Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Grove Center during CMS and state inspections, most recent first.
A resident with a court-appointed public guardian had their Lithium dosage increased for worsening hallucinations and delusions without documented discussion with or consent from the guardian, despite a care plan requiring guardian involvement in decisions and informed consent for psychotropic medications. The social worker described a process in which nursing should obtain guardian approval for decisions, but the guardian later reported learning of the Lithium change only after it occurred and stated that voicemail or email notifications do not constitute consent, noting the resident cannot provide their own consent.
Surveyors found that the facility did not provide adequate housekeeping and maintenance services, resulting in unsanitary bathrooms with urine odors, dirty floors, chipped paint, broken fixtures, and uncleanable surfaces in multiple resident rooms and common areas. The laundry room also had uncleanable carts and broken or missing light lenses. Facility leadership confirmed these findings during the environmental tour.
Nebulizer and CPAP equipment for several residents was found improperly stored, including being left unbagged on personal items or the floor, rather than being cleaned and bagged as required. Staff confirmed these practices and were sometimes unaware of proper storage procedures, leading to potential cross-contamination.
Three residents with PTSD did not have trauma-informed care plans in place, as their records lacked identification of trauma history, triggers, or interventions to prevent re-traumatization. The absence of individualized trauma-informed approaches was confirmed by the Market Clinical Advisor.
Staffing shortages resulted in nurses and CNAs being unable to complete timely wound care, medication administration, and respond promptly to call bells. The removal of the medication technician role increased the workload for nurses, causing delays in treatments and care, especially during periods with multiple admissions, discharges, and complex care needs. Residents reported long wait times for assistance, and the DON confirmed that weekend staffing was insufficient to meet resident needs.
The facility did not ensure that two authorized staff signed the shift count page for controlled substances at each shift change, as required by policy. This resulted in missing verification signatures for multiple days, with the issue confirmed by nursing staff and leadership during review and interviews.
Surveyors found that medications, including inhalers and nasal sprays, were left at the bedside of two residents without physician orders, IDT assessments, or secure storage. Medication carts contained both topical and oral medications together, with several items undated or discontinued but still accessible. Insulin pens were not dated when opened, some were expired, and expired IV antibiotics were found in emergency stock. Improper storage was also noted, such as a refrigerator with ice buildup and vaccines not kept refrigerated, all in violation of facility policy.
Surveyors found that dumpsters were left open or had broken covers, exposing trash and debris over several days. Staff interviews confirmed that dumpsters should be closed, but a broken flap had not been addressed for weeks. The Administrator acknowledged these findings.
Surveyors found that the facility failed to maintain complete and accurate clinical records for several residents, including missing documentation of required psychiatric evaluations, lack of self-administration assessments for respiratory medications, absence of post-fall risk assessments after repeated falls, and failure to monitor for side effects of psychotropic medications. Additionally, inconsistencies were noted in documentation related to bathing restrictions for a resident with a dialysis catheter.
The facility's Quality Assurance Committee failed to ensure that corrective actions for previously cited deficiencies were effective, resulting in repeated citations for inadequate housekeeping, lack of written bed hold notices, incomplete care plans, unsecured chemicals, insufficient staffing, incomplete clinical records, and inadequate infection control.
Staff failed to follow Enhanced Barrier Precautions for a resident with a urinary catheter and a history of multi-drug resistant organisms. During care activities, CNAs only wore gloves despite posted instructions requiring additional PPE, and staff provided inconsistent information about the required precautions. The facility did not ensure adherence to its own infection control policies and CDC guidelines for residents with indwelling devices.
The facility did not develop or implement complete care plans for three residents, omitting necessary interventions for dental care, medication management, and wound care. These deficiencies were confirmed by staff review and involved residents with missing dental appliances, self-administered medications, and multiple high-risk conditions.
Two residents and/or their representatives were not provided with written information about their rights to accept or refuse treatment or to formulate an advance directive, with one case involving a resident with significant communication barriers and another lacking any documentation of such information being offered or reviewed.
A resident with a PASRR Level II determination requiring specialized mental health services did not have an order for psychiatric services in place, despite care plan documentation indicating the need for such services due to bipolar disorder and anxiety. Staff interviews confirmed that the referral process for these services was not completed, and there was no evidence the resident had been previously offered or refused psychiatric care.
A resident's care plan was not reviewed and revised by the interdisciplinary team (IDT) within 7 days following a completed MDS assessment, as required. The last documented IDT meeting for this resident occurred prior to the most recent assessment, and facility staff confirmed the lack of timely follow-up.
Surveyors found an unlabeled medicated cream and a chemical odor eliminator left unsecured on a table in a shared resident bathroom. The Market Clinical Advisor confirmed these items should not have been accessible, as their presence constituted an accident hazard according to their Safety Data Sheets.
Failure to Obtain Guardian Consent for Psychotropic Medication Change
Penalty
Summary
The facility failed to ensure that a court-appointed public guardian was notified and able to exercise decision-making rights regarding a resident’s medication change. A resident with a court order dated 10/31/18 appointing the Department of Health and Human Services as full public guardian and conservator had an increase in Lithium, a mood stabilizer and antimanic agent, from 300 mg twice daily to 450 mg twice daily for increased hallucinations and delusions. The resident’s care plan, last revised 9/11/25, documented that the state guardian would be involved in decisions and that informed consent would be provided to the resident or healthcare decision maker for psychotherapeutic medications. Despite these documented interventions, the clinical record lacked evidence that the Lithium dose increase was discussed with or consent obtained from the guardian. In interviews, the facility’s social worker stated that for any change in condition or need to send a resident out, nursing is to call and get approval from the guardian for anything requiring a decision. However, the resident’s Public Guardian Representative reported that the primary provider increased the Lithium dose without obtaining the guardian’s consent. Email correspondence between the facility and the guardian showed the guardian later raised concerns that the facility failed to obtain consent for treatment and medication changes, clarifying that a phone call with voicemail or an email notification of what is going to be done does not constitute consent. The guardian specifically stated they learned after the fact that the Lithium had been changed and emphasized that the resident was unable to provide their own consent, which was the reason for the state guardianship.
Failure to Maintain Sanitary and Comfortable Environment Across All Units
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary, orderly, and comfortable environment across all three units and the laundry room. Specific findings included bathrooms with urine around the base of toilets and strong urine odors, dirty floors, chipped and missing paint on walls and heaters, broken and rusty sink overflow drains, and uncleanable surfaces due to gouged sheetrock and missing laminate. Additionally, there were unlabeled and unbagged bedpans and urinals left in resident bathrooms, as well as dirty plungers on the floor. The dining room and multiple resident rooms had marred walls, chipped paint, and dust and debris in bathroom light lenses. In the laundry area, surveyors found three laundry carts with untreated wooden bases that could not be properly cleaned, a cracked and broken ceiling light lens, and two ceiling lights missing their lenses. These deficiencies were confirmed during an interview with the Senior Maintenance Director, Administrator, and Maintenance Director, who acknowledged the findings during the environmental tour.
Failure to Maintain Sanitary Storage of Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care equipment for four out of five residents reviewed. Observations revealed that nebulizer equipment and CPAP masks were not stored according to facility policy, which requires rinsing, drying, and bagging of equipment after use. Specifically, nebulizer tubing and masks were found resting directly on personal items such as stuffed animals, dressers, and TV stands without any barrier, and in one case, a CPAP mask was found unbagged on the floor under a resident's bed. These storage practices allowed for potential cross-contamination between the respiratory equipment and the surrounding environment. Staff interviews confirmed the improper storage of respiratory equipment, with some staff unaware of why equipment was present in resident rooms or not following the required storage procedures. In one instance, a nurse stated that a nebulizer had not been used for over a week but was still present in the room, and in another, a nurse described the intended storage method for CPAP masks, which was not followed. The Director of Nursing and unit managers confirmed the findings during observations.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify and address the trauma-related needs of three residents with a current diagnosis of Post-Traumatic Stress Disorder (PTSD). For each of these residents, the care plans did not include trauma-informed approaches or identify specific triggers that could lead to re-traumatization. Record reviews showed that, despite documentation of PTSD in the Minimum Data Set (MDS) and clinical records, there was no evidence that the facility had determined the causes of PTSD or outlined measures to avoid potential triggers for these residents. Interviews with the Market Clinical Advisor confirmed that trauma-informed care plans were not established for the affected residents. The care plans lacked details regarding the residents' trauma histories, potential triggers, and interventions to prevent re-traumatization. This deficiency was observed for all three sampled residents with PTSD, as their records and care plans did not reflect individualized trauma-informed care or culturally competent services.
Insufficient Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of residents across all units, as evidenced by staff interviews, observations, and record reviews. The transition to a primary nursing model and the removal of the medication technician position resulted in nurses being responsible for both medication administration and treatments, leading to delays of up to an hour. On one occasion, a registered nurse reported that wound care would be provided late due to inadequate staffing, as she was also responsible for a discharge and IV antibiotic administration. Another LPN indicated an inability to complete scheduled wound care on time due to a heavy workload, including multiple admissions, discharges, and complex dressing changes, while also being responsible for all medication and insulin administration. Payroll Based Journal staffing reports confirmed low weekend staffing during the first quarter of 2025. Residents reported concerns about lengthy call bell response times and staff not addressing the needs of all residents in shared rooms. Staff interviews revealed that the unit manager did not routinely provide direct care, and that the new staffing model resulted in periods where nurses were solely responsible for medication and treatment administration, coinciding with resident falls and admissions. The Director of Nursing acknowledged awareness of weekend staffing shortages and confirmed that the facility did not have enough staff to meet resident needs during this period.
Failure to Document Controlled Substance Shift Counts
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. Specifically, on one of three units reviewed, the required signatures from two authorized medication administration staff were missing from the Shift Count page in the Controlled Substances Book at the change of shift for multiple shifts. According to the facility's policy, both medication nursing staff members participating in the count must sign the shift count page to acknowledge a correctly reconciled count. However, review of the Controlled Substance Books and Shift Counts revealed that on several days, either the staff coming on duty or the staff going off duty did not sign as required. These findings were confirmed during observations and interviews with nursing staff and facility leadership. The missing signatures were noted on multiple specific dates, indicating that the controlled substances count was not properly verified and documented as completed on those occasions. The deficiency was identified during a medication storage observation and discussed with the Director of Nursing and the Market Clinical Advisor.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and biologicals over several days. Medications, including inhalers and nasal sprays, were found at residents' bedsides without physician orders, interdisciplinary team (IDT) assessments, or care plans for self-administration, contrary to facility policy. In one instance, a resident's inhaler was left on the over-bed table by an RN, who acknowledged there was no order for self-administration. Another resident had a saline nasal spray at the bedside without a corresponding physician order or assessment, and the medication was not stored in a lock box as required. Medication storage practices were also found to be deficient. Topical and oral medications were stored together in medication carts, and several topical medications were undated when opened. Discontinued medications, such as antifungal powder, remained accessible, and some medication containers were missing pharmacy labels. Insulin pens in use were not dated when opened, and some had expired but were still available for use. Surveyors also observed expired intravenous antibiotics in the emergency stock and noted improper storage conditions, such as a medication refrigerator with significant ice buildup and insulin pens stored next to the ice. Additionally, single-dose vaccines requiring refrigeration were found stored in a plastic bag on a treatment cart rather than in a refrigerator. These findings were confirmed through interviews with nursing staff and unit managers, who acknowledged the lack of compliance with facility policies and procedures regarding medication storage, labeling, and removal of expired or discontinued medications.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
Surveyors observed that the facility failed to maintain garbage storage areas in a sanitary condition over multiple days. Specifically, one dumpster was found with its right-side slide door open and trash exposed, along with debris on the ground. Another dumpster had a broken and open right-side top cover, also exposing trash. These issues were observed on several occasions, with the broken cover persisting for at least a couple of weeks. During interviews, staff confirmed that dumpsters are supposed to be kept closed, but acknowledged the ongoing issue with the broken flap. The Administrator confirmed these findings during the survey. No information about residents or their medical conditions was included in the report, and the deficiency was limited to the improper disposal and storage of garbage and refuse.
Incomplete and Inaccurate Clinical Records for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for several residents, resulting in multiple deficiencies. For one resident with a mental health disability and a PASRR Level II indicating the need for specialized psychiatric services, there was no evidence in the clinical record that an initial psychiatric evaluation was completed or that any psychotropic medications were ordered, despite care plan documentation referencing such medications. Another resident, who had orders for self-administration of duo nebs and an inhaler, did not have a corresponding self-administration assessment documented in the clinical record, even though the resident was observed keeping and using these medications independently in their room. Additionally, a resident with a history of repeated falls did not have post-fall risk assessments documented after each incident, contrary to facility policy and staff statements that such assessments are required. For another resident with diagnoses including anxiety, bipolar disorder, and psychotic disturbance, there was a lack of documentation showing monitoring for side effects of prescribed psychotropic medications, despite care plan instructions to do so. A further deficiency was identified for a resident with end stage renal disease and a central tunneled dialysis catheter, where documentation was inconsistent regarding bathing practices. Nursing notes indicated the resident had a shower on a date when the treatment administration record showed no showers for the month, and there was an active order prohibiting showers while the catheter was in place. These findings were confirmed through interviews with facility staff and review of clinical records.
Repeat Deficiencies in Quality Assurance and Facility Operations
Penalty
Summary
The facility's Quality Assurance Committee did not ensure the effectiveness of the Plan of Correction for previously identified deficiencies from the prior Annual Long Term Care Survey. During the most recent survey, the same federal citations—F584, F625, F656, F689, F725, F842, and F880—were cited again for the same reasons as before. These deficiencies included failure to provide adequate housekeeping and maintenance for a sanitary and comfortable environment, failure to issue written bed hold notices with cost information to residents or their representatives, failure to implement comprehensive person-centered care plans, failure to secure chemicals to prevent accident hazards, failure to schedule sufficient direct care staff to meet resident needs, failure to maintain complete and accurate clinical records, and failure to maintain an effective infection prevention and control program. These findings were confirmed during an interview with the Administrator.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device and MDROs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident requiring Enhanced Barrier Precautions (EBP). Surveyors observed two CNAs entering the resident's room, which was posted with a Contact Precautions sign instructing the use of gown, gloves, mask, and face shield, but the CNAs only wore gloves. One CNA stated that gowns were only required when providing foley or pericare, not for other care activities. The resident had a foley catheter and a recent diagnosis of a urinary tract infection (UTI) with Pseudomonas aeruginosa and Serratia marcescens, and the care plan indicated the need for EBP. However, staff were unclear about the current required precautions, with conflicting information provided by the CNAs, an LPN, and the Unit Manager regarding the resident's status and the appropriate use of PPE. Further review revealed that the signage on the resident's door had been changed from Enhanced Barrier Precautions to Contact Precautions at some point, and staff were not consistently following the posted instructions. The Director of Nursing and Market Clinical Advisor later confirmed that the resident required Enhanced Barrier Precautions due to the presence of an indwelling urinary catheter and a history of multi-drug resistant organisms (MDROs). The facility's policy and CDC guidelines require the use of gloves and gowns for high-contact care activities for residents with indwelling devices, but these protocols were not followed during the observed care activities.
Failure to Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for three of four sampled residents, as required by their own Person-Centered Care Plan policy. For one resident, there was no care plan addressing dental needs despite a physician's note documenting a missing dental bridge, sore gums, and a referral for a partial denture. The care plan for this resident did not include any goals or interventions related to dental care, which was confirmed by the unit manager and discussed with the Director of Nursing. Another resident's care plan included self-administration of medication but lacked assessment or interventions for the use of a duo neb or inhaler, as required by the care plan intervention. Additionally, a third resident was receiving multiple high-risk medications, including a diuretic, opioid, and anticoagulant, and had three stage II pressure sores on the left lower extremity. However, the care plan for this resident did not include goals or interventions for medication management or wound care. These omissions were confirmed by the unit manager and discussed with the Director of Nursing.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide two residents and/or their representatives with written information regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. For one resident admitted in October 2024, a review of the entire medical record showed no evidence that the facility offered or reviewed these rights with the resident or their representative. This was confirmed by the Market Clinical Advisor during an interview, who acknowledged the absence of documentation in the medical records. For another resident admitted in February 2025, the social services assessment noted significant communication barriers, including severe hearing impairment and difficulty reading. Despite these challenges, there was no evidence in the clinical record that the facility provided or reviewed written information about advance directives with the resident or their representative. The Director of Social Services mentioned a possible conversation with the resident's spouse about advance directives but admitted that this was not documented, and the clinical record did not reflect any such discussion.
Failure to Implement PASRR Level II Specialized Services
Penalty
Summary
The facility failed to ensure that the State mental health authority's Pre-Admission Screening and Resident Review (PASRR) Level II requirements were implemented for one resident. The resident had a PASRR Level II approval indicating the need for specialized services, including an initial psychiatric evaluation to determine diagnosis and develop a plan of care. The resident's care plan reflected the need for specialized services due to diagnoses of bipolar disorder and anxiety, and stated that the resident would be offered and/or engage with behavioral health and counseling services. However, a review of the resident's current orders showed no evidence that an order for psychiatric services (Medi Tele) had been placed. Interviews with facility staff revealed that the Licensed Social Worker (LSW) was unaware that the necessary follow-through on PASRR requirements had not occurred, as the responsibility for referrals was with the Unit Manager. The LSW had uploaded the PASRR Level II document but did not confirm whether the referral for services was completed. The Unit Manager confirmed that there was no active order for psychiatric services and that the resident was not on psychotropic medications. Documentation did not show that the resident had previously been offered or had refused psychiatric services prior to the survey.
Failure to Timely Review and Revise Care Plan by IDT After MDS Assessment
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or their representative after each Minimum Data Set (MDS) assessment for one resident. Specifically, a review of the clinical record for this resident showed that a Quarterly MDS Assessment was completed on 1/6/25, but there was no evidence that an IDT meeting was held within 7 days following this assessment. During an interview, the Director of Social Services confirmed that the last IDT meeting for this resident occurred on 11/13/24 and acknowledged the absence of documentation indicating an IDT meeting was held within the required timeframe after the most recent MDS assessment.
Unsecured Chemicals and Unlabeled Cream Found in Resident Bathroom
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe environment free from accident hazards in a resident area. Specifically, an unlabeled medicated cream and a chemical product, FunkAway Odor elimination beads, were found sitting on a small table in a shared bathroom between resident rooms. The presence of these items was confirmed during the survey, and the Market Clinical Advisor acknowledged that these substances should not have been accessible in the bathroom, as this posed an accident hazard. A review of the Safety Data Sheets (SDS) for both the Clinical Silicone Cream and FunkAway Beads Odor Eliminator detailed the necessary first aid measures in case of exposure, indicating the potential for harm if mishandled. The incident was documented as occurring during two separate observations on one of the four days of the survey, affecting the environment for residents in the specified rooms. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 110 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakewood A Continuing Care Center | 1 mi | ★★★★★ | 24 | 0 |
| Waterville Center For Health And Rehab | 1.9 mi | ★★★★★ | 22 | 0 |
| Maine Veterans Home - Augusta | 14 mi | ★★★★★ | 12 | 0 |
| Woodlawn Rehabilitation & Nursing Center | 15.2 mi | ★★★★★ | 6 | 0 |
| Cedar Ridge Center | 16.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.