Windward Gardens

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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])

Inspectors wroteBased 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]).

Inspectors wroteBased 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]).

Inspectors wroteBased 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].

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased 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]).

Inspectors wroteBased 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 )

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on facility policy review, record reviews and interview, the facility failed to ensure physician orders for an as needed (PRN) anti-psychotic contained a duration/stop date and failed to ensure the physician evaluated a resident and wrote a new physician order to renew the PRN anti-psychotic medication every 14 days, for 1 of 5 residents reviewed for unnecessary medications (Resident #10 [R10]).

Inspectors wroteBased on facility policy, record review, and interview, the facility failed to notify the State Agency after potential abuse concerns were identified, failed to investigate allegations of potential abuse, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 1 of 1 incident reviewed for abuse.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that the admission Minimum Data Set (MDS) 3.0 was coded accurately to indicate that a resident had a Level II Pre-admission Screening and Resident Review (PASARR) for 1 of 2 residents reviewed for PASRR (Resident #2 [R2]).

Inspectors wroteBased on record reviews and interview, the facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASRR) Level II determination outcome into a resident's assessment, care planning, and transitions of care for 1 of 2 sampled resident (Resident #2 [R2]).

Inspectors wroteBased on interview and record review the facility failed to update a care plan with goals and interventions after a resident obtained a leg fracture for 1 of 11 complaints reviewed during an annual survey (Resident #35).

Inspectors wroteBased on interviews and record review the facility failed to ensure a care plan was accurately revised for 1 of 2 residents reviewed for nutrition. (Resident #37)

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a physician order was followed for 1 of 3 residents reviewed for nutrition. (Resident #37)

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information on a daily basis for 1 of 4 days of survey (12/1/25).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 of 1 resident reviewed for food choices (Resident #78 [R78]).

Inspectors wroteBased on interviews and record review the facility failed to follow provider orders for wound care and failed to follow the facilities Skin Integrity and Wound Management policy for 1 of 2 Residents reviewed for pressure ulcer management. (Resident #310)

Inspectors wroteBased on record review, interview and Payroll Based Journal Report (PPJ), the facility failed to ensure it was sufficiently staffed on weekends for 1 of 1 quarter reviewed (10/1/24 through 12/31/24/ [39 days]).

Inspectors wroteBased 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), the laundry room and a hallway for 2 of 2 facility tours.

Inspectors wroteBased on care plan review, observations, interviews, and facility policy, the facility failed to provide a resident with a continuous resident centered activities program. This failure has the potential to affect all residents that would normally participate in activities.

Inspectors wroteBased on record review and interviews, the facility failed to assess and monitor a resident after a fall, and failed to follow their own Fall management and Neurological evaluation policies and procedure by obtaining neurological assessments a resident who has an unwitnessed fall for 1 of 3 residents reviewed for falls. (Resident #18). In addition, the facility failed to ensure a resident received wound care/orders for 1 of 1 residents reviewed for pressure ulcers. (Resident #37).

Inspectors wroteBased on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards by ensuring room, closet and bathroom doors had laminate that was not gouged and splintered creating sharp edges on 2 of 4 units(North Wind and Windward Center) for 2 of 2 environmental tours (4/14/25 and 4/16/25). In addition, the facility failed to store oxygen tanks securely for 1 of 4 days.

Inspectors wroteBased on observations, interviews, and review of the Food Storage policy (dated 2013), the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a hood system, a fan, ceiling lights, ceiling tiles, ceiling vents, floors, a chemical hose, a food slicer and an exit door. Additionally, the facility failed to ensure that foods in the walk-in freezer were sealed, dated and labeled.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for palliative care/hospice (Resident #308), falls for 1 of 1 (Resident #258), and weights/catheter care and Activities of Daily Living (ADL) documentation for 1 of 9 resident's reviewed for a complaint (Resident #37).

Inspectors wroteBased on record review, interview and facility policy, the facility failed to ensure the resident's representative was notified timely of a significant change and/or incident for 1 of 3 residents reviewed for falls (Resident #56).

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 of 3 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #18).

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing information in a prominent place, readily accessible and visible to all residents, for 3 days.( 4/12/25 , 4/13/25 and 4/14/25).

Inspectors wroteBased on record review and interview, the facility failed to review, revise and update a care plan for a newly discovered pressure ulcer for 1 of 1 resident reviewed for pressure ulcer (Resident #1 [R1]).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a physician order for a wound clinic consultation was followed for 1 of 1 resident reviewed for pressure ulcer (Resident #1 [R1]).

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 1 resident reviewed (Residents #1 [R1]).

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure the attending physician made required visits, at least every 30 or every 60 days (depending on date of admission) and wrote a progress note for 1 of 1 sampled residents (Resident #1 [R1,].

Inspectors wroteBased on record review and interview, the facility failed to notify the resident's representative (Resident #1 [R1]) of a fall with fracture.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a care plan was developed for a change in a resident's condition-fractured right humerus for 1 of 1 resident reviewed for a fracture. (Resident #1 [R1])

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information in the area of weights for 2 of 3 Residents (Resident #1, and #2), meal intakes for 3 of 3 Residents (Resident's #1, #2, and #3), palliative care for 1 of 3 Residents (Resident #1), falls for 1 of 1 Resident (Resident #1), and positioning for 1 of 1 Resident (Resident #2) reviewed during a complaint investigation.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of significant change in condition when a resident was noted to have a change in meal intakes and significant weight loss for 1 of 3 residents reviewed during a complaint investigation (Resident #1).

Inspectors wroteBased on interviews, record review, 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 1 of 3 residents reviewed during a complaint investigation (Resident #1).

Inspectors wroteBased on record review, interviews and facility policy, the facility failed to follow-up on significant weight loss, and reduced meal intake for 1 of 3 residents reviewed during a compliant investigation (Resident #1).

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to monitor for side effects of psychotropic medications for 1 of 3 residents reviewed during a complaint investigation (Resident #1).

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to assess a resident after returning from a surgical procedure for 1 of 3 residents reviewed during a complaint investigation (Resident #1), and failed to complete admission assessment for 1 of 3 residents (Resident #3).

Inspectors wroteBased on record reviews, interviews, the facility failed to update/implement goals and interventions for 3 of 3 care plans reviewed during a complaint investigation (Resident's #1, #2, and #3).

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to adequately assess, and obtain wound care orders for 1 of 3 residents reviewed during complaint investigation (Resident #1).

Inspectors wroteBased 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 interior for the 4 of 4 units (Spring Gardens, North Wind, Penbscoto and Windward Center), the laundry room and hallways for 2 of 2 facility tours (4/22/24 and 4/25/24).

Inspectors wroteBased on record reviews and interviews, the facility failed to update/implement goals and interventions in the area of antipsychotic medication use for 1 of 6 residents reviewed for medications (Resident #10)

Inspectors wroteBased on interview, observation and record review, the facility failed to revise the care plan to reflect a resident's current status for 1 of 3 residents reviewed for falls (#49).

Inspectors wroteBased on record reviews and interviews, the facility failed to follow physician orders for 2 of 11 sampled residents (Resident #219 and Resident #269).

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to show evidence of documentation to justify the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (#10).

Inspectors wroteBased 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 interior for the 3 of 4 units (Spring Gardens, Windward Center and North Wind) for 1 of 1 facility tours (1/9/24).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the residents environment was free from the potential risk of accident relating to moving dollies, a floor heater unit, and exit doors and exit pathways for 2 of 2 observations for 2 of 2 days of survey. (1/8/24 and 1/9/24) In addition, the facility failed to provide adequate supervision and complete an assessment of resident capabilities and deficits to determine resident safety for 2 of 2 residents reviewed for smoking (#24, #26).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that foods in the kitchenette refrigerators and cupboards we're labeled and securely closed for 1 of 4 kitchenettes (Spring Gardens Unit) for 1 of 2 survey days (1/8/24). Additionally the facility failed to ensure that staff working in the kitchen we're wearing hair protectors and/or facial hair protectors for 1 of 1 kitchen tour on 1 of 2 survey days (1/9/24).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 7 of 7 residents reviewed for activities of daily living (#11, #12, #13, #14, #15, #20, #21).

Inspectors wroteBased on interviews and facility policy review, the facility failed to implement their Abuse Prohibition policy to ensure an alleged violation involving verbal abuse was reported within 2 hours to the Division of Licensing and Certification (State Agency) for 1 of 29 residents reviewed. (#5)

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 7 residents sampled for hospitalizations. (#22)

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 7 residents sampled for hospitalizations. (#22) Finding Resident #22's clinical record revealed the resident was transferred to an acute care hospital on 4/23/23 and subsequently admitted . The clinical record lacked evidence that Resident #22 and/or the resident representative were provided with a written bed hold notice. On 1/9/24 at approx. 11:00 a.m., during an interview, the Director of Nursing confirmed the above finding.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 6 residents that were reviewed for baseline care plans. (#21)

Inspectors wroteBased on record review and interview, the facility failed to review/revise and update care plan interventions for the problem area of Activities of Daily Living (ADL) care for 1 of 2 residents reviewed for falls.

Inspectors wroteBased on record review and interviews, the facility failed to identify a resident's care needs and provide timely treatment to manage pain for 1 of 2 residents reviewed for falls with injury (#13).

Inspectors wroteBased on observation and interview, the facility failed to ensure a treatment cart containing multiple medicated creams, powders, ointments, syringes, insulin and inhalation treatment medications was locked on 2 of 7 units. (Penobscot House & Spring Gardens)

Inspectors wroteBased on observation and interview, the facility failed to post the current daily nurse staffing information between 8/31/23 and 9/6/23.