Maine Veterans Home - Bangor

F-F609 for details).

On 3/12/25 at 1:09 p.m. during an interview with facility administration, the surveyor confirmed that the facility failed to ensure residents were free from psychological, verbal and physical abuse.

Please see F-0000 Initial comments for details related to the IJ template, removal plan, and removal of the IJ.

32540

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 205185 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205185 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maine Veterans Home - Bangor 44 Hogan Rd Bangor, ME 04401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 32540

Residents Affected - Some Based 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[Resident R1], Resident R2, Resident R3, and Resident R5) and failed to report an injury of unknown origin for 1 of 3 residents sampled Resident R3.

Findings:

A review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation of Property revised 4/24/23, under the heading, on page 1, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, punishment that causes or is likely to cause physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is the use of oral, written or gestured language that includes disparaging and/or derogatory terms to residents or their families within their hearing distance, regardless of their age, ability to comprehend or disability. Physical abuse is physical assaults, cruel discipline, excessive use of physical or chemical restraints, or unnecessary or incorrect medication that may cause pain, inability to move a limb, burns, cuts, internal injuries, marks or bruises. Mental abuse is verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. On page 3 under section 5.4 Identification/detection: 5.4.1 Resident abuse may be overt or covert. It may be perpetrated by anyone, including but not limited to a staff member, another resident, a family member or another visitor. 5.4.2 reasons to suspect that abuse has taken place may include but are not limited to: 5.4.2.1 Resident complaints of abuse 5.4.2.2 actual observation of physical, verbal or sexual attack 5.4.2.4 unexplained bruises or other injuries 5.4.2.5 resident complaints of pain that are new or sudden and cannot be correlated to any of the resident's diagnosis. 5.4.2.6 resident's apparent fear of another person, whether staff, resident or visitor. 5.4.3 any of the reasons listed above, or any unexplained changes in a resident physical condition or behavior may indicate the possibility that the resident has been subjected to abuse and should be brought to the attention of the Supervisor immediately, but not later than 2 hours if serious bodily injury is involved. Section 5.6 protection 5.6.1 staff will intervene immediately to protect the resident(s) in any situation of actual or potential abuse, neglect, exploitation, or mistreatment. 5.7 Reporting and Response: 5.7.1 staff members will be expected to report actual or suspected abuse, neglect, exploitation or misappropriation of property to their supervisor immediately with subsequent reports to the Administrator and DNS (Director of Nursing Services) 5.7.2 licensed or certified staff and unlicensed assistive personnel are required by Maine law to report actual or suspected abuse, neglect, or exploitation to DHHS and APS. 5.7.5 as required by Maine law and regulation, a report must be made to DHHS with 24 hours and followed up by a written report if requested by DHHS.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 205185 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205185 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maine Veterans Home - Bangor 44 Hogan Rd Bangor, ME 04401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 On 2/26/25 the DLC received a facility report with an allegation that a Certified Nursing Assistant (CNA) was witnessed swearing towards residents. The date of the alleged abuse was 2/20/25 and was not reported to Level of Harm - Minimal harm or the DLC until 2/26/25. potential for actual harm

On 2/26/25 at 3:24 p.m., the DLC received a reportable incident from the facility, alleging that on 2/20/25 Residents Affected - Some CNA1 reported that she witnessed CNA2 being physically and verbally abusive to residents (Resident R1, Resident R2, and Resident R3)

she stated this has been going on for approximately 3 weeks to a month and did not report it. This allowed CNA2 to work 36 shifts continuing to subject the residents to his verbal and physical abuse.

On 3/11/25 at 12:14 p.m. during an interview with the DON she stated she asked CNA1 why this wasn't reported sooner, CNA1 stated she had told her charge nurse, the charge nurse RN1 denied being told until

the morning of 2/20/25. DNS stated that CNA1 was re-educated on the spot about reporting things immediately and not waiting. CNA1 reported to DNS that she was afraid of CNA2.

At this time the surveyor confirmed that an observed allegation of verbal and physical abuse was not reported to the State timely.

On 3/12/25 during a clinical record review for Resident R3 there was a note dated 12/23 for an order to x-ray right hip and upper thigh due to bruise to back of right hip and upper thigh measuring 15cm x 7.5 cm. It is documented that this bruise was found on 12/22/24 and there is no evidence that this injury of unknown origin was reported or investigated.

On 3/12/25 at 1:09 p.m. during an interview with a Unit Manager RN3, a surveyor confirmed that this injury of unknown origin was not reported to the DLC.

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A review of a facility Internal Fact-Finding Summary dated 2/27/25 stated, Synopsis of Issues: On 1/30/25 Resident R5 was found in Resident R6's room. Resident R6 had pants down and Resident R5's mouth was on Resident R6's penis.

On 2/14/25 RN4 reported to RN5 that Resident R5 was being pushed in a wheelchair by Resident R6. RN4 reported that Resident R5 cowered into the nurse's station and appeared to be afraid of Resident R6. At this time Resident R6 was moved to another unit.

On 3/13/25 at 1:36 p.m. in an interview with the DNS, a surveyor confirmed that the facility failed to notify DLC of potential sexual abuse on 1/30/25 involving Resident R6 to Resident R5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 205185 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205185 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maine Veterans Home - Bangor 44 Hogan Rd Bangor, ME 04401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 32540 potential for actual harm Based on clinical record reviews and interviews, the facility failed to investigate an injury of unknown origin Residents Affected - Some after a resident was found with a bruise for 1 of 6 residents reviewed for abuse (Resident #3 [Resident R3]).

Findings:

On 3/12/25 at 11:30 a.m. during a clinical record review for Resident R3, there is a nursing note dated 12/22/24 at 11:38 a.m. documenting a bruise on the back of the right thigh measuring 15 centimeters (cm) by 7.5 cm. additional note at 11:43 a.m. documents the bruise is to the back right hip/upper thigh area. The clinical

record lacks evidence that this area of bruising injury of unknown origin was investigated by the facility.

On 3/12/25 at 1:09 p.m. during an interview with a Unit Manager RN3, the surveyor confirmed that the injury of unknown origin was not investigated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 205185 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205185 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maine Veterans Home - Bangor 44 Hogan Rd Bangor, ME 04401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 35904

Residents Affected - Few Based 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 [Resident R5]).

Findings:

1. Clinical record review indicated Resident R5 has a diagnosis of vascular dementia. The care plan updated 2/26/25 identified the following:

-A care area identified on 9/21/23, indicated Dementia. No goal listed. An approach dated 1/31/25 indicated Resident may exhibit sexual behaviors with male residents and If resident displays sexual behaviors, assess resident for signs of behavior changes related to sexual behaviors. If resident appears agitated, anxious, or is crying, redirect resident away from male residents. Notify supervisor or nurse manager if sexual behavior is occurring and is creating an unwanted interaction. If resident is engaging in consensual sexual behavior, provide privacy.

On 3/12/25 at 2:28 p.m., during an interview with a surveyor and RN6, Resident R5's care plan was reviewed. The care plan did not address Resident R5's cognitive ability to engage in consensual sexual activity. At this time the surveyor confirmed Resident R5's care plan was not resident centered or updated for an accurate approach due to Resident R5 diagnosis of dementia and inability to consent to sexual activity. At this time the surveyor confirmed Resident R6's care plan was not updated and implemented to meet Resident R5's needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 205185 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205185 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Maine Veterans Home - Bangor 44 Hogan Rd Bangor, ME 04401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35904 potential for actual harm Based on clinical record review and interviews, the facility failed to ensure physician orders were followed for Residents Affected - Some 1 of 2 sampled residents (Resident #6, [Resident R6]).

Findings:

Review of Resident R6's physician order sheet, handwritten, dated 10/28/24, stated, in one month present case to Doctor #1 (DR1).

Review of Resident R6's physician order sheet, handwritten, dated 10/29/24, stated, medroxyprogesterone 2.5 m.g PO (by mouth) daily for hypersexual behaviors. POA (power of attorney) consented for use.

Review of Resident R6's physician order sheet, handwritten, dated 11/11/24, stated, increase medroxyprogesterone to 5 m.g QD (every day).

Review of Resident R6's physician orders signed 11/14/24, page 3, stated under medications, 11/11/24 medroxyprogesterone acetate 5 m.g tablet by mouth daily given for antisocial sexual behavior (sexual-associated behavior disruptive to others).

Review of Resident R6's physician order sheet, handwritten, dated 12/13/24, increase medroxyprogesterone to 10 m.g PO daily. Re-present to DR1 next opportunity.

Review of Resident R6's physician orders signed on 1/16/25, page 2, stated diagnoses to include, Z72.51 high risk for heterosexual behavior.

Review of Resident R6's clinical record dated 2/14/25, acute visit, provider PA-C, stated, Resident R6, [AGE] years old, was seen today for escalation of sexually inappropriate behaviors. Staff reports that the patient has been going

after several female residents, trying to get them alone closing doors in order to attempt to have inappropriate sexual relations. He/she has been seen making sexual gestures to several female residents. Medroxyprogesterone was resumed subsequently increased. On 1/31/25, medroxyprogesterone 5 m.g daily was initiated due to inappropriate sexual behaviors, with a plan to increase to 10 m.g daily on 2/15/25.Given

the fact that the patient has been targeting certain female residents and attempted again today, nursing reached out to management and the patient will be moved to a different room off of the unit to avoid any further incidents.

On 3/13/25 at approximately 12:50 p.m., during record review and interview with RN3, a surveyor could not find evidence that Resident R6's case has been presented to DR1 as ordered on 10/28/24 and 12/13/24. RN3 stated DR1 is no longer available, and RN3 and surveyor could not find evidence of follow-up pertaining to DR1 referrals with ordering PA-C as of 3/13/25, 121 days beyond the first order from the PA-C for case to be presented to DR1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 205185