Every finding on record at Bangor Nursing & Rehabilitation Center

Based 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.Findings:1. On 7/21/26 at 9:00 a.m., and at 12:11 a.m., observations of room [ROOM NUMBER], the surveyor found the room to have a strong urine smell, a stand fan that was heavily covered in dust, the floors were dirty and the room was disorganized.2. On 7/21/26 at 12:15 p.m., room [ROOM NUMBER] was observed to have large black markings on the wall next to the bed.On 7/21/26 at 12:25 p.m., during an interview with the Director of Nursing the surveyor confirmed the above findings.

Based 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])Finding:On 7/21/26 at 9:00 a.m., during an interview with R1, he/she stated that they are assisted with transfers with 1 staff person standing by to make sure he/she maintains their balance.On 7/21/26 at 9:10 a.m., during an interview with a staff member who was providing care to R1, they stated that R1 is a contact guard assist for all transfers. Explaining that all they have to do for R1 is stand by and make sure they keep their balance and doesn't fall. Explaining further that R1 has always been a contact guard assistance with one staff.On 7/21/26, during a clinical record review R1's Kardex (a list of how to provide care, used by staff) indicates that R1 transfers are listed as a totally dependent with 2 assists of staff for transferring. Review of R1's care plan has an intervention of resident being totally dependent 2 assist of staff for transferring.On 7/21/26 at 12:40 p.m., during an interview with Occupational Therapist, and a review of R1's therapy notes. It was determined that R1 is a contact guard assist for all transfers. The surveyor confirmed at this time that R1's care plan was not revised to reflect his/her current abilities.

Based 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])Findings:On 7/21/26 at 9:00 a.m., a surveyor observed R1 with unclean hands and long jagged fingernails with a dark substance built up under and around the nails. Record review revealed R1was assessed to need substantial assist by 1 staff for personal hygiene which includes nail care. On 7/21/26 during lunch service R1 was being assisted with their meal. His/her nails were observed to be long and jagged with a dark substance under and around his/her nails.On 7/21/26 at 12:25 p.m., during an interview with the Director of Nursing the surveyor confirmed the above findings.

Based 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.Findings:1. On 7/21/26, a review of R1's clinical record was completed. Documentation indicated that a required regulatory visit was conducted on 12/9/25. A provider progress note was completed on 12/9/25, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 12/9/25 required regulatory visit. R1's physician block orders were signed on 1/12/26 34 days after the regulatory visit.2. Documentation indicated that a required regulatory visit was conducted on 2/12/26. A provider progress note was completed on 2/12/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 2/12/26 required regulatory visit. R1's physician block orders were signed on 3/8/26 24 days after the regulatory visit.3. Documentation indicated that a required regulatory visit was conducted on 4/14/26. A provider progress note was completed on 4/14/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 4/14/26 required regulatory visit. R1's physician block orders were signed on 5/4/26 20 days after the regulatory visit. 4. Documentation indicated that a required regulatory visit was conducted on 6/4/26. A provider progress note was completed on 6/4/26, but there was no evidence that the physician block order was signed. The facility was unable to provide evidence that the physician block order was signed on the day of the 6/4/26 required regulatory visit. R1's physician block orders were signed on 6/29/26 25 days after the regulatory visit. On 7/21/26 at 12:05 p.m., during an interview with the Director of Nursing the surveyor confirmed this finding.

Based 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])Finding:On 3/10/26 at 11:15 a.m., in an interview with the surveyor, R1 stated that they were discharged from the hospital and arrived at the nursing facility around 2:50 p.m. R1 stated they asked for pain medication because they were having pain in their fractured left leg. R1 stated they were told their medications had not arrived from the pharmacy and were waiting for a code from the pharmacy to get one out of the Cubex medication machine. (A Cubex medication machine is automated with dispensing cabinets that securely store, manages and tracks controlled substances. The facility pharmacy that provides the Cubex gives the facility nurse a code for them to open the Cubex machine and retrieve the narcotic to give to the residents). R1 stated they did not get pain medication until after 11:00 p.m.On 3/10/26, a review of R1's clinical record was completed. Documentation in R1's admission nurse's note indicated a pain scale number of 6 (1 being little to no pain and 10 being extreme pain). In addition, documentation indicated R1 has chronic hip and knee pain.Documentation in the hospital discharge orders indicated R1 had an order for Oxycodone (Roxicodone) 5 milligrams, take one tablet by mouth every 4 hours as needed for pain x 14 days.Documentation on R1's Medication Administration Record (MAR) indicated that R1 received the pain medication-Oxycodone at 11:05 p.m. with a documented pain scale number of 6. (approximately 8 hours after R1 requested pain medication)There was no evidence in R1's clinical record that indicated the facility attempted to contact a physician for alternate pain medication orders. There was no documented evidence that non-pharmaceutical interventions were attempted such as positioning, activities for distraction, discussing with R1 what may have helped relieve their pain in the past.On 3/10/26 at 1:00 p.m., in an interview with the surveyor, the Director of Nursing confirmed that there was no evidence to indicate that non-pharmaceutical interventions or attempts to contact a physician were done while waiting to get a code to open the Cubex medication machine.

Based 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. On 1/6/26 at 8:00 a.m., on the Skilled Unit, in the corridor near rooms [ROOM NUMBERS], a strong odor of urine was observed and again 1:15 p.m., a strong urine odor was observed. On 1/8/26 at 1:15 p.m., in an interview with the Administrator, the surveyor discussed the above findings. On 1/5/26 upon entrance of the facility for their annual survey it was noted by this surveyor a strong odor of urine in the long-term hallway (the end closer to the dining area) this odor remained for the survey hours of 10:30 a.m. – 3:00 p.m On 1/6/26 during survey the strong odor of urine was noted again in the long-term hallway, areas were near the horseshoe area and near the Director of Nursing (DON) office. This odor was noted during the survey hours 7:00 a.m. – 3:30 p.m. On 1/7/26 at 7:20 a.m. the long-term hallway had a strong odor of urine, at 8:25 a.m. the surveyor and the DON went into the long-term hallway and both the surveyor and the DON acknowledged the strong odor of urine. The DON stated she has been in all rooms this morning and did not smell urine in the resident rooms. She notices the smell but is unable to determine where the smell is coming from. On 1/8/25 at 2:00 p.m. two surveyors noted the strong urine odor in long-term hallway, from mid-hall to dining area doorway. On 1/8/26 at 10:23 a.m. in a confidential interview with a resident's family, they stated that the smell of urine in the facility is really bad a lot of the time and was told by the facility that this is a non-fume place, meaning it's a facility that doesn't use aerosols to get rid of odors, so the resident's family member has had to use Vicks their self to stop smelling the odor of urine in the facility when visiting.

Based 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]). Findings: 1. The facility policy, Abuse, Neglect and Exploitation, revised 11/1/25, indicated under the section of Screening that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property by the following: - Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. - Screens may be conducted by the facility itself, third-party agency or academic institution. - The facility will maintain documentation of proof that the screening occurred. On 1/6/26, between 12:30 p.m. - 1:00 p.m., a surveyor reviewed employee files and confirmed the following with the Assistant Director of Nursing: - CNA1 was hired on 3/4/24. The employee file lacked evidence of the facility completing a Maine background check prior to hire. The background check in the employee file was dated 8/19/22 (over 1 year prior to hire) and was ordered by a staffing agency, not the facility. - CNA2 was hired on 10/9/24. The Maine background check in the employee file was completed on 10/30/24, 21 days after being hired. - CNA3 was hired on 10/9/24. The Maine background check in the employee file was completed on 10/30/24, 21 days after being hired. - T1 was hired on 10/28/25. The employee file lacked evidence of references being checked. 2. On 1/6/26, a review of R28's clinical record was completed. In a nurse's note, dated 1/3/26, it indicated that R28 had been touched in a sexually inappropriate manner by a male resident. A review of both resident's clinical records indicated that both residents are wheelchair bound and have dementia. A nurse note dated 1/5/26, indicated that R28's guardian was notified of the incident. On 1/8/26 at 8:31 a.m., in an interview with the surveyor, the Director of Nursing (DON), confirmed that the incident occurred on Saturday, 1/3/26, and she was not notified until Monday, 1/5/26, and at that time she notified the state agencies (Licensing and Certification and Adult Protective Services) of the incident. The DON confirmed that the state agencies were not notified in a timely manner.

Based 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). Findings:1. On 1/7/26, a review of R5's clinical record was completed. R5 had an indwelling Foley catheter and a pressure wound on the left heel and buttocks. On 1/7/26 at 9:00 a.m., an Enhanced Barrier Precautions (EBP) sign was observed hanging on R5's clothes closet and Personal Protective Equipment (PPE) was stored in the closet. A review of R5's current care plan addressed the pressure wounds and catheter, but there was no evidence that the care plan addressed that R5 is on Enhanced Barrier Precautions (EBP). On 1/7/26 at 11:51 a.m., in an interview with the surveyor, the Director of Nurses, confirmed that the care plan did not address EBP. 2. On 1/7/26, a review of R17's clinical record was completed. R17 had a non-weight bearing status, and pressure wounds on the left and right heels. There is no evidence of the pressure wounds, weight bearing status and EBP being addressed in R17's care plan. On 1/7/26 at 10:10 a.m., in an interview with the surveyor, the Director of Nurses, confirmed that the care plan did not address EBP, weight bearing status or the current pressure wounds on R17's heels. 3. On 1/7/26 a review of R11's clinical record was completed. R11 had a pressure wound to left buttock, and a wound to the right inner thigh. On 1/7/26, a review of R11's current care plan addressed the wounds, but there was no evidence that the care plan addressed that R11 is on EBP. On 1/7/26 at 11:48 a.m., in an interview with the surveyor, the Director of Nurses, confirmed that the care plan did not address EBP.

Based 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)Findings:On 1/5/26 at 1:45 p.m., during the first observation and attempted interview with R29 the surveyor observed that his/her dentures were not clean and were falling down in his/her mouth and was not able to speak to surveyor. They appeared to be caked with food substance. On 1/5/26 during a record review for R29, his/her care plan was reviewed, and the care plan addresses that he/she does need substantial assistance of 1 staff to assist with personal hygiene and oral care. On 1/6/26 at 9:42 a.m. R29 during the second attempt to interview R29 was not able to talk without his/her dentures falling in his mouth. On 1/6/26 at 9:50 a.m. during an interview with a Certified Nursing Assistant (Cna) she was asked if R29's dentures not fitting properly was a daily issue. She stated she had tried Fixodent before but R29 did not tolerate it very well so she tried a smaller amount and that didn't work so she has not been putting anything on the dentures and has not said anything to the Social Worker or nursing. On 1/7/26 at 12:35 p.m. during an observation of R29, he/she was in their bed with his/her lunch tray in front of them. He/she stated he/she could not eat this. As he/she was talking their dentures were falling out of his/her mouth. R29 stated he/she needed some adhesive for his/her teeth. This surveyor made the nurse aware and he went to get R29 some denture adhesive. When nurse came back to room he asked resident for their dentures and they were rinsed but not brushed, and mouth care was not done. Adhesive was applied to dentures and with a second dollop of adhesive R29 was able to keep dentures in place and stated oh that is so much better he/she was able to talk and eat with his/her dentures not falling. On 1/7/26 at 1:45 p.m. during an interview with Cna7, who is assigned to assist R29, she stated she had not gotten to R29 yet as she had a lot of people ringing and voiding a lot that took a lot of her time. She was not aware that he/she used denture adhesive. She will wash R29 up soon. On 1/7/26 at 2:00 p.m., during an interview with the Director of Nursing the surveyor was able to confirm that R29 had not been assisted with oral care and his/her dentures were not fitting and was not assisted with using denture adhesive on 1/5/26, 1/6/26 and 1/7/26.

Based 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).Findings: 1.On 1/8/26 at 2:29 p.m. during a clinical record review for R42 a review of his/her Medication Administration Report (MAR) for [DATE] and [DATE] was completed. It was documented that R42 was admitted with an order for Keppra Oral Tablet 500 (milligrams) mg Give 1 tablet by mouth two times a day for epilepsy. During this clinical record review, it was identified that this order was entered into their electronic Health Care System (point click care [PCC] inaccurately. It was entered as an unsupervised self-administration medication and during this clinical record review, it was determined that R42 was not self-administering any medications. By the nurse entering this order as an unsupervised self-administration medication it caused R42 to miss 40 doses of Keppra Oral Tablet 500 mg a medication that is used for epilepsy. On 1/8/26 at 12:56 p.m. during an interview with the Director of Nursing the surveyor confirmed that due to the inaccurate medication entry R42 missed 40 doses of her Keppra medication an Epilepsy medication, in December 2025 and January 2026. 2.Resident 11 has an active diagnosis of heart failure. Review of R11's physician order on the Treatment Administration Record (TAR), 1/1/2026-1/31/26 states, Monthly weight every day shift starting on the 1st and ending on the 7th every month. Call MD (Doctor of Medicine [physician]) if 2-3 lbs (pounds) weight gain -Start Date- 10/01/2025 0700. Review of R11's weights in the clinical record, under Weights are as followed: On 1/4/26 at 15:17 (3:17 p.m.) R11's weight was 251.0 lbs. (pounds). On 1/5/26 at 10:26 a.m. R11's weight was 250.6 lbs. On 1/5/26 at 10:27 a.m. R11's weight was 260.6 lbs. On 1/6/26 at 6:47 a.m. R11's weight was 260.6 lbs. On 1/6/26 at 10:51 a.m. R11's weight was 260.6 lbs. On 1/6/26 at 10:51 a.m. R11's weight was 260.6 lbs. On 1/6/26 at 14:46 (2:46 p.m.) R11's weight was 259.9 lbs. The physician order on the TAR dated 10/1/25 directed the physician to be notified of, 2-3 lbs weight gain. The clinical record lacks evidence that the provider was contacted of the weight gain as directed. On 1/7/26 at 11:48 a.m. in an interview with the Director of Nursing, a survey confirmed that there is no evidence in the clinical record that the physician was notified of a weight gain of more than 2-5 lbs. on 1/5/26 when R11 had a weight gain of 9.4 lbs.

Based 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). Findings: 1. CNA1 was hired on 3/4/24. The facility was unable to provide evidence that an annual performance evaluation had been completed. 2. CNA2 was hired on 10/9/24. The facility was unable to provide evidence that an annual performance evaluation had been completed. 3. CNA3 was hired on 10/9/24. The facility was unable to provide evidence that an annual performance evaluation had been completed. On 1/06/26 at 11:50 a.m., during an interview with a surveyor, the Assistant Director of Nursing stated they were unable to find any annual evaluations for the 3 CNAs.

Based 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). Findings:On 1/5/26 at 12:24 p.m. on top of Food Cart #2, a surveyor observed one open carton of Thick & Easy (beverage that is thickened) that was not labeled with an opened date. Storage and handling instructions on the carton were to discard if not used within 4 days of open. On 1/5/26 at 12:38 p.m. on top of Food Cart #1, a surveyor observed 1 open carton of Thick & Easy (beverage that is thickened) that was not labeled with an opened date. Storage and handling instructions on the carton were to discard if not used within 4 days of open. On 1/5/26 at 12:38 p.m. in an interview with the Kitchen Supervisor, a surveyor confirmed that the open Thick & Easy carton's on Food Cart #2, and Food Cart #1 were available for Resident use and not labeled with an opened date. The Kitchen Supervisor removed the carton's at this time.

Based 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]. Findings: Findings: 1. On 1/05/26 at 11:27 a.m., a surveyor observed Registered Nurse #1 (RN1) complete a medication pass for a resident; at the end of the observation, RN1 took the resident's cup used for water and placed it in the garbage at the medication cart. RN1 immediately started to prepare the next resident's medications but failed to wash her hands or use hand sanitizer after completing the previous medication pass or prior to starting this medication pass. At 12:03 p.m., during an interview with RN1, a surveyor confirmed this finding. 2. On 1/5/26 at 11:48 a.m., a surveyor observed RN1 use the mobile vital signs monitor in an Enhanced Respiratory precautions room; the monitor was moved outside of room (not sanitized after use in a contact room) and a surveyor stayed in the area to continue observations. On 1/5/26 at 12:20 p.m., a staff member moved the monitor from outside of room [ROOM NUMBER] to the wall between room [ROOM NUMBER] and 31, still uncleaned and available for use. On 1/5/26 at 12:30 p.m., during an interview with the Infection Preventionist (IP), a surveyor confirmed that this monitor was used in room [ROOM NUMBER] but has been out of sight of the staff member that initially used the machine multiple times, it has been moved to a different location, and has been available for use but not cleaned for at least 40 minutes. The IP stated that she would clean it now. 3. The facility's policy, Bangor Nursing and Rehabilitation Center (BNRC) Respiratory Viral Pathogen Outbreak Plan, undated, indicated that the following Personal Protective Equipment (PPE) for a resident with or suspected coronavirus (COVID): N95 respirator, gown, gloves, and eye protection. On 1/5/26 at 11:15 a.m., a surveyor observed a sign that notified staff that room [ROOM NUMBER] was on Enhanced Respiratory Precautions and that the following PPE was required: gown, N95 respirator or higher level respirator, eye protection (goggles or face shield), and one pair of gloves. There was a plastic drawer storage located outside of the room with the PPE. On 1/5/26 at 12:23 p.m., two surveyors observed Certified Nursing Assistant #4 (CNA4) in room [ROOM NUMBER] standing next to a resident who was in bed. CNA4 was wearing a blue surgical mask, disposable gown, and gloves but not wearing an N95 respirator or eye protection. The surveyor confirmed with CNA4, after review of the posted sign, that she was not wearing the proper PPE for this room. 4. On 1/7/26, a review of Resident #5 (R5) clinical record was completed. In the physician order section, it indicated R5 had treatments to open wounds on the left heel (pressure ulcer) and buttocks. On 1/7/26 at 9:00 a.m., the surveyor observed the unit Charge Nurse perform the wound treatments to the heel and buttocks. While observing the wound treatments, it was observed that on R5's clothes closet was anEnhanced Barrier Precaution sign indicating the Personal Protective Equipment (PPE) face mask, gloves and gown were required whenperforming any direct care to the resident. The unit Charge Nurse did not wear all the required PPE's during the wound treatments (no gown). On 1/7/26 at 10:15 a.m., in an interview with the surveyor, the unit Charge Nurse, confirmed that she did not don all the required PPE's prior to doing the pressure ulcer/wound dressing changes. The Centers for Disease Control and prevention Definition and Scope of Enhanced Barrier Precautions: dated 6/23/24 states, Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). EBP expand the use of gown and gloves beyond anticipated blood and body fluid exposures . Standard Precautions still apply while using EBP. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. On 1/7/26, a review of the Facilities Enhanced Barrier Precautions dated 1/1/25 - 12/31/25 indicated: Overview: Enhanced Barrier Precautions (EBP) focus on residents with infection or colonization with MDRO's and residents at risk for developing or becoming colonized. Enhanced barrier precautions are precautions that in addition to Standard Precautions, will be implemented during high contact resident care activities . Procedure: precautions should be applied to all residents .Enhanced barrier precautions are to be implemented in addition to standard precautions when other transmission-based precautions do not apply, when the facility identifies any resident with: . any indwelling medical device, for example urinary catheters. 5. On 1/7/26, a review of R17's clinical record was completed. In the physician order section, it indicated R7 had treatments to open wounds on the right and left heel (pressure ulcer). A review of the Facilities Enhanced Barrier Precautions dated 1/1/25 - 12/31/25 indicated: Overview: Enhanced Barrier Precautions (EBP) focus on residents with infection or colonization with MDRO's and residents at risk for developing or becoming colonized. Enhanced barrier precautions are precautions that in addition to Standard Precautions, will be implemented during high contact resident care activities . Procedure: precautions should be applied to all residents .Enhanced barrier precautions are to be implemented in addition to standard precautions when other transmission-based precautions do not apply, when the facility identifies any resident with: . any indwelling medical device, for example urinary catheters. On 1/7/26 at 7:45 a.m. during a wound care dressing change with LPN2 the surveyor observed the Charge Nurse LPN2 perform the wound treatments to the right and left heels. While observing the wound dressing change, it was observed that R17's room did not have an Enhanced Barrier Precaution sign and LPN2 was performing direct care/wound care to R17. LPN2 did not wear all the required PPE's during the wound dressing change (no gown). On 1/7/26 at 10:10 a.m., in an interview with the surveyor, the Director of Nursing stated they misread the second page of their policy she thought EBP was used for chronic wounds only and that R17 was not on EBP because the wounds developed after R17's admission.

Based 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.Finding: The facility's policy, Antimicrobial Stewardship Program Long Term Care, Jan.1 2025-Dec. 31, 2025, indicated the following: the purpose (of the program is to reduce the risk of multidrug-resistant developmentCovenant Health is dedicated to helping reduce the risk of multi-drug resistant development by following the Centers for Disease Control and Prevention's seven core measures for antimicrobial stewardship.The seven core elements of Antibiotic Stewardship are leadership commitment, accountability, drug expertise, actions, for improvement, tracking, reporting, and education.Tracking: The facility will monitor all antibiotic prescribing (dose, duration, indication), clinical assessments (diagnostic testing and symptoms), and adherence to facility-specific treatments using the U.S. Department of Health and Human Services monitoring tool. The facility will monitor all patterns of multidrug-resistant organism. On 1/6/26 at 9:16 a.m., during an interview with a surveyor, the Infection Preventionist (IP) shared September 2025's infection and Antibiotic tracking tool which included the following documentation: Location/unit, resident name, skilled/long term care, Room/Bed, date of admission, infection resolved or resident discharged , date of infection, date of resolution, age of infection in days, days to resolve, facility acquired, infection, Fever onset, symptom, met facility adopted criteria, culture or test obtained, source of culture/test, [NAME] blood cell count, Colony count for urine, culture results, were culture results reviewed within 48-72 hours of results, antibiotic names, start and end dates, days of treatment for month, total days of treatment without end date, hospital start, prescriber, prophylaxis or treatment, and re-assessment within 48-72 hours of facility start. During September's review, it was observed that sections of this monitoring tool contained no information including Location/unit and resident room number (which could be used to identify location trends) and information regarding if the infections were resolved or if the resident was discharged , the date of resolution, and number of days to resolve noting that some antibiotic use end dates documented were in September. During this review, the IP stated that she has not had a chance to complete the monitoring tool; September 2025 was the last month with information entered as October and November were not done. The surveyor confirmed that tracking had not been completed during this interview.

Based 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. Finding: On 1/6/26, at 9:16 a.m., during an interview with a surveyor, the Infection Preventionist (IP) stated that she had not completed the training yet. She has hired in July 2025, and the old IP left the end of August 2025. She stated she had started the Center for Disease Control (CDC) modules but during the process, the CDC changed the version, and she had to start all over again.

Based 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).Findings:1. On 1/5/26, a surveyor reviewed R28's clinical record and noted that the resident was admitted in September 2024; a review of the immunizations tab in the electronic clinical record contained no documentation regarding a pneumococcal vaccination status and uploaded in the files of the clinical record was a blank pneumococcal consent form, dated September 2024. On 1/5/26 at 2:50 p.m., during an interview with a surveyor, the Infection Preventionist (IP) stated they were waiting on consents from the guardian. On 1/6/26 at 9:13 a.m., during an interview with a surveyor, the IP stated she called the guardian, got consent to administer the pneumococcal vaccine, and ordered the vaccine after the surveyor inquired yesterday. 2. On 1/5/26, a surveyor reviewed R33's clinical record and noted that the resident received the Pneumococcal polysaccharide vaccine 23(PPV23) in November 2023. The CDC PneumoRecs VaxAdvisor App for Vaccine Providers recommended to give one dose of Pneumococcal conjugate vaccines (PCV) of either PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23. On 1/5/26 at 2:50 p.m., during an interview with the IP, a surveyor asked if R33 had been offered the PCV20 based on the recommendations. On 1/6/26 at 9:16 a.m., during an interview with a surveyor, the IP stated she had consent to administer the pneumococcal vaccine and ordered the vaccine after the surveyor inquired yesterday.

Based 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) Findings: 1.On 1/8/26 at 10:15 a.m., during a resident observation R48 was being assisted by a staff person down the hallway, R48's feet were dragging on the floor, and R48 stated stop my feet, the staff person then said to R48 well if you would lift your feet it wouldn't hurt, It was observed that R48 was wheeled to an office to sit with this staff person. On 1/8/26 at 10:30 a.m. during an interview with the Director of Nursing (DON) she was made aware of the observation. The surveyor asked the DON what the facilities policy was for transporting residents in a wheelchair. She stated that residents who can self-propel the footrests are removed to prevent any trip hazards. If staff transport the residents they need to have the footrests in place. She then stated they are all aware of this as they have been working with therapy to find the footrests for all chairs. The staff person who was assisting R48 and made the statement was the staff sitting with R48 in the office, this person was identified as the schedular, she is also Cna (Cna6). At this time the surveyor confirmed this observation with the DON. 2. On1/8/26 at 1:46 p.m. the surveyor observed Cna1 pulling R7 backwards in a shower chair while in the hallway. R7 was observed being pulled down the hallway backwards with his/her buttocks and thighs exposed. At the time of the observation the surveyor confirmed with Cna1 that R7 should have been covered better not to expose his/her body parts and should not have been pulled backwards in the chair.

Based 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]). Finding:On 1/6/26, a review of R28's clinical record was completed. R28 is cognitively impaired and is wheelchair dependent. In the nurse note section, a note indicated on Saturday/1/3/25, in the afternoon, R28 was inappropriately sexually touched by a cognitively impaired male resident who is wheelchair dependent).A nurse note dated 1/5/26 (Monday), indicated the Director of Nursing and the Social Worker were notified of the resident-to-resident sexual altercation.On 1/8/26, a review of the facility Abuse-Risk Management Folder, under Take Action - (When an allegation of abuse is made), #3 Based on allegation: notify State agency, Adult Protective agency .A review of the facility Compliance with Reporting Allegations of Abuse/Neglect/Exploitation-Procedure for Response-#2a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident.On 1/8/26 at 8:31 a.m., in an interview with the surveyor, the Director of Nursing confirmed that the incident occurred on Saturday 1/3/26 and should have been reported to Licensing and Certification at that time. She stated she was not notified of the incident until Monday 1/5/26, at which time she notified the state agency (Licensing and Certification).

Based 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.

Based 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])Finding: Review of Resident #42's clinical record noted that he/she was admitted to the facility on 1218/25. The clinical record lacked evidence that the base line care plan was developed to include the instructions needed to provide minimum healthcare information necessary to properly care for R42. On 1/8/26 at 12:54 p.m., during a clinical record for R42 and during an interview with the Director of Nursing the surveyor confirmed that R42's baseline care plan was not developed within the 48 hours after admission.

Based 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. Finding: On 12/6/24, the facility sent a reportable incident form to the State Agency alleging that Licensed Practical Nurse #1 (LPN1) documented that she had changed R42's pressure wound dressing on 12/2/24 and 12/4/24 but on 12/6/24, the pressure wound dressing was observed by Registered Nurse #1 (RN1), dated 11/30/24. On 12/16/24, R42's clinical record was reviewed. R42's December Treatment Administration Record (TAR) included a physician ordered treatment (started 11/19/24) for the right heel pressure wound that directed staff to cleanse with normal saline or wound wash, pat dry, apply Medihoney alginate, then Mepilex or foam equivalent, and may secure with gauze roll or kerlix and to change every other day on the night shift and as needed (PRN). R42 was to wear off-loading boots to bilateral feet when in bed. Review of R42's December TAR was signed by LPN1 to indicate that a weekly skin check was completed on 12/1/24 and documented at 8:00 p.m. in the clinical record, under Skin Check-LPN, that a foot evaluation completed and described wound #3 as a blister; however on 11/25/24, Family Nurse Practitioner (FNP) documented that it was a new unstageable open area on right heel-malodorous and draining purulent drainage. some discomfort and ordered an antibiotic. On 12/3/24, documentation indicated that Family Nurse Practitioner (FNP) visited R42 but did not observe the right heel dressing and documented that that off-loading boot was on. On 12/5/24, R42's Brief Interview for Mental Status (BIMS]) was 15 (cognitively intact), refused a weekly pressure wound assessment two times and the dressing was not observed as R42 was wearing the off-loading boots. On 12/17/24 at 1:50 p.m., during an interview with a surveyor, FNP stated that she observed the unstageable pressure wound on 11/25/24; it looked like a blister that had popped. FNP stated she ordered an antibiotic (Keflex times (x) 7 days) due to the drainage and odor of the wound (the last dose administered was 12/2/24). FNP stated that on 12/7/24, she ordered R42 be transferred to the hospital because he/she needed a wound debridement to the right heel pressure ulcer. On 12/17/24 at 2:10 p.m., during a joint interview with Registered Nurse #1 (RN1), RN2 and a surveyor, RN1 stated that on 12/6/24, he saw [Resident] 42 and asked how he/she was doing. [Resident] 42 mentioned that his/her (right) foot was hurting and RN1 stated that he asked how the dressing changes were going; [Resident] 42 stated they haven't been changed for a while. RN1 stated he took the green boot off which was covering the (right heel) dressing and saw 11/30/24 written on the dressing (a photo of the dated dressing was taken and provided to the surveyor). RN1 stated he last saw the wound on 11/28/24 and it looked good (On 12/6/24 at 6:00 p.m., RN1 documented that the wound now had a new odor and with new blackened tissue present with dried drainage observed on the old dressing). RN2, who observed the wound on 11/28, stated that it was healing well, to the point of wanting to contact the provider about maybe discontinuing the Medihoney, as it did its job. RN2 stated that weekly pressure wound assessments are supposed to be done weekly but they are not always done by her. RN1 stated that he called FNP and a televisit was completed to review the status of the right heel wound. FNP ordered a mobile x-ray that was completed 12/7/24 and they thought it was possible osteomyelitis (bone infection) and [Resident] 42 was sent to the hospital for further tests. RN1 stated he called the hospital to obtain status on [Resident] 42 and found it was not osteomyelitis, but [Resident]42 was admitted for broad spectrum IV antibiotics (intravenous medication used when a bacterial infection is suspected but the group of bacteria is unknown). [Resident] 42 did not return to the facility. R42's care plan, last updated 11/14/24, for the care area of, The resident has pressure ulcer right heel pressure ulcer development related to (r/t) immobility, with interventions added on 11/14/24 that included: Administer treatments and monitor for effectiveness; assess/record/monitor wound healing measure length, width, and depth where possible; assess and document status of wound perimeter, wound bed and healing progress; monitor/document/report as needed (PRN) any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length times (x) width x depth), stage; and weekly treatment documentation to include the measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage). On 12/17/24 at 8:34 a.m., the Director of Nursing (DON) provided the surveyor with the weekly pressure wound assessments that were completed for R42's right heel pressure injury which included the dates of 11/13/24 and 12/6/24. The surveyor confirmed that weekly pressure wound assessments were not completed every week. On 12/17/24 at 3:15 p.m., during an interview with a surveyor, the DON stated that weekly skin checks are to be done on shower days. The surveyor confirmed LPN1's inaccurate description of a weekly skin check completed on 12/1/24, documenting the description of an unstageable pressure wound (as described by FNP on 11/25/24) as a blister and LPN1 would have needed to remove the dressing, dated 11/30/24, in order to see the area to complete the weekly skin check. The surveyor also confirmed that R42 had a dressing change scheduled every other day and PRN, R42 was on an antibiotic until 12/2/24 due to drainage of the wound, and wore off-loading boots while in bed. There was no evidence that staff had been monitoring the area (as directed by the care plan), because if they would have removed the right foot off-loading boot to observe the treatment for effectiveness, staff would have seen that the last time the dressing had been changed was 11/30/24. On 12/31/24 at 2:03 p.m., the surveyor spoke with LPN1 via telephone. LPN1 stated that she did not remember completing or documenting that she had completed a foot/skin check on 12/1/24 or a dressing change to R42's right heel pressure wound on 12/4/24. LPN1 did state that on 12/2/24, at the beginning of her shift, she documented that she had completed R42's right heel pressure wound dressing change but then was pulled to pass medications She stated that she informed R42 that the dressing change wouldn't be done until after 10 p.m. to which R42 stated that was too late. LPN1 stated that she forgot to change the documentation to indicate that the dressing had not been changed.

Based on a review of the facility's internal investigation, written statements by staff, interviews and clinical record review, the facility failed to protect a resident from physical abuse by staff resulting in the resident experiencing anger, fear and disbelief. Finding: On 12/20/19 the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form which indicated the following: On 12/20/19 a Certified Nursing Assistant-Medication (CNA-M) witnessed a Certified Nursing Assistant (CNA) forcefully sit resident on toilet, resident was combative. [CNA-M] further reports that [CNA] took both of her hands and grabbed resident's left side of head and hair and shook [resident] 3 times. On 2/24/2020, Resident #1's clinical record was reviewed, and it indicated the following: the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also indicated that the resident resides in the facility's secure Memory Care Unit (MCU). The facility's internal investigation, dated 12/23/19 indicated the following: on 12/20/2019 at 12:09 p.m., CNA #1 escorted Resident #1 into the bathroom on the MCU to provide incontinent care and the resident was hitting and scratching at the CNA during this escort into the bathroom; CNA-M entered the bathroom and witnessed CNA #1 physically abuse Resident #1; the CNA-M left the bathroom at approximately 12:11 p.m., and reported her observation to the Registered Nurse (RN) who was in the MCU; the RN and CNA-M reported the incident immediately to the Director of Nurses (DNS); the DNS spoke to CNA #1 who admitted to the physical abuse; and CNA #1 wrote a statement related to the incident. CNA #1 was immediately suspended and sent home and on 12/23/19 her employment was terminated. CNA #1's written statement, dated 12/20/19, indicated the following: she brought the resident into the bathroom despite the patient's resistance; the resident was hitting her and scratching her; she forcefully made the resident sit on the toilet; she grabbed the resident's hair and shook him/her. The CNA further wrote that she was tired, out of control and should not have done that. CNA-M's written statement, dated 12/20/2019, indicated the following: when she walked into the bathroom she observed CNA #1 pushing Resident #1 onto the toilet with all her might; the resident swung at CNA #1 and missed hitting her; CNA responded by grabbing the resident by the hair and shook the resident violently; CNA-M calmed the resident down and CNA #1 moved away from the resident. The CNA-M then reported what she had witnessed. On 2/24/20 at 9:00 a.m., in an interview with the surveyor, the DNS stated that C.N.A. #1 did admit to her that she physically abused Resident #1 and did write a statement saying so. The DNS stated she implemented monitoring of Resident #1 for three days to ensure that he/she did not have a neck or head injury. No injury was noted. On 2/24/20 at 12:15 p.m., C.N.A.-M added to her written statement that she witnessed C.N.A.#1 push Resident #1 down onto the toilet and Resident #1 was yelling no-no. She wrote that after C.N.A. #1 stopped shaking the resident's head, C.N.A. #1 stated to the resident; There, take that. She also added that the resident's face was flushed and had an expression of anger and disbelief. On 2/24/2020 at 12:15 p.m., the CNA-M was interviewed and stated the following to the surveyor: she witnessed CNA #1 with all of her might push Resident #1 onto the toilet; the resident was yelling no, no; CNA #1 stepped back and the resident swung out towards CNA #1 but made no contact; CNA #1 then grabbed the resident's hair with both hands and shook the resident violently three times; CNA #1 let go of the resident's hair and stated to the resident There take that; and the resident responded by attempting to hit CNA #1; and she went to the resident and calmed the resident down. The CNA-M stated that after the resident had been assaulted the resident's face was flushed and red and he/she had a look of anger and disbelief. On 2/25/20 PM at 9:36 a.m., CNA #1 was interviewed and she indicated the following: she grabbed Resident #1's head and shook it; she knew the resident was combative but felt she had to clean the resident up and could not wait until the resident calmed down; she denied she stated to the resident there take that; she was tired, was working alone, and takes full responsibility for the physical abuse. Based on the above information, Resident #1, who has dementia and was dependent on staff for care, was physically assaulted by CNA #1 on 12/20/19. Resident #1 was in need of incontinence care; CNA #1, who knew the resident could be combative with care, felt she needed to clean the resident up and she could not wait until the resident calmed down; the resident was taken to the bathroom; once in the bathroom CNA-M #1 witnessed CNA #1 push the resident with all her might onto the toilet; the patient responded by yelling no, no and swung out at CNA #1; CNA-M witnessed CNA #1 respond by grabbing the resident's head and shaking the resident's head; CNA #1 admitted to grabbing the resident's head and shaking it; CNA-M witnessed CNA #1 say to the resident after letting go of the resident's head there take that; the resident responded to this assault by attempting to hit CNA #1; and resident needed to be calmed down. Resident #1 is unable to verbally express his/her feeling about the incident that occurred. However, he/she demonstrated a need to defend himself/herself after being pushed onto the toilet and after his/her head was grabbed and shaken. He/she also showed a response to this abuse by his/her face becoming red and flushed and a look of anger and disbelief. A reasonable and prudent person would experience pain and discomfort when his/her head was grabbed and shaken; would experience fear during an assault from a caregiver they were dependent on for care; and would experience ongoing disbelief that someone, that they were dependent on for care, would treat them in this manner.

Based on record reviews, interviews, and observation, it was determined the Facility has violated Resident #253's right to be free from discrimination, coercion, and interference as evidenced by the facility's refusal to readmit him/her because of the resident's known [MEDICAL CONDITION], attempts to transfer Resident #253 to another nursing facility without the resident's consent, and by not honoring a Hearing Officer's decision to re-admit, for 1 of 1 resident's reviewed (Resident #253). Finding: A review of the Facility Assessment, dated [DATE], indicated the Facility cared for individuals with a [DIAGNOSES REDACTED]. Resident #253 was admitted to the Facility in (MONTH) of (YEAR) with a [DIAGNOSES REDACTED]. The resident's Minimum Data Sets (MDS) 3.0 assessments, dated [DATE] and [DATE], indicated the following: -He/she required extensive assistance with the support of two or more persons providing physical assistance for bed mobility, toilet use, and personal hygiene; -He/she was totally dependent with the support of two or more persons providing physical assistance with bathing; -He/she was occasionally incontinent of urine (less than 7 episodes of incontinence over a 7-day period) per the [DATE] MDS and was always continent of urine per the [DATE] MDS -He/she was always continent of bowel -He/she did not require a toileting program to manage his/her continence. -His/her weight was 473 pounds and 481 pounds respectively. -He/she was at risk for pressure ulcers but did not have pressure ulcers. -There was no active discharge plans and the resident did not want to talk to anyone about the possibility of leaving this Facility and returning to live and receive services in the community. On [DATE], the primary care provider (PCP) assessed the resident's leg and decided the resident needed intravenous (IV) antibiotics at the hospital; therefore, the patient was transferred to the hospital and was admitted . The MDS 3.0 assessment, dated [DATE], indicated the following: -This discharge was unplanned and it was anticipated the resident would return to the Facility. -He/she required extensive assistance with bed mobility, toilet use, and personal hygiene. -He/she was totally dependent on staff for transfer and bathing. -He/she was always continent of urine and bowel. -His/her weight was 578 pounds. -He/she did not have any pressure ulcers. -There was not an active discharge in place for the resident to return to the community. Between admission in (MONTH) (YEAR) through [DATE], there was no evidence that the Facility was unable to meet this resident's needs despite his/her [DIAGNOSES REDACTED]. Written communication between the hospital and the Facility, dated [DATE] and [DATE], was reviewed and indicated the following: -The resident was concerned about losing his/bed at the Facility ([DATE]). -The Facility was notified that the resident was ready for discharge ([DATE]). -The Facility representative informed the hospital that the resident's readmission status was changed to declined; No appropriate bed; and Patient too complex ([DATE]). -The Facility representative wrote Our facility can no longer meet (Resident #253) needs due to (Resident #253) bariatric status. On [DATE], the Facility sent a letter to Resident #253 indicating your bed hold has expired, and you have been discharged from our facility. We will not be able to accept you to Bangor Nursing & Rehabilitation Center on the basis that your current needs cannot be met by our facility. The letter provided information on how the resident could appeal this decision, and further informed the resident .a nursing facility may not transfer or discharge a resident until a decision is rendered if that resident has requested a hearing within 10 days of receipt of notice. Unless the health or safety individuals is in immediate risk or immediate transfer or discharge is necessitated by the resident's urgent medical need. On [DATE], four days after the discharge letter, Resident #253 appealed the notice of Facility-initiated discharge and requested a hearing. On [DATE], an appeal hearing was held. The appeal decision was as follows: Bangor Nursing & Rehabilitation Center did not meet the regulatory requirements for an involuntary discharge of (Resident #253). Bangor Nursing & Rehabilitation Center shall readmit (Resident #253) to (his/her) previous room if available or immediately upon the first availability of a bed in a semi-private room . On [DATE] at 1:09 p.m., during the Facility's most recent Federal survey, the Director of Nursing (DON) was interviewed. It was confirmed, with the DON, that Resident #253 had not been readmitted to the Facility pending the appeal process, had not been readmitted after the appeal hearing decision, and that there was no documentation, by a Physician, that indicated any specific need that the resident required that the Facility could not meet. The Facility was issued a statement of deficiencies, dated [DATE], for regulatory violations (F622 and F6262) regarding this Facility-initiated discharge and the refusal to comply with the resident's right to return to the Facility. On [DATE], 206 days after the patient was transferred to the hospital, the Medical Director wrote a document that indicated, (Facility) does not have the staff, expertise, equipment, or infrastructure in place to care for (Resident #253) in (his/ her) current condition in a manner consistent with applicable standards of care. This opinion is based upon the following: -(Facility) does not have a wall suction unit. Without this unit, (Resident #253) would be consistently exposed to urine and this would lead to skin breakdown, pressure sores and possible infections. -Moving (Resident #253) in bed to provide skin care and hygiene support requires assistance from 3 to 4 CNAs. The staffing ratios in nursing homes generally and at (Facility) specifically make this not feasible. If (Facility) was required to support this level of staffing, it would negatively impact care of other patients at (Facility). -(Facility)cannot institute [MEDICAL CONDITION] treatment. It does not have access to specialized staff or equipment. In fact, there is none available in the greater Bangor area. -(Facility) is not permitted to restrict (Resident #253) diet in any way as this violates her rights per applicable nursing home regulations. This includes not being able to prohibit third parties from bringing in outside food that exacerbates (his/her) obesity and heart failure, and BNRC cannot prevent (Resident #253) from ordering fast food to be delivered to the facility. -Applicable nursing home regulations require that (Facility) care for (Resident #253's) overall wellbeing including (his/her) psychosocial needs. To meet this standard in the context for (Resident #253) (Facility) may be in a position to have to modify its physical infrastructure and hire additional CNAs and medical staff with specific expertise, among other possible operational impacts. On [DATE] between 9:30 a.m. and 10:00 a.m., the Administrator and DON were interviewed, and they indicated the following: -The Facility could not readmit Resident #253 related to his/her need for [MEDICAL CONDITION] treatment and currently there was no clinic in the greater Bangor area. -The Facility could not evacuate Resident #253 out of his/her room in an emergency. -The amount of staff required to take care of Resident #253 would take away from the care of other residents at the Facility. This investigation through a review of the resident's medical records from the Facility and the hospital, interviews, and/or an observation determined the following: -At the hospital, Resident #253's is utilizing a PureWick female catheter attached to wall suction. However, there was no indication that this treatment would be required upon readmission to the Facility. -Resident #253's [MEDICAL CONDITION] was not a new [DIAGNOSES REDACTED]. In addition, [MEDICAL CONDITION] treatment is available in the Bangor area. -Resident #253 required the assistance of 2 or more staff prior to being admitted to the hospital on [DATE]; therefore, the number of staff to care for this resident was not a new issue impeding the resident's return to the Facility. -Resident #253 has not experienced a significant weight gain while in the hospital. The resident's weight was 578 pounds when he/she was transferred to the hospital on [DATE] and his/her weight was 587 pounds on [DATE]. -The resident's wheelchair was too wide to fit through the doorway and staff had been instructed on ways to transfer the resident to his/her wheelchair outside of his/her room. On [DATE] at 9:30 a.m., the current Administrator indicated a mock evacuation had been conducted (prior to hospitalization ) with three firemen from the Bangor Fire Department and they were able to evacuate Resident #253 from his/her room. On [DATE] at 3:00 p.m., the Assistant State Fire Marshall, confirmed that the expectation for Long-Term Care Facilities was to protect residents in place and evacuation is considered a last resort. He stated that he had a conversation with the Bangor Fire Chief to verify the fire departments ability to evacuate Resident #253 in the event of an emergency and the Bangor Fire Chief stated, Bangor Fire would be able to remove the resident in an emergency. -On [DATE] at 10:10 a.m., the following equipment, which is owned by Resident #253 and stored in the Facility's garage, was observed: an electric bariatric transfer lift rated to lift [PHONE NUMBER] pounds; an electric-hand cranked bed that is rated for 650 pound capacity; one electric-hand crank bed that is rated for 1000 pound capacity; a bariatric commode; and a bariatric wheelchair. During a further review of Resident #253's clinical record, the following was noted: -Resident #253 was receiving counseling services between (MONTH) (YEAR) to (MONTH) (YEAR). Resident #253 discussed his/her concerns about remaining in the Bangor area to be close to his/her family; his/her concerns about his/her family members' health and wellbeing; his/her feelings about food, food and fluid restriction, and obesity; his/her fear and concern about the Facility trying to force him/her out of the nursing home and send him/her to another facility. -A Social Services Note, dated [DATE], indicated the resident was informed of his/her Medicare 100th day was [DATE] and the resident asked about remaining at this facility as LTC (Long-Term Care) because (he/she) has nowhere else to go. (He/She) states the staff here knows (him/her) and (he/she) is very comfortable with our staff. Informed (him/her) that (he/she) could remain here. -A Social Service Note, dated [DATE], indicated the following: the Licensed Social Worker (LSW) discussed with the resident the possibility of perhaps moving to a different facility to better accommodate (his/her) needs; the resident indicated that he/she did not want to move from the Facility as he/she waited two years to be able to be admitted to the Facility; and that a meeting would be held on [DATE] to discuss concerns from staff. -Social Service Notes, between [DATE] and [DATE], indicated the Facility was attempting to find a facility to transfer the resident to and several facilities were contacted regarding the potential transfer. These attempts were made without the resident's consent and after he/she had expressed on [DATE] that he/she did not want to move. - A plan of care meeting was held on [DATE] with Resident #253, Resident #253's family members, the Assistant DON, the Rehabilitation Services Manager, and the Social Service Director present. The meeting note indicated there was discussion about the resident's weight gain; the resident's poor choices with food; that he/she had ordered out often; and he/she frequently stayed up at night requesting sandwiches and snacks. The resident indicated that he/she was not getting what he/she ordered from the kitchen. The note indicated the dietary department had worked very closely with Resident #253 multiple times to help him/her lose the weight. Resident #253 stated that he/she was addicted to food. The notes also indicated that the resident stated that he/she was worried that he/she would be kicked out of BNRC, despite being told that he/she was the key to his/her well-being, and that he/she needed to make better choices and get himself/herself back on that losing track again. There was no documentation to indicate that the Interdisciplinary Team identified the reasons and causes for the resident's deviation from the care plan related to the resident's weight and implemented necessary changes for resident success. - On [DATE], the resident was seen by his/her counselor. The counselor documented the following: Patient was in bed resting. Patient was in a sad mood, and (he/she) was upset. Patient stated, 'I had a meeting today. The social worker came in and told me that I would have to go somewhere else where I was safe, and she wanted me to sign papers. I didn't sign them and I'm tired of them moving me all around this state because I'm obese and they don't want to lift me.' Patient was crying and feeling hopeless, helpless, and judged. Patient was able to talk about feeling that (he/she) was being treated this way because of (his/her) weight. Patient feels they are trying to get rid of (him/her) because it takes 3 people to move (him/her). Patient feels that they'd rather have (him/her) in bed than to get someone to move (him/her). On [DATE] at 12:25 p.m., the Facility's DON, confirmed Resident #253 had not wanted to leave the Facility and that resident's greatest concern was being near his/her family in Bangor. On [DATE] at 12:50 p.m., the LSW stated that prior to the resident's hospitalization , on [DATE], the Facility care team, nursing, therapy, dietary, and social services had concerns about being able to meet the resident's needs at the Facility. She confirmed that she had a talk with the resident about this concern and she confirmed the resident indicated that he/she did not want to leave the Facility. On [DATE] at 11:15 a.m., Resident #253 was interviewed in his/her room at the hospital. When asked how he/she would feel about returning to BNRC, the resident stated, I am reluctant, in a way. They had the fire department come to see if they would be able to get me out of the room, and the nurse said, while the fire department was there, that they would never be able to get me out the door. I don't want them to misuse me at the nursing home. I don't think they want me there. I want to stay close to my (family) in Bangor. My (family) can't travel, and (my family) has been through so much. I worry about (my family) and want to be able to see (my family). On [DATE] at 11:47 a.m., the Facility's Medical Director was interviewed. When asked if she could reference any provider progress notes for Resident #253 that supported that the Facility was providing poor quality of care or if she could provide any notes to support that the Facility was unable to meet Resident #253's care needs, she stated, There are no provider notes to support that we could not meet that resident's needs. She further stated, (Resident #253) was sent to the hospital on [DATE]. I sent (him/her) for treatment at the hospital and I expected (him/her) to come back to the nursing home. I had no knowledge that the Facility was going to discharge the resident. If the Facility accepted this resident back for care now, I would have to care for (him/her). The failure of the Facility to protect the resident's rights for a dignified existence and access to quality of care regardless of his/her [DIAGNOSES REDACTED].#253's fear of isolation from his/her family, and the Facility's refusal to allow Resident #253 to return to his/her home has resulted in increased sadness and feelings of being judged and not valued as a human being because of his/her weight.

Based on record reviews, observations, and interviews, the facility failed to ensure the resident environment (a locked garden area designated for residents) was free from accident hazards for 1 of 1 sampled residents who used this area independently this time of year (Resident #1). This failure resulted in an avoidable accident in which the resident fell and sustained a serious injury where by surgical intervention was the course of treatment chosen by the resident. Finding: The Division of Licensing and Regulatory Services (DLRS) received, via fax, a "Nursing Facility Reportable Incident Form", completed by the Director of Nursing, which indicated the following: On 11/7/13 at 10:10 a.m., "Resident was out in garden area - fell on an apple under the apple tree," he/she was found by a staff member, the resident complained of pain in his/her right shoulder, he/she was transported to the hospital and he/she had a torn bicep tendon. Documentation in Resident #1's record indicated that on 11/7/13 the resident was found face down in the garden area with his/her right side on the grass, which was littered with apples, and his/her left side on the walkway. A Certified Nursing Assistant (C.N.A.) had opened the drapes from a garden facing room and observed the resident on the ground. Several staff immediately went to the area. The resident complained of right shoulder pain and he/she indicated the pain was at a level of a 7 to 8. Pain at a level of a 7 to 8 was considered "severe pain" in accordance to the scale used by the facility. The documentation also indicated the resident stated "I think it's broke." The resident was transported to the hospital, via ambulance, for evaluation. The "Emergency Department Discharge Instruction" form, dated 11/7/13, indicated that Resident #1 had a "biceps tendon rupture," an appointment was made for the resident to have a Magnetic Resonance Imaging (MRI) and an appointment was made for the resident to be seen by a surgeon. In addition, the resident had a new order for a pain medication (Norco 5/325 milligrams) to be administered every four hours if needed (prn). The resident returned to the facility, from the emergency roiagnom on [DATE], with an immoblizier for his/her right arm. On 11/8/13, the resident was seen by the Physician's Assistant. On 11/8/13 at 6:35 p.m., new orders were written for the resident to have his/her pain medication every four hours instead of every four hours prn, he/she was to receive warm compresses to the right arm for 15 minutes twice a day, and he/she was to wear the arm immobilizer, except when sleeping. On 11/12/13, the resident had a MRI of the right arm. The MRI indicated the resident had complete tearing of two tendons and probable severe partial tearing of another tendon with possible complete tearing of the tendon. On 11/13/13, the resident was seen by the surgeon. Treatment options were discussed with the resident and he/she chose to have surgical repair of the tendons. He/she had surgery on 11/14/13 and returned to the facility on [DATE]. On 11/15/13, the surveyor requested and reviewed the incident and accident report. The "Falls Management Investigation - Post Fall Tool" form, dated 11/7/13, indicated the fall was not observed, the resident fell in the facility garden, and the resident was "found prone with right side of body on apple littered lawn under the tree and left side on walkway." Documentation on this form also indicated the following: patient "in apple garden bending to ground and/or reaching for tree." On 11/15/13 at 9:15 a.m., the surveyor was shown the garden area by the Director of Nursing (DON). The surveyor observed that the garden area had an apple tree in the corner of the fenced in area and many apples were on the ground under the tree, on the walkway, and on the ground on the other side of the walkway. The DON stated, to the surveyor, that staff have to let residents or family members into this fenced in garden area and this resident was the only resident currently who comes into the area alone. On 11/15/13 at 1:42 p.m., the surveyor interviewed Resident #1. He/She informed the surveyor that he/she had fallen in the garden area when he/she was on the walkway; he/she "slipped on the rotten apple and hit the big rock," there were "hundreds of apples out there," and "they were slippery." The resident also stated that his/her shoulder hurt a lot. On 11/15/13 at 1:52 p.m., the surveyor observed the garden area again. The surveyor observed that all of the apples had been removed from the ground in the garden area and there was a rock near the apple tree. On 11/15/13 at 2:03 p.m., the surveyor interviewed a Certified Nursing Assistant. She stated, to the surveyor, that Resident #1 liked to be outside, he/she would pick the apples, rake, sit out at the tables and would do other gardening tasks in the summer. On 11/15/13 at 2:06 p.m., the surveyor interviewed a Maintenance staff person. He stated, to the surveyor, that for approximately two to three weeks the Maintenance staff have not been cleaning or maintaining the garden area on a weekly basis as they do in the summer. He stated, prior to today, they had not removed any apples from the garden area and he was unaware how many had fallen recently in the garden area. In an interview on 11/25/13 at 8:15 a.m., the Administrator indicated the resident was known to go under the apple tree and pick the apples; he/she was known to do unsafe things which was evident throughout the resident's chart. He indicated that camera footage of the garden area indicated that there were no apples on the walkway when the resident fell . He felt that their responsibility was to keep the walkway clear and that a reasonable person would know not to go under the tree where the apples were on the ground. On 11/26/13 at 2:15 p.m., two representatives from DLRS went to the facility to view the actual camera footage. The camera takes shots when there was movement within the camera range. The representatives were able to see the footage which indicated that the resident went outside, could see the resident off the walkway by the rock area and the apple tree, was able to see the resident bend towards the ground and then was able to see the resident on the ground. The camera footage did not show the resident actually falling, therefore, his/her exact location of where he/she fell was unable to be determined. The camera footage was not clear enough to be able to identify the "apple littered area" and there did not appear to be anything on the walkway near the apple tree on 11/7/13. According to the Centers of Medicare and Medicaid Services (CMS), the "Resident environment " includes the physical surroundings to which the resident has access (e.g., room, unit, common use areas, and facility grounds, etc.). The locked garden area, to which Resident #1 was given access, would be expected to be free from any potential accident hazards. This resident was known to go under the apple tree, the area under and around the apple tree was "littered" with apples, and there had not been any maintenance of this area to ensure the area was free from avoidable accident hazards. Based on all of the the information gathered during the investigation, the facility failed to ensure the resident environment (a locked garden area designated for residents) was free from accident hazards (apples on the ground) on 11/7/13. This failure resulted in an avoidable accident in which the resident fell and sustained a serious injury which surgical intervention was the course of treatment chosen by the resident.

Based on record review and interview, the facility failed to follow a physician order [REDACTED]. Finding: On 06/12/2012, Resident #1 stated to the Hospice Nurse and her family member that he/she was having increased abdominal pain. On 06/12/2012, a physician order [REDACTED]. The [MEDICATION NAME] order was transcribed on the Medication Treatment Record as: [MEDICATION NAME] 15 mg SL every two hours. On 06/12/2012, from 4:00 p.m. to 4:00 a.m. on 06/13/2012, Resident #1 received 7 "scheduled" doses of [MEDICATION NAME]. This was in addition to receiving a scheduled order for [MEDICATION NAME] 15 mg SL every 4 hours. Because of the transcription error for the prn [MEDICATION NAME], by 4:00 a.m. on 06/13/2012, the resident was extremely confused, agitated, was making several attempts to crawl out of bed and had no awareness for his/her own safety. According to the Hospice Nurse Note, dated 06/13/2012 at 5:00 a.m., "Nurse from facility called to report that the resident had increased agitation/confusion with attempts to get out of bed and fall risk. They were giving [MEDICATION NAME] every two hours but it was ordered prn. On 06/13/12, the 6:00 a.m. dose of [MEDICATION NAME] was held. Confusion was felt to be related to the increased doses of [MEDICATION NAME]. Resident seemed a little more alert but had some rambling and incoherent talk. Was reaching for the air." On 08/10/2012 at 12:20 p.m., in an interview with the Director of Nurses, she was aware that the [MEDICATION NAME] had been transcribed incorrectly.

Based on record review and interview, the facility failed to ensure that 1 of 1 sampled resident (Resident #1) had not received an excessive dose of [MEDICATION NAME]. This failure resulted in the resident experiencing an extreme change in mentation, extreme agitation and an extreme increase in confusion and a decrease in self awareness. Finding: On 06/12/2012, Resident #1 had an order for [REDACTED]. On 06/12/2012, from 4:00 p.m. to 4:00 a.m. on 06/13/2012, Resident #1 received 7 "scheduled" doses of [MEDICATION NAME] instead of "prn." This was in addition to receiving a scheduled order for [MEDICATION NAME] 15 mg SL every 4 hours. Because of the transcription error for the prn [MEDICATION NAME], by 4:00 a.m. on 06/13/2012, the resident was extremely confused, agitated, was making several attempts to crawl out of bed and had no awareness for his/her own safety. According to the Hospice Nurse Note, dated 06/13/2012 at 5:00 a.m., "Nurse from facility called to report that the resident had increased agitation/confusion with attempts to get out of bed and fall risk. They were giving [MEDICATION NAME] every two hours but it was ordered prn. On 06/13/12, the 6:00 a.m. dose of [MEDICATION NAME] was held. Confusion was felt to be related to the increased doses of [MEDICATION NAME]. Resident seemed a little more alert but had some rambling and incoherent talk. Was reaching for the air." On 08/10/2012 at 12:20 p.m., in an interview with the Director of Nurses, she was aware that the [MEDICATION NAME] had been transcribed incorrectly.