Windward Gardens

In the surveyor’s words

From the most serious findings on record at Windward Gardens, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 18, 2023

  Based on record review and interviews, the facility failed to ensure that a two-person, mechanical lift assist was provided during a transfer for 1 of 5 sampled residents (Resident #1) reviewed for incidents with injuries. The failure resulted in Resident #1 falling during an improper transfer from the bed to the wheelchair. The injury sustained from the fall led to Resident #1's death 7 days later. Findings: On 3/14/23 at 12:56 p.m., a Report of Facility Incident was received from the facility. […]

• No harm, potential for more than minimal, widespreadF725Apr 17, 2025

  Based on record review, interview and Payroll Based Journal Report (PPJ), the facility failed to ensure it was sufficiently staffed on weekends for 1 of 1 quarter reviewed (10/1/24 through 12/31/24/ [39 days]). Findings: Review of Center for Medicare & Medicaid (CMS)PPJ Report revealed the facility triggered for low weekend staffing during the first quarter (10/1/24 through 12/31/24). During a review of first quarter weekend staffing with Administrator and Scheduler on 4/17/25 at 12:27 p.m., the Administrator confirmed the facility was not adequately staffed for 32 of 39 days reviewed.

• No harm, potential for more than minimal, patternF684May 20, 2026

  Based on record reviews and interviews, the facility failed to ensure physician orders were followed for 4 of 19 sampled residents (Resident #22 (R22), R3, R34, and R29. Findings: 1. R22's Treatment Administration Record (TAR) for March was reviewed and contained an order (dated 5/22/24) to inject 8 units of Lispro Insulin before meals but to hold the insulin if blood sugar was less than 100. The following was observed as documented on the March 2026's TAR: -On 3/4/26, the 11:30 a.m. blood sugar was 110, but insulin was not administered. -On 3/5/26, the 7:30 a.m. blood sugar was 103, but insulin was not administered. -On 3/15/26, the 7:30 a.m. blood sugar was 102, but insulin was not administered. -On 3/20/26, the 7:30 a.m. […]

• No harm, potential for more than minimal, patternF812May 20, 2026

  Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing dishes and food in a sanitary manner, monitoring food temperatures to prevent food borne illness prior to serving residents, and not ensuring that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 days of survey (5/18/26 and 5/19/26). Findings: 1. On 5/18/26 at 10:55 a.m., a surveyor and the Food Service Manager (FSM) observed and confirmed the following were on the shelf and available for use in the walk-in refrigerator: -3 Open beverage containers. […]

• No harm, potential for more than minimal, patternF842May 20, 2026

  Based on clinical record reviews, and interviews, the facility failed to ensure that clinical records contained complete and accurate information for 3 of 19 residents reviewed on survey (Resident #38 [R38], R22, and R29). Findings: 1. On 5/19/26 at 8:52 a.m. during a medication administration observation with an RN, it was observed that the medication that was scheduled was not available. R38 had an order for fluticasone prop 50 microgram (mcg) spray (Flonase) 1 spray in each nostril two times a day for allergies. This medication was not in the medication cart or in the medication supply room. The RN stated she would look for it later and give it to R38. On 5/20/26 at 6:30 a.m. […]