Winship Green Center For Health & Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bath, Maine.
- Location
- 51 Winship St, Bath, Maine 04530
- CMS Provider Number
- 205078
- Inspections on file
- 17
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Winship Green Center For Health & Rehab, Llc during CMS and state inspections, most recent first.
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 facility failed to inform a resident's representative about the use of an antipsychotic medication, Risperidone, prescribed for behavioral disturbances. The resident, with multiple diagnoses including delirium, was not properly informed about the medication's side effects or given the opportunity to consent. The facility's documentation was incorrect, and the representative was not notified of medication changes, contrary to facility policy.
The facility failed to deliver mail to two residents within the 24-hour timeframe as per policy. Residents reported delays of two to three days in receiving their mail. The Activities Director indicated that mail delivery is delayed because it must be sorted by the Business Office first, which can take a few days. The Business Office Manager confirmed the delay, especially for Saturday's mail, and acknowledged resident complaints about the issue.
The facility failed to provide or obtain written information about the right to accept or refuse treatment and formulate an advance directive for eight residents. This deficiency was confirmed by interviews with family members and staff, highlighting a systemic issue in handling advance directives.
Surveyors identified several maintenance deficiencies in the facility, including a buildup of black material on ceiling vents and tiles, and black substance on shower grout across multiple units. Additionally, a bathroom contained unlabeled salad tongs, and a glove box holder was broken with sharp edges. These issues were confirmed with the Administrator.
The facility failed to conduct interdisciplinary team (IDT) care plan meetings for six residents following their MDS assessments. Surveyors found no evidence of these meetings, which should have included resident and representative participation. Interviews with staff and family members confirmed the absence of these meetings, highlighting a lack of compliance with care plan review and revision protocols.
The facility failed to maintain sanitary conditions in the kitchen, with numerous food items found undated, unlabeled, and improperly stored. Temperature logs for refrigerators and freezers were incomplete, and cleaning protocols were not followed, resulting in visibly dirty equipment and areas. Staff interviews revealed a lack of adherence to facility policies on food storage and kitchen sanitation.
A resident with quadriplegia, dependent on staff for all ADLs, was observed with an inaccessible call bell on two occasions. The resident's care plan requires the call bell to be within reach, but it was found behind and on top of the pillow, making it unusable. A CNA confirmed the bell's inaccessibility, acknowledging the resident's need for it to be reachable to request assistance.
A facility failed to update care plans for two residents, leading to deficiencies in addressing their needs. One resident with quadriplegia and depression had an outdated care plan that inaccurately assessed self-harm risk. Another resident with dementia and diabetes had a care plan with an expired wander guard and outdated foot care orders. An LPN confirmed the inaccuracies and the responsibility of nursing staff to maintain current care plans.
A facility failed to provide a continuous resident-centered activities program for a resident, as required by policy. The resident's activity participation was inconsistently documented, and they were not invited to a music event despite expressing interest. Interviews revealed that staff did not consistently offer or document one-on-one activities, leading to a deficiency in meeting the resident's needs.
A resident with dementia and high elopement risk had an expired wander guard, which was confirmed by an LPN as a nursing oversight. Additionally, a standing fan was found obstructing a fire door on two occasions, which was addressed after surveyor intervention.
The facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours on two specific days, as required. This deficiency was identified during a review of nursing work schedules and discussed with the Administrator.
A surveyor found an expired Covid-19 vaccine in the medication refrigerator during a survey. The RN confirmed the vaccine was expired and disposed of it immediately. The facility's policy requires regular checks to remove expired medications prior to their expiration date, which was not followed in this instance.
A facility failed to maintain accurate medical records for a resident at high risk for elopement. The resident's Treatment Administration Record did not accurately document the expiration date of a wander guard, which was found to be expired during a survey. An LPN confirmed the inaccuracy and acknowledged the nursing staff's responsibility to check the device. The issue was discussed with the DON.
A resident's wheelchair was observed to be soiled on three consecutive days, indicating a failure in maintaining cleanliness standards. The issue was confirmed by the Administrator during an interview.
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.
Failure to Inform Resident Representative of Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide evidence that the Resident Representative was informed of a physician order for an antipsychotic medication, informed of the side effects of that medication, and given the opportunity to agree or disagree with the use of medication for a resident. The resident, who had been admitted from an acute care hospital with multiple diagnoses including urinary tract infection, metabolic encephalopathy, and delirium, was prescribed Risperidone for behavioral disturbances. However, the facility's documentation was incomplete and incorrect, as the medication was listed under the wrong class and did not include the necessary FDA Black Box Warning for antipsychotic use in the elderly. The resident experienced agitation and confusion, leading to a transfer to the emergency department, where they were treated for a urinary tract infection. Upon return, the resident continued to display altered mental status and behavioral disturbances. Despite these issues, there was no evidence that the resident's representative was informed of the medication change or the potential risks and benefits. The facility's policy required notification of the resident or responsible party when psychoactive medication doses were changed, but this was not adhered to, as confirmed by interviews with the prescribing provider and facility staff.
Delayed Mail Delivery to Residents
Penalty
Summary
The facility failed to deliver resident mail in a timely manner to two out of four residents who receive mail. According to the facility's policy titled 'Therapeutic Recreation,' mail should be delivered to residents unopened or postmarked within 24 hours, including Saturdays. However, interviews with two residents revealed that they were not receiving their mail for two or three days after it arrived at the facility. The Activities Director stated that mail delivery is delayed because they have to wait for the Business Office to sort it, which can take a few days. The Business Office Manager confirmed that mail is not always delivered within 24 hours, especially mail received on Saturdays, and acknowledged that timely mail delivery has been a known challenge due to resident complaints.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide or obtain written information concerning the right to accept or refuse medical or surgical treatment and to formulate an advance directive for eight residents. These residents were identified as #10, #35, #46, #67, #37, #9, #63, and #23. The clinical records for these residents lacked evidence that the facility had provided or obtained the necessary documentation regarding their rights to make decisions about their medical care. This deficiency was confirmed during interviews with family members and facility staff. For instance, Resident #10's family member, who is the legal guardian, indicated that they had never been asked to supply documentation of their status. Additionally, the Regional Director of Operations confirmed that advance directives were not obtained, offered, or declined for the residents in question. This oversight indicates a systemic issue in the facility's process for handling advance directives and ensuring residents' rights are communicated and documented.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed by surveyors. On July 9, 2024, a surveyor noted a moderate to heavy buildup of black material on the ceiling vents and surrounding ceiling tiles in all hallways and the main dining room across three resident units. This observation was confirmed with the Administrator. On July 10, 2024, during a facility tour with the Administrator and the Maintenance Manager, further deficiencies were observed. In the Passport Unit, the shower room had a moderate to heavy buildup of black substance on the shower grout. The Pemaquid Unit's shower room had a brown stain on the floor and a buildup of black substance on the grout. Additionally, a bathroom contained unlabeled salad tongs on the toilet, and a shared bathroom had a broken glove box holder with sharp edges. In the [NAME] Unit, the shower room had a heavy amount of black substance on the grout, and the doorframe had a large chip with a sharp edge. These findings were confirmed with the Administrator at the end of the tour.
Failure to Conduct IDT Care Plan Meetings
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team (IDT) meeting, which included the participation of the resident and their representative, after each Minimum Data Set (MDS) 3.0 assessment for six residents. The surveyors found no evidence of IDT meetings being held for these residents following their comprehensive MDS assessments. This deficiency was confirmed through interviews with the Social Services Director and other staff members, as well as through record reviews. For Resident #16, the surveyor could not find evidence of IDT meetings after three MDS assessments. Similarly, Resident #10's guardian reported not being invited to a care plan meeting since 2023, and the facility only held such meetings every six months. Resident #13's family member could not recall the last care plan meeting, and the Social Services Director confirmed that meetings were not held for Residents #10 and #13. Additionally, no evidence of IDT meetings was found for Residents #31, #23, and #26, with confirmations from the Director of Social Services and Resident #26's guardian.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey conducted over three days. Numerous food items in the kitchen, including sliced cheese, a yellow substance, chopped red chili peppers, and various other items, were found undated, unlabeled, and improperly stored. The dry storage room contained items such as cream of wheat, sliced almonds, and peanut butter crackers that were open to air and undated. The walk-in refrigerator and freezer also contained undated and unlabeled food items, and the floors in these areas were visibly dirty with debris. The facility's policy on food storage, which requires all perishable foods to be stored at proper temperatures and labeled with dates, was not adhered to. Temperature logs for various refrigerators and freezers lacked evidence of documented temperatures on multiple days, indicating a failure to monitor and maintain appropriate storage conditions. Interviews with dietary staff revealed a lack of understanding and adherence to procedures for documenting and addressing temperature discrepancies. Additionally, the facility's policy on kitchen sanitation, which mandates daily cleaning and proper maintenance of food contact surfaces, was not followed. Observations revealed visibly dirty equipment, such as a stand mixer and flour containers, and a dishwashing room with caked-on debris. The dietary staff failed to ensure that personal food items brought in by residents' families were dated and discarded after 72 hours, as required by facility policy. Interviews with staff indicated a lack of compliance with these policies, contributing to the unsanitary conditions observed.
Inaccessible Call Bell for Quadriplegic Resident
Penalty
Summary
The facility failed to ensure that a call bell was accessible to a resident with quadriplegia, who is totally dependent on staff for all Activities of Daily Living. The resident can only rotate their head from left to right and relies on a tap call bell placed on the right side of their head to request assistance. The care plan for the resident, updated on 4/4/24, specifies that the call light should be within reach. However, on two separate days of observation, the call bell was found to be out of reach. On 7/09/24, the call bell was observed behind the resident's pillow, and on 7/10/24, it was on top of the pillow, both times inaccessible to the resident. During an interview, the resident attempted to demonstrate how they would call for help but was unable to reach the bell. A Certified Nursing Assistant confirmed that the call bell was not in reach and acknowledged that it must be accessible for the resident to call for help.
Deficiencies in Care Plan Updates for Residents
Penalty
Summary
The facility failed to update and implement care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #10, who has a history of traumatic brain hemorrhage, quadriplegia, depression, bilateral extremity contractures, and expressive aphasia, was found to have an outdated care plan. The care plan included interventions for depression that were not applicable, as the resident was unable to independently move his/her hands or arms and had no access to pills, making the risk of self-harm unlikely. The facility's administrator confirmed that the care plan had not been updated to accurately reflect the resident's current needs. Resident #13, diagnosed with dementia, a history of traumatic brain injury, and a seizure disorder, also had an outdated care plan. The care plan indicated a high risk for elopement and included a wander guard with an expired expiration date. Additionally, the care plan contained an outdated order for foot care related to diabetes, which had been discontinued. An LPN confirmed that it was the nursing staff's responsibility to ensure the accuracy of the wander guard expiration date and acknowledged that the care plan had not been updated to reflect the current orders.
Failure to Provide Continuous Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide a continuous resident-centered activities program for a resident who was reviewed for activity participation. The facility's policy requires that an individual's level of involvement in recreation programming be documented daily and that regularly scheduled programming be provided to all patients, including those who cannot tolerate or prefer not to participate in group activities. However, the review of the resident's activity participation record revealed that the resident was offered or refused activity participation on only a few days over several months, indicating a lack of consistent engagement. Observations and interviews further highlighted the deficiency. During a live music event, the resident was not present, and it was revealed that the resident was not asked if they wanted to attend, despite expressing interest in music. The Activity Director confirmed that all residents should be asked about attending activities, and any refusals should be documented. However, the resident's participation logs lacked evidence of one-on-one activities being offered or refused. The Activity Assistant admitted to not inviting the resident to the music activity because the resident was in bed, confirming the oversight.
Expired Wander Guard and Blocked Fire Door
Penalty
Summary
The facility failed to ensure the safety of a resident at high risk for elopement due to an expired wander guard. The resident, who has dementia, anxiety, and is legally blind, was observed self-propelling in a wheelchair in the hallways. The resident's care plan indicated a high risk for elopement, with a history of wandering behavior and attempts to open doors to the outside. Despite this, the wander guard attached to the resident's wheelchair was found to be expired. During an interview, an LPN confirmed that it was the nursing staff's responsibility to check the expiration date of the wander guard, acknowledging the oversight. Additionally, the facility was found to have a blocked fire door on one of its units on two separate survey days. A standing fan was observed obstructing an open fire door in the hallway, which was moved after being noticed by the surveyor. The obstruction was noted again on a subsequent day, and staff were alerted to move the fan. These observations were discussed with the Regional Director of Operations, highlighting a failure to maintain clear egress in case of an emergency.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of nursing work schedules from January 1, 2024, to July 8, 2024. Specifically, on Sunday, February 4, 2024, and Friday, July 5, 2024, the facility did not have an RN on duty for the mandated hours. This issue was discussed with the Administrator by a surveyor on July 10, 2024.
Expired Vaccine Found in Medication Storage
Penalty
Summary
The facility failed to ensure that an outdated vaccine was removed from the medication supply available for use. During a survey, a Covid-19 vaccine with an expiration date of 6/28/24 was found in the medication refrigerator on 7/10/24. This observation was made in the medication storage room with a Registered Nurse (RN) present. The RN confirmed that the vaccine was expired and disposed of it immediately. The facility's policy, titled Medication Storage Regulation, requires a system to regularly check the entire medication refrigerator for expired medications and to remove these medications from regular stock prior to their expiration date. This policy was not adhered to, leading to the presence of the expired vaccine in the medication storage room.
Inaccurate Documentation of Wander Guard Expiration
Penalty
Summary
The facility failed to ensure that a resident's medical record contained accurate information regarding the expiration date of a wander guard, a device used to prevent elopement. During a review of the Treatment Administration Record (TAR) for a resident, it was found that the order to check the wander guard's expiration date weekly was not accurately documented. The care plan indicated that the resident was at high risk for elopement due to wandering behavior, and the wander guard attached to the resident's wheelchair was observed to be expired. An LPN confirmed that it was the nursing staff's responsibility to check the functionality and expiration date of the wander guard, and acknowledged that the clinical record did not contain accurate information. The issue was discussed with the Director of Nursing.
Failure to Maintain Cleanliness of Resident's Wheelchair
Penalty
Summary
The facility failed to maintain cleanliness standards for a resident's wheelchair over a period of three days. On July 8th, 9th, and 10th, 2024, a resident was observed sitting in a soiled wheelchair in the hallway. These observations were made at different times each day, indicating a consistent issue with the cleanliness of the wheelchair. During an interview on July 10th, the Administrator confirmed that the resident's wheelchair was indeed soiled.
Latest citations in Maine
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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