Maine Veterans Home - Bangor

Inspectors wroteBased on observation and interview, the facility failed to provide care for residents in a manner that maintained the residents dignity and respect when resident treatments; that were labeled with room number and body area to be treated, were left in a D-Unit corridor for 1 of 1 observation (Resident #1 [R1], R2, R3).

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair in 1 of 1 tour of the D-Unit dishwashing room, dining room and kitchenette.

Inspectors wroteBased on facility policy review, record review, observation, and interviews, the facility failed to ensure administration of medications for 2 of 3 sampled residents using insulin were done correctly and in accordance to their medication administration policies (Resident #33 [R33] and R30). Facility's Medication Administration policies and procedures that was provided by their Pharmacy with a revision date of October 2017 titled Policies and Procedures Pharmacy Services for Nursing Facilities Section II- Medication Administration lists the following steps for medication administration: On page 87 Section B under number 4. When medications are administered by mobile cart taken to the resident's location medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time, number 5. instructs: [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure that the a ware washer was maintained in good repair and in safe operating condition on 1 of 2 units (D-Unit). On 8/11/25 at 11:45 a.m., a surveyor observed a wet bath blanket on the floor in front of the ware washer in the D-Unit kitchenette. A Food Service Worker (FSW) put dirty dishes in the ware washer and turned the washer on. Once turned on, hot, steaming water spewed out from the bottom of the washer door onto the bath towel on the floor. At that time, in an interview with the FSW, she stated it has been that way for a while. On 8/11/2025 1:47 p.m., during an interview with a surveyor, a FSW stated that the dishwasher leaked which is why the towels were currently on the floor. When asked how long it had been that way, FSW stated she has been employed about a month and it has been that way since she has been here.

Inspectors wroteBased on clinical 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 2 residents reviewed for Dialysis (Resident #91 [R91]). On 8/14/25, R91's clinical record was reviewed and indicated that R91 was admitted to the facility in July 2025. The clinical record lacked evidence that R91's baseline care plan was developed and implemented within 48 hours of admission to include problems, goals, and interventions, for the monitoring and treatment of Type 1 Diabetes Mellitus with insulin dependence, and/or End Stage Renal Disease with dependence on renal dialysis. On 8/14/25 at 10:57 a.m., during an interview with a surveyor and the B-unit Manager, R91's medical record was reviewed. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 1 of 2 residents reviewed for Dialysis (Resident #91 [R91]). On 8/14/25, R91's clinical record was reviewed, and indicated R91 has an active diagnoses of Type 1 Diabetes Mellitus with insulin dependence and End Stage Renal Disease with dependence on renal dialysis. The Physician's Orders (signed on 7/9/25), contained orders for insulin to treat Type 1 Diabetes, blood glucose checks four times per day, and if [blood sugar (BS)] is higher than 500 and the resident has two of the following symptoms (nausea, vomiting, abdominal pain, fever, pulse >100, or [respiratory rate (RR)] >25) the provider is called. [...]

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure physician orders were followed for the use on insulin for 2 of 3 sampled residents (Resident #2 [R2] and R33). 1. On 8/12/25 at 12:49 p.m., a surveyor observed a medication pass completed by Registered Nurse #1 (RN1) for R2. When the surveyor asked RN1 how much Insulin Aspart R2 was to receive, RN1 stated 6 units and changed the pre-set Insulin pen from 5 units to 6 units; RN1 administered the Insulin subcutaneously to R2. On 8/12/25 at 1:25 p.m., a surveyor reviewed R2's clinical record and noted that the physician order for the Insulin Aspart was to administer 5 units, and not 6 units. The surveyor confirmed this finding with RN1 at this time. 2. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain their Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection by keeping a water-soaked bath blanket on the floor in front of the ware washer in the D-Unit kitchenette for 2 of 3 observations. In addition, the facility failed to ensure medications were prepared in a sanitary manner during 1 of 5 medication observation passes. 1. On 8/11/25 at 11:45 a.m., observed a wet bath blanket on the floor in front of the ware washer in the D-Unit kitchenette. A Food Service Worker put dirty dishes in the ware washer and turned the washer on. Once turned on, hot, steaming water spewed out from the bottom of the washer door onto the bath towel on the floor. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident record contained accurate and complete information for 1 of 3 residents reviewed for hospitalization (Resident #7 [R7]). On 8/12/25, a surveyor observed documentation in R7's clinical record from Third Eye Health with a service date and time of 8/10/25 at 9:17 a.m., Central Time that named R7 with a Primary Chief Complaint of transfer notification on Page 1 and included R7's information for Patient data on page 3. However, the second page, which included the Summary with chief complaint, Orders and follow up, and disposition lists another persons name that did not reside in the Long Term Care Facility. On 8/12/25 10:13 a.m., during an interview with a surveyor, D Unit Manager stated she would check into this. [...]

Inspectors wroteBased on a review of the reports from Adult Protective Services (APS), the facility's internal investigations, facility policies, clinical record reviews and interviews, the facility failed to assess a resident (Resident#5 [R5]) for the ability to consent to sexual behavior with another resident (R6). The failure to assess R5 for the ability to consent resulted in R5 not being free from potential sexual abuse. Additionally, the facility failed to ensure that residents were free from verbal and physical abuse by a Certified Nursing Assistant (CNA) for 3 of 3 residents reviewed for abuse. This failure created an immediate jeopardy situation. (R5, R3 and R2).

Inspectors wroteBased on a review of the Nursing Facility Reportable Incident submitted to the Division of Licensing and Certification (DLC) on 2/26/25, the incident report from Adult Protective services on 2/26/25, the facility's internal investigations, written statements by staff, facility policies, clinical record reviews and interviews, the facility failed to ensure staff reported allegations of psychological, physical, verbal, and sexual abuse immediately for 4 of 4 residents reviewed during complaint investigations, (Resident #1[R1], R2, R3, and R5) and failed to report an injury of unknown origin for 1 of 3 residents sampled R3.

Inspectors wroteBased on clinical record reviews and interviews, the facility failed to investigate an injury of unknown origin after a resident was found with a bruise for 1 of 6 residents reviewed for abuse (Resident #3 [R3]).

Inspectors wroteBased on clinical record review and interviews, the facility failed to ensure physician orders were followed for 1 of 2 sampled residents (Resident #6, [R6]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a care plan was resident centered and updated accurately for 1 of 6 residents reviewed during complaint investigations (Resident #5 [R5]).

Inspectors wroteBased on observations, and interviews, the facility failed to ensure that bowls were dried properly and failed to ensure the kitchen was free from insects for 1 of 2 kitchen tour ([DATE]). In addition, the facility failed to ensure that milk was not expired during 1 of 2 meal observations on the B Unit ([DATE]).

Inspectors wroteBased on facility policy review, record reviews and interviews, the facility failed to ensure that resident records contained accurate, complete, and/or readily accessible information for 3 of 5 resident records reviewed for falls (Resident #84 [R84], R74 and R7).

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to maintain an effective infection control program, and failed to analyze and follow-up on known infections in the facility. This has the potential to affect all residents receiving an antibiotic in the facility. In addition, the facility failed to ensure a shared glucometer was cleaned after each use for 1 of 2 observations (8/20/24)

Inspectors wroteBased on facility policy review, record reviews, and interviews, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic.

Inspectors wroteBased on observation and interview the facility failed to promote care to residents in a manner that maintains each resident's dignity for 3 of 4 meal observations in 2 dining rooms on the B Unit.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was admitted with a diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 5 sampled residents reviewed for PASRR (Resident #30 [R30]).

Inspectors wroteBased on record review and interviews, the facility failed to update/implement a care plan in the area of communication for 1 of 1 resident reviewed for communication (Resident #76).

Inspectors wroteBased on record review, facility policy review, and interviews, the facility failed to complete neurological assessments after unwitnessed falls for 1 of 4 residents reviewed for falls (Resident #7 [R7]).

Inspectors wroteBased on record review and interview, the facility failed to recognize a potential significant weight loss for 1 of 1 sampled residents reviewed for nutrition (Resident #101 [R101]).

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 #101 [R101]).

Inspectors wroteBased on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 1 of 5 residents reviewed for unnecessary medications (Resident #19 [R19]).

Inspectors wroteBased on facility policy review, interviews, and record reviews, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS), used to monitor for potentially irreversible side effects of antipsychotic medications, was completed when an antipsychotic medication was started, when a dose changed, or every 6 months, for 2 of 4 sampled residents reviewed (Resident [R] 19. R74). In addition, the facility failed to ensure the physician wrote a rationale and/or order with a duration to extend an as needed (PRN) psychotropic medication beyond the 14-day limit, for 1 of 1 resident reviewed (R19) .

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 of 5 residents reviewed for immunizations included documentation in the medical record to indicate the resident received a pneumococcal immunization (Resident #7).

Inspectors wroteBased on facility policy, record reviews and interviews, the facility failed to follow physician orders for 1 of 3 sampled residents review for medications (Resident #3).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a resident requiring feeding assistance was done in a dignified manner for 1 of 1 resident observed requiring feeding assistance (Resident #2).

Inspectors wroteBased on record review, observations, and interview, the facility failed to provide interventions outlined in the resident's care plan in the area of Self-care deficit and Nutrition for 1 of 3 sampled residents. (Resident #2)

Inspectors wroteBased on record review and interviews, the facility failed to protect a resident ' s right to be free from physical abuse by staff, when a Certified Nursing Assistant (C.N.A.) held a residents arms down during care, causing the resident to sustain bruising on arms and causing the resident to be angry for 1 of 1 residents reviewed (Resident #1 [R1]).

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure that care plans were updated to reflect a resident's current needs for 8 of 8 residents reviewed that had a diagnosis of Post Traumatic Stress Disorder. (Resident #2 [R2], Resident #15 (R15), Resident #23 (R23), Resident #25 [R25], Resident #37 (R37), Resident #54 [R54], Resident #80 (R80) and Resident #83 (R83)].

Inspectors wrote2. On 9/26/23, R2's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. The most recent MDS was dated 7/17/23. This MDS indicated, under Active Diagnosis Section I6100, that the resident had PTSD. The surveyor was unable to find information in the clinical record that indicated what R2's PTSD was caused by or what events might cause re-traumatization. On 9/27/23 at 10:55 a.m., in an interview with the surveyor, the Social Services Director (SSD) confirmed there were no trauma assessments completed that identified the cause of the resident's PTSD and what triggers would cause re-traumatization. 3. On 9/26/23, R25's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. The most recent MDS was dated 8/16/23. This MDS indicated, under Active Diagnosis Section I6100, that the resident had PTSD. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to revise/update care plans to reflect/address residents current needs and behaviors for 2 of 22 sampled residents (Resident [R] 202 and R252).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a treatment was followed for 1 of 2 sampled residents reviewed for pressure ulcers (Resident [R} 83).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the physician completed a required visit before renewing an as needed (PRN) anti-psychotic medication for 1 of 3 residents reviewed on PRN anti-psychotics (Resident (R) 60).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an environment to help prevent the development of urinary tract infections on 3 of 4 survey days (9/25/23, 9/26/23, and 9/27/23), and also failed to use appropriate personal protection equipment, use of gowns, to prevent the risk of infection on 1 of 4 survey days (9/26/23).

Inspectors wroteBased on record review and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, and dementia management by failing to ensure that 1 of 5 Certified Nursing Assistant's (CNA) employed, completed the required annual training (CNA1).