Bangor Nursing & Rehabilitation Center

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping services necessary to maintain the building in a sanitary, orderly, and comfortable environment for 1 of 1 days of observations.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure a care plan was accurately revised for 1 of 1 resident reviewed for transfers. (Resident #1 [R1])

Inspectors wroteBased on observations, record review, and interviews, the facility failed to meet the personal hygiene preferences for 1 of 1 resident who are dependent on staff to complete Activities of Daily Living needs. (Resident #1 [R1])

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that during the regulatory visit, the Provider reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the physician block orders for 1 of 1 resident reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to provide pain management in a timely manner for 1 of 1 resident reviewed for pain management. (Resident #1 [R1])

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair for 1 of 1 environmental tour and failed to adequately provide housekeeping and maintenance services necessary to maintain an environment free from offensive odors. On 1/5/26 between 10:45 a.m. and 11:10 a.m., the following were observed on the Skilled Unit: In room [ROOM NUMBER], the divider curtain is unhooked in different places. In room [ROOM NUMBER]-2, behind head of the bed, the wall plaster has several gouge marks. In room [ROOM NUMBER], the trapeze over the resident's bed is soiled. In room [ROOM NUMBER], three red droplets are observed on the floor near the room sink. At 11:15 a.m., in an interview with the unit Charge Nurse, she confirmed the droplets looked like blood and had the area cleaned immediately. [...]

Inspectors wroteBased on employee record reviews, facility policy review, and interviews, the facility failed to implement its own Abuse, Neglect and Exploitation policy to ensure Maine background checks and references were completed for new employees before they were permitted to work for 4 of 7 sampled employees (Certified Nursing Assistant #1 [CNA1], [CNA2], [CNA3], and Therapist #1 [T1). In addition, the facility failed to implement its own Abuse, Neglect and Exploitation policy by not reporting to the state agency (Licensing and Certification) an allegation of resident-to-resident inappropriate sexual contact in a timely manner for 1 of 1 resident-to-resident incident reviewed Resident #28 [R28]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure care plans were resident centered and updated accurately for 3 of 20 sampled resident care plans reviewed. (Resident #5 [R5], R17, R11).

Inspectors wroteBased on observations and interviews, the facility failed to provide a resident with oral care on 3 of 4 days of survey. (Resident #29 [R29], on 1/5/26, 1/6/26 and 1/7/26)

Inspectors wroteBased on clinical record reviews and interviews, the facility failed to follow physician orders for 1 of 12 residents reviewed for admissions (Resident #42 [R42]), and failed to notify the provider of a significant weight gain as ordered by a provider for 1 of 2 residents reviewed for pressure ulcers (R11).

Inspectors wroteBased on employee record reviews, and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 3 sampled staff (Certified Nursing Assistant #1 [CNA1], CNA2, and CNA3).

Inspectors wroteBased on observations and interviews, the facility failed to label beverage thickeners with an open date on 2 of 3 food carts (Food Cart #1, and Food Cart #2).

Inspectors wroteBased on observations, facility policy reviews, and interviews, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to ensure staff wash hands during a medication pass observation, failed to ensure equipment was cleaned after used in a contact room, and failed to utilize proper personal protective equipment (PPE) in contact rooms for 3 of 3 observations of EBP designated rooms Rooms #12 (Resident #5 [R5]) and #29 [R17].

Inspectors wroteBased on facility policy review, Infection and Antibiotic monitoring tool reviews, and interview, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use for 3 of 3 months reviewed (September, October and November 2025). This has the potential to affect all residents receiving an antibiotic.

Inspectors wroteBased on interview. the facility failed to designate a qualified staff member to function as the Infection Preventionist who was responsible for the facility's Infection Control Program and worked at least part time in the role for 4 of 4 months reviewed (September, October, November, and December 2025). This has the potential to affect all residents in the facility.

Inspectors wroteBased on record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interviews, the facility failed to offer/administer a Pneumococcal vaccination to 2 of 5 residents (Resident # [R28] and R33).

Inspectors wroteBased on observations and interviews, the facility failed to promote care for residents (Resident #48 [R48 and R7) in a manner that maintains the resident's dignity and respect during resident observations on 1 of 1 days of survey (1/8/26)

Inspectors wroteBased on record review, the facility policy and procedure for reporting and interview, the facility failed to notify the State Agency (Division of Licensing and Certification) of a resident -to-resident sexual altercation in a timely manner for 1 of 1 resident reviewed for a resident -to-resident sexual. altercation (Resident #28 [R28]).

Inspectors wroteBased on record review and interview, the facility failed to provide a written bed hold notice to a resident who was transferred to the hospital for medical evaluation for 1 of 3 closed record residents reviewed (R61). On 1/7/26, R61's clinical record was reviewed. On 2/24/25 R61 was transferred to the hospital for medical evaluation and treatment following a fall with major injury. The clinical record lacked evidence that R61 and/or R61's representative received a bed hold notice upon transfer. On 1/8/26 at 9:45 a.m., during an interview with a surveyor, the Licensed Social Worker stated she looked through the entire record and found several bed holds but not for the day in question. At this time the surveyor confirmed R61 did not receive a bed hold notice for the transfer to the hospital on 2/24/25.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 7 residents reviewed (Resident #42 [42])

Inspectors wroteBased on observations and interviews, the facility failed to ensure opened Fluticasone Propionate (Advair Discus) inhalation medication was labeled with an open date and that liquid Lorazepam was kept in a refrigerator in 2 of 2 medication carts (Skilled and Long-Term Care).

Inspectors wroteBased on record review, observations and interview, the facility failed to provide assistive devices (Kennedy cups; which is a spill proof drinking cup with a secure lid and handle) for 1 of 2 residents reviewed for nutrition (Resident #16 [R16]) and in addition the facility failed to have enough eating equipment/utensils for between meals and snack times for 3 of 4 days of survey. (1/6, 1/7 and 1/8/26)

Inspectors wroteBased on observation and interview, the facility failed to maintain a garbage storage area and in a sanitary condition to prevent the harborage and feeding of pests for one trash dumpster and for an area outside the back kitchen door for 1 of 4 days of survey (1/7/25).

Inspectors wroteBased on a clinical record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 3 sampled residents (Resident #42 [R42], R4).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded for Hospice services for 1 of 1 resident reviewed for Hospice services Resident #44 [R44]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a resident received monitoring and wound care for 1 of 3 residents reviewed with a pressure ulcer wound (Resident #42 [R42]). This lack of monitoring and wound care resulted in the pressure wound deteriorating and requiring a transfer and admission to the hospital for further treatment.

Inspectors wroteBased on record reviews, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive, for 7 of 14 residents reviewed for Advance Directive. (Resident #19 [R19], R16, R17, R11, R18, R37 and R102)

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 1 of 1 environmental tour (12/18/24).

Inspectors wroteBased on record reviews and interviews, the facility failed to incorporate recommendations from the Preadmission Screening Resident Review (PASARR) level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 3 of 4 sampled resident (Resident #19 [R19, R16, and R37]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that physician orders for treatments were followed for 2 of 20 sampled residents. (Resident #11 [R11]), R19). The facility failed to monitor a residents treatment until 4 days after treatment was administered for 1 of 1 sampled resident (12/13/24 to 12/16/24).

Inspectors wroteBased on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 4 of 6 residents reviewed for medications (Resident #11 [R11], R16, R34 and R37).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection for residents on precautions and during a medication pass observation for 3 of 4 days of survey (12/16/24, 12/17/24, and 12/18/24).

Inspectors wroteBased on record review, and interview, the facility failed to ensure residents were offered pneumococcal vaccinations in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for 5 of 5 residents reviewed for immunizations (Resident [R]3, R43, R25, R28, and R12).

Inspectors wroteBased on record reviews and interview, the facility failed to notify the Provider of a change in status for 1 of 1 sampled resident (Resident #11[R11]).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents reviewed that were admitted in the last 30 days (Resident #54 [R54])

Inspectors wroteBased on record review and interview, the facility failed to provide recommended nutritional services for 1 of 1 residents reviewed for dialysis [Resident #102 (R102)].

Inspectors wroteBased on observations and interviews, the facility failed to provide oxygen therapy in a sanitary manner for 1 of 2 sampled residents using oxygen (Resident #25 [R25]).

Inspectors wroteBased on record review and interview, the facility failed address the needs of a resident in order to minimize triggers that may cause re-traumatization for 1 of 2 resident reviewed for Mood/Behavior (Resident #15 [R15]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that physician ordered medications were available for use to meet the needs of the residents for 1 of 3 residents reviewed as a closed record. (Resident #51 [R51]).

Inspectors wroteBased on observations, and interviews, the facility failed to monitoring food temperatures to prevent food borne illness prior to serving residents for 1 of 4 days of survey (12/17/24), and the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code on 2 of 4 days of survey (12/17/24, and 12/18/24). This has the potential to effect all residents in the facility.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for pressure ulcers (Resident #42 [R42]) and 1 of 1 reviewed for Respiratory care.

Inspectors wroteBased on interviews and observations the facility failed to provide incontinence care timely for 4 of 7 residents interviewed during a complaint investigation [Resident # (R1), (R2), (R3), and (R4)].

Inspectors wroteBased on interviews, and observation, the facility failed to ensure sufficient staff were scheduled and on duty to meet the needs of residents [Resident #1 (R1), R2, R3, and R4]. This has the potential to effect all residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's representative was notified immediately of a significant change in the resident's medical condition for 1 of 2 residents reviewed for a change in condition [Resident #8(R8)]. This had the potential to delay decisions in medical care.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective training program for nursing staff contracted through the Clipboard Application (App) in the areas of dementia care, resident rights, and abuse, neglect and exploitation training by failing to ensure contracted Clipboard Professionals (Users) completed trainings prior to independently providing services to residents.

Inspectors wroteBased on interviews and record review the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff attempted to have a resident receive nail care in contrast to their preferences and to disclose a private conversation for 1:1 resident(s) reviewed (Resident #1 [R1]).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that physician orders were followed for 1 of 3 residents reviewed for provider orders (Resident #1 [R1]).

Inspectors wroteBased on record reviews and interviews, the facility failed to obtain dental services for a resident with chipped and broken teeth for 1 of 1 resident reviewed for dental services (Resident #1 [R1]).

Inspectors wroteBased on record review and interviews related to mandatory submission of staffing information, the facility failed to ensure complete and accurate direct care staffing information based on payroll data was submitted to CMS (Centers for Medicare and Medicaid Services) for fiscal year quarter 3 (April 1 - June 30, 2023). This has the potential to affect all residents (51).

Inspectors wroteBased on observations and interview, the facility failed to ensure the confidentiality of protected health information for 9 of 51 residents during 1 of 4 days of survey (Resident (R) #1, #10, #206, #17, #105, #43, #31, #9, and #47).

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to follow a physician order for making a referral to a specialist for 1 of 5 residents reviewed for unnecessary medications (Resident #26 [R26]) and failed to follow it's own policy for 1 of 2 residents reviewed with a fall (Resident #46[R46]).

Inspectors wroteBased on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #37 [R37], and Resident #39 [R39]).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean manner on 3 of 4 days of survey (10/23/23, 10/24/23, 10/25/23) the facility failed to ensure that dented cans were removed from use, failed to label thawed whipped topping with a thaw date on 1 of 4 days of survey. (10/23/23)

Inspectors wroteBased on interview, the facility failed to ensure that the facility's Infection Preventionist (IP) had completed specialized training prior to starting the IP position.

Inspectors wroteBased on employee record review and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on dementia for 4 of 5 licensed staff reviewed (Certified Nursing Assistant #1 [CNA1], CNA2, Certified Nursing Assistant-Medications #1 [CNA-M1], and CNA-M2).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's choice in the area of bathing was being followed for 1 of 1 sampled residents (Resident #26 [R26]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnoses, and was updated for 1 of 2 residents reviewed for PASRR (Resident 39 [R39]).

Inspectors wroteBased on record review and interview, the facility failed to review/revise and update care plan interventions for the problem areas of Post Traumatic Stress Disorder (PTSD) for 1 of 17 sampled residents/care plans reviewed (Resident #19)(R19).

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure that a treatment was followed for 1 of 1 resident reviewed for pressure ulcers (Resident #33 [R33]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's physician supervised and evaluated weight loss for 1 of 1 residents reviewed with significant weight loss (Resident #31 [R31]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that physician ordered medications were available for use to meet the needs of the residents for 1 of 4 sampled residents (Resident #22[R22]).

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 resident reviewed for pressure ulcers (Resident #33 [R33]).

Inspectors wroteBased on employee record review, and interviews, the facility failed to complete annual performance evaluations at least every 12 months for 4 of 5 sampled licensed staff (Certified Nursing Assistant (CNA) #1, #2, and Certified Nursing Assistant-Medications (CNA-M) #1, and #2).

Inspectors wroteBased on review of the facility's Infection Prevention and Control Program (IPCP) and interview, the facility failed to ensure that the IPCP was reviewed annually.

Inspectors wroteBased on record reviews, and interviews the facility failed to ensure that physician orders were followed for 1 of 3 resident's reviewed that were transferred to the hospital (Resident #1 [R1]).