Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Westbrook during CMS and state inspections, most recent first.
QAPI infection control minutes did not include measurable surveillance data analysis, trend review, or documented action planning. The IP reported she collected infection information in a folder and compiled the report after month-end, which prevented timely analysis for QAPI discussion. Minutes from multiple quarters listed infection counts, percentages, and goals, but did not identify root causes, patterns, audit findings, or specific interventions beyond general staff education.
Failure to implement infection control measures included not placing symptomatic residents on TBP, not using PPE or signage consistently, not properly cleaning a multi-resident whirlpool tub, and not rinsing or air-drying nebulizer attachments after use. Residents with cough, congestion, fever, hoarseness, and SOB were observed in common areas and rooms without clear precautions, while nebulizer masks and tee pieces remained attached to machines on bedside tables and the whirlpool chair cushion was not cleaned underneath as directed.
The facility failed to properly handle unpasteurized eggs and monitor food, refrigerator, and freezer temperatures, leading to potential foodborne illness risks. Unpasteurized eggs were served runny to residents despite the dietary manager's awareness that they should be cooked hard. Dietary staff lacked training on handling unpasteurized eggs, and temperature monitoring sheets were not provided for January, resulting in unmonitored temperatures.
The facility failed to maintain an effective infection control program, leading to a potential Norovirus outbreak among residents and staff. The infection preventionist did not conduct adequate surveillance or ensure timely precautions, and staff returned to work too soon after symptoms resolved. Additionally, the whirlpool tub was not properly disinfected between uses, and there was a lack of communication and oversight from the facility's leadership.
The facility's antibiotic stewardship program was found deficient due to a lack of protocols and monitoring systems, affecting all residents. Antibiotic use was not properly documented or reviewed, with no physician consultations for ongoing treatments. The IP failed to track antibiotic use, and no staff covered infection control duties during her absence, leading to oversight issues acknowledged by the DON and administrator.
The facility's infection preventionist (IP) lacked appropriate training and oversight, failing to perform daily infection control surveillance, maintain documentation, or ensure program continuity during absences. The IP did not document or investigate infections properly, including a Norovirus case, and was unaware of reporting requirements for potential outbreaks. The Director of Nursing expected the IP to follow facility policies, but the IP did not meet these expectations, and the administrator was unaware of related staff and resident illness correlations.
A resident with intact cognition and at risk for pressure ulcers developed a sore on her right ankle, which was not reported to the provider. Despite having a pressure relief mattress and primarily using a wheelchair, the sore was first noted in late December, but the provider was not informed, and no treatment orders were documented. The facility's policy required notifying the physician and documenting treatment orders, which was not adhered to.
The facility failed to secure hazardous areas, allowing two residents with severe cognitive impairments and wandering behaviors to access unsecured rooms containing hazardous substances and tools. One resident entered an unattended tub room with personal care products and cleaning agents, while another room with toxic chemicals and tools was left open. The administrator acknowledged the oversight, noting that such areas should be secured to prevent resident access.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist for three residents, leading to a deficiency in medication management. One resident with severe cognitive impairment and multiple diagnoses, another with dementia and anxiety, and a third with intact cognition but requiring significant care assistance, all lacked documented pharmacist reviews for two months. The facility faced challenges with the consulting pharmacist's availability and timely review completion.
A facility failed to justify the use of a prophylactic antibiotic for a resident with severe cognitive impairment and a history of frequent UTIs. The resident was admitted with an order for Macrobid, but there was no documentation of UTI symptoms or a culture test. Staff interviews revealed a lack of awareness and evaluation of the medication's necessity, and the care plan did not mention the antibiotic. The facility did not provide a policy for unnecessary medications or prophylactic antibiotic use.
QAPI Infection Control Data Lacked Analysis and Documented Action Planning
Penalty
Summary
The facility failed to ensure the Infection Preventionist brought measurable data to the Quality Assurance Performance Improvement (QAPI) committee and that the quarterly Infection Control minutes included analysis of findings and a documented plan based on the data reviewed. Review of four quarterly QAPI meeting minutes showed infection control documentation with counts and percentages of infections, but the minutes did not include a breakdown of the data, analysis of trends or sources, or discussion of ongoing plans tied to the findings. In one quarter, the minutes listed a goal of less than 7% compared to a current performance of 10.19%, but did not identify what was included in the percentage or include surveillance data or investigation into patterns. The minutes from another quarter documented the number and type of resident infections with comparison to the previous month, but there was no documentation of root cause analysis or discussion of interventions beyond general comments to educate staff as needed. The minutes also noted audits of 48-hour progress notes had been completed, but did not identify the audit findings or any related intervention plan. During interview, the Infection Preventionist stated she had not been providing on-time infection control surveillance and instead collected infection information in a folder on her desk and compiled a report the week after the end of the month, which she acknowledged did not allow her to analyze the data and develop discussion for QAPI meetings. The administrator stated the expectation was for the IP to provide evidence of surveillance, analysis, and suggestions for discussion of a plan to monitor and prevent potential outbreak of infections.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to provide surveillance and implement Transmission Based Precautions for residents who were experiencing cold and respiratory signs and symptoms, and it also failed to ensure nebulizer equipment was rinsed and dried after each use and that a multi-resident whirlpool tub was cleaned and disinfected appropriately. The report identified that these deficiencies affected residents with respiratory symptoms, residents using nebulizers, and the whirlpool bathing equipment used for multiple residents. During observation of the whirlpool tub room, a nursing assistant prepared the tub for disinfection by placing the bath chair back into the tub, closing the door, and turning on the air jets briefly. The bath chair cushion remained attached while the assistant scrubbed the tub surfaces, back rest, and top of the cushion, but did not clean the bottom of the cushion. The printed manufacturer instructions directed staff to lift the seat bottom off the chair and scrub the tub, chair, and underneath the seat bottom. When the cushion was later removed, dried white residue was seen on the underside and a brown substance was noted along the edge of the opening in the seat cushion. The administrator observed the cushion had not been cleaned appropriately and stated all components of the tub and chair were expected to be cleaned and disinfected after each bath. The facility also failed to place residents with respiratory symptoms on TBP or consistently use PPE and signage. Residents identified with congestion, cough, fever, hoarse voice, and shortness of breath were observed without precautions in place, including residents who were out of their rooms and in the dining room without masks. Staff entered rooms without PPE, and there was no signage on the doors to indicate TBP. One resident with a harsh cough attended group activities in the dining room while symptomatic. The infection preventionist stated nursing staff should place residents on precautions when respiratory symptoms are observed and complete COVID and influenza testing, but the records reviewed did not show respiratory assessments, monitoring, or clear documentation that precautions had been initiated at the time symptoms were noted. The facility further failed to ensure nebulizer attachments were cleaned after use for residents receiving nebulized medications. In shared rooms, nebulizer tee pieces and masks remained attached to the machines on bedside tables and had not been disconnected, rinsed, or left to air dry between uses. The DON stated nebulizer attachments were to be taken apart, rinsed after each use, and left to air dry. The report also noted that one resident with COPD and another with multiple chronic conditions had nebulizer equipment left in this condition, and a third resident's nebulizer equipment was observed similarly not cleaned and dried after use.
Improper Handling of Unpasteurized Eggs and Temperature Monitoring Lapses
Penalty
Summary
The facility failed to appropriately handle and prepare unpasteurized eggs, which were identified in the refrigerator during a kitchen tour with the dietary manager (DM). The DM admitted to not providing temperature monitoring sheets for January, resulting in unmonitored refrigerator and freezer temperatures. The DM also acknowledged that unpasteurized eggs were cooked hard, but some residents were served runny eggs, indicating a lack of adherence to safe food handling practices. Interviews with dietary staff revealed a lack of training and awareness regarding the handling of unpasteurized eggs. Dietary cook (C)-A was unaware of the pasteurization status of the eggs and had not received education on their preparation. Despite knowing that unpasteurized eggs should be cooked hard, some residents, including R27, R5, R25, and R26, were served runny eggs upon request. The dietary assistant (DA)-B also confirmed a lack of training on handling unpasteurized eggs. The administrator and director of nursing were unaware of the use of unpasteurized eggs and expected staff to be trained in their handling. The dietician confirmed that unpasteurized eggs should only be used for baking and must be cooked hard if served for breakfast. The facility's failure to monitor and document food, refrigerator, and freezer temperatures, as well as the improper handling of unpasteurized eggs, posed a risk of foodborne illnesses, as confirmed by the medical director.
Inadequate Infection Control and Norovirus Outbreak
Penalty
Summary
The facility failed to maintain a current and effective infection prevention and control program, which led to a potential outbreak of Norovirus and COVID-19 among residents and staff. The infection preventionist did not conduct adequate surveillance to identify potential outbreaks or ensure timely implementation of transmission-based precautions. There was a lack of documentation regarding the investigation of illness patterns among staff and residents, and the facility did not report the Norovirus outbreak to the appropriate state agency. Additionally, staff members returned to work before the recommended 72-hour period after the resolution of gastrointestinal symptoms, increasing the risk of further transmission. The infection control reports from September to November 2024 revealed multiple instances of antibiotic use among residents, with no documented rationale for some treatments. The reports also identified a COVID-19 outbreak, but there was insufficient documentation of transmission-based precautions or investigation into potential contacts and sources of infection. The infection preventionist failed to correlate the Norovirus diagnosis of one resident with similar symptoms reported by other residents and staff, indicating a lack of thorough investigation and response to the outbreak. Furthermore, the facility did not ensure proper disinfection of the whirlpool tub between resident uses, as observed during a survey. The nursing assistant responsible for cleaning the tub did not follow the manufacturer's instructions to keep surfaces wet with disinfectant for the required 10 minutes. This oversight was due to a lack of training and awareness among staff. The director of nursing and the administrator were unaware of these deficiencies and the potential correlation between the Norovirus diagnosis and other illnesses, highlighting a breakdown in communication and oversight within the facility's infection control program.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop an effective antibiotic stewardship program, which is crucial for preventing antibiotic resistance. The program lacked protocols and a system to monitor antibiotic use, affecting all 29 residents. The infection control reports from September to November 2024 showed numerous antibiotic orders without proper documentation of symptoms, culture/sensitivity results, or physician notifications to ensure appropriate medication use. For instance, in October 2024, a resident continued on an oral antibiotic without documented rationale or physician contact. Another resident was admitted with a prophylactic antibiotic for recurrent UTIs, but there was no investigation or consultation with a physician regarding the necessity of continued use. Interviews revealed that the physician was unaware of the ongoing need for antibiotics for certain residents and had not been consulted about their continued use. The Infection Preventionist (IP) admitted to not tracking antibiotic use to resolution or performing necessary timeouts, citing a vacation as the reason for incomplete December data. The Director of Nursing and the administrator acknowledged the lack of oversight in the antibiotic stewardship program, especially during the IP's absence, and the failure to assign someone to cover infection control duties during that time.
Inadequate Infection Control Program Oversight
Penalty
Summary
The facility failed to ensure that the infection preventionist (IP) had appropriate training and oversight of the infection control (IC) program. The IP did not perform current, daily cumulative infection control surveillance activities, maintain documentation of incidents, findings, and any corrective actions required, or ensure the IC program continued in her absence. The IP tracked staff illness using an illness/absence report but did not include all necessary documentation, such as the case of a resident tested for Norovirus. The IP also failed to document surveillance or resolution of infections and did not investigate or question prophylactic antibiotic orders. Additionally, the IP was unaware of the need to report potential Norovirus outbreaks and did not implement measures to prevent the spread of infection. The Director of Nursing (DON) expected the IP to correlate potential outbreak concerns and investigate root causes, but the IP did not follow facility policy and procedures regarding IC surveillance and documentation. The DON confirmed that antibiotics should not be started until a culture was received and that a timeout should be implemented 48 hours after starting an antibiotic. The administrator was unaware of a possible correlation between a resident hospitalized with Norovirus and staff illness with similar symptoms. The IP failed to designate someone to cover infection control surveillance during her vacation, and the facility's Infection Prevention and Control Program Policy required annual review and compliance with nationally accepted standards.
Failure to Notify Provider of Pressure Ulcer Reoccurrence
Penalty
Summary
The facility failed to update the provider following the re-development of an unstageable pressure area on a resident's right ankle. The resident, who had intact cognition and required extensive assistance for activities of daily living, was identified as at risk for pressure ulcers but had no unhealed pressure areas at the time of her last assessment. Despite having a pressure relief mattress and primarily using a wheelchair, the resident developed a sore on her right ankle, which was covered with a Band-Aid. The resident was unsure of when the sore occurred or how often the bandage was changed by staff. The director of nursing (DON) reported that the wound was first noted on December 28, 2024, but there was no documentation that the provider had been notified or that orders for treatment had been received. The wound was described as having a red outer aspect with a pink, scabbed center. Although a skin assessment was documented on December 29, 2024, the provider was not informed of the wound's reoccurrence, even during rounds on December 31, 2024. The facility's policy required the registered nurse to notify the physician of any skin issues and document orders for treatment, which was not followed in this case.
Failure to Secure Hazardous Areas for Wandering Residents
Penalty
Summary
The facility failed to prevent potential accident hazards for two residents with severe cognitive impairments who exhibited wandering behaviors. One resident, identified as having severe cognitive impairment and a history of wandering, was observed entering an unsecured tub room containing hazardous substances such as personal care products and cleaning agents. The room was unattended, and the resident was able to move around the room without staff intervention, posing a risk of exposure to these substances. The administrator acknowledged that the room should not have been left open and unattended, and the items should have been secured. Additionally, another unsecured room at the end of a hallway was found to contain toxic and flammable chemicals, such as Drano and WD-40, as well as various tools. This room was also left open, with no staff or residents in the immediate area. The administrator confirmed that the door should always be locked to prevent access by residents, particularly those with dementia who are at risk. The facility's policy requires that all chemicals and disinfectants be stored in a manner that eliminates risk, but this was not adhered to, leading to the deficiency.
Failure to Complete Monthly Pharmacist Reviews
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews by a licensed pharmacist were completed for three residents, leading to a deficiency in medication management. Resident 21, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and major depressive disorder, did not have documented pharmacist reviews for November and December 2024. This resident required extensive assistance with activities of daily living and was on several medications, including antipsychotics and antidepressants. Similarly, Resident 19, with severe cognitive impairment and diagnoses of dementia and anxiety, also lacked documented pharmacist reviews for the same months. This resident exhibited verbal and physical behaviors and was on psychotropic medications. Resident 10, who had intact cognition but required significant assistance with daily care, also did not have documented pharmacist reviews for November and December 2024. This resident was on multiple medications, including insulin and anticoagulants, and had a history of stroke and depression. The facility administrator acknowledged issues with the consulting pharmacist, who was unavailable due to illness, and noted difficulties in obtaining timely reviews. The absence of a pharmacy contract and the inability to consistently communicate recommendations to providers were also highlighted as contributing factors to the deficiency.
Failure to Justify Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to investigate and document the justification for a prophylactic antibiotic prescribed to a resident with severe cognitive impairment and a history of frequent urinary tract infections (UTIs). The resident was admitted with an order for Macrobid, an antibiotic, for chronic UTIs, but there was no documentation of signs or symptoms of a UTI, nor was there a culture and sensitivity test conducted. The care plan did not mention the prophylactic antibiotic, and interviews with staff revealed a lack of awareness and evaluation regarding the continued need for the medication. The Director of Nursing and the resident's primary provider were unaware of any evaluation for the necessity of the antibiotic since the resident's admission. The primary provider noted that the resident had been on the medication since before admission and had not shown any UTI symptoms since. The Infection Preventionist did not identify the prophylactic antibiotic use as a concern under antibiotic stewardship criteria. The facility did not provide a policy for unnecessary medications or prophylactic antibiotic use by the end of the survey period.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Lawn Senior Care | 14.1 mi | ★★★★★ | 10 | 0 |
| Valley View Manor Hcc | 15.2 mi | ★★★★★ | 13 | 2 |
| Prairie View Senior Living | 15.5 mi | ★★★★★ | 6 | 0 |
| Good Samaritan Society - Windom | 20.1 mi | ★★★★★ | 23 | 1 |
| Good Samaritan Society - Mountain Lake | 25.9 mi | ★★★★★ | 3 | 0 |
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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.