, modify medication orders, and assess the ongoing need for additional behavioral health services, as well as individual therapy by a licensed behavioral health professional for ongoing counseling. On 12/2/25, the resident’s clinical record and care plan were reviewed by the Licensed Social Worker, Administrator, and surveyor, and there was no evidence that the care plan included the resident’s PASRR Level II specialized services. During an interview, the Market Clinical Lead stated that the resident had not been set up with a psychiatrist but was seeing a licensed behavioral health professional for ongoing counseling services, and the surveyor confirmed that the PASRR Level II requirement for psychiatrist specialized services was not being followed.
Care Plan Not Updated After G-Tube Removal
Penalty
Summary
The facility failed to ensure a care plan was accurately revised for Resident #37, who was admitted in June 2025 with a G-Tube. The clinical record showed the G-Tube was removed on 9/18/2025, and a care plan meeting occurred on 9/23/2025, but the resident’s care plan did not reflect the removal of the G-Tube. During an interview on 12/4/25 at 1:30 p.m., the Market Lead Clinical Specialist confirmed the information.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to ensure a physician order was followed for Resident #37, who had orders for all meals to be directly supervised, small bites and sips, to be positioned bolt upright in a chair, to remain up for 30 to 45 minutes after meals, and to discontinue intake if the resident began to cough significantly. During observation on 12/1/25, CNA #2 served breakfast and then left the dining room for about 30 seconds, and later left the dining room again with no additional staff present. At lunch, CNA #2 left Resident #37 unattended in the dining room from 12:43 p.m. to 12:45 p.m., during which the surveyor observed the resident take two bites of cake. From 12:45 p.m. to 12:50 p.m., RN #1, RN #2, and CNA #2 were present in the dining room but frequently out of the resident’s eyesight, and from 12:50 p.m. to 12:51 p.m. the resident was again left unsupervised before CNA #2 sat down at the table with the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis for 1 of 4 days of survey, specifically on 12/1/25. On 12/1/25 at 7:30 a.m., two surveyors observed posted staffing sheets dated Wednesday, 11/26/25; Thursday, 11/27/25; and Friday, 11/28/25. The finding was discussed with the Administrator, Market Clinical President, and Market Clinical Lead during the exit conference on 12/4/25 at 2:30 p.m.
Failure to Provide Allergy-Appropriate Meal Options
Penalty
Summary
The facility failed to provide food that accommodated a resident’s allergies, intolerances, and preferences for 1 of 1 resident reviewed for food choices. During a breakfast observation, a CNA delivered the resident’s tray with pancakes, and the resident asked whether the pancakes were made without milk. The CNA said she was not sure and left the room, then returned a few minutes later and said an alternative entree would be sent. The resident stated that he/she has a dairy allergy and has had to ask at every meal since admission whether the meal was prepared according to the allergy needs. Review of the resident’s meal ticket showed allergies listed as lactose, bell pepper, pear, green/red peppers, and cayenne, yet the ticket also listed pancakes with 2% milk. The clinical record included a physician order for a regular/liberalized diet and noted allergies to lactose, capsicum annuum extract and derivatives, cayenne, and green pepper. On a later breakfast observation, the resident again received items with 2% milk listed on the tray ticket and stated he/she did not know whether the scrambled eggs or biscuit were prepared with milk, so he/she was eating personal snacks brought into the facility. The resident also stated he/she had not been able to choose meals and had not seen a menu since admission. The FSD stated newly admitted residents are automatically given the first menu option until menu choices are reviewed within 72 hours, and acknowledged that 2% milk should not have been indicated on the resident’s tickets and that a lactose-free milk option should have been triggered in the system.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Camden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Breakwater Commons | 7.1 mi | ★★★★★ | 22 | 0 |
| Harbor Hill Center | 16 mi | ★★★★★ | 26 | 0 |
| Cove's Edge Inc | 25.8 mi | ★★★★★ | 13 | 0 |
| Maine Veterans Home - Augusta | 33.7 mi | ★★★★★ | 12 | 0 |
| Augusta Center For Health & Rehabilitation, Llc | 34 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.