Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bangor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
The facility did not follow its Abuse, Neglect and Exploitation policy by allowing several new employees to begin work without required pre-employment screening and by delaying required reporting of an allegation of resident-to-resident sexual contact. Employee file review showed that multiple CNAs began work without a current Maine background check completed by the facility, with some checks done weeks after hire, and a therapist was hired without documented reference checks. Separately, documentation showed that a wheelchair-bound resident reported being touched in a sexually inappropriate manner by another wheelchair-bound resident, but the DON was not informed until two days after the event, and state agencies were not notified until that time, contrary to the policy’s requirement for timely reporting.
Housekeeping and maintenance services were not adequately provided to keep the facility in good repair and free from offensive odors. Surveyors observed an unhooked divider curtain, wall gouge marks, a soiled trapeze, and red droplets on the floor that the Charge Nurse said looked like blood. Surveyors also repeatedly noted a strong urine odor in the Skilled Unit corridor and LTC hallway, including near the DON office and dining area, and a family member reported the urine smell was really bad and used Vicks when visiting.
Care plans were not resident centered or accurately updated for 3 sampled residents. A resident with a Foley catheter and pressure wounds, a resident with non-weight bearing status and heel wounds, and a resident with buttock and thigh wounds all had care plans that failed to address EBP; one resident’s plan also omitted the pressure wounds and weight-bearing status. The DON confirmed the missing care plan elements.
Failure to provide oral care and denture assistance: A resident who required substantial help with personal hygiene and oral care was observed with dirty dentures that were falling out and caked with food. Staff did not provide mouth care, and a CNA stopped using denture adhesive after it was poorly tolerated without reporting the issue. The resident later stated adhesive was needed to speak and eat, and the DON confirmed the resident had not received oral care or denture assistance over multiple days.
Failure to follow orders affected two residents: one resident with epilepsy missed 40 doses of Keppra after the med was entered incorrectly as unsupervised self-administration, and another resident with HF had a documented 9.4 lb wt gain without evidence the MD was notified as ordered. The DON confirmed both issues in interview.
Failure to complete annual performance evaluations for 3 CNAs. The facility could not provide evidence that annual evaluations had been completed for CNA1, CNA2, or CNA3, all of whom were hired in 2024. During an interview, the ADON stated they were unable to find any annual evaluations for the 3 CNAs.
Unlabeled open beverage thickeners were found on 2 food carts. A surveyor observed open cartons of Thick & Easy on Food Cart #1 and Food Cart #2 that were available for resident use but did not have opened dates, despite carton instructions to discard within 4 days of opening. The Kitchen Supervisor confirmed the cartons were unlabeled.
A facility failed to maintain infection control during med pass, equipment use, and resident care. A RN did not perform hand hygiene after a med pass, a mobile vital signs monitor used in an enhanced respiratory precautions room was left uncleaned and moved for later use, and staff did not wear the required PPE in EBP rooms. A CNA entered one room without an N95 or eye protection, and an LPN performed wound care without a gown despite posted EBP requirements.
Failure to Complete ASP Monitoring: The facility failed to implement its ASP antibiotic use protocols and monitoring system for 3 reviewed months. The IP provided an antibiotic tracking tool with missing entries for resident location, room number, infection resolution, and days to resolve, and stated that only September had been entered because October and November were not completed.
Failure to designate a qualified Infection Preventionist responsible for the Infection Control Program was identified for 4 of 4 months reviewed. During an interview, the IP stated she had not completed the required training, had been hired in July, and had to restart CDC modules after a version change.
The facility failed to offer or administer pneumococcal vaccination to two residents. One resident had no documented pneumococcal status and only a blank consent form in the chart, while another resident had previously received PPSV23 and was due for a PCV dose per CDC guidance. The IP stated the facility was waiting on guardian consent and later said consent was obtained and the vaccine was ordered after surveyor inquiry.
The facility failed to timely report a resident-to-resident sexual altercation to the State Agency as required by its abuse reporting policies. A cognitively impaired, wheelchair-dependent resident was inappropriately sexually touched by another cognitively impaired, wheelchair-dependent male resident. Although the incident was documented in the nurse’s notes, the DON and Social Worker were not informed until two days later, and the State Agency was only notified after the DON became aware, exceeding the policy requirement to notify appropriate agencies immediately and within 24 hours of discovery.
A resident who experienced a fall with major injury and was transferred to the hospital for evaluation and treatment did not receive the required written bed-hold notice at the time of transfer. Review of the clinical record showed no documentation that the resident or representative was given a bed-hold notice for that hospitalization, and a social worker confirmed during interview that, although other bed-hold notices existed in the record, none corresponded to the date of this specific transfer.
A facility failed to maintain resident dignity during transport and personal care. One resident was wheeled down a hallway with feet dragging while a staff member made an undignified remark, and another resident was pulled backwards in a shower chair with buttocks and thighs exposed.
A resident admitted to the facility did not have a baseline care plan developed and implemented within 48 hours of admission. The clinical record lacked evidence of the instructions needed to provide the minimum healthcare information necessary to properly care for the resident, and the DON confirmed during record review that the baseline care plan had not been completed on time.
Drugs and biologicals were not labeled and stored properly in 2 medication carts. An LPN and a CNA-M were observed with liquid Lorazepam kept in locked narcotic boxes even though the bottles were labeled for refrigeration, and opened Fluticasone Propionate packages were missing open dates despite directions stating the medication was good for 30 days after opening.
Failure to provide assistive eating and drinking equipment: A resident whose meal slip directed use of a Kennedy cup was repeatedly served coffee in a regular mug, and the resident and family stated this happened daily. Observations of the LTC kitchenette also found no extra cups, bowls, coffee mugs, regular drinking glasses, or assistive devices available for between-meal and snack use, and staff reported the items were not on the floor or in the kitchen.
Improper Garbage Storage and Unsanitary Back Dock Conditions: A surveyor observed a bag of garbage on the ground instead of in the dumpster and several soiled gloves on the back dock floor/ground outside the back kitchen door. The Administrator and Food Service Director were present, and the surveyor confirmed the findings at the time of observation.
Incomplete and inaccurate clinical records were found for two residents. One resident's chart contained conflicting code status entries, including CPR active, DNR, and do not intubate documentation. Another resident's Keppra order for epilepsy was entered incorrectly as an unsupervised self-administration medication, and the resident missed 40 doses because the resident was not actually self-administering medications.
A resident’s MDS 3.0 was not coded for Hospice services. A Social Service note showed the resident had started Hospice, but the significant change MDS did not include Hospice under J1400 or OK1, and the MDS Coordinator confirmed the omission during interview.
A resident with a pressure ulcer did not receive proper monitoring and wound care, leading to the deterioration of the wound and hospitalization. The facility failed to adhere to the treatment plan, with missed dressing changes and inaccurate documentation by staff. The resident's condition worsened, requiring hospital admission for further treatment.
The facility failed to provide and document that Advance Directives were offered or reviewed with residents and their representatives for several residents. Clinical records lacked evidence of written information concerning Advance Directives, and there was a discrepancy in code status documentation for a resident. Interviews with staff confirmed the absence of a process to ensure residents were informed about Advance Directives.
The facility was found deficient in maintaining a safe and clean environment, with issues such as chipped paint, damaged furniture, and uncleanable surfaces in several rooms. Observations included soiled walkers, ripped wheelchair armrests, and unpainted patched walls, indicating inadequate maintenance and housekeeping services.
The facility failed to incorporate PASARR Level II recommendations into the care plans for three residents with serious mental illnesses. These residents required ongoing psychiatric services, socialization activities, and supportive counseling, which were not provided or included in their care plans. The DON was unaware of the specific services needed and had not read the Level II reports, leading to deficiencies in care planning and service provision.
The facility failed to follow up on pharmacist recommendations for four residents, including confirming diagnoses, evaluating medication doses, and updating medication records to include daily limits. The Director of Nursing confirmed that these recommendations were not reviewed or acknowledged by the medical provider, indicating a lapse in the facility's process for addressing pharmacist recommendations.
The facility failed to offer pneumococcal vaccinations to five residents in accordance with CDC guidelines. Despite previous vaccinations, there was no evidence that these residents were reviewed or offered the PCV20 vaccine as recommended. The Infection Preventionist confirmed the oversight during a survey.
The facility failed to follow physician orders for two residents, resulting in unsupervised meals for one and incorrect insulin administration for another. Additionally, a third resident was not monitored for treatment effectiveness after being treated for lice.
The facility failed to maintain an effective Infection Control Program, with staff observed handling medications with bare hands and providing care to residents requiring Enhanced Barrier Precautions without proper PPE. Signage and PPE were not adequately provided, leading to multiple breaches in infection control protocols.
A resident experienced significant vomiting and other health changes, but the facility failed to notify the provider despite an existing order to do so. The resident vomited a large amount of dark brown/black liquid, had hypoactive bowel sounds, and coarse crackles in the lungs. The lack of communication was confirmed by the DON.
A facility failed to implement a baseline care plan within 48 hours for a resident admitted after a fall with fractures. The resident required therapy, pain monitoring, and had conditions including diabetes, anti-coagulant use, and a pressure ulcer. These care areas were not added to the care plan until several days post-admission, as confirmed by the DON and a surveyor.
A facility failed to provide the recommended nutritional services for a resident dependent on renal dialysis. The resident was supposed to follow a renal, carb consistent, low sodium diet, but was mistakenly placed on a House/Regular diet upon returning from a hospital discharge. Interviews confirmed the discrepancy in diet recommendations, and the facility did not adhere to the prescribed dietary management.
A facility failed to maintain sanitary conditions for a resident's oxygen therapy. During an inspection, a surveyor noted that the oxygen concentrator's filter was dusty while the resident was using it. This was confirmed by the Director of Plant Operations and the Healthcare Services Group District Manager.
A facility failed to address the needs of a resident with a history of trauma, leading to potential re-traumatization. The resident, admitted with hospice services and diagnosed with anxiety, hallucinations, delusional disorder, and dementia, reported feeling molested and afraid, possibly triggered by a male caregiver. Surveyors confirmed the lack of interventions to prevent re-traumatization.
A resident missed two doses of prescribed IV Vancomycin due to the facility's failure to ensure timely availability of the medication from the pharmacy. The resident, admitted for a surgical wound infection, left the facility against medical advice to seek treatment elsewhere. The Infection Preventionist acknowledged issues with medication delivery, which were confirmed by a surveyor.
The facility failed to monitor food temperatures adequately, with ground and pureed chicken served below the safe holding temperature. Additionally, improper air gaps on the ice machine's drain line were observed, risking contamination of the water supply.
The facility failed to maintain accurate clinical records for two residents. An LPN documented dressing changes for a resident with a pressure ulcer that were not performed, and there was a discrepancy in the wound's condition. Another resident's oxygen tubing change was inaccurately recorded in the TAR. These issues were confirmed by surveyors.
The facility failed to provide timely incontinence care for four residents, leading to issues such as skin redness, rawness, and heavily saturated briefs. Residents reported significant delays in response to call bells, with one resident waiting over six hours for assistance. These delays were confirmed by a surveyor with the facility's administration.
The facility failed to provide sufficient staffing, resulting in delayed responses to call bells and inadequate incontinence care. Residents reported long wait times for assistance, with one fearing a urinary tract infection due to care delays. A physical therapist noted having to assist residents out of bed due to busy nursing staff.
A resident with Parkinsonism and Dementia experienced significant changes in condition, including disorientation and refusal of medications. Despite these changes, the facility failed to promptly notify the resident's POA, potentially delaying medical decisions. The DON confirmed the delay, as the RN wanted to assess intervention effectiveness first.
The facility failed to ensure contracted nursing staff completed essential trainings in dementia care, resident rights, and abuse prevention before providing care. The Clipboard app used for staffing did not require these trainings, and the facility's Scheduler and DON could not verify their completion.
A facility failed to respect a resident's dignity and self-determination by pressuring them to disclose a private conversation with APS and insisting on nail care against their preferences. The resident was distressed by being questioned about the APS conversation and feared eviction. Despite the resident's refusal, the LSW continued to discuss nail trimming, citing APS concerns.
A resident did not receive necessary dental care despite multiple provider orders over six months. The resident's electronic medical record and paper chart contained instructions for dental referrals, but no appointments were scheduled. Interviews confirmed the resident had not seen a dentist, resulting in multiple broken teeth.
A resident with chipped and broken teeth did not receive timely dental care. Despite a provider order for a dental referral due to a dental infection and instructions for a dental examination, no appointments were scheduled. This resulted in a six-month delay in dental services.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Follow Abuse Policy for Staff Screening and Timely Reporting of Resident-to-Resident Sexual Incident
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy regarding pre-employment screening for multiple staff. The policy, revised 11/1/25, required that potential employees, contracted staff, students, volunteers, and consultants be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credential checks, with documentation maintained as proof. Review of employee files on 1/6/26 with the Assistant DON showed that one CNA hired on 3/4/24 had no Maine background check completed by the facility prior to hire; the only background check present was from a staffing agency dated more than a year before hire. Two CNAs hired on 10/9/24 had Maine background checks completed 21 days after their hire dates, rather than before they began working. A therapist hired on 10/28/25 had no evidence in the file that references were checked, contrary to the facility’s policy requirements. The facility also failed to implement its Abuse, Neglect and Exploitation policy regarding timely reporting of an allegation of resident-to-resident inappropriate sexual contact. A nurse’s note dated 1/3/26 documented that a resident had been touched in a sexually inappropriate manner by a male resident; both residents involved were wheelchair-bound. Another nurse’s note dated 1/5/26 indicated that the affected resident’s guardian was notified of the incident. In an interview on 1/8/26, the DON confirmed that the incident occurred on 1/3/26, but she was not informed until 1/5/26, at which time she notified the state agencies (Licensing and Certification and Adult Protective Services). The DON acknowledged that the state agencies were not notified in a timely manner, as required by the facility’s abuse, neglect, and exploitation policy.
Housekeeping, Maintenance, and Urine Odor Issues
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to keep the building in good repair during the annual survey. On the Skilled Unit, a divider curtain in one room was unhooked in different places, the wall plaster behind the head of the bed in another room had several gouge marks, a trapeze over a resident's bed was soiled, and three red droplets were observed on the floor near a room sink. The unit Charge Nurse confirmed the droplets appeared to be blood and stated the area was cleaned immediately. The facility also failed to maintain an environment free from offensive odors. Surveyors repeatedly observed a strong urine odor in the Skilled Unit corridor near several rooms and in the long-term hallway, including near the horseshoe area, near the DON office, and near the dining area doorway. The odor was noted across multiple survey times and days, and the DON acknowledged smelling the urine odor in the long-term hallway but stated she could not determine where it was coming from. A resident's family member also reported that the smell of urine in the facility was really bad a lot of the time and said they had used Vicks to block the odor when visiting.
Care Plans Not Updated for EBP, Weight-Bearing Status, and Wounds
Penalty
Summary
The facility failed to ensure care plans were resident centered and accurately updated for 3 of 20 sampled residents. Resident #5 had an indwelling Foley catheter and pressure wounds on the left heel and buttocks; although the current care plan addressed the pressure wounds and catheter, it did not address Enhanced Barrier Precautions (EBP), even though an EBP sign was observed hanging on the resident’s closet and PPE was stored in the closet. Resident #17 had non-weight bearing status and pressure wounds on both heels, but the care plan did not address the pressure wounds, weight-bearing status, or EBP. Resident #11 had a pressure wound to the left buttock and a wound to the right inner thigh, and while the care plan addressed the wounds, it did not address EBP. In interviews, the DON confirmed that the care plans did not address EBP for Residents #5 and #11, and did not address EBP, weight-bearing status, or the current heel wounds for Resident #17.
Failure to Provide Oral Care and Denture Assistance
Penalty
Summary
The facility failed to provide oral care for a resident who required substantial assistance from 1 staff member for personal hygiene and oral care. On 1/5/26, the resident was observed with dentures that were not clean, were falling down in the mouth, and appeared caked with food substance, and the resident was not able to speak to the surveyor. The care plan identified the resident’s need for substantial assistance with oral care, but the resident was not assisted with oral care on that day. On 1/6/26, the resident again could not talk without the dentures falling in the mouth. A CNA stated she had tried Fixodent before, but the resident did not tolerate it well, so she stopped using it and did not report the issue to the SW or nursing. On 1/7/26, the resident was observed in bed with a lunch tray and stated he/she could not eat; the dentures continued to fall out while speaking, and the resident said he/she needed adhesive for the teeth. The nurse obtained denture adhesive, and the dentures were rinsed but not brushed and mouth care was not done. Later that day, the assigned CNA stated she had not yet gotten to the resident and was not aware the resident used denture adhesive. The DON confirmed the resident had not been assisted with oral care and the dentures were not fitting and not assisted with adhesive on 1/5/26, 1/6/26, and 1/7/26.
Failure to Follow Medication Orders and Notify Provider of Weight Gain
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with epilepsy when Keppra 500 mg was entered inaccurately in the electronic health care system as an unsupervised self-administration medication. The resident was not self-administering medications, and this entry resulted in the resident missing 40 doses of Keppra in December 2025 and January 2026. During interview, the DON confirmed that the missed doses occurred because of the inaccurate medication entry. The facility also failed to notify the provider of a significant weight gain for a resident with an active diagnosis of heart failure. The resident had a physician order for daily weights on the 1st through the 7th of each month and to call the MD for a 2-3 lb weight gain. The clinical record showed weights increasing from 250.6 lbs to 260.6 lbs, including a 9.4 lb gain, but there was no evidence the provider was contacted as ordered. The DON confirmed there was no documentation that the physician was notified of the weight gain.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations at least every 12 months for 3 of 3 sampled staff members, including CNA1, CNA2, and CNA3. CNA1 was hired on 3/4/24, CNA2 and CNA3 were hired on 10/9/24, and the facility was unable to provide evidence that annual performance evaluations had been completed for any of them. During an interview on 1/06/26 at 11:50 a.m., the Assistant Director of Nursing stated they were unable to find any annual evaluations for the 3 CNAs.
Unlabeled Open Beverage Thickeners on Food Carts
Penalty
Summary
The facility failed to label open beverage thickeners with an opened date on 2 of 3 food carts, including Food Cart #1 and Food Cart #2. On 1/5/26 at 12:24 p.m., a surveyor observed one open carton of Thick & Easy on top of Food Cart #2 that was not labeled with an opened date, even though the carton’s storage and handling instructions stated to discard it if not used within 4 days of opening. On 1/5/26 at 12:38 p.m., a surveyor observed one open carton of Thick & Easy on top of Food Cart #1 that was also not labeled with an opened date, with the same discard instructions. During an interview at 12:38 p.m., the Kitchen Supervisor confirmed that the open cartons on Food Cart #2 and Food Cart #1 were available for resident use and were not labeled with an opened date.
Infection Control and PPE Failures During Resident Care
Penalty
Summary
The facility failed to maintain an infection control program when a RN completed a medication pass and then immediately began preparing medications for the next resident without washing hands or using hand sanitizer after handling the previous resident’s cup and garbage. The RN confirmed this observation during interview. The facility also failed to ensure equipment used in an Enhanced Respiratory Precautions room was cleaned after use. A mobile vital signs monitor was used in the room, moved outside the room without being sanitized, and later relocated to another area while still uncleaned and available for use. The Infection Preventionist confirmed the monitor had been used in the room, had been out of sight of the staff member who initially used it, and had remained uncleaned for at least 40 minutes. The facility further failed to use the required PPE in rooms designated for Enhanced Barrier Precautions. In one room, a CNA entered while wearing a surgical mask, gown, and gloves but not an N95 respirator or eye protection, despite a posted sign requiring gown, N95 or higher respirator, eye protection, and gloves. In another room, a charge nurse performed wound care on a resident with pressure ulcers to the heel and buttocks without wearing a gown, even though an EBP sign indicated mask, gloves, and gown were required for direct care. The DON stated the facility had misread its EBP policy and believed EBP applied only to chronic wounds, and that the resident was not on EBP because the wounds developed after admission.
Failure to Complete Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP), including antibiotic use protocols and a system to monitor antibiotic use, for 3 of 3 months reviewed: September, October, and November 2025. The facility policy, "Antimicrobial Stewardship Program Long Term Care, Jan. 1 2025-Dec. 31 2025," stated that the program was intended to reduce the risk of multidrug-resistant development and required monitoring of all antibiotic prescribing, clinical assessments, diagnostic testing, symptoms, and adherence to facility-specific treatments using the U.S. Department of Health and Human Services monitoring tool. During interview, the Infection Preventionist provided September 2025's infection and antibiotic tracking tool, which included fields for resident location/unit, room/bed, infection status, resolution dates, days to resolve, culture and test information, antibiotic names, start and end dates, and reassessment within 48-72 hours. However, several sections were left blank, including location/unit and room number, infection resolution or discharge status, date of resolution, and days to resolve. The Infection Preventionist stated that she had not had a chance to complete the monitoring tool, and that September 2025 was the last month with information entered because October and November were not done. The surveyor confirmed during the interview that tracking had not been completed.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to function as the Infection Preventionist responsible for the Infection Control Program and to work at least part time in that role for 4 of 4 months reviewed, September through December 2025. During an interview on 1/6/26 at 9:16 a.m., the Infection Preventionist stated that she had not completed the required training yet. She reported that she was hired in July 2025, that the prior Infection Preventionist left at the end of August 2025, and that she had started the CDC modules but had to start over when the CDC changed the version during the process.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or administer pneumococcal vaccination to 2 of 5 residents reviewed, including R28 and R33. R28 was admitted in September 2024, and review of the immunization record showed no documentation of pneumococcal vaccination status; the electronic record also contained a blank pneumococcal consent form dated September 2024. During interview, the Infection Preventionist stated the facility was waiting on consent from the guardian. R33 had received PPSV23 in November 2023, and the CDC PneumoRecs VaxAdvisor App recommended a dose of PCV15, PCV20, or PCV21 at least 1 year after the PPSV23 dose. When asked about this recommendation, the Infection Preventionist stated consent had been obtained and the vaccine was ordered after the surveyor inquired.
Failure to Timely Report Resident-to-Resident Sexual Altercation to State Agency
Penalty
Summary
The facility failed to timely notify the State Agency of a resident-to-resident sexual altercation involving a cognitively impaired, wheelchair-dependent resident (R28). Record review showed that on a Saturday afternoon, R28 was inappropriately sexually touched by a cognitively impaired, wheelchair-dependent male resident. Nursing notes documented the incident in the clinical record, but the Director of Nursing (DON) and Social Worker were not notified until the following Monday. Facility policies in the Abuse-Risk Management Folder and the Compliance with Reporting Allegations of Abuse/Neglect/Exploitation procedure require that appropriate agencies, including the State Agency and Adult Protective Agency, be notified immediately and no later than 24 hours after discovery of an allegation of abuse. In an interview, the DON confirmed that the incident occurred on Saturday and acknowledged it should have been reported to Licensing and Certification at that time, but the State Agency was not notified until she became aware of the incident on Monday.
Failure to Provide Required Bed-Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notice to a resident who was transferred to the hospital for medical evaluation and treatment following a fall with major injury. Record review on 1/7/26 showed that the resident was transferred on 2/24/25, but the clinical record contained no evidence that the resident or the resident’s representative received the required written bed-hold notice at the time of transfer. During an interview on 1/8/26 at 9:45 a.m., the Licensed Social Worker reported that she had reviewed the entire record and found several bed-hold notices, but none corresponding to the date of the hospital transfer in question, confirming that the notice was not provided for that hospitalization. This deficiency is based solely on the absence of documentation of a bed-hold notice for the specific transfer date and the Licensed Social Worker’s confirmation during the surveyor interview that no such notice was given for that event.
Failure to Maintain Resident Dignity During Transport
Penalty
Summary
The facility failed to promote care for residents in a manner that maintained dignity and respect during observations involving two residents. One resident was being assisted down the hallway in a wheelchair when the resident's feet were dragging on the floor and the resident stated, "stop my feet," but the staff person responded, "well if you would lift your feet it wouldn't hurt," and then wheeled the resident to an office to sit. During another observation, a CNA was seen pulling a resident backwards in a shower chair down the hallway with the resident's buttocks and thighs exposed. The surveyor confirmed with the CNA that the resident should have been covered better to avoid exposing body parts and should not have been pulled backwards in the chair.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #42, who was admitted on 12/18/25. Review of the resident’s clinical record showed no evidence that the baseline care plan was completed to include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. On 1/8/26 at 12:54 p.m., during review of the clinical record and an interview with the DON, the surveyor confirmed that the baseline care plan had not been developed within 48 hours after admission.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles in 2 of 2 medication carts. During review of the Skilled medication cart with an LPN, surveyors found 2 bottles of liquid Lorazepam stored in the locked narcotic box even though the bottle sticker indicated refrigeration was required; the LPN called the pharmacy in the surveyor’s presence and pharmacy personnel stated the unrefrigerated Lorazepam was no good. In the same cart, 2 opened packages of Fluticasone Propionate were not labeled with an open date, despite the box directions stating the medication was good for 30 days after opening. During review of the LTC medication cart with a CNA-M, surveyors found 3 bottles of liquid Lorazepam stored in the locked narcotic box with stickers indicating refrigeration was required.
Failure to Provide Assistive Eating and Drinking Equipment
Penalty
Summary
The facility failed to provide assistive eating and drinking equipment for a resident who had a meal slip directing use of a Kennedy cup. During a meal observation, the resident had a Kennedy cup with milk and a regular mug of coffee, and the resident stated the coffee was always served in a regular mug rather than the covered cup. The resident's son, who was present, stated this was a daily occurrence. Later, when the resident requested more coffee, a CNA returned with coffee in a regular cup instead of the Kennedy cup listed on the meal slip, and stated there were no Kennedy cups on the floor and no additional cups available in the kitchen. The facility also lacked enough eating equipment and utensils for use between meals and at snack times. Observations of the kitchenette on the LTC side showed no assistive devices such as Kennedy cups or covered cups, and no regular drinking glasses, coffee cups, bowls, or built-up utensils; only a small package of Styrofoam cups was available. A CNA-medication aide stated there were no bowls to use with soup and no microwave to heat it, and that this was a daily issue. On repeated observations over several days, the kitchenette remained empty of extra cups, bowls, coffee mugs, regular drinking cups, and assistive devices. The FSD acknowledged that the facility did not have enough assistive devices like Kennedy cups for between-meal and snack use, and later stated that bowls, cups, glasses, and built-up utensils seemed to go missing.
Improper Garbage Storage and Unsanitary Back Dock Conditions
Penalty
Summary
The facility failed to maintain a garbage storage area and an area outside the back kitchen door in a sanitary condition to prevent the harborage and feeding of pests. During observation with the Administrator and Food Service Director, a surveyor found a bag of garbage on the ground and not contained in the dumpster. The surveyor also observed several soiled gloves on the back dock floor/ground that were not contained in a garbage bag, and the surveyor confirmed these findings at the time of observation.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 sampled residents, including R4 and R42. For R4, the electronic medical record contained conflicting code status information: a prescriber order summary listed Advance Directive/CPR Order Status as active, while another signed attachment under CODE STATUS indicated DO NOT RESUSCITATE. A separate signed DNR directive also stated DO NOT INTUBATE. During review with the DON, the surveyor confirmed that R4's record contained two different directions for code status. For R42, the MAR and admission record showed an order for Keppra 500 mg by mouth twice daily for epilepsy. On the day of admission, a nurse entered the order incorrectly in the electronic health care system as an unsupervised self-administration medication. Because the order was entered this way, R42 missed 40 doses of Keppra. During the record review, it was determined that R42 was not self-administering any medications, and the DON confirmed that the inaccurate medication entry caused the missed doses.
MDS Not Coded for Hospice Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded for Hospice services for Resident #44. A Social Service note dated 11/17/25 indicated the resident was started on Hospice services, but the 11/25/25 significant change MDS did not code Hospice under J1400 or OK1. During an interview on 1/8/26 at 1 p.m., the MDS Coordinator confirmed that the significant change MDS was not coded for Hospice in either section.
Inadequate Wound Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate monitoring and wound care for a resident with a pressure ulcer, leading to the deterioration of the wound and subsequent hospitalization. The resident, who was cognitively intact, had a physician-ordered treatment plan for a right heel pressure wound, which included specific dressing changes and the use of off-loading boots. However, the facility did not adhere to the treatment plan, as evidenced by the lack of regular dressing changes and inaccurate documentation by the staff. On multiple occasions, the dressing on the resident's wound was not changed as scheduled, and the wound was not properly assessed. A Licensed Practical Nurse (LPN) documented dressing changes that did not occur, and a Registered Nurse (RN) discovered that the dressing had not been changed for several days, leading to the wound developing an odor and blackened tissue. The Family Nurse Practitioner (FNP) had previously identified the wound as unstageable and ordered antibiotics due to infection concerns, but the lack of consistent care and monitoring allowed the wound to worsen. The facility's failure to conduct weekly pressure wound assessments and adhere to the care plan resulted in the resident's condition deteriorating to the point of requiring hospital admission for further treatment. The Director of Nursing confirmed that the required weekly assessments were not completed, and the LPN admitted to not remembering performing or documenting the necessary care. This lack of proper wound care and monitoring highlights significant deficiencies in the facility's adherence to care protocols.
Failure to Provide and Document Advance Directives
Penalty
Summary
The facility failed to provide evidence that Advance Directives were offered or reviewed with residents and/or their representatives for seven out of fourteen residents reviewed. The clinical records for these residents lacked documentation showing that the facility provided written information concerning the right to formulate an Advance Directive. Specific residents, including R19, R16, R17, R11, R18, R37, and R102, were identified as not having this documentation in their records. Interviews with facility staff, including the Administrator and Social Services Interim, confirmed the absence of such documentation and the lack of a process to ensure residents and their representatives were informed about Advance Directives. Additionally, there was a discrepancy in the code status documentation for one resident, R102, where the electronic medical record indicated a 'Do Not Resuscitate' status, but the printed demographic at the nurse's station showed a 'Full Code' status. This inconsistency was confirmed during an interview with a Registered Nurse and further validated by surveyors. The Administrator acknowledged the lack of evidence in the Social Services office or resident records to show that Advance Directives were offered or reviewed, confirming the findings of the surveyors.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as evidenced by multiple maintenance and housekeeping deficiencies observed during an environmental tour. In several rooms, there were issues such as chipped paint near televisions and bed enablers, damaged nightstand coverings, water-stained ceiling tiles, missing dresser drawer handles, and broken trim on headboards and footboards. Additionally, some rooms had uncleanable surfaces due to torn or cracked vinyl seats on chairs and cracked wheelchair backs. Dust and dirt were visible on the windows both inside and outside, and there were gouged areas on walls under plastic shelves. Further observations revealed heavily soiled walkers with crusted debris stored behind doors, and ripped armrests on wheelchairs, creating uncleanable surfaces. In the horseshoe-shaped hallway, multiple areas on the walls were patched but not painted, contributing to the overall lack of maintenance. These deficiencies indicate a failure to provide adequate maintenance and housekeeping services necessary to keep the facility in good repair and sanitary conditions, compromising the residents' right to a safe and comfortable environment.
Failure to Incorporate PASARR Level II Recommendations
Penalty
Summary
The facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASARR) Level II determination into the assessment, care planning, and transitions of care for three residents. Resident #16 was diagnosed with serious mental illness, specifically depression, which led to functional limitations. The PASARR Level II required ongoing psychiatric services, peer support, and rehabilitative services, including socialization activities and supportive counseling. However, during a review, it was found that these services were not included in the care plan or provided to the resident. The Director of Nurses (DON) was unaware of the specific services required and had not read the Level II report. Similarly, Resident #19, diagnosed with bipolar disorder and anxiety, required ongoing psychiatric services, socialization activities, and family involvement in care. The review revealed that these services were not incorporated into the care plan or provided. The DON acknowledged the lack of psychiatric services due to a long waitlist and had not ensured the inclusion of necessary services in the care plan. Resident #37, diagnosed with depression and anxiety, also required ongoing psychiatric services, individual therapy, and various rehabilitative services. The care plan review showed that these services were not provided or included. The DON had placed the resident on a waitlist for in-person psychiatric services, dismissing a telehealth option. The surveyors confirmed the absence of evidence that the required Level II services were provided or included in the care plan.
Failure to Address Pharmacist Recommendations
Penalty
Summary
The facility failed to follow up on pharmacist recommendations in a timely manner for four residents reviewed for medications. For Resident #11, the pharmacist recommended confirming a diagnosis for Buspar therapy and evaluating the dose of Risperidone, but there was no evidence that these recommendations were reviewed or responded to by the medical provider. Similarly, for Resident #16, the pharmacist suggested reviewing the dosing schedule for Oxybutynin and Gabapentin and evaluating the dose of Sertraline, yet there was no indication that these recommendations were addressed. The Director of Nursing confirmed the lack of responses to these pharmacy recommendations. For Resident #34, the pharmacist recommended updating the Medication Administration Record (MAR) to include a daily limit for Tums, but the orders were not updated. Resident #37 had a similar issue, with the pharmacist recommending a daily limit for Acetaminophen, but the orders remained unchanged. In both cases, the Director of Nursing confirmed that there was no evidence of the recommendations being reviewed or acknowledged by the provider. These findings indicate a failure in the facility's process for addressing pharmacist recommendations, as confirmed by interviews with the Director of Nursing and surveyors.
Failure to Offer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations. During a survey, it was found that five residents, identified as R3, R43, R25, R28, and R12, were not reviewed, offered, or received the pneumococcal vaccine as per the guidelines. The Infection Preventionist confirmed that these residents should have been offered the PCV20 vaccine five years after their last pneumococcal vaccine, as per CDC guidance. However, there was no evidence in the immunization records to show that these residents were reviewed or offered the vaccine. Each of the residents had been admitted to the facility at different times, with some having received previous pneumococcal vaccinations years prior. For instance, R3 had received a PPSV23 in 2018 and a Pneumovax Dose 2 in 2006, while R43 had received a PPSV23 in 2011. Despite these previous vaccinations, there was no documentation indicating that these residents were assessed for the need for the PCV20 vaccine. The surveyor confirmed the lack of compliance with CDC recommendations during an interview with the Infection Preventionist.
Failure to Follow Physician Orders and Monitor Treatments
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For one resident, a diet order required constant supervision during meals, but observations revealed that the resident was left unsupervised during breakfast. A CNA confirmed that the resident ate alone, and an RN, new to the facility, was unaware of the supervision requirement. This lack of supervision was confirmed by a surveyor, indicating a failure to follow the prescribed dietary order. Another resident with diabetes had a physician order to hold insulin if their blood sugar was below 100. However, the resident received 44 units of Lantus despite having a blood sugar level of 86, contrary to the physician's instructions. Additionally, a third resident was treated for lice with a medicated shampoo, but there was no evidence of monitoring the treatment's effectiveness for four days post-treatment. The Infection Preventionist confirmed the lack of monitoring, highlighting a failure to follow up on the prescribed treatment plan.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by multiple observations and interviews during the survey. On one occasion, a Certified Nursing Assistant (CNA) was observed handling medications with bare hands while administering them to a resident, which is a breach of infection control protocols. Additionally, a resident with a Foley catheter and a history of Extended-spectrum beta-lactamase (ESBL) was not properly managed under contact precautions. The required personal protective equipment (PPE) was not available outside the resident's room, and staff were observed providing care without wearing the necessary gowns and gloves. Further deficiencies were noted with another resident who had a wound requiring Enhanced Barrier Precautions (EBP). There was no signage or PPE cart outside the room, leading to staff providing care without the necessary protective equipment. Similarly, another resident with a Foley catheter did not have appropriate EBP signage or PPE available, and staff were unaware of the need for PPE until informed later. These lapses indicate a systemic failure in implementing and maintaining infection control measures, as outlined in the facility's policy.
Failure to Notify Provider of Resident's Health Change
Penalty
Summary
The facility failed to notify the provider of a change in status for a resident, identified as Resident #11 (R11), who experienced a significant health event. On October 11, 2024, R11 vomited a large amount of dark brown/black liquid containing undigested food and medication. The resident's bowel sounds were hypoactive, and coarse crackles were heard throughout all lung lobes, although the resident was afebrile with a pulse of 87, blood pressure of 97/66, and oxygen saturation of 95% on room air. Despite these findings, there was no documentation that the provider was informed of this incident, even though there was a physician's order dated August 10, 2024, to notify the provider if vomiting recurred. This lack of communication was confirmed during an interview with the Director of Nurses on December 18, 2024.
Failure to Implement Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted after experiencing a fall that resulted in fractures. The resident required therapy and pain monitoring and had diagnoses including diabetes, use of an anti-coagulant, and a pressure ulcer to the sacrum. These critical care areas were not included in the baseline care plan until more than 48 hours after admission. During an interview, the Director of Nursing confirmed that the nurses are responsible for creating the baseline care plan, and the surveyor verified that the necessary care areas were not added until several days after the resident's admission.
Failure to Provide Recommended Nutritional Services for Dialysis Resident
Penalty
Summary
The facility failed to provide the recommended nutritional services for a resident who was dependent on renal dialysis. The resident was admitted with a care plan indicating a renal diet, which was revised to include a carb consistent, low sodium diet. However, upon returning from a hospital discharge, the resident was mistakenly placed on a House/Regular diet, which is not considered low sodium, contrary to the discharge orders. Interviews with the Kitchen Manager and the Director of Nursing confirmed the discrepancy in diet recommendations, and it was noted that the facility did not adhere to the prescribed dietary management for the resident upon their return from the hospital.
Unsanitary Oxygen Therapy Equipment
Penalty
Summary
The facility failed to provide oxygen therapy in a sanitary manner for a resident using oxygen. During an environmental tour, a surveyor observed a resident wearing oxygen via nasal cannula attached to an oxygen concentrator. The concentrator's filter, located on the back of the machine, was found to be dusty. This observation was confirmed during an interview with the Director of Plant Operations and the Healthcare Services Group District Manager.
Failure to Prevent Re-traumatization in Resident with Trauma History
Penalty
Summary
The facility failed to address the needs of a resident to minimize triggers that may cause re-traumatization. The resident, who was admitted with hospice services, had significant diagnoses including anxiety disorder, hallucinations, delusional disorder, and dementia with behavioral disturbance. On two occasions, the resident reported feeling molested and afraid, suggesting a possible trigger from a male caregiver due to a history of old trauma. Despite these reports, the clinical record lacked evidence of interventions to prevent re-traumatization, as confirmed by surveyors during an interview with the Director of Nursing.
Failure to Provide Timely IV Medication
Penalty
Summary
The facility failed to ensure the availability of physician-ordered medications for a resident, leading to a deficiency in pharmaceutical services. A resident was admitted to the facility after a hospital stay for a surgical wound infection and required Vancomycin HCI in dextrose IV solution to be administered twice daily. However, the Treatment Administration Record indicated that the medication was not available from the pharmacy, resulting in the resident missing the evening dose on the first day and the morning dose on the following day. The resident and their spouse expressed dissatisfaction with the care and the unavailability of the IV medication, deciding to leave the facility against medical advice to seek treatment at the emergency room. The Infection Preventionist acknowledged ongoing issues with timely medication delivery from the pharmacy, noting that while there are pharmacy runs during the week, the facility struggles to obtain IV medications from local sources like Walgreens. This deficiency was confirmed by a surveyor, who verified that the resident missed two doses of the prescribed IV antibiotics due to the unavailability of the correct formulation.
Food Temperature Monitoring and Plumbing Deficiencies
Penalty
Summary
The facility failed to monitor food temperatures adequately, which could lead to foodborne illness. On December 17, 2024, a surveyor observed the Kitchen Manager serving mashed potatoes, pureed green beans, and ground chicken from a steam table. The food was placed on an early plate before the lunch service began. The surveyor noted that the Kitchen Manager checked the holding temperatures of the food after the plate was prepared. The ground chicken was at 133 degrees Fahrenheit, and the pureed chicken was at 126 degrees Fahrenheit, both below the minimum safe holding temperature of 135 degrees Fahrenheit. The Kitchen Manager confirmed that the food was not maintained at a safe temperature. Additionally, the facility did not ensure proper installation of plumbing fixtures to prevent backflow, as required by the Maine State Plumbing Code. On December 17 and 18, 2024, a surveyor observed an improper air gap on the drain line of the ice machine. This finding was confirmed with the Kitchen Manager. The lack of a proper air gap could potentially lead to contamination of the water supply, food, and food utensils, affecting all residents in the facility.
Inaccurate Clinical Records for Residents
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to deficiencies in care documentation. For one resident with a pressure ulcer, a Licensed Practical Nurse (LPN) documented dressing changes on specific dates, but the dressing was observed unchanged since an earlier date, and there was a discrepancy in the wound's condition as documented by different healthcare professionals. Additionally, the Treatment Administration Record (TAR) inaccurately reflected that the oxygen tubing for another resident was changed on a date when it was not, as confirmed by the date on the tubing itself. These inaccuracies were confirmed through interviews and observations by surveyors.
Delayed Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely incontinence care for four residents, as observed during a complaint investigation. Resident 1, who has a history of urinary tract infections and intact cognition, reported that call bells went unanswered for up to 40 minutes, and incontinence checks were not performed on specific nights. Resident 2, with a diagnosis of cerebral infarction and intact cognition, activated the call light for incontinence care, which was delayed by 45 minutes, resulting in skin redness and rawness. Resident 3, with multiple sclerosis and moderate cognitive impairment, requested assistance at 5 a.m. but did not receive care until over six hours later, leading to heavily saturated briefs and bedding. Resident 4 reported waiting an hour and a half for assistance, leading to soiling the bed due to staff not emptying the urinal timely. These incidents highlight a pattern of delayed response to incontinence care needs, which is critical for maintaining skin integrity and preventing infections. The residents involved have varying degrees of cognitive and physical impairments, necessitating prompt and regular care. The surveyor confirmed these findings with the facility's Administrator and Director of Nursing, indicating a systemic issue in responding to residents' needs for incontinence care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, as evidenced by multiple instances of delayed response to call bells and inadequate incontinence care. Interviews with anonymous staff members revealed that the facility was not staffing according to resident acuity, leading to situations where residents were left in soiled conditions. One staff member reported that call bells could go unanswered for about 40 minutes due to staff being busy. This was corroborated by residents who reported long wait times for assistance, with one resident expressing fear of developing a urinary tract infection due to delays in care. Specific incidents included a resident who reported not being checked for incontinence during the night shift on two occasions, and another resident whose call bell went unanswered for 35 minutes, resulting in a 45-minute wait for incontinence care. Additionally, a resident requested assistance at 5 a.m. but was not attended to until after noon, resulting in heavily saturated bedding. Another resident reported waiting an hour and a half for assistance and expressed a desire to refuse medication to prevent incontinence due to the lack of timely care. The facility's physical therapist noted that she often had to assist residents out of bed because the nursing staff was too busy.
Failure to Notify Resident's Representative of Significant Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified immediately of a significant change in the resident's medical condition. The resident, who had diagnoses of Parkinsonism, Dementia, and hallucinations, was found on the floor and exhibited symptoms such as disorientation, lethargy, and refusal of medications. Despite these significant changes, there was no evidence that the resident's Power of Attorney (POA) was informed in a timely manner, which could have delayed medical decision-making. Nursing notes documented several concerning observations, including the resident's dark bloody urine, confusion, difficulty speaking, and a high respiratory rate. The resident was eventually sent for further evaluation and treatment, but the Director of Nursing confirmed that the POA was not notified promptly. The Registered Nurse had delayed contacting the resident's representative to assess the effectiveness of interventions first, which led to the deficiency noted by the surveyor.
Deficiency in Training for Contracted Nursing Staff
Penalty
Summary
The facility failed to implement and maintain an effective training program for nursing staff contracted through the Clipboard Application in critical areas such as dementia care, resident rights, and abuse, neglect, and exploitation training. The deficiency was identified through interviews and record reviews, revealing that contracted professionals were not required to complete these essential trainings before independently providing services to residents. The Clipboard app, which serves as a marketplace for professionals to sign up for shifts, does not mandate these trainings as part of its requirements, as confirmed by the facility's Scheduler and a contracted CNA. During interviews, the Scheduler and the DON were unable to provide evidence that the necessary trainings were completed by contracted staff. The Scheduler admitted to not typically checking for these trainings, and the DON could not verify their completion either. This lack of oversight and verification led to the deficiency, as contracted staff were allowed to provide direct care to residents without the necessary training in dementia care, resident rights, and abuse prevention.
Violation of Resident's Dignity and Self-Determination
Penalty
Summary
The facility failed to uphold a resident's right to dignity and self-determination by attempting to provide nail care against the resident's preferences and by disclosing a private conversation. During an interview, a resident expressed distress after being brought into an office and questioned about a private conversation with Adult Protective Services (APS), fearing eviction if they did not disclose the details. The resident also expressed a preference for their nails to remain at their current length, which was not respected by the Licensed Social Worker (LSW). The LSW continued to discuss nail trimming with the resident despite their refusal, citing concerns raised by an APS representative. This interaction occurred after an activity, where the resident was brought to the office to discuss both the APS visit and nail care, contrary to the resident's expressed wishes.
Failure to Follow Physician Orders for Dental Care
Penalty
Summary
The facility failed to follow physician orders for a resident who required dental care. A provider order was placed in the resident's electronic medical record on December 7, 2023, for a referral to a dentist due to a dental infection. Additional instructions for dental services were given on April 26, 2024, and May 30, 2024, but no appointments were scheduled. Interviews with the resident and staff confirmed that the resident had not been to a dentist, despite needing an appointment for multiple broken teeth. This deficiency persisted over six months, with no referrals or appointments made as ordered by the providers.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who had chipped and broken teeth. On June 11, 2024, the resident reported to a surveyor that they had not been to a dentist despite needing an appointment due to a chipped tooth that had worsened into multiple broken teeth. The facility's Scheduler confirmed that no dental appointments were scheduled for the resident. A review of the resident's clinical record on June 12, 2024, revealed a provider order from December 7, 2023, for a dental referral due to a dental infection, which was not completed or scheduled. Additionally, instructions for a dental examination were noted in the resident's paper chart on April 26, 2024, and May 30, 2024. Despite these orders, no referrals or appointments were made, resulting in a six-month delay in dental services for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bangor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westgate Center For Rehab & Alzheimers Care | 0.4 mi | ★★★★★ | 5 | 0 |
| Ross Manor | 1.7 mi | ★★★★★ | 0 | 0 |
| Stillwater Health Care | 2.3 mi | ★★★★★ | 12 | 0 |
| Brewer Center For Health & Rehabilitation, Llc | 2.8 mi | ★★★★★ | 7 | 0 |
| Eastside Center For Health & Rehabilitation, Llc | 3 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.