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 Street, 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
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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