Gorham House

Inspectors wroteBased on observations, interviews, record reviews and the facility's policies, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the kitchen floors and food mixer. In addition, the facility failed to remove expired foods, date and label foods in the reach in the refrigerator and ensure staff personal food was not stored in the reach in refrigerator. Additionally, the facility failed to monitor the dishwasher wash and rinse cycle temperatures, as well as the chemical sanitizer levels for the dishwasher, monitor the temperatures for the walk-in freezer, Produce Walk in Refrigerator, Stock Room Freezer, Ice Cream Freezer, Windsor 1 Unit refrigerator/freezer, Windsor 2 Unit Refrigerator/Freezer, [NAME] Unit Refrigerator/Freezer, [NAME] Unit Refrigerator/Freezer, and Cottage # 2 Unit Refrigerator/Freezer. [...]

Inspectors wroteBased on observations, interviews, record review and facility policy, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 3 of 3 units (Windsor I, Windsor II and Cottage). In addition, the facility failed to ensure a resident's personal belongings are kept safe and secure for 1 of 1 resident reviewed for personal property. (Resident #4) 1. On 2/11/26 at 8:25a.m. surveyor observed the Kitchen for unit Windsor 2, a surveyor observed that the floor was excessively dirty and with a build-up of debris in the corners. It was observed that all of the flat services were covered with a heavy layer of dust. Housekeeper #1, stated that she was here and cleaned this unit yesterday. 2. On 2/22/26 at 8:40a.m. [...]

Inspectors wroteBased on clinical record review and interviews, the facility failed to follow a Physician order for 1 of 5 sampled resident reviewed for unnecessary medications (#2), failed to ensure the prescribed medication included a specific, diagnosed, and documented condition with symptoms which may be causing distress to the resident (#67), and failed to monitor side effects of psychotropic medications for 1 of 2 residents reviewed for psychotropic medications (Resident #8 and #42). 1. Resident #2's medical record contained a provider's order dated 6/27/25 for Trazodone HCl 50 mg (milligram). Give 0.5 tablet by mouth at bedtime for insomnia. AND Give 0.5 tablet by mouth every 12 hours as needed for anxiety 0.5 tab = 25mg x 90 days. Review of the medication administration record from October 2025 through February 2026 indicated the as needed Trazadone was still available for administration. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that the resident's environment was free of accident hazards relating to unsafe flooring in resident areas, a broken electrical outlet, and a broken floor heater for 1 of 3 units (Cottage Unit).

Inspectors wroteBased on record review and interview, the facility failed to follow up on Consultant Pharmacist recommendations timely, and failed to ensure that the Consultant Pharmacist reported on identified ongoing irregularities for 2 of 5 residents reviewed for unnecessary medications (Resident #1 and #2).

Inspectors wroteBased on interviews and record review, the facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly communicated to the residents or their representatives and not required as a condition of admission due to the agreement being a part of the admission paperwork for 3 of 3 residents reviewed for Arbitration. (Residents 63, 77, 56, and 76) 1- On 2/9/26 at 9:30a.m., during the Entrance Conference, the Acting Administrator and when asked, she stated that there were no residents with a Binding Arbitration Agreement with the facility. 2- On 2/10/26 at 8:30a.m., during a review of the admission Packet, a surveyor discovered a form for Binding Arbitration in the admission Packet. A review of the Electronic Medical Record (EMR) for selected residents, it was discovered that three residents had electronically signed the Binding arbitration agreement. [...]

Inspectors wroteBased on review of the facility's incident report, record review, interview, and internal investigation, the facility failed to ensure staff spoke to residents in a dignified manner for 1 of 29 residents reviewed in the initial pool sample for abuse (R10).

Inspectors wroteBased on record review and interview, the facility failed to inform a Resident Representative (RR), in advance, of treatment risks and benefits, options, and alternatives related to use of psychotropic medications for 1 of 5 sampled residents reviewed for psychoactive medication use (R67).

Inspectors wroteBased on record review and interview, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights and the name and address of the Office of the State Long-Term Care Ombudsman, and a written bed-hold notice which specifies the duration of the bed-hold for to residents or their representative for 2 of 4 sampled residents transferred/discharged by the facility to an acute care hospital (Resident #67 and #69.)1. Documentation in Resident #67's clinical record indicated that the resident was transferred to the acute care hospital on [DATE]. [...]

Inspectors wroteBased on record review and interview, the facility failed to review, revise and update a care plan in the areas of wound care, psychotropic drug use, and dementia care to reflect the current needs for 1 of 22 sampled residents (R67).

Inspectors wroteBased on interviews and record review, the facility failed to make a Good Faith effort to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life, as evidenced by the failure to follow-up on the multiple emails reporting the unsafe conditions of The Cottage unit.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to clean and sanitary seating for residents. (Resident #60).

Inspectors wroteBased on review of the Facility Reported Incident (FRI), 5-day incident follow-up, facility's abuse prohibition policy, and investigative report, the facility failed to ensure that 1 of 6 sampled residents was free from verbal abuse. (#1)

Inspectors wroteBased on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 3 of 3 units (Windsor I, Windsor II and Cottage) for 1 of 1 environmental tour.

Inspectors wroteBased on facility policy, record review, observations, and interviews, the facility failed to follow their own policy and failed to provide an environment to help prevent the development and transmission of disease and infection related to organisms colonized in urine. In addition, the facility failed to implement Infection Control Contact Precautions for a 2 of 2 residents (Resident #10 and #43) diagnosed with Extended Spectrum Beta-Lactamase (ESBL- a Multidrug-Resistant Organism) for 2 of 3 days of survey. (3/27/23 and 3/28/23). This has the potential to affect all 16 residents on the Windsor 1 unit.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 2 of 28 sampled residents (#10 and #19).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that the resident's environment was free of accident hazards relating to patient lift and a hallway bumper guard for 1 of 1 facility tour, for 1 of 3 units(Cottage) on 1 of 3 days of survey. (3/27/23) In addition, the facility failed to ensure that the resident's environment was free of accident hazards relating to a string of lights in a resident's room (Windsor 2 Unit) for 1 of 3 days of survey (Resident #20).

Inspectors wroteBased on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 2 units, (Windsor 1 unit) and failed to ensure that medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications, on 1 of 3 days of survey. (Windsor 1 unit)

Inspectors wroteBased on observations, interviews, the facility's Dish Machine Use - Policy Interpretation and Implementation, the facility's Refrigerators and Freezers - Policy Interpretation and Implementation, the facility's Main Kitchen Refrigerator/Freezer Temperature Logs and the facility's Sanitation Compliance- Dish Machine policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, an exhaust vent, air intake vents, a blender, a slicer, and a floor mixer. The facility also failed to ensure products in the reach-in refrigerator, the walk-in refrigerator, the walk-in freezer, and a unit refrigerator(Cottage) were labeled and dated, and failed to label whipped topping with a thaw date. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 1 of 3 residents sampled for hospitalizations. (#10)

Inspectors wroteBased on record review and interview, the facility failed to issue a bed hold notice which included the daily bed hold cost, to a resident, known family member or legal representative for 1 of 3 residents sampled for hospitalizations. ( #10) Finding Resident #10's clinical record revealed the resident was transferred to an acute care hospital on 9/22/22 and 12/30/22 and subsequently admitted . The clinical record lacked evidence that the facility issued a bed hold notice to the resident and the family member or legal representative for both of the transfers. On 3/29/23 at 9:38 a.m., during an interview with the Licensed Social Worker Conditional the above

Inspectors wroteBased on observation and interviews, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to for facility census for 3 of 3 survey days.

Inspectors wroteBased on observation and interview, the facility failed to adequately store medication (insulin pens) in a locked compartment of the treatment administration cart on 1 of 4 days of survey and on 1 of 3 units in the facility (Windsor 1).

Inspectors wroteBased on clinical record review and interviews, the facility failed to ensure that dental services were scheduled and provided as ordered on 1 of 33 residents selected for further investigation. (Resident #16.)

Inspectors wroteBased on clinical record review and interviews, the facility failed to ensure that a clinical record contained documentation for pressure ulcer care on 2 dates in 1 of 33 residents selected for further investigation. (Resident #42.)