Maine Veterans Home - Bangor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bangor, Maine.
- Location
- 44 Hogan Rd, Bangor, Maine 04401
- CMS Provider Number
- 205185
- Inspections on file
- 20
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Maine Veterans Home - Bangor during CMS and state inspections, most recent first.
Resident dignity was compromised when treatments labeled with room numbers and specific body areas, including sensitive locations, were left unattended in a corridor accessible to residents and visitors. An RN-Charge Nurse confirmed dispensing and labeling the treatments before leaving them out for C.N.A.s.
Surveyors found that the dining and kitchenette areas had multiple maintenance and cleanliness issues, including soiled metal molding, cracked and uncleanable floor tiles, heavily dust-laden ceiling air vents, and a damaged protective plastic panel with sharp edges at the nurse's station. These deficiencies were confirmed during a tour with a Maintenance Assistant.
A resident with dementia and under guardianship was not assessed for capacity to consent to sexual activity with another resident known for hypersexual behaviors, resulting in unreported incidents of potential sexual abuse. Additionally, a CNA repeatedly verbally and physically abused multiple residents, including using profane language and forceful handling, with one resident sustaining a significant bruise. The facility failed to intervene or report these incidents in a timely manner, leading to immediate jeopardy.
Staff did not promptly report or investigate multiple allegations of psychological, physical, verbal, and sexual abuse, as well as an injury of unknown origin. A CNA failed to report observed abuse by another CNA for several weeks, and an injury with significant bruising was not reported or investigated. Additionally, a potential sexual abuse incident and signs of resident fear were not reported to authorities as required.
A resident was found with a large bruise on the back of the right hip/upper thigh, and the facility did not investigate the injury of unknown origin. Clinical records lacked documentation of any investigation, and this omission was confirmed by a Unit Manager RN during interview.
A resident with a history of sexually inappropriate behaviors had physician orders requiring case review by a specific doctor and medication adjustments. The facility did not provide evidence that the case was ever presented to the doctor as ordered, nor was there documentation of follow-up, despite ongoing behavioral issues and changes in care.
A resident with vascular dementia had a care plan that addressed potential sexual behaviors but did not include a goal or consider the resident's cognitive ability to consent to sexual activity. The care plan was not updated or implemented to reflect the resident's needs related to their dementia diagnosis.
The facility was found deficient in food storage and pest control practices. Wet stacked bowls and fruit flies near a floor drain were observed in the kitchen, and expired milk was found during a meal observation, confirmed by an RN.
The facility failed to maintain accurate and complete documentation of neurological assessments for three residents who experienced falls. Assessments were not documented in the electronic medical record at the time they occurred, with significant delays and inconsistencies noted. In one case, assessments were discarded before being recorded, leading to incomplete medical records.
The facility failed to maintain an effective infection control program, with 60 documented facility-acquired infections over three months lacking analysis or follow-up. Interviews revealed no efforts to identify trends or root causes. Additionally, a CNA was observed using a shared glucometer on two residents without cleaning it between uses, despite having cleaning supplies available.
The facility failed to implement its Antibiotic Stewardship Program, as required by its policy, to optimize antibiotic use and prevent infections. Infection reports showed numerous facility-acquired infections treated with antibiotics without evidence of review or discussion. Interviews revealed that the DON and IP did not analyze trends or discuss antibiotic use in QAPI meetings, and many prescriptions did not meet criteria.
The facility failed to maintain resident dignity during meal service, with staff standing while assisting residents due to a lack of chairs and significant delays in serving meals. A resident's request for a specific meal was unmet, and an LPN publicly discussed their medical details. Two residents were served last at their table during breakfast, indicating disorganized meal service.
A facility failed to notify the State mental health authority for PASRR after admitting a resident with PTSD and anxiety disorder. The resident's PASRR evaluation, completed by the hospital, indicated no level II was required, despite the mental health diagnoses. The PASRR was not updated to include these diagnoses, and the oversight was confirmed by a Licensed Social Worker.
A facility failed to update a care plan to address the hearing needs of a resident with a hearing deficit. Despite the resident's requirement for hearing aids and an ENT referral for ear issues, the care plan lacked specific goals and interventions for hearing loss. The DON confirmed the omission during an interview.
A resident with severe cognitive impairment experienced two unwitnessed falls, and the facility failed to complete the required neurological assessments. Despite hearing the falls, staff did not document follow-up assessments in the electronic medical record, contrary to facility policy. The DON confirmed the lack of documentation and adherence to post-fall procedures.
A resident with dementia and abnormal weight loss experienced a significant decline in weight over several months, dropping from 111.4 to 100 pounds. Despite the care plan noting potential for unintended weight loss, the facility did not notify the medical provider or dietitian, nor initiate nutritional interventions.
A resident experienced significant weight loss over four months, dropping from 111.4 lbs to 100.0 lbs, without evidence of physician supervision or evaluation. The clinical record lacked documentation of provider notification or progress notes addressing the weight loss, as confirmed by a surveyor during an interview with the B Unit Manager.
A facility did not timely follow up on pharmacist recommendations for a resident's PRN Trazodone order. The order, placed without a specified duration, was not discontinued until several weeks after the pharmacist advised limiting PRN antidepressants to 14 days unless documented otherwise by the prescriber.
The facility failed to complete AIMS tests for two residents when antipsychotic medication doses were changed or initiated, as per policy. Additionally, a resident received a PRN antidepressant without a documented duration or rationale, violating the 14-day limit requirement. These deficiencies were confirmed during reviews with the ADON and B Unit Manager.
A facility failed to document and administer a pneumococcal vaccine to a resident who had signed a consent form. The resident's clinical record showed a signed consent, but there was no evidence of the vaccine being given. The Education Coordinator confirmed the oversight during an interview.
A resident's medications were not administered according to physician orders, with Levothyroxine given after the prescribed time and Sinemet doses not aligned with specified schedules, sometimes being administered with meals. The resident's family raised concerns about the timing of Parkinson's medication, which was confirmed by the DON.
A facility failed to provide dignified feeding assistance to a resident. A CNA placed a breakfast tray in front of a resident and walked away without assisting. After 26 minutes, the CNA returned, fed the resident two bites, and left again. The CNA later collected the uneaten tray without speaking to the resident. This was discussed with the DON and ADON.
A resident with dementia and dysphagia, requiring assistance with eating, did not receive the care outlined in their care plan. The CNA placed a meal tray in front of the resident and left, later returning to offer food without following the care plan's instructions to alternate bites with liquids or reheat the food. The resident refused the food, and the CNA did not attempt to reapproach or offer fluids, eventually removing the uneaten tray without further interaction.
A resident with dementia and severe agitation was physically abused by a C.N.A. who held the resident's arms down during care, causing bruising. The resident accused the C.N.A. of throwing them around, and other staff confirmed the bruises were not present the day before. The facility's Abuse Policy defines such actions as physical abuse.
Resident Dignity Compromised by Improper Handling of Treatments
Penalty
Summary
The facility failed to maintain resident dignity and respect by leaving resident treatments, labeled with room numbers and specific body areas to be treated, unattended in a corridor accessible to all residents and visitors. During a tour of the D-Unit, three medication cups and two packets of cream were observed on a counter/storage area in the corridor across from two resident rooms. The medication cups were labeled with the room number and the body area for application, including sensitive areas such as the groin, big toe, and penis. The RN-Charge Nurse confirmed that she dispensed and left the treatments out for Certified Nurse Assistants (C.N.A.s) and labeled them accordingly.
Failure to Maintain Clean and Safe Dining and Kitchenette Areas
Penalty
Summary
During a tour of the D-Unit dining area, surveyors observed several deficiencies related to housekeeping and maintenance. The metal molding at the base of the kitchenette counter was found to be soiled with dried liquids. In the dining room, four floor tiles located at the outside wall across from the dishwasher room were cracked, resulting in an uncleanable surface. Additionally, two ceiling air vents—one over the middle dining tables and another next to the cooking area—were heavily soiled with dust. At the nurse's station, the protective plastic panel facing the dining room was cracked, missing pieces, and had sharp edges. These findings were confirmed by the Maintenance Assistant during the tour.
Failure to Protect Residents from Sexual, Verbal, and Physical Abuse
Penalty
Summary
The facility failed to assess a resident with vascular dementia and under guardianship for the ability to consent to sexual behavior with another resident who had a known history of hypersexual behaviors. Multiple incidents occurred where the resident with dementia was found in compromising situations with the other resident, including being found in the other resident's room with the door barricaded and appearing distressed. Despite clear documentation that the resident lacked capacity to consent, the facility did not conduct an assessment or report the incidents as potential sexual abuse, instead labeling the interactions as consensual. Additionally, the facility failed to protect residents from verbal and physical abuse by a Certified Nursing Assistant (CNA). Over the course of several weeks, a CNA was reported by a colleague to have repeatedly used profane and threatening language towards residents, forcefully grabbed residents, and instructed others on how to physically restrain residents using inappropriate methods. One resident was found with a large bruise on the thigh, consistent with the method described by the CNA, and there was no evidence of a fall or other explanation for the injury. The abusive behavior was witnessed on multiple occasions, and the CNA continued to work for 36 shifts after the initial incidents were observed due to delayed reporting. The facility's internal investigations and interviews confirmed that residents were not free from potential sexual, verbal, and physical abuse. The administration acknowledged the failure to ensure resident safety and did not report the sexual abuse incident to the appropriate authorities. The lack of timely assessment, intervention, and reporting contributed to an immediate jeopardy situation for the residents involved.
Failure to Timely Report and Investigate Abuse and Injuries
Penalty
Summary
Staff failed to immediately report allegations of psychological, physical, verbal, and sexual abuse for multiple residents, as well as an injury of unknown origin. Specifically, a CNA witnessed another CNA being verbally and physically abusive to several residents over a period of three weeks to a month but did not report the incidents promptly, allowing the alleged abuser to continue working and potentially subjecting residents to further abuse. The delay in reporting was confirmed during interviews, with the witnessing CNA stating she was afraid of the alleged abuser. Additionally, an injury of unknown origin involving a significant bruise was not reported or investigated as required. Further, the facility did not notify the appropriate authorities of a potential sexual abuse incident involving two residents, nor did they report observed resident fear and behavioral changes that could indicate abuse. These failures were identified through review of internal investigations, staff statements, clinical records, and interviews, all of which confirmed that the required immediate reporting and investigation protocols were not followed for the incidents in question.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident. During a clinical record review, a nursing note documented a bruise measuring 15 cm by 7.5 cm on the back of the right thigh, with an additional note specifying the location as the back right hip/upper thigh area. The clinical record did not contain any evidence that this bruising, which was of unknown origin, was investigated by the facility. This was confirmed during an interview with a Unit Manager RN, who acknowledged that no investigation had been conducted regarding the injury.
Failure to Follow Physician Orders for Case Review
Penalty
Summary
The facility failed to follow physician orders for a resident who exhibited sexually inappropriate behaviors. The clinical record shows that the resident had multiple physician orders requiring the case to be presented to a specific doctor (DR1) on two separate occasions, as well as medication adjustments for managing the resident's behaviors. Despite these orders, there was no evidence found in the clinical record that the resident's case was ever presented to DR1 as directed. Interviews confirmed that DR1 was no longer available, and there was no documentation of any follow-up or alternative action taken regarding the required physician review. The resident in question had a history of escalating sexually inappropriate behaviors, which led to changes in medication and room assignment to prevent further incidents. The lack of compliance with the physician's orders, specifically the failure to present the case to DR1 or document any follow-up, persisted for over 120 days after the initial order. This deficiency was identified through clinical record review and staff interviews, which confirmed the absence of required documentation and follow-up actions.
Care Plan Not Updated for Resident's Cognitive Ability to Consent
Penalty
Summary
The facility failed to ensure that a care plan was resident-centered and accurately updated for a resident with vascular dementia. The clinical record showed that the care plan, last updated on 2/26/25, identified dementia as a care area but did not include a goal. An approach added on 1/31/25 addressed potential sexual behaviors, outlining steps for staff to take if such behaviors occurred, including assessment, redirection, and notification of supervisors. However, the care plan did not address the resident's cognitive ability to consent to sexual activity, despite the diagnosis of dementia. During an interview, it was confirmed that the care plan was not updated or implemented to meet the resident's needs, as it failed to consider the resident's inability to consent due to cognitive impairment.
Deficiencies in Food Storage and Pest Control
Penalty
Summary
The facility failed to adhere to professional standards in food storage and preparation, as evidenced by two key observations. During a kitchen tour, it was noted that 30 cereal bowls and 30 small white bowls were improperly stored in a wet stacked/nestled manner, which can lead to contamination. Additionally, fruit flies were observed near the baking station area, emanating from and around the floor drain, indicating a lack of proper pest control measures. Furthermore, during a meal observation in the East Wing dining room on the B Unit, two unopened 1% milk cartons were found with expired dates, which was confirmed by a Registered Nurse, highlighting a lapse in monitoring food expiration dates.
Inaccurate and Incomplete Documentation of Neurological Assessments
Penalty
Summary
The facility failed to ensure that resident records contained accurate, complete, and readily accessible information for three residents who experienced falls. The facility's policy required neurological assessments to be completed and documented in the electronic medical record (ECS) after any incident or fall where a head injury was suspected. However, for Resident #84, the neurological assessments were not documented in the clinical record at the time they occurred, with significant delays in documentation noted. Similarly, for Resident #74, the assessments were not documented at the time they occurred, and there were inconsistencies in the documentation, such as missing vital signs and extra checks not listed on the Treatment Administration Record (TAR). Resident #7's clinical record lacked evidence of neurological assessments after two unwitnessed falls. Staff members reported that initial assessments and vitals were documented in a fall packet but were discarded before being recorded in the ECS. The Director of Nursing and other staff confirmed that post-fall investigations and documentation were not consistently completed or retained, leading to incomplete medical records. Interviews with staff revealed that there was confusion and inconsistency in the process of documenting and retaining post-fall assessments. The Director of Nursing stated that a post-fall investigation should be completed within 20 minutes, involving multiple staff members, but acknowledged that assessments might be discarded if staff felt it was not a fall. This practice resulted in incomplete and inaccurate medical records, failing to meet the facility's policy and professional standards for maintaining resident-identifiable information.
Infection Control Deficiencies in Antibiotic Use and Glucometer Cleaning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by their inability to analyze and follow up on known infections. During the months of June, July, and August 2024, there were a total of 60 documented facility-acquired infections that were prescribed antibiotics. However, the facility's infection report lacked evidence of analysis or follow-up on these infections. Interviews with the Director of Nursing and the Infection Preventionist revealed that while antibiotics are reviewed during monthly Antibiotic Stewardship meetings, there has been no effort to identify trends or root causes of the infections. The Infection Preventionist acknowledged the high antibiotic use and the lack of tracing or surveillance to determine the root cause of infections. Additionally, the facility failed to ensure proper cleaning of a shared glucometer between uses. A surveyor observed a Certified Nursing Assistant (CNA) using a shared glucometer to check blood sugar levels on two residents consecutively without cleaning the device in between. During an interview, the CNA admitted to sometimes forgetting to clean the glucometer, despite having the necessary cleaning supplies available. This oversight in infection control practices was confirmed by the surveyor during the observation.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) as outlined in its policy, which aims to optimize antibiotic use and prevent multi-drug resistant organisms and Clostridium difficile infections. The policy requires tracking and trending of antibiotic use, but the facility did not adhere to these protocols. The review of the facility's infection reports for June, July, and August 2024 showed numerous facility-acquired infections treated with antibiotics, yet there was no evidence that these antibiotic prescriptions were reviewed or discussed. Additionally, the Quality Pharmacy Reports for several quarters lacked evidence of antibiotic use review during meetings. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) revealed further deficiencies. The DON admitted that while the infection report is reviewed during monthly ASP meetings, trends or root causes were not analyzed. The DON also confirmed that antibiotic stewardship was not discussed in Quality Assurance and Process Improvement (QAPI) meetings. The IP acknowledged a high level of antibiotic use and noted that many prescriptions did not meet established criteria, and there was no prior discussion of antibiotic use with providers or implementation of tracking systems.
Inadequate Meal Service and Communication Affect Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service in the B Unit dining rooms. During lunch observation, a surveyor noted that a Certified Nursing Assistant (CNA) was standing while assisting a resident with eating due to a lack of available chairs. Additionally, there were significant delays in meal service, with some residents receiving their meals much later than their tablemates. For instance, one resident received their meal at 12:43 p.m., while their tablemates had not been served by 12:55 p.m. The kitchen staff was observed bringing trays without clear direction, leading to disorganized meal service. In another instance, a resident requested a sliced turkey sandwich but stopped eating when it was not provided. A Licensed Practical Nurse (LPN) publicly discussed the resident's medication, diagnosis, and dietary restrictions, which compromised the resident's dignity. Furthermore, during breakfast observation, two residents were served last at their table, with staff prioritizing other tables first. These observations were confirmed with the Administrator, highlighting a pattern of inadequate meal service and communication that affected residents' dignity.
Failure to Update PASRR and Notify State Mental Health Authority
Penalty
Summary
The facility failed to notify the State mental health authority for Pre-Admission Screening and Resident Review (PASRR) after admitting a resident with a mental health diagnosis. The resident's clinical record included a PASRR evaluation completed by the hospital, which indicated that no PASRR level II was required, despite the resident having a mental health diagnosis of anxiety. Upon admission, the resident's clinical record was updated to include diagnoses of Post-traumatic stress disorder (PTSD) and anxiety disorder. However, the PASRR was not updated to reflect these diagnoses, and the State mental health authority was not notified. This oversight was confirmed during an interview with the Licensed Social Worker.
Failure to Address Hearing Needs in Care Plan
Penalty
Summary
The facility failed to update and implement a comprehensive care plan addressing the communication needs of a resident with a hearing deficit. The resident, who was admitted with a diagnosis requiring the use of hearing aids, had a care plan updated on 6/21/24 that identified impaired communication but did not include specific goals and interventions for hearing loss or the use of hearing aids. A review of the Minimum Data Set confirmed the resident's need for hearing aids. Additionally, a Physician Order Sheet dated 7/12/24 indicated an ENT referral for right ear pain and a ruptured tympanic membrane. During an interview, the Director of Nursing acknowledged the omission of hearing-related goals and interventions in the care plan.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments after unwitnessed falls for a resident diagnosed with Vascular Dementia. The resident, who had severe cognitive impairment as indicated by a BIMS score of 1 and 3 on separate assessments, experienced two unwitnessed falls. Despite the facility's policy requiring neurological checks following any fall with a suspected head injury, the clinical record lacked evidence of follow-up assessments after these incidents. Staff interviews revealed that the falls were heard but not witnessed, and although initial fall assessments were started, they were discarded without being recorded in the electronic medical record. The Director of Nursing confirmed that a post-fall investigation should be completed within 20 minutes, involving input from multiple staff members and documentation of provider and family notifications. However, the resident's clinical record did not show that the required neurological assessments were conducted after the unwitnessed falls. This oversight indicates a failure to adhere to the facility's policies for managing falls and ensuring resident safety.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to recognize and address a potential significant weight loss for a resident diagnosed with dementia and abnormal weight loss. The resident was admitted with a weight of 111.4 pounds, and over the course of several months, experienced a weight decline to 100 pounds, indicating an 8% weight loss in one month and a 10.23% loss over four months. Despite the addition of a potential for unintended weight loss to the resident's care plan, there was no evidence that nursing staff notified the medical provider or registered dietitian, nor were nutritional interventions such as supplements initiated to address the weight loss.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's physician supervised and evaluated significant weight loss. The clinical record of a resident, who was admitted with a weight of 111.4 pounds, showed a decrease to 108.7 pounds and then to 100.0 pounds over a period of four months, indicating an 8% weight loss in one month and a 10.23% weight loss over four months. Despite this significant weight loss, there was no evidence in the clinical record that the provider was notified, nor were there any Provider Progress notes addressing the weight loss. This deficiency was confirmed during an interview with the B Unit Manager.
Failure to Timely Address Pharmacist Recommendations for PRN Medication
Penalty
Summary
The facility failed to follow up on pharmacist recommendations in a timely manner for a resident reviewed for unnecessary medications. On April 18, 2024, an order was placed for Trazodone 50 milligrams as needed (PRN) at bedtime for the resident, with no specified duration for the order. The pharmacist made recommendations on April 19, 2024, and May 16, 2024, indicating that the use of PRN antidepressants must be limited to 14 days unless the prescriber documents their rationale in the patient's medical record and specifies the duration for the PRN order. Despite these recommendations, the order was not discontinued until June 11, 2024. This finding was confirmed by the surveyor with the B Unit Manager.
Deficiencies in Antipsychotic Monitoring and PRN Medication Orders
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring of antipsychotic medications through the Abnormal Involuntary Movement Scale (AIMS) for two residents. Resident 19 had a dose increase of Risperidone, an antipsychotic medication, but did not have an AIMS test completed at the time of the dosage change. The last AIMS test for this resident was conducted several months prior. Similarly, Resident 74, who was admitted with an order for Seroquel, another antipsychotic medication, did not have a baseline AIMS test recorded, and the most recent AIMS test was outdated. These oversights were confirmed during a review with the Assistant Director of Nursing (ADON). Additionally, the facility did not ensure compliance with regulations regarding the use of PRN psychotropic medications. Resident 19 had an order for Trazodone, a PRN antidepressant, without a specified duration, which is required to be limited to 14 days unless a rationale and duration are documented by the prescriber. The order expired, but the resident received a dose after the expiration date, indicating a lapse in adherence to the facility's policy and regulatory requirements. This issue was confirmed during a review with the B Unit Manager.
Failure to Administer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure proper documentation and administration of a pneumococcal immunization for one of the five residents reviewed for immunizations. The clinical record of the resident showed a signed consent for the pneumococcal vaccine dated 11/6/23. However, there was no evidence in the medical record that the vaccination was actually administered. During an interview, the Education Coordinator confirmed that the resident had signed the consent form but did not receive the pneumococcal immunization.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for one of the sampled residents, specifically regarding the timing and conditions under which medications were to be given. The facility's Medication Administration Procedure requires medications to be administered at specified times unless otherwise directed by physician services. However, the review of Resident #3's clinical records and interviews revealed multiple instances where medications were administered outside of the prescribed times. For example, Levothyroxine, which was ordered to be given at 7:00 a.m. on an empty stomach, was consistently administered after 8:00 a.m. Additionally, Sinemet, prescribed for Parkinsonism, was not given at the specified times and was sometimes administered with meals, contrary to the neurologist's instructions. The resident's family representative expressed concerns about the untimely administration of Parkinson's medication, which was confirmed by the Director of Nursing during an interview. The Medication Administration Record (MAR) showed several instances where Sinemet doses were given either too close together or at incorrect times, such as a 3:00 p.m. dose being administered at 5:15 p.m. and a 10:00 p.m. dose given at 8:56 p.m. These discrepancies indicate a failure to follow the specific timing and administration instructions provided by the resident's healthcare providers, leading to a deficiency in the facility's medication management practices.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that a resident requiring feeding assistance was treated in a dignified manner. During a breakfast tray pass, a resident was observed sitting in a Broda chair at the entrance to the dining area. A CNA placed the resident's breakfast tray on the tray table in front of them and walked away without assisting. The CNA continued to deliver trays to other residents and returned to the resident after 26 minutes, fed them two bites of food, and then walked away again. Later, the CNA collected the uneaten tray without speaking to the resident or asking if they wanted more food. This incident was discussed with the Director of Nursing and Assistant Director of Nursing.
Failure to Implement Care Plan for Resident with Self-Care Deficit and Nutritional Needs
Penalty
Summary
The facility failed to implement the care plan interventions for a resident with a self-care deficit and nutritional needs. The resident, diagnosed with dementia and dysphagia, was nonverbal and required assistance with eating. The care plan specified that the resident was dependent on one assist for eating, with instructions to alternate bites of food with sips of liquid and to reapproach if the resident refused a meal. Additionally, the nutrition care plan required staff to assist the resident with eating, set up foods as needed, feed all meals, and maintain eye contact during feeding. On the observed date, the resident was left unattended in a Broda chair with a meal tray placed in front of them by a CNA, who then walked away. The CNA later returned, attempted to feed the resident, who refused the food, and did not follow the care plan's instructions to offer fluids or reheat the food. The CNA only offered two spoonfuls of food before leaving again, and eventually collected the uneaten tray without further interaction with the resident. This lack of adherence to the care plan was discussed with the Director of Nursing and Assistant Director of Nursing.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. A Certified Nursing Assistant (C.N.A.1) was reported to have held a resident's arms down during care, resulting in bruising on the resident's arms and causing the resident to become angry. The resident, diagnosed with dementia, anxiety, severe agitation, and psychosis, resides in a secured memory care unit. On the day of the incident, the resident was observed with new bruises on the left upper and lower forearm and the upper right arm. The resident accused C.N.A.1 of throwing them around, which was corroborated by another C.N.A. (C.N.A.2) who observed the bruises and reported the incident to the Registered Nurse-Nurse Manager (RN-NM). C.N.A.1 admitted to holding the resident's arm down on the toilet's safety rail during care to prevent the resident from hitting him. Interviews with other staff members, including C.N.A.2, the day Charge Nurse, and C.N.A.3, confirmed that the bruises were not present the day before the incident. C.N.A.3 also reported that the resident claimed C.N.A.1 had grabbed them. The facility's Abuse Policy defines physical abuse as actions that may cause pain, inability to move limbs, burns, cuts, internal injuries, marks, or bruises. The incident was identified as a failure to adhere to this policy, resulting in physical abuse of the resident by C.N.A.1.
Removal Plan
- The RN-NM terminated C.N.A.1.
- The Staff Development Coordinator and the Assistant Director of Nursing provided all direct care staff and licensed nurses on all the facility's Units on Resident Abuse, Neglect and Exploitation.
- Staff were in-serviced on 'Burn Out'.
Latest citations in Maine
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
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.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
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 Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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