Every finding on record at Windward Gardens

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. blood sugar was 115, but insulin was not administered. -On 3/26/26, the 7:30 a.m. blood sugar was 96, but insulin was administered. -On 3/29/26, the 7:30 a.m. blood sugar was 110, but insulin was not administered. On 5/20/26 at 11:07 a.m., during an interview with a surveyor, the Market Clinical Lead stated she could find no additional information on why the blood sugar or insulin was held or given outside of parameters. R22's Treatment Administration Record (TAR) for April was reviewed and contained an order (dated 4/14/26) to administer insulin as needed per sliding scale if blood sugar is as follows: -If 150-200, administer 2 units; -201-250, administer 4 units; -251-300, administer 6 units; -301-350, administer 8 units. The following was observed as documented on the April 2026's TAR: -On 4/16/26, the 9:00 p.m. blood sugar was 162, but insulin was not administered. -On 4/17/26, the 11:30 a.m. blood sugar was 175, but insulin was not administered. -On 4/18/26, the 9:00 p.m. blood sugar was 154, but insulin was not administered. On 5/20/26 at 12:20 p.m, during an interview with a surveyor, the Market Clinical Lead stated she could not find any information on why the insulin was held when outside of parameters. 2. On 5/18/26 at 2:30 p.m., during an interview with a surveyor, R3 stated he/she has been to the hospital recently a couple of times. On 5/20/26, R3's clinical record was reviewed and contained a Physician Order (dated 4/9/26) to notify the provider if there is a weight gain greater than 3 pounds (lbs) in 1 day or 5 lbs in one week. On 4/9/26 at 6:35 a.m., R3's documented weight was 245.4 lbs and on 4/10/26 at 9:50 a.m., R3's documented weight was 250 lbs, a weight gain of 4.6 lbs in one day. On 5/6/26 at 7:00 a.m., R3's documented weight was 242.6 lbs, and on 5/7/26 10:06 a.m., R3's documented weight was 246.6 lbs, a weight gain of 4 lbs in one day. On 5/20/26 at 12:20 p.m., during an interview with a surveyor, the Market Clinical Lead stated she was unable to find evidence that the provider was notified per Physician Order. 3. On 5/20/26, R34's clinical record was reviewed and included an order (dated 3/27/25) for Metoprolol succinate Extended Release 24 hour 100 milligram tablet to be held in systolic blood pressure is less than 110 or heart rate less than 60; a review of the March and April TARs indicated the following: -On 3/24/26, R34's systolic blood pressure was 107, but the medication was documented as administered. -On 3/27/26, R34's systolic blood pressure was 109, but the medication was documented as administered. -On 3/31/26, R34's systolic blood pressure was 107 and the heart rate was 56, but the medication was documented as administered. -On 4/17/26, R34's systolic blood pressure was 106, but the medication was documented as administered. On 5/20/26 at 1:45 p.m., during an interview with Market Clinical Lead, a surveyor confirmed that the medication was administered when it should have been held according to the parameters. 4. On 3/20/26, R29's clinical record was reviewed and included the following: -On 3/7/26, a provider order stated, Outline redness of stump and call provider if redness spreads outside the line. Every day and night shift. -On 5/7/26-5/11/26, documentation on the Treatment Administration Record (TAR) indicated the redness of the stump was outlined and assessed for spread of the redness. -On 3/10/26, the wound documentation and photo lacked evidence that the redness was outlined to monitor for spread of the redness outside of the line. On 5/20/26 at 12:16 p.m., during an interview, a surveyor and the Market Clinical Director reviewed R29's clinical record and confirmed that the redness around R29's stump was not outlined in the photos as ordered.

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. The FSM stated the open beverages belonging to dietary staff and confirmed they should not be stored with resident's food storage. -1 open package, containing 22 hot dogs, labeled with an expiration date of 5/17/26. -1 open, 5-pound package of shredded cheese, labeled with an expiration date of 5/15/26. -1 container of chopped lettuce, labeled with an expiration date of 5/17/26. On 5/18/26 at 11:00 a.m., a surveyor and the FSM observed and confirmed the following were on the shelf and available for use in dry food storage: -1 open, 5-pound package of seasoned breadcrumbs, labeled with an open date of 4/8/26 and an expiration date of 5/8/26. At 11:15 a.m., a surveyor and the FSM observed and confirmed the following: -food debris was observed on the shelves around stacked clean dishes. A rubber glove was pressed between 2 piles of clean plates. All kitchen surfaces were moderately soiled with food debris unrelated to the meal service. At 11:23 a.m., a surveyor observed the cook pick up a wet cloth that had been laying on a countertop throughout the kitchen observation and use it to wipe a food thermometer, then begin to check the food temperature of the macaroni and cheese. There appeared to be green food debris on the cloth. Surveyor requested to look closer at the cloth and the cook immediately threw the cloth in a large trash bin, then closed the lid over it with bare hands. The cook picked up the food thermometer and began to check the temperature of the broccoli. At this time the surveyor confirmed with the cook that she had not washed her hands after being in contact with the trash bin and prior to touching the thermometer. This was also confirmed with the FSM at the time of the observation. On 5/18/26 at 11:36 a.m., a surveyor observed the cook serve the mechanical soft turkey onto a plate. At 11:37 a.m., during an interview with a surveyor, the cook confirmed she had not taken food temperatures on the mechanical soft turkey, the pureed turkey, the green bean and potato puree, or either of the 2 pans of gravy. At 11:44 a.m., a surveyor and the FSM observed and confirmed the holding temperature for the mechanical soft turkey was 123.6 degrees Fahrenheit (F), the holding temperature for the pureed turkey was 122.6 degrees F, and the holding temperature for the green bean and potato puree was 118 degrees F. The FSM confirmed the minimum holding temperature is 135 degrees F. 2. On 5/19/26 at 1:57 p.m., a surveyor observed a dietary staff member stack large steam table pans dripping with water. The surveyor confirmed the presence of wet stacking with the FSM at the time of the observation. On 5/18/26, between 11:35 a.m. - 11:40 a.m., during a tour of the Spring Gardens Unit, the refrigerator was observed with the following: - An opened container of Thickened Apple Juice not dated to indicate when it was opened. The directions on the carton indicated to discard after 7 days from opening. - Multiple opened food items including milk-based seafood chowder brought in on 5/14/26, a salad dated 5/13/26 with wilted lettuce with moisture inside the container, and half a meat sandwich with wet lettuce with bites missing (bread appeared wet along the bitten edges) with a sell by date of 5/14/26. These were confirmed with Certified Nursing Assistant #1 (CNA1) at the time of the observations. The Licensed Social Worker and Assistant Director of Nursing who were on the Spring Gardens Unit, both stated that the limit was 3 days and that these items needed to be discarded. On 5/18/26 at 1:06 p.m., the Maintenance Director and surveyor observed an improper air gap on the ice machine located in Spring Gardens. 3. On 5/18/26, between 11:15 a.m. and 11:55 a.m., an initial tour of the North Wind Unit was completed. During the tour, an ice machine located on the kitchenette counter was observed to have an improper air gap. On 5/18/26 at approximately 1:00 p.m., the improper air gap was discussed with the Maintenance Director. 4. On 5/18/26, between 11:55 a.m. and 12:30 p.m., an initial tour of the Windward Center unit was done. During the tour, an ice machine located on the kitchenette counter was observed to have an improper air gap. On 5/18/26 at approximately 1:00 p.m., the surveyor confirmed the improper air gap with the Administrator and the Maintenance Director.

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. during a review of R38's Medication administration record (MAR) the documentation indicated that R38 did receive two doses of Flonase on 5/19/26. On 5/20/26 during an observation of the medication cart with LPN2, the Flonase for R38 was not in the cart and was not available. Review of the MAR with LPN2 and the night nurse who was at the end of her shift they both stated that the box was green and had a check mark with staff initials LPN3 indicating that the medication was administered. The surveyor at this time confirmed that the medication was signed off indicating the medication was administered and that the Flonase was not available nor was it in the cart for use. On 5/20/26 at approximately 1:30 p.m. the Market clinical advisor stated she spoke to the nurse who initialed the medication as being given (LPN3). The nurse stated she did sign the medication as being given because she thought the other nurse just forgot to sign it. The Market clinical advisor educated the nurse that she could not have given the medication as it was not available, and she should not sign for something she did not do herself. The Flonase was picked up at the local pharmacy that morning and R38 received her scheduled morning dose on 5/20/26. 2. On 5/20/26, R22's clinical record was reviewed and contained a treatment dated 12/17/25, to inject a Dexcom sensor (continuous glucose system sensor) every 10 days. The Treatment Administration Record (TAR) indicated that this treatment was held on 3/7/26, 3/17/26, 4/6/26, 4/26/26, and 5/16/26. The TARs were documented that these were held or to see nurse's notes on why these were not completed but the clinical record lacked that documentation. On 5/20/26 at 10:15 a.m., during an interview with a surveyor, the Consulting Administrator - Maine and Market Clinical Lead stated they were unable to find the documentation in R22's clinical record on why these treatments were not completed. 3. 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 3/5/26, the 7:30 a.m. blood sugar was 103 but insulin not administered and the TAR was documented to see nurses notes. On 3/20/26, the 7:30 a.m. blood sugar was 115, but insulin was not administered and the TAR was documented to see nurses notes. On 5/20/26 at 11:07 a.m., during an interview with a surveyor, the Market Clinical Lead stated she could not find documented nurses notes as indicated on the TAR. 4. On 3/20/26, R29's clinical record was reviewed and included the following: -On 3/3/26, a provider order stated, WOUND MONITOR: Right [Above Knee Amputation (AKA)]. Monitor sites daily for status of surrounding tissue and wound pain. Monitor for status of dressings, if applicable Additional Documentation in [Nurse Notes (NN)] if needed every shift. -On 3/3/26 at 11:49 a.m., a Skin Issues note stated, Skin issue has been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. Progress: Stable: previously deteriorating wound characteristics plateaued. Incision approximated: Yes. Dehiscence: partial or complete separation of the outer layers of the joined incision: No. -On 3/4/26 at 6:31 p.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/5/26 at 11:46 a.m., a progress note stated, Skin: Skin on [R29's] right residual leg is viewed. Incision is with more redness than previous when compared to pictures. -On 3/6/26 at 12:46 a.m., a Skin Check note stated, Skin warm [and(&)] dry, skin color [within normal limits (WNL)] and [elasticity of the skin (turgor)] is normal. Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/6/26 at 6:17 p.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/7/26 at 12:30 a.m., a clinical note stated, Skin warm & dry, skin color WNL and turgor is normal. Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/7/26, a provider order stated, Outline redness of stump and call provider if redness spreads outside the line. Every day and night shift. Review of documentation on the Treatment Administration Record (TAR) from 5/7/26-5/11/26, indicated the redness of the stump was outlined and assessed for spread of the redness. Wound documentation, pictures, and clinical notes indicate the surgical wound was outlined or evaluated for spread of redness (see F684). -On 3/7/26 at 5:47 p.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/8/26 at 2:26 p.m., Skin issue has not been evaluated. Location: Right above knee – amputation site. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/9/26 at 12:20 p.m., a progress note stated, Skin: Skin on [R29's] right residual leg is viewed. Surgical sites not viewed today. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/9/26 at 2:26 p.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/10/26 at 10:00 a.m., a Skin Issues note stated, Skin issue has been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. Progress: Deteriorating: wound characteristics deteriorated. Tunneling: Yes. Number of tunnels: 1. Tunnel length [centimeters (cm)]: 10. -On 3/10/26 at 2:29 p.m., a general note stated, [R29] was sent to [Emergency Room(ER)] for further evaluation of right above knee amputation stump wound drainage and tunneling. -On 3/17/26 at 4:10 p.m., a general note stated R29 returned to the facility with an intact dressing over the AKA. Wound documentation contained a blank photo. -On 3/17/26 at 7:53 p.m., a Skin Issues note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. Tunneling: Yes. Number of tunnels: 1. The note indicates the wound was not evaluated but contained identical documentation of the Skin Issue prior to R29's transfer to the ER. -On 3/18/26 at 2:04 a.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. Tunneling: Yes. Number of tunnels: 1. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/18/26 at 8:08 p.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. Tunneling: Yes. Number of tunnels: 1. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/19/26 at 2:49 a.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. Tunneling: Yes. Number of tunnels: 1. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/19/26 at 2:13 p.m., a Skilled Evaluation note stated, Skin issue has not been evaluated. Location: Right above knee – amputation site. Issue type: Surgical wound. Tunneling: Yes. Number of tunnels: 1. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/19/26 at 2:48 p.m., a progress note stated, Skin on [R29's] right residual leg is viewed. Surgical sites not viewed today.Inspection: Right [above knee (transfemoral)] amputation. There is a dressing in place and wounds are not viewed. Photographs are viewed of the wound from 3/10, which shows non-healing areas around the incision with some open ulceration and scabbing. Skin surrounding the wound looks pink. The photo was taken prior to the hospitalization for deteriorating wound condition. The clinical record lacks evidence that the surgical wound was monitored for improvement or deterioration. -On 3/24/26, a photo in the wound documentation shows Dehiscence of the surgical wound on the right AKA. The clinical record does not identify when or how dehiscence occurred. The clinical record lacks documentation of wound progression. The clinical record lacks evidence that nursing staff notified the provider of deteriorating wound conditions. On 5/20/26 at 11:24 a.m., during an interview with a surveyor, the Market Clinical Lead, the Administrator, and the Market Clinical Director, the clinical record for R29 was reviewed. At this time the surveyor confirmed that multiple notes indicate the wound was not assessed, there was no documentation to show the provider was notified of the deteriorating wound condition, and no documentation of how or when dehiscence occurred. The Situation Background Assessment and Recommendation (SBAR) does not contain information to what occurred, only contains ER recommendation and a set of vitals. There was no documentation following the incident to identify when or how dehiscence occurred. The Market Clinical Lead and the Market Clinical Director requested more time to find more information. On 5/20/26 at 11:30 a.m., the Market Clinical Director stated the notes are not where they would look. She stated if you look at the TAR you can see there were dressings done every day so the wound would be assessed by staff. Surveyor confirmed the TAR did not contain documentation of wound improvement or deterioration, and that the clinical record did not reflect this information or if it were communicated with the provider. The Market Clinical Director provided a provider note that stated ATSP (Asked to see patient) at the beginning and stated this is how they know staff communicated with the provider. At this time the surveyor confirmed the clinical record lacked complete and accurate documentation regarding R29's right AKA surgical wound.

Based on record review and interview, the facility failed to ensure an as needed (PRN) psychotropic medication met the required 14-day limit and the facility failed to provide evidence of documentation to justify the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident #10 [R10])Finding: A review of the clinical record for R10 revealed that he/she had an order dated 4/21/26 for Lorazepam Gel 2 milligram/milliliter (mg/ml), apply to wrist, neck, back, arms topically every 8 hours as needed (PRN) for agitation/anxiety, dementia like behavior to give 1ml dose. This order's 14-day limit would end on 5/5/26. Review of his/her medication administration record (MAR) documented that R10 received 12 doses after the 14-day limit ended on 5/5/26. He/she also had an order dated 4/14/26 for diazepam 2 mg, give 1 tablet by mouth every 12 hours as needed for agitation, anxiety, calling out until 5/14/26 x 30 days, this orders 14-day limit would end on 4/28/26 the clinical record lacks evidence of the rationale for the extended time limit past the required 14-day limit and his/her MAR for May documents that he/she received 1 dose after the 14-day limit ended on 4/28/26. Review of R10's nursing notes in his/her clinical record lacks evidence of documentation that justifies the use of his/her PRN lorazepam and diazepam orders. On 5/20/26 at 10:30 a.m. during interviews with the Market Clinical Advisor and the Market Clinical Lead the surveyor confirmed that the prn lorazepam and prn diazepam did not have correct stop dates (14-day limit) and that R10 received 12 doses of the lorazepam beyond the 14-day limit. At this time the surveyor also confirmed that the clinical record lacked evidence of documentation to justify the use of PRN psychotropic medications.

Based on record reviews, and interviews, the facility failed to ensure that residents and/or resident representatives received assistance/follow up assistance concerning the right to formulate an advanced directive, or appoint a surrogate, for 2 of 24 residents reviewed (Resident #37 [R37], and R63).Findings:1. On 5/9/26, R37's clinical record was reviewed and indicated the following:-R37 was admitted in the spring of 2023.-On 12/26/25, a social services assessment indicated R37 has an advanced directive, that there is not a copy in the medical record, and there was no additional conversation regarding advanced care planning provided. The clinical record lacked evidence that the facility followed up to obtain a copy of R37's advanced directive, or that the resident received assistance/follow up assistance concerning the right to formulate an advanced directive.-On 3/11/26, a social services assessment indicated R37 has an advanced directive, that there is not a copy in the medical record, and there was no additional conversation regarding advanced care planning provided. The clinical record lacked evidence that the facility followed up to obtain a copy of R37's advanced directive, or that the resident received assistance/follow up assistance concerning the right to formulate an advanced directive.-On 3/31/26, a social services assessment indicated R37 has an advanced directive, that there is not a copy in the medical record, and there was no additional conversation regarding advanced care planning provided. The clinical record lacked evidence that the facility followed up to obtain a copy of R37's advanced directive, or that the resident received assistance/follow up assistance concerning the right to formulate an advanced directive.On 5/19/26 at 3:20 p.m., during an interview with a surveyor and the Licensed Social Worker (LSW), R37's clinical record was reviewed. The LSW confirmed that according to the medical record R37 has an advanced directive, but the clinical record lacked evidence that the facility obtained a copy. 2. On 5/19/26, R63's clinical record was reviewed and indicated R63 had an advanced directive. The clinical record lacked evidence that the facility followed up to obtain a copy of R63's advanced directive, or that the resident received assistance/follow up assistance concerning the right to formulate an advanced directive.On 5/19/26 at 3:20 p.m., during an interview with a surveyor and the LSW, R63's clinical record was reviewed. The LSW confirmed R63's spouse visits daily and that according to the medical record R63 has an advanced directive, but the clinical record lacked evidence that the facility followed up to obtain a copy.On 5/20/26 at 8:00 a.m., during an interview with a surveyor and the Market Clinical Director, the clinical record for R63 was reviewed. The Market Clinical Director stated, R63 does not have an advanced directive, and more follow-up is needed as some people don't really understand which form is needed and may not have an advanced directive. At 8:06 a.m., a surveyor and the Market Clinical Director reviewed and confirmed R37's clinical record lacked evidence that the facility followed up to obtain a copy of R37's advanced directive, or that the resident received assistance/follow up assistance concerning the right to formulate an advanced directive. At this time, the surveyor confirmed the above findings.

Based on observation and interview the facility failed to provide or offer a lunch meal to a resident on 1 of 3 days of survey on 5/19/26. (Resident #33 [R33].Finding: On 5/19/26 at 12:45 p.m., during an interview with a family member for R33, she stated she was waiting for R33's lunch. Lunch meal service normally comes to the floor at 11:45 a.m. The surveyor asked staff who were in the dining area where R33's lunch tray was. R33's lunch tray was found in the meal cart towards the back of the cart with his/her meal slip on the tray. When the tray was removed and the cover was lifted it was observed there was a small dish of macaroni salad on the plate and the egg salad sandwich was not there, remnants of the sandwich (egg crumbs) were observed on the plate. During interviews with staff, they could not say where R33's full lunch was. The CNA who was assigned to care for R33 stated she did not bring R33 or offer R33 his/her lunch tray because she thought R33's daughter had brought her a crab cake for lunch. R33 is a dependent resident for all care including meals. On 5/19/26 at approximately 12:50 p.m., during an interview with the Market Clinical Advisor, the surveyor and R33's daughter. R33's daughter stated that even if she brings in things for R33 to eat she would expect R33 to receive their meals as scheduled. The surveyor confirmed at this time that R33 was not delivered or offered their lunch meal.

Based on observations, interviews, and record review, the facility failed to update a care plan in the area of oxygen use for 1 of 1 resident reviewed for respiratory care (Resident #3 [R3]). Finding: On 5/18/26 at 2:36 p.m., during an interview with R3, a surveyor observed the resident wearing a nasal cannula attached to the oxygen concentrator which was set at 8 liters per minute (LPM). R3's clinical record was reviewed and indicated the current oxygen order was for 3 - 5 LPM for the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 5/18/26 at 3:00 p.m., during an interview with a surveyor, R3 stated that he/she changed the LPM setting to 8 and that he/she often changes it. On 5/18/26 at 3:03 p.m., during an interview with a surveyor, Licensed Practical Nurse #1 (LPN1) stated that R3 changes the setting all the time, but she would go check on it. R3's care plan was reviewed under the care area of Respiratory complications related to . The care plan, last updated 4/27/26, indicated that the oxygen settings were to be 3-5 LPM but did not indicate that R3 would made changes themselves and that staff needed to monitor. On 5/19/26 at 2:48 p.m., during an interview with R3, a surveyor observed the oxygen concentrator settings at 6 LPM. R3 stated that he changed that later yesterday afternoon and that he/she often changes it between 6 - 8 LPM depending upon what he/she is doing. On 5/19/26 at 3:14 p.m., during an interview with Consulting Administrator - Maine, R3's care plan was reviewed and did not include an intervention that noted that R3 would increase this setting often themselves. On 5/19/26 at 3:37 p.m., during an interview with a surveyor, the Consulting Administrator - Maine stated she had updated R3's care plan

Based on record reviews and interviews, the facility failed to develop and implement a person centered care plan for suicidal ideations for 1 of 2 residents reviewed for mood and behaviors. (Resident#8 [R8]) and failed to to implement a care plan in the area of oxygen use for 1 of 1 resident reviewed for respiratory care (Resident #3 [R3]).Finding: 1. On 5/19/26, a review of R8's clinical record was completed. Documentation in the nurse note, dated 3/22/26, indicated the resident stated he/she would rather be dead. R8 was sent to the emergency department (ED) for evaluation of his/her suicidal ideations. On 3/23/26, documentation indicated R8 told the ED Provider that he/she did not want to be around anymore but was not going to harm himself/herself. On 3/23/26, after R8 had his/her room changed, R8 voiced not wanting to be around anymore. On 3/26/26, R8 was seen by telehealth Provider and the assessment indicated R8 has suicidal ideations with expressed intent to go into traffic, decreased oral intake with concern for dehydration, and behavioral changes with threatening statements. The plan is to send R8 to hospital for psychiatric evaluation. On 4/10/26, resident seen by Provider for suicidal ideations. On 4/12/26, R8 expressed wanting to be dead but does not have a plan for self harm and that he/she is depressed. On 5/19/26 at 2:05 p.m., in an interview with the surveyor, the facility Market Clinical Lead confirmed that there was not a specific care plan problem developed to address R8's suicidal ideations. 2. On 5/18/26 at 2:36 p.m., during an interview with R3, a surveyor observed the resident wearing a nasal cannula attached to the oxygen concentrator which was set at 8 liters per minute (LPM). Licensed Practical Nurse #1 (LPN1) entered the room to change the nasal cannula R3 was wearing that was attached to the oxygen concentrator. R3's clinical record was reviewed and indicated the current oxygen order was for 3 - 5 LPM for the diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and that staff were to check this setting each shift – 3 times a day to keep saturation between 88-92 percent. On 5/18/26 at 3:03 p.m., during an interview with a surveyor, LPN1 stated that she attached the new nasal cannula to the oxygen concentrator but did not observe the LPM setting. LPN1 stated that she did not provide any education regarding the LPM setting when she changed the cannula but stated that R3 changes the setting all the time, but she would go check on it. R3's care plan was reviewed under the care area of Respiratory complications related to . The care plan indicated that the oxygen settings were to be 3-5 LPM and that staff was to provide education regarding risk factors and interventions. On 5/19/26 at 2:48 p.m., during an interview with R3, a surveyor observed the oxygen concentrator settings at 6 LPM. R3 stated that he/she changed that later yesterday afternoon and that he/she often changes it between 6 - 8 LPM depending upon what he/she is doing. On 5/19/26 at 3:14 p.m., during an interview with Consulting Administrator - Maine, R3's Treatment Administration Record (TAR) and care plan were reviewed. The May TAR directed staff to check R3's oxygen saturations 3 times a day (each shift) but did not have a place to document what the oxygen LPM on the concentrator was set at. This TAR contained documentation that R3's oxygen saturations were above 92%, 26 times out of 56 shifts documented. The clinical record lacked evidence of adjustments to the settings or education provided when the oxygen LPM were greater than 5 LPM. On 5/19/26 at 3:37 p.m., during an interview with a surveyor, the Consulting Administrator - Maine stated she had updated R3's care plan and TAR.

Based on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for falls during a complaint investigation (Resident #1).Finding:Resident #1 was admitted with diagnoses to include but not limited to atrial fibrillation on anticoagulation (a blood thinner medication).A review of Resident #1's clinical record revealed an active physician order for Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 Tablet by mouth two times a day .Review of Resident #1's March 2026 Medication Administration Record (MAR) indicated that Resident #1 received his/her scheduled doses of Eliquis two times a day from March 1-18, 2026.Further review of Resident #1's clinical record revealed an SBAR (Situation, Background, Appearance, Review, and Notify) Communication Form and Progress Note, dated 3/12/26 and 3/17/26, used when notifying the physician of a resident's change in condition. The form states, Before calling MD [Medical Doctor]/NP [Nurse Practitioner]/ PA [Physician Assistant]: Evaluate the Resident: Complete relevant aspects of the SBAR form below. The forms indicated that Resident #1 sustained a fall on 3/12/26 and 3/17/26, and the Background section of the form, under Medication Alerts, lacked indication that Resident/patient is on other anticoagulant.On 4/1/26 at 3:16 p.m., the above finding was discussed with the Administrator and the Market Clinical Lead during an interview.On 4/1/26 at 3:50 p.m., the Market Clinical Lead confirmed that the SBAR communication form used to notify the physician of Resident #1's fall on 3/12/26 and 3/17/26 did not reflect his/her being on an anticoagulant.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 1 of 4 units observed during a complaint investigation (North Wind unit).Findings:On 3/13/26, the Division of Licensing and Certification received a complaint that states .there are dirty washcloths in client's [resident's] room after staff washed client off.On 3/31/26 at 4:52 p.m. during a telephone interview, the complainant indicated that staff leave soiled washcloths sitting on the resident's shelves.On 4/1/26 from 10:10-10:26 a.m., during the onsite investigation, a surveyor conducted a tour of the North Wind unit and observed the following:In resident room [ROOM NUMBER]-2, orange peels and various food debris were on the floor next to and underneath the resident's bed.In Resident #2's room, the bathroom trash can was overflowing with debris and used exam gloves, and an unbagged soiled washcloth were on the floor next to the trash can. An unbagged sheet and a trash bag were on the floor outside of the resident's shower. A visibly soiled washcloth and a medicine cup containing red liquid residue were on the resident's sink. An unbagged wash basin containing a soiled washcloth was on the floor under the sink.In resident room [ROOM NUMBER]-1, a soiled washcloth was on the resident's over-the bed table and an exam glove was on the nightstand. An unbagged soiled washcloth was on the floor.In resident room [ROOM NUMBER], a pair of non-skid socks and a plastic spoon were on the floor by the resident's bed. A tubigrip stocking and a medicine cup containing an unknown white cream were on top of the resident's nightstand. The resident's nebulizer tubing was hanging out of the top drawer of the nightstand. An unbagged washcloth, visibly soiled with what appeared to be feces, was in the resident's bathroom sink. The trash can located outside of the bathroom had oxygen tubing hanging over the top of the trash can and extending down to the floor.On 4/1/26 from 10:30 a.m.- 10:38 a.m., the surveyor conducted a tour of the North Wind unit with the Market Clinical Lead and confirmed the above findings. At approximately 10:35 a.m., during an interview while observing Resident #2's room, Resident #2 stated that a night shift staff was going to empty his/her overflowing bathroom trash can but that her shift was over, so she left it.On 4/1/26 at 10:40 a.m. during an interview the Market Clinical Lead stated that the facility has identified environmental concerns on the North Wind and Spring Gardens units, and that designated staff will be conducting rounds and audits. The surveyor asked if a Performance Improvement Plan or staff education had been implemented, and at this time the Market Clinical Lead stated that the concern was recently discussed during the facility's Quality Assurance and Performance Improvement (QAPI) meeting, dated 3/27/26, and that audits have not yet been implemented and that she would look for evidence of education. No evidence of staff education was provided prior to the end of the survey.On 4/1/26 at 2:45 p.m. during a repeat tour of the North Wind unit, in resident room [ROOM NUMBER]-2, the surveyor observed crushed crackers/chips on the floor next to the resident's trash can. The trash can did not have a trash bag liner and contained a medicine cup, spoon, and other refuse.On 4/1/26 at 4:30 p.m. during the exit conference, the surveyor discussed the repeat observation with the Administrator and the Market Clinical Lead.

Based on interviews and record reviews the facility failed to ensure neurological [neuro] checks were completed for 1 of 3 residents reviewed for falls during a complaint investigation (Resident #1).Findings:Resident #1 was admitted with diagnoses to include dementia and history of falls. Review of fall Incident Report dated 12/12/25 at 6:30 a.m., states Incident Location: Residents Room. Patient was found in [his/her] room laying on [his/her] right side on the floor. Patient states I got up and slid on the floor. Patient assessed and found to have no injuries . Initial Neuro checks complete and patient passed. the medical record lacked evidence that neuro checks were completed after this unwitnessed fall.Review of fall Incident Report dated 12/16/25 13:35 (1:35 p.m.) states Incident location: Hallway. The resident had fallen to the floor and was witnessed by the Nurse while rendering care to another patient near the hallway of the unit entrance door. He landed on his left arm and didn't hit his head. No injuries and pain noted. ROM (range of motion) and vital signs checked. All within normal limits. He was safely transferred back to the chair using a sit-to-stand device and situated near the nurses' station. Description: POM and vital signs check done. All within normal limits. He was safely-transferred back to the chair using a sit-to-stand device and situated near the nurses' station for close monitoringDuring an interview on 1/7/26 at 1:33 p.m., Director of Nursing (DON) stated neuro checks are done for every unwitnessed fall and they are done on paper. DON provided writer with neuro check sheet dated 12/16/25. DON states she believes the neuro checks that were dated for 12/16/25 were supposed to be 12/12/25. At this time medical record lacked documentation for neurological checks for 12/12/25 fall. The finding was confirmed with the DON.

Based on interviews, the facility failed to designate a qualified staff member to function as the Infection Preventionist who works at least part time and who is responsible for the facility's Infection Control Program since September 2025. This has the potential to affect all residents in the facility. Findings: On 12/4/25 at 7:49 a.m., during an interview with 2 surveyors, the Director of Nursing (DON) stated that she had completed the Infection Preventionist (IP) Training and was the IP until September, when she took the role of DON and had worked full time in the role of DON since then. Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated she was hired as the Infection Preventionist and currently is working 20 hours a week in that role, in addition to working the floor as a Charge Nurse. The Market Lead Clinical Specialist stated that part time is considered 20 hours a week. When a surveyor asked if LPN/IP had completed the training for the role of IP, LPN/IP stated that she was on module 12 for training and had not completed the training yet. The surveyors confirmed the facility did not have a qualified IP who worked at least 20 hours in the IP role.

Based on observations, record review, interviews, and facility procedure, the facility failed to follow their own Enhanced Barrier Precautions (EBP) procedure for 1 of 1 resident reviewed for urinary catheters (Resident #1 [R1]) and failed to provide a sanitary environment to help prevent the development and transmission of infections related to personal protective equipment (PPE) for 1 of 4 units observed (Windward). Findings: 1 Facility Procedure Enhanced Barrier Precautions, revised 5/1/25 states, .Post the appropriate Enhanced Barrier Precautions (EBP) sign on the patient's room door. Personal protective equipment (PPE) should be readily accessible and located outside of the patient's room. perform hand hygiene upon exiting the room. The procedure also states, Follow the Centers for Disease Control and Prevention [CDC] guidance per table below . The table indicates gown and gloves are required PPE during urinary catheter care and that .Face protection may also be needed if performing activity with risk of splash or spray. R1 was admitted in October 2025 with diagnoses to include Retention of Urine, indwelling urinary catheter, and Urinary Tract Infection (UTI). On 12/1/25 at 10:06 a.m. observation of R1's urinary catheter to gravity drainage on R1's bed frame. There was no EBP sign posted on R1's door, and there was no PPE cart located outside R1's room. A review of R1's care plan indicated .has UTI due to infectious organism . and . at risk for MDRO colonization/infection due to: indwelling devices .Enhanced Barrier Precautions. A review of R1's active physician orders revealed an order with a start date of 11/28/25 for Ciprofloxacin HCl Oral Tablet 500 MG. Give 1 tablet by mouth two times a day for bacterial infection. A review of R1's November and December 2025 Treatment Administration Records (TAR) indicated Registered Nurse #2 (RN2) changed R1's indwelling catheter on 11/3/25 and performed R1's indwelling catheter care on 11/1/25, 11/3/25, 11/6/25, 11/7/25, 11/10/25, 11/13/25, 11/15/25, 11/16/25, and 12/1/25. On 12/1/25 at 1:59 p.m. during an interview, a surveyor and RN2 observed R1's room. At this time, RN2 stated that R1 is on EBP for his/her urinary catheter, and there should be a sign outside his/her door and stated when staff provide catheter care they need to wash their hands and wear gloves. When a surveyor asked RN2 if she wears any additional PPE for R1's urinary catheter care, RN2 stated just gloves. On 12/1/25 at 2:10 p.m. the above finding was discussed with the Administrator and the Market Clinical Lead. 2. On 12/3/25 at 9:00 a.m., a surveyor observed Certified Nursing Assistant #3 (CNA3) enter R1's room to set up his/her breakfast tray. CNA3 then exited the room and without sanitizing her hands, proceeded to walk down the hallway. At this time, a surveyor intervened, and CNA3 stated that she was wearing gloves to set up R1's breakfast tray since he/she is on EBP. CNA3 then stated that she doffed (took off) her gloves in R1's room and that she usually sanitizes her hands after doffing her gloves but forgot. On 12/3/25 at 9:21 a.m., the above finding was discussed with the Market Clinical Lead. 3.During an observation of contact precaution room [ROOM NUMBER]-2 on 12/1/25 at 12:10 p.m., Certified Nursing Assistant (CNA1) was observed wearing gloves in the room leaning over resident who was on contact precautions for shingles. At this time CNA1 stated that she was aware that resident was on contact precautions and should be wearing a gown and gloves, and did gown and glove when giving care earlier this am but just needed to get his/her oxygen saturation (02 sat) really quick. During an interview on 21/1/25 at 12/1/25 at 12:15 p.m., the above was confirmed with Registered Nurse (RN3)

Based on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 16 sampled residents reviewed (Resident #2 [R2], R35).Findings: 1.Review of Resident #35's Medication Administration Record (MAR) and Treatment Administration Record (TAR) effective November 2025 revealed the following: -Diabetic foot check MAR/TAR lacked evidence this was completed/refused on 10/14/25 Does the patient need to have the Head of Bed elevated to avoid shortness of breath while lying flat? Every day and night shift: MAR/TAR lacked evidence this was completed/refused during night shift of 10/14/25. - Encourage deep breathing when awake every shift. every shift for Cough. MAR/TAR lacked evidence this was completed/refused on night shift on 10/14/25 - Resident free from side effects of psychotherapeutic medications?(if no, document side effects in PN) every day and night shift. MAR/TAR lacked evidence of this was completed/refused during the night shift on 10/14/25 Review of Resident #35's GG-Eating for November 2025 lacked evidence that evening meal was documented on 11/22/25 and 11/30/25 During an interview on 12/3/25 at 10:05 a.m., the above was discussed with Consulting Administrator-Maine. 2. On 12/3/25 at 9:19 a.m., R2's clinical record was reviewed and included a physician order, dated 5/22/25, to administer sliding scale insulin four times a day based on the resident's finger stick blood sugar (FSBS) results. November 2025's Treatment Administration Record (TAR) was reviewed with the Market Lead Clinical Specialist (MLCS) and it was noted that the TAR lacked evidence of FSBS results and if sliding scale was needed for 6:30 a.m. treatments on 11/3, 11/11, 11/17, and 11/20. MLCS stated she would check the record to see if it was documented elsewhere. On 12/3/25 at 10:35 a.m., the MLCS stated she was unable to find the missing documentation. The surveyor confirmed this finding at this time.

Based on observations, interviews, and review of the facility's Food Storage: Dry Goods policy/procedure, the facility's Food Storage: Cold Foods policy/procedure and the facility's Refrigerated/Frozen Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for fans, floors, a food mixer, a food processor, and metal shelving; failed to ensure kitchen staff with facial hair wore facial protection; failed to ensure foods were dated/labeled and/or secured shut in the reach in a walk-in refrigerator, a walk-in freezer, a dry storage room and in kitchen work areas; and failed to ensure the ice machine was properly installed to prevent backflow as required by the Maine State Plumbing Code requirements to prevent food contamination for 1 of 1 kitchen tour. (12/1/25)Findings: The facility's Food Storage: Dry Goods policy/procedure, revised 2/2023 noted:5. All packaged and canned foods items will be kept clean, dry, and properly sealed.6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The facility's Food Storage: Cold Foods policy/procedure, revised 2/2023 noted:5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's Refrigerated/Frozen Storage policy/procedure, revised 9/2017 noted:1.4 All foods are labeled with name of product and the date received and use by date once opened. 1.5 Prepared foods are labeled and dated with name of product, date opened, and use by date. This direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one-inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. On 12/1/25 from 7:45 a.m. to 8:20 a.m., an initial kitchen tour was completed by a surveyor in which the following findings were observed:- There was a male kitchen worker, with facial hair, that was was observed not wearing facial hair protection. - There was a dish room wall mounted fan that was dusty/dirty.- There was a section of cement floor, under the dich machine, that had chipped/missing paint creating an uncleanable surface. - There was a food mixer that had dried food particles and dried liquid residue on the unit base and the mix arm area. Additionally, the mix arm had chipped/missing paint. - There was a food processor that had dried food particles on the lid and the unit- There was a round table fan that was running, next to a food preparation area being used at the time, that was missing the front screen guard and was dusty/dirty.- There was a clear 2-quart pitcher, on a food preparation table with a white powder-like substance in it, that was not labeled and dated.- There was a metal shelf, under large storage bins, that had chipped/missing paint and was rusty creating an uncleanable surface. - The dry storage room had 2 previously opened packages, containing a brown powder type substance, that were not sealed and had not been labeled and dated. - The walk-in refrigerator had 2 fruit cups, a container of a chicken salad, a package of cheese slices and a previously opened package of shredded cabbage that were not labeled and dated. - The walk-in freezer had 2 packages of French toast and 2 packages of pan cakes that were not labeled and dated. Additionally, there was a case of pizza dough and a case of biscuit dough that had been previously opened and that were open to the air and not secured closed. - The ice machine was observed to not be plumbed with an appropriate air gap. On 12/1/25 at 8:20 a.m., in an interview with a surveyor, the Food Service Director confirmed the findings.

Based on observations, record review, and interviews, the facility failed to ensure expired medications and unlabeled medications were removed from the supply available for resident use for 1 of 4 medication carts observed (Penobscot Unit) for 1 of 4 days of survey. Furthermore, the facility failed to adequately ensure medications and biologics were monitored in 4 of 4 refrigerators observed for 3 of 3 months of medication refrigerator logs reviewed.Findngs:1. On 12/3/25 at 12:45 p.m., observation of Penobscot Unit medication cart with LPN #1 (Licensed Practical Nurse) revealed expired and unlabeled medication listed below:-Magnesium Oxide 400mg tablets expired on 11/2025.-Calcium 600 and DS tablets expired on 7/2025.-Acidophilus Probiotic tablets expired on 10/2025.-Lantus Insulin pen containing a little over 220 Units with no resident identifier and no open date.-Humalog Kiwi pen with no open date.On 12/3/25 at 1:35 p.m., the above information was confirmed with the Facility Administrator.2. On 12/3/25 at 2:00 p.m., observation of the Spring Garden medication storage room refrigerator which contained 2 shingles vaccinationsOn 12/3/25 a surveyor reviewed the facilities Temperature Log for Medication/Vaccine Refrigerator for the months of September, October, and November:-September 1st through September 30th lacked evidence of twice daily temperature readings for 21 out of the 30 days.-October 1st through October 31st lacked evidence of twice daily temperature readings for 4 out of the 31 days.-November 1st through November 30th lacked evidence of twice daily temperature readings for 6 out of the 30 days.3. On 12/3/25 at 2:05 p.m., Observation of the Windward Center medication storage room refrigerator which contained 1 Flu vaccine, 1 COVID vaccine, and 1 Prevnar 20 vaccineOn 12/3/25 a surveyor reviewed the facilities Temperature Log for Medication/Vaccine Refrigerator for the months of September, October, and November:-September 1st through September 30th lacked evidence of twice daily temperature readings for 21 out of the 30 days.-October 1st through October 31st lacked evidence of twice daily temperature readings for 4 out of the 31 days.-November 1st through November 30th lacked evidence of twice daily temperature readings for 5 out of the 30 days.4. On 12/3/25 at 2:10 p.m., Observation of the Penobscot medication storage room refrigerator which contained 8 Flu vaccines and 2 Covid Vaccines.On 12/3/25 a surveyor reviewed the facilities Temperature Log for Medication/Vaccine Refrigerator for the months of September, October, and November:-September 1st through September 30th lacked evidence of twice daily temperature readings for out 14 of the 30 days.-October 1st through October 31st lacked evidence of twice daily temperature readings for 18 out of the 31 days.-November 1st through November 30th lacked evidence of twice daily temperature readings for 14 out of the 30 days.5. On 12/3/25 at 2:00 p.m., Observation of the North Wind medication storage room refrigerator which contained 40 Covid vaccines, 12 Flu vaccines, 13 Prevnar 20 vaccines, and 1 Hep B vaccine.On 12/3/25 a surveyor reviewed the facilities Temperature Log for Medication/Vaccine Refrigerator for the months of September, October, and November:-September 1st through September 30th lacked evidence of twice daily temperature readings for 22 out of the 30 days.-October 1st through October 31st lacked evidence of twice daily temperature readings for 18 out of the 31 days.-November 1st through November 30th lacked evidence of twice daily temperature readings for 19 out of the 30 days.6. On 12/4/25 at 12:12 p.m., During an interview with the Market Lead Clinical Advisor, she states that Windward Gardens follows Centers of Disease Control and preventionl (CDC) guidelines for temperature monitoring for immunizations.A review of CDC guidelines titled Handle with Care: Protect Your Vaccine, Protect Your Patients states Check and record current temperatures a minimum of 2 times (at start and end of workday).On 12/4/25 at 12:12 p.m., During an interview with Market Lead Clinical Specialist, the above information was confirmed.

Based on facility policy review, record reviews, and interviews, the facility failed to ensure the pharmacist identified an irregularity for a scheduled II medication and failed to ensure that the physician responded to a pharmacist recommendation timely for 2of 5 residents reviewed for unnecessary medications (Resident [R2], R 35). Findings: The facility's policy, Medication Regimen Review and Reporting, revised 1/24, indicated the following: The Medication Regimen Review (MRR) includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument ([NAME]), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care. In performing medication regimen review, the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards, such as the American Society of Consultant Pharmacists (ASCP) Practice Standards, and clinical standards such as the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines and American Medical Directors Association (AMOA) Clinical Practice Guidelines. The nursing care center follows up on the-recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record. 1. On [DATE], R2's clinical record was reviewed. R2's physician order's included orders for Oxycodone 10 milligrams (mg) (scheduled II narcotic), to be administered every 6 hours as needed for pain. This order entered on [DATE] had no duration and was in effect at time of review of the clinical record. Per State of Maine Regulations Governing the Licensing and Functioning of Skilled Nursing Facilities and Nursing Facilities, 10-144 CMR 110 Chapter 16.A.7 Orders for Schedule II controlled substances shall be in effect for no longer than one (1) week, unless there are specific written orders to the contrary. In no case shall the order be in effect for a period of more than thirty (30) days. According to the November Medication Administration Record (MAR), the resident continued to receive the Oxycodone without a valid physician's order. On [DATE] at 8:39 a.m., during an interview with Market Lead Clinical Specialist, a surveyor confirmed this finding. 2.Review of Resident #35 pharmacy MD Recommendations dated [DATE] states this resident has been taking the antidepressant citalopram 20 mg since 2023. Please evaluate the current dose and consider a dose reduction. This resident is also on Seroquel 25 mg twice daily and is due for an AIMS test (every 6 months). Review of Provider response dated [DATE] states Disagree: condition is not well controlled. Review of Resident #35's clinical record lacked evidence that the provider responded to this recommendation prior to surveyor intervention on [DATE]. During an interview on [DATE] at 8:26 a.m., with 3 surveyors Clinical Marketing Specialist confirmed above findings

Based on record reviews, interviews, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 5 of 16 residents reviewed for baseline care plans (Residents #1 [R1], R33, R76, R78, R2 )Findings: 1.Resident #33 was recently admitted to the facility and has diagnoses to include alcohol abuse. Review of Resident #33 baseline care plan lacked evidence that goals and interventions were put into place for alcohol abuse During an interview on 12/4/25 at 1:12 p.m., confirmed with Market Lead Clinical Specialist confirmed the above. 2.R2 was recently admitted to the facility with multiple mental health diagnoses that included Attention Deficit Hyperactivity Disorder, Borderline Personality Disorder, Bipolar, anxiety, and depression as well as a Level II Pre-admission Screening and Resident Review (PASRR). A review of R2's baseline care plan lacked evidence that goals and interventions were put into place with 48 hours of admission. On 12/3/25 at 2:19 p.m., during an interview with Market Lead Clinical Specialist, a surveyor confirmed this finding. 3. Facility policy, Person-Centered Care Plan, revised 9/15/25 states, . A baseline care plan must be developed within 48 hours and include the minimum healthcare information necessary to properly care for a patient including, but not limited to.Dietary orders.assistance with activities of daily living. 3.R1 was recently admitted with diagnoses to include Failure to Thrive and Severe Protein-Calorie Malnutrition. A review of R1's clinical record revealed dietary orders for Regular/Liberalized diet . and House Supplement two times a day . A review of R1's baseline care plan lacked evidence that goals and interventions were put into place in the area of dietary orders and instructions until 9 days after R1's admission. 4. R76 was recently admitted with diagnoses to include Dementia and repeated falls. Review of R76's baseline care plan indicates Resident requires assistance for bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting . but lacked evidence of the type of assistance R76 needs with his/her Activities of Daily Living (ADL). 5. R78 was recently admitted with diagnoses to include left femur fracture and recent left hip surgery. A review of R78's clinical record revealed an order for Regular/Liberalized diet .Note patient is allergic with lactose, capsicum annuum extract & derivatives (Bell pepper & capsicum), Cayene [cayenne] and green pepper. A review of R78's baseline care plan lacked evidence that goals and interventions were put into place in the area of dietary orders and instructions. Further review of the baseline care plan indicates Resident requires assistance for bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to recent left hip surgery. but lacked evidence of the type of assistance R78 needs with his/her Activities of Daily Living (ADL). On 12/3/25 at 2:18 p.m., a surveyor and the Market Clinical Lead reviewed the baseline care plans for the above residents and confirmed they lacked goals and interventions for the dietary orders and ADLs. Resident #75's was recently admitted to the facility. A review of Resident #37's baseline care plan indicated he/she requires assistance for bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting . The baseline care plan lacked evidence of the resident's level of assistance needed for Activities of Daily Living. On 12/3/25 at 2:30 p.m., During an interview with the Market Lead Clinical Specialist, the above information was confirmed.

Based on record reviews, policy review, and interviews, the facility failed to issue a written transfer/discharge notice to a resident and their legal representative for a facility-initiated transfer/discharge for 3 of 3 sampled residents transferred/discharged to an acute care facility. (Residents #9, and #11). In addition, the facility failed to ensure that information was communicated to the Assisted Living Facility (ALF) to ensure a safe and effective transition of care when the facility failed to notify the ALF of a date before a resident was discharge and signed physician orders were not sent to the ALF until the day after discharge, for 1 of 2 sampled residents reviewed for discharge (Resident #80 [R80]). Findings: 1. Documentation in Resident 9's clinical record indicated that he/she was transferred to an acute hospital on 9/8/25 and 9/16/25. The clinical record lacked evidence that the facility issued written transfer/discharge notices and bed hold notices to the resident and/or legal representative for both transfers. On 12/3/25 at 12:09 a.m., in an interview with a surveyor, the Clinical Lead confirmed that Resident 9's clinical record lacked evidence that transfer/discharge notices and bed hold notices were given to the resident and resident family/representative in writing. 2. Documentation in Resident 11's clinical record indicated that he/she was transferred to an acute hospital on 6/30/2025, 7/19/25 and 9/11/25. The clinical record lacked evidence that the facility provided written transfer/discharge notices and bed hold notices to the resident legal representative for all three transfers. On 12/3/25 at 11:00 a.m., in an interview with a surveyor, the Clinical Lead confirmed that Resident 11's clinical record lacked evidence that transfer/discharge notices and bed hold notices and were provided to the resident family/representative in writing for all three of the resident's transfers to an acute hospital. 3 The facility policy, Discharge Planning Process, revised 9/15/25, indicated that The Center must develop and implement an effective discharge planning process that focuses on the patient's/resident's (hereinafter patient) discharge goals, preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions. All patients being discharged to home, to an assisted living facility, or another community-based setting will be given a Discharge Transition Plan and Discharge Packet. The Discharge Transition Plan must include, but not be limited to: -A final summary of the patient's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the patient or patient representative. -Where the patient plans to reside, any arrangements that have been made for the patient's follow-up care and any post-discharge medical and non-medical services. On 6/9/25, the Division of Licensing and Certification received a complaint from a Level 1 ALF, stating that R80 was discharged back to the ALF without notification of the date of discharge and that R80 returned 6/8/25 (Sunday) without signed physician orders. The ALF stated that Licensed Social Worker #2 (LSW2) was aware of the ALF's readmission practice and that they needed signed physician orders to administer medications to R80 upon his/her return as the Level 1 ALF does not have a physician to approve physician orders; the signed physician orders have to come from the discharging facility or the resident's personal primary care doctor (the doctor's office was not open on Sunday 6/8/25). On 6/7/25, the spouse returned to the ALF and informed staff of R80's return tomorrow after learning of the discharge from the facility. The ALF attempted telephone contact with staff at the facility to remind them that signed physician orders would be needed, or else R80 would not be able to receive medications until signed orders were received. On 6/8/25, staff at ALF again attempted calls to the facility but signed physician orders were not received by ALF. On 12/2/25, a surveyor reviewed R80's clinical record and was unable to find documentation of communication with ALF (community-based setting that was providing services to R80 upon discharge) prior to or at the time of discharge to the ALF. On 12/2/25 at 10:15 a.m., a surveyor reviewed R80's clinical record with Market Clinical Lead (MCL) - Maine, with the following information reviewed: - 6/5/25, R80 received notification that skilled services were going to be discontinued on 6/7/25. R80, with help from LSW2, filed an appeal with R80's insurance company. - 6/7/25 at 3:15 p.m. (Saturday), LSW2 checked the insurance website and saw that R80 lost the appeal to continue skilled services. LSW2 met with R80 and spouse and informed them of the discharge plan for 6/8/25. - 6/8/25, R80 was discharged with the Discharge Transition Plan reviewed with the spouse by a nurse. - 6/9/25, the day after discharge, LSW2 contacted R80 and informed him/her of a follow up date with R80's primary care and faxed signed physician orders to ALF. - 6/9/25 at 3:49 p.m., LSW2 documented she faxed signed physician orders to ALF. During this review, MCL - Maine stated that LSW2 would have been responsible for providing the receiving facility discharge orders before or on the day of discharge. The surveyor confirmed that LSW2 sent the signed physician orders to ALF the day after discharge. On 12/2/25 at 10:48 a.m., a staff member at ALF stated that in order for the ALF to administer medications to R80, signed physician orders are needed. Between 12/8/25 - 12/10/25, a surveyor spoke with the Director of ALF. The Director stated that when a resident is admitted to another facility, and there are plans to return to the ALF, whether it is a readmission from the hospital or a rehab facility, staff at the ALF will send a copy of our readmission policy stating the requirements the residents must meet before they can return to services. A potential discharge was discussed with the facility, but ALF had no actual discharge date . On 6/7/25, once R80's spouse told us that R80 might get discharged the next day (6/8/25), attempts were made to contact the facility to obtain signed physician orders. The Director stated that both R80 and the spouse receive medication services from ALF and therefore could not administer medications to R80 on 6/8/25 until signed physician orders were received on 6/9/25.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 4 of 4 wings (North Wind, Spring Gardens, Windward Center and Penobscot House) for 1 of 1 facility tours.(12/4/25)Findings:On 12/4/25 from 8:50 a.m. to 9:20 a.m., an Environmental tour was completed with the Senior Maintenance Director, the Administrator, and the Housekeeping/Laundry District Manager in which the following findings were discussed and/or observed: Spring Garden - Resident room [ROOM NUMBER] - The bathroom had an unlabeled dirty urinal on the back of the toilet. There were three cracked/broken floor tiles across from the sink. The bathroom door had gouged/chipped treated wood exposing untreated wood. The wall across from the toilet had chipped/[NAME] paint creating an uncleanable surface. The sink countertop had chipped/missing edge laminate and was also stained.- Resident room [ROOM NUMBER] - There were two wash basins on the floor under the sink. The bathroom door had gouged/chipped treated wood exposing untreated wood. The sink countertop had chipped/missing laminate. The wall across from the sink had chipped/missing paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - There were two large bed pans on the floor under the sink. The bathroom, shared by four residents, had an unlabeled dirty urinal on the back of the toilet and also had an unlabeled denture cup and an unlabeled water pitcher on the sink countertop. There were nine broken floor tiles under the bed to the left. There was a graduated cylinder on the floor by the toilet. - Resident room [ROOM NUMBER] - There were two broken floor tiles by the head and foot of the bed. The bathroom door had gouged/chipped treated wood exposing untreated wood.North Wind- Resident room [ROOM NUMBER] - The bathroom had a bed pan and commode seat parts on the bathroom floor under the sink. Penobscot- Resident room [ROOM NUMBER] - The bathroom ceiling light fixtures had visible dust/debris in them. - Resident room [ROOM NUMBER] - The bathroom ceiling light fixtures had visible dust/debris in them. -- Resident room [ROOM NUMBER] - The bathroom ceiling light fixtures had visible dust/debris in them.- Resident room [ROOM NUMBER] - The bathroom ceiling light fixtures had visible dust/debris in them.- Resident room [ROOM NUMBER] - The bathroom ceiling light fixtures had visible dust/debris in them.Windward Center- Resident room [ROOM NUMBER]-Resident #10's wheelchair armrests were both ripped/torn creating uncleanable surfaces.On 12/4/25 at 9:20 a.m., in an interview with a surveyor, the Senior Maintenance Director, the Administrator, and the Housekeeping/Laundry District Manager confirmed the discussed and observed findings.

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. The facility reported a resident presenting with unexplained bruising, pain, and swelling of the right thigh. On 3/16/23 at 4:24 p.m., the facility submitted a 5 Day Follow Up investigation, dated 3/16/23, in which it stated Investigation found a fall from 3/ 11/23, that was not adequately documented. Fall was identified as the cause of injuries sustained in the original report. [Resident #1] was sent to the hospital upon identification of injury. Hospital sent [Resident #1] back without new orders or further recommendations. No x-rays were obtained during this visit. Due to continuous pain, a physician order was placed by our in-house provider to have the injured area x-rayed. X-ray identified a right femur fracture. Provider was notified of results, and an order was obtained to send to the emergency room for further evaluation. Resident returned from hospital with a hospice referral and orders for morphine. The Follow Up also included a written statement from the CNA #1, who stated he/she worked at another facility and was asked to work the overnight shift. The CNA stated Upon coming in I had never been on that unit, never worked with any of the residents. In the report I was told that [Resident #1] was a 1 (person) assist. I was asked to have people dressed in the morning. I thought that when I was getting [Resident #1] dressed I should try to get him/her up as well as he/she was only 1-assist. So I tried doing a stand pivot from bed to the wheelchair. It was almost a successful transfer, I just needed to scoot him/her back in the wheelchair. He/she started going forward too much so I lowered resident to the floor. When I made sure he/she seemed ok, I called down to the nurse that was covering both my unit and the one downstairs. I relayed exactly what happened, (the nurse) looked him/her over and we got a Hoyer to get him/her up and back into bed. Resident #1's clinical record revealed diagnoses that included: Dementia, Spinal Stenosis, Osteoarthritis, and obesity. A Lift Transfer Reposition Assessment, dated 1/28/23, determined staff were to use a sit to stand lift for transferring [Resident #1]. Resident #1's Minimum Data Set (MDS) 3.0, quarterly review, dated 2/20/23, under section G. Functional Status, G0110, Activities of Daily Living (ADLs) Assistance, B. Transfer: Self Performance is coded 3 - Extensive assistance, resident involved in activity, staff provide weight-bearing support, and 2. Support Provided is coded 3 - Two+ persons physical assist. Resident #1's Care Plan, last revised 6/24/22, indicated under Focus: At risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting. Interventions included: If resident is unable to bear weight, sit to stand is to be used. Certified Nursing Assistant (CNA) Kardex for Resident #1, section Ambulation/Mobility/Transfers stated Provide resident/patient non ambulatory. Provide resident/patient with 2 assist for bed mobility. CNA documentation of interventions and tasks provided to Resident #1 during March 2023, indicated that Resident #1 received extensive to total assistance with 2-person support provided for transfers. Nursing documentation on 3/13/23 at 1:36 p.m., stated [Resident #1's] representative was notified of the right leg bruising and pain, and with the plan to transfer to the hospital for evaluation. On 3/14/23 at 1:30 a.m., nursing staff noted there were no changes to [Resident #1's] leg since going to the hospital. On 3/15/23 at 11:09 a.m., the record stated stat (urgent) x-rays of right knee and femur this shift. X-ray tech in to do imaging spoke with provider. Order to send to hospital for orthopedic consult. A telehealth provider's note, dated 3/13/23, stated The nurse states that she was trying to do some therapy with the patient when she noticed that [resident] had some swelling of the right thigh area with some bruises that she had not noticed before. There is no documented injury. Unfortunately, the patient is somewhat confused and was unable to determine or knowledge (of) any injury had occurred. The patient would cry and pain with any manipulation of the right leg. The provider ordered transfer to the emergency room for evaluation. Provider's visit note, dated 3/15/23, stated Patient was evaluated in emergency roiagnom on Sunday (3/12/23) and x-rays not taken and patient transferred back to facility. Given increased pain and decreased range of motion, stat x-ray obtained at facility and concerns for displaced femur. Discussed with [representative] and will send to emergency room for orthopedic consult. On 3/15/23 at 6:53 p.m., nursing documentation stated X-ray done by (mobile x-ray) this morning, results showed fracture of right femur and malalignment of knee replacement joint. Seen by provider. Order to send to (emergency department) for evaluation by Orthopedics. Returned at 4:30 p.m., resident is on comfort measures, Hospice referral pending. Scheduled Morphine 15 mg (milligram) tablet every 4 hours as needed. On 3/30/23 at 11:00 a.m., in an interview, the surveyor asked the Director of Nursing (DON) if the transfer of Resident #1 had been performed correctly. The DON stated it was her understanding the transfer was completed and the resident slid out of the wheelchair after the transfer was done. The CNA reported to the RN on duty what had happened, and the RN assessed Resident #1 and there had been no complaints. The DON stated CNA #1 had received report from the previous CNA and was told Resident #1 was a 1-person, pivot-transfer assist. The DON stated the RN had not reported the incident. It was not reported until bruising was discovered by another nurse. On 4/6/23 at 12:56 p.m., in a telephone interview with a surveyor, CNA #1 stated he/she was told Resident #1 was a 1-assist. I had one other resident like him/her who was a stand-pivot transfer so I thought ok, I can do this. I almost had him/her in the chair and he/she scooted out a little bit. I lowered him/her down to the floor with his/her pants and at that point, he/she was fine. His/her legs were out in front of him/her. On 4/10/23 at 11:20 a.m., in a telephone interview with a surveyor, the RN on duty at the time of Resident #1's fall stated CNA #1 had notified him/her for help after the fall. The RN stated he/she assessed Resident #1 and did not see signs of injury and there were no complaints of pain. Resident #1 was then assisted back to bed using a Hoyer lift. The RN confirmed the fall had not been reported until the next day when Resident #1 began to demonstrate pain. A review of Resident #1's Certificate of Death, dated 3/20/23, noted the cause of death as Complications of femur fracture due to blunt force injury. The facility's Safe Resident Handling/Transfer Equipment Policy, with a revision date of 10/1/21, stated The Sit to Stand Lift will be used for those patients who meet the following criteria: Can follow simple instructions; Cannot be transferred from sitting to standing comfortably and safely by other transfer techniques; and have some weight bearing ability and head/trunk control.

Based on record review, facility policies, review of a reportable incident form, and interviews the facility failed to ensure that a resident was free from injury when the facility failed to properly transfer a resident causing the resident to sustain a laceration resulting in receiving 26 stitches for 1 of 26 residents. (#9) In addition, based on observations and interviews, the facility failed to ensure that hot water temperatures, accessible to residents, did not exceed 120 degrees Fahrenheit on 1 of 4 days of survey. Findings: 1. Resident #9's Care plan dated 9/19/18 indicated resident requires extensive assists with bathing, dressing, grooming, personal hygiene and bed mobility. Interventions include to provide resident with total assist of 2 for transfers using a total lift, remove legs of wheel chair for safety when transferring resident with lift. A Safe Resident Handling/Transfer Equipment policy effective 1/1/13, revision date 5/15/17 indicates the Total Lift will be used as the primary intervention to manual lifting, transferring, and repositioning and requires a minimum of two persons to perform the lift. On 11/30/18, The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 11/29/18 at 8:30 a.m. Resident #9 was being transferred out of bed to the wheelchair and received a laceration to the right rear lower extremity. EMS was activated, arrived on unit. Care was transferred to EMS staff at 0850. On 11/30/18 at 11:30 a.m. Certified Nurse Aide (CNA) #1 reported to CNE that he/she was not in the room with CNA #2 when Resident #9 was transferred with the total lift from bed to transfer. Progress Note dated 11/29/18 6:41 p.m. indicates Resident #9 returned from emergency room after incident of laceration to right lower leg. emergency room nurse reported 26 stitches intact, dressing dry and intact. Skin lacerations approximately 9.5 cm x 4 cm at widest point on right medial calf. The RMS Event Summary Report indicates under the section of Summary of findings indicates employee was attempting to transfer the resident and failed to get a second person and did not remove the leg rest. On 12/7/18 at approximately 12:00 p.m. a surveyor confirmed the above findings with the Administrator. 2. On 12/3/18 at 11:20 a.m., a surveyor noted in Resident room [ROOM NUMBER] a hot water temp of 122.2 degrees Fahrenheit. - On 12/3/18at 11:20 a.m., a surveyor noted in Resident room [ROOM NUMBER] a hot water temp of 122.0 degrees Fahrenheit. -On 12/3/18 at 11:21 a.m., a surveyor noted in Resident room [ROOM NUMBER] a hot water temp of 122.1 degrees Fahrenheit. - On 12/3/18 at 11:25 a.m., a surveyor noted in Resident room [ROOM NUMBER] a hot water temp of 121.8 degrees Fahrenheit. - On 12/3/18 at 11:30 a.m., a surveyor noted in Resident room [ROOM NUMBER] a hot water temp of 121.8 degrees Fahrenheit. - On 12/3/18 at 11:40 a.m., two surveyors and the Director of Maintenance noted in Resident room [ROOM NUMBER] a hot water temp of 123.4 degrees Fahrenheit. - On 12/3/18 at 11:40 a.m., two surveyors and the Director of Maintenance noted in Resident Room 208 a hot water temp of 123.0 degrees Fahrenheit. On 12/3/18 at 11:43 a.m., 2 surveyors informed the Facility Administrator of the high hot water temperatures, who, along with the Maintenance Director, indicated that they were not aware of the high hot water temperatures, but that the temperatures are checked on a routine basis. A review of the hot water temperature logs for the past 3 months indicated that no hot water temperatures were documented at 120 degrees Fahrenheit or above. The Facility Administrator and the Maintenance Director proceeded to diagnose and correct the problem. On 12/3/18 at 11:43 a.m., 2 surveyors confirmed the findings in an interview with the Facility Administrator and the Maintenance Director. No further high temperatures were noted the remainder of the survey.