Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Waterville Center For Health And Rehab during CMS and state inspections, most recent first.
Surveyors identified that clinical records for several residents were incomplete or inaccurate, including missing documentation of ROM exercises, bathing, vital signs, and follow-up on physician orders. Staff confirmed that required entries were not made, and legal documents such as POA and Advance Directives were not present in the records despite being referenced in care plans.
Housekeeping and maintenance services were not adequately provided on multiple units. Surveyors observed a soiled wedge cushion and ripped wheelchair armrests in one resident room, food particles and debris in kitchenette cabinets, heavily dust-soiled wall fans in two resident rooms, and in another room dirty bathroom floor tiles, a broken baseboard heater cover, and a wheelchair with dirty, stained tape on the brakes. Unit managers, the Administrator, and the DFO confirmed the findings.
A facility failed to keep a resident area free of accident hazards when a container of germicidal wipes was left in a lower unlocked cabinet accessible to residents. The facility also failed to adequately supervise a resident with dementia, anxiety, and disorganized schizophrenia who was known to wander; the resident was later found in an elevator on the first floor, walking in circles without a helmet after apparently entering when a family member did not wait for the doors to close.
Kitchen sanitation and food storage deficiencies: Surveyors observed dusty and dirty fans, vents, air conditioning units, a heavily soiled wall behind the steamer, and a food mixer with chipped paint and dried food particles. They also found opened jelly and preserves stored unrefrigerated in a kitchenette, no drinking cups available, and multiple dry and frozen food items that were not dated or labeled; the FSD and Cove Unit Manager confirmed the findings.
Improper Disposal of Garbage and Refuse: Surveyors observed loose trash in an uncovered wheeled cart and a dumpster with the back top lid open, exposing trash outside the kitchen area on multiple survey days. The Food Service Director was present during one observation and confirmed the findings.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
A resident admitted with a specialized mental health diagnosis was not screened for PASRR Level I, and no evidence was found that the required documentation was submitted to the state authority prior to admission. This lapse was confirmed by facility leadership during surveyor interviews.
The facility did not ensure that care plans were reviewed and revised by the IDT within the required timeframe after each MDS assessment for several residents. In some cases, IDT meetings were delayed, held before the assessment was completed, or lacked evidence of timely review. Additionally, care plans were not updated to address current diagnoses and care needs, such as chronic pain, atrial fibrillation, genital herpes, and MRSA.
Failure to Provide Written Advance Directive Information: The facility lacked evidence that it provided written information about the right to formulate an advance directive for four residents. Record reviews showed no documentation that the information was offered or provided, and the Social Services Director confirmed that the residents did not have and/or did not decline an advance directive.
A resident admitted with a wound VAC had the device discontinued when the canister was full and replacement supplies were unavailable. The nurse applied a wet to dry dressing without a physician order, and the Provider was not notified of the change in treatment until several days later. A progress note also showed the wound VAC was still documented as in place after it had been removed.
A resident with chronic embolism and thrombosis had an active Eliquis order, but the care plan did not include goals or interventions for anticoagulant use. Another resident tested positive for COVID-19, yet the care plan was not updated to reflect the positive result and quarantine period, and the DON confirmed the resident had been quarantined and no residents were currently COVID-positive.
Failure to document and monitor after an unwitnessed fall. A resident with a hx of anticoagulant use and falls sustained an unwitnessed fall, but the nursing record lacked evidence of VS at the time of the fall, notification to the provider about anticoagulant use, and initiation of neuro checks at the time of the event. The facility policy required immediate assessment and neuro monitoring for unwitnessed falls or residents on anticoagulants, and the PIP reviewed by the surveyor addressed fall prevention and reduction but not documentation, assessment, or monitoring.
A resident with dementia, anxiety, and major depressive disorder had delayed provider responses to consultant pharmacist recommendations for psychotropic medications. Pharmacy recommended a GDR of sertraline and later a GDR of haloperidol after multiple falls and concern for an unfavorable risk profile, but provider documentation of review was not entered until months later. The record also showed no evidence the pharmacy report was reviewed at the provider recertification note, and the DON stated pharmacy recommendations should be reviewed within 24-48 hours.
A resident with depression had active orders for sertraline and venlafaxine ER, but the clinical record lacked evidence of monitoring for side effects of these psychotropic medications. The care plan called for monitoring, documenting, and reporting side effects and effectiveness, and the DON confirmed the resident was not being monitored for side effects.
Infection control failed when a resident with a suprapubic catheter was repeatedly observed with the catheter drainage bag hanging below the wheelchair and touching or dragging on the floor. The facility also did not notify residents and families on other units about a COVID-19 outbreak, even though multiple residents and staff tested positive across the facility.
A facility failed to maintain complete and accurate clinical records for a resident with venous stasis ulcers and DVT. The resident's care plan indicated a risk for DVT, but physician orders lacked evidence of monitoring for DVT signs. Daily skilled assessments were incomplete or missing on several dates. The Unit Manager confirmed the lack of documentation and incomplete assessments during an interview.
A resident was found restrained in a wheelchair with a sheet, without a physician's order or proper documentation, leading to an immediate jeopardy situation. Staff interviews revealed confusion and lack of accountability, with some believing the family was responsible. The facility's Restraint Use policy was not followed, as there was no documentation or consent for the restraint.
The facility failed to report a suspected abuse incident involving a resident being restrained in a wheelchair, violating the resident's right to be free from physical restraint. Despite facility policies requiring immediate reporting to authorities, the incident was not reported to law enforcement or the State Survey Agency. Interviews with staff revealed confusion about the incident, with some believing the family was responsible. The failure to report within the required timeframe resulted in immediate jeopardy for all residents.
A facility failed to investigate an incident where a resident was allegedly restrained with a bedsheet, violating their right to be free from physical restraint. Despite awareness of the incident, staff could not recall specific details, and the facility's records lacked documentation of a comprehensive investigation. The resident, who had severe cognitive impairment, was unable to be interviewed, and the failure to investigate placed all residents at risk.
A resident with severe cognitive impairment and multiple diagnoses was found restrained to a wheelchair with a bedsheet, leading to increased anxiety and distress. The incident occurred when the facility was reportedly short-staffed, and the resident, who could independently transfer, experienced a change in condition. Hospice was notified, and new medication orders were issued to manage the resident's anxiety.
The facility failed to provide or obtain written information about the right to accept or refuse treatment and formulate an Advance Directive for eight residents with various medical conditions, including liver transplant and chronic kidney disease. This deficiency was confirmed by the Administrator and Social Worker during an interview.
The facility failed to maintain a sanitary and comfortable environment, with issues such as mildew, fruit flies, and maintenance problems observed in two units. Staff confirmed these findings during facility tours.
The facility failed to maintain a sanitary environment for respiratory care equipment for three residents. A resident's nebulizer and oxygen tubing were not labeled or bagged, and another resident's oxygen concentrator filter was heavily soiled. Additionally, a third resident's oxygen tubing was outdated, and the concentrator was missing a filter. Staff confirmed these deficiencies, indicating non-compliance with facility policies.
The facility failed to maintain adequate staffing levels, affecting resident care. Interviews and record reviews revealed that residents missed scheduled baths and experienced delays in care due to insufficient staff. Staff reported challenges in managing care, particularly for residents requiring two-person assistance. The facility did not meet minimum staffing ratios on several occasions, as confirmed by the DON and surveyor.
The facility failed to ensure controlled medication counts were conducted and documented at shift changes on two units. The Harbor and Cove units' medication logs lacked evidence of counts by oncoming and outgoing nurses on multiple occasions. These deficiencies were confirmed by CNAs and the Administrator, with the DON acknowledging awareness of the issue due to a previous improvement plan.
The facility failed to properly label, store, and dispose of drugs and biologicals, with expired vaccines found in storage and controlled substances not securely locked. Additionally, there were significant gaps in monitoring medication refrigerator temperatures, contrary to facility policies.
The facility failed to serve meals at appropriate temperatures, with residents reporting lukewarm or cold food that often required reheating. Test trays confirmed that hot foods were served below the required 140 degrees Fahrenheit. Operational inefficiencies, such as delays in serving due to limited staff, contributed to the issue. The Interim Food Service Director acknowledged the inappropriate temperatures.
The facility failed to maintain a clean and sanitary kitchen, with issues such as a soiled fan, improper dishwasher temperatures, and unlabeled food. Staff were observed without hair protection, and documentation for dish machine and refrigerator/freezer temperatures was incomplete. The Administrator confirmed these deficiencies.
The facility failed to ensure residents' well-being due to multiple deficiencies in care and management, affecting all 91 residents. Issues included lack of access to personal funds, failure to provide medical rights information, unsanitary conditions, unnecessary restraints, inadequate staff training, and improper medication management. These failures highlight significant lapses in the facility's operations.
The facility failed to implement proper infection control measures for residents with wounds on enhanced barrier precautions (EBP). Over two days, surveyors observed a lack of necessary signage and PPE, aside from gloves, in the rooms of three residents. This issue was confirmed during a tour with the Memory Care Unit Manager, who acknowledged the oversight.
The facility failed to offer pneumococcal vaccinations to several residents as per their policy and CDC guidelines. Despite the policy requiring assessment and offering of the vaccine within thirty days of admission, records showed that five residents were not reviewed, offered, or received the vaccine. An LPN confirmed these findings during an interview.
The facility's kitchen dish machine was not maintained in safe operating condition, operating at only 110°F instead of the required 150°F. Despite being instructed to wash dishes by hand, staff continued using the malfunctioning machine, which leaked water and required the water to be turned off after each use to prevent flooding. The Director of Facilities Operations and Interim Food Service Director were aware of the issues, but the machine remained in use until the Administrator intervened.
A resident was denied access to personal funds due to incorrect deductions for the cost of care. The facility deducted $1,291.00 instead of the usual $1,251.00 for two months, leaving the resident without the allocated $40.00 per month for personal use. The issue was identified when the resident's guardian attempted to access the funds and found them insufficient. The Nursing and Operations Assistant confirmed the error, which was pending resolution with the Corporate office.
The facility did not complete required Maine background checks for a CNA and an RN before they began working with residents, contrary to its policy on preventing abuse, neglect, and misappropriation of resident funds or property. The CNA's check was completed 48 days after hire, and the RN's check was completed 295 days after hire, as confirmed by the HR Director.
The facility failed to issue written transfer or discharge notices to two residents or their legal representatives for facility-initiated transfers to a hospital. One resident with dementia and other conditions was transferred without notice, and another with multiple diagnoses, including chronic respiratory failure, also did not receive the required notice. The absence of documentation was confirmed by the administrator during a survey review.
The facility failed to issue written bed hold notices to two residents or their legal representatives upon transfer to a hospital. One resident, with dementia and other conditions, was transferred without receiving a notice. Similarly, another resident with multiple diagnoses, including chronic respiratory failure, was also transferred without a written notice. The facility administrator confirmed these omissions during interviews with surveyors.
The facility did not ensure that residents with specialized mental health diagnoses were referred for PASRR evaluation and determination. A resident with bipolar disorder, anxiety disorder, and depression was not re-evaluated for a PASRR Level II determination after their Convalescence Categorical exemption ended, as confirmed by the Administrator.
A facility failed to update and follow physician orders for a resident, leading to the continued administration of an incorrect acetaminophen dosage and lack of physical and occupational therapy. Staff interviews revealed unawareness of the new orders, which were filed without being addressed.
The facility did not complete annual performance evaluations for a CNA hired in 2021, missing evaluations for 2023 and 2024. This was confirmed by the Administrator during a surveyor interview.
A resident with muscle weakness and dysphagia was not provided with necessary adaptive eating equipment, such as a Kennedy cup and built-up utensils, as required by their care plan. Observations over several days showed the absence of these items on the resident's meal trays, and an LPN confirmed the lack of adaptive dishes.
The facility failed to maintain accurate clinical records and proper maintenance of oxygen equipment for three residents. One resident's records lacked evidence of medication administration or refusal, while two residents had inaccurate documentation regarding oxygen tubing changes. Additionally, one resident's oxygen concentrator was heavily soiled, and another's lacked a filter.
The facility did not provide required yearly education on Resident Rights for a CNA hired in 2022. The HR Director confirmed the CNA had not received the necessary training in 2023 and 2024.
The facility failed to ensure a CNA completed the required yearly training for Abuse, Neglect, Exploitation, and Misappropriation of Property. Despite the facility's assessment indicating the necessity of at least 12 hours of in-service training per year, including dementia management and resident abuse prevention, CNA4, hired in 2022, had not received this training in 2023 and 2024, as confirmed by the HR Director.
The facility failed to provide mandatory training on its QAPI program to a CNA hired in 2022. A review of the CNA's education records showed no evidence of the required annual training, which was confirmed by the HR Director during a surveyor interview.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for multiple residents. For several residents, documentation was missing or inaccurate regarding range of motion (ROM) exercises and bathing, with no evidence that these activities were completed or refused on numerous dates. Interviews with facility management confirmed the absence of required documentation in the residents' records. In other cases, clinical records lacked documentation of significant clinical events and follow-up. One resident experienced low blood pressure and dizziness, but the initial low blood pressure reading, the re-check, and physician notification were not documented, despite staff confirming these actions occurred. Another resident had a physician order for a urinalysis due to suspected infection, but the record did not show that the sample was collected, sent, or refused, nor that the provider was notified of the inability to obtain the sample, as required. Additional deficiencies included the absence of required legal documentation, such as Power of Attorney (POA) and Advance Directives, despite care plans and meeting notes indicating their existence. There were also inconsistencies in documenting the timing and assessment of a resident's fall, with vital signs and neurologic checks not accurately recorded in relation to the incident. Facility staff acknowledged these documentation gaps during interviews.
Housekeeping and Maintenance Deficiencies in Resident Areas
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on 3 of 4 units, including Harbor, Cove, and Memory Care. On 8/25/25, a surveyor and the Memory Unit Manager observed in Resident room [ROOM NUMBER]-R a soiled wedge cushion against the wall across from Resident #86's bed and both of Resident #86's wheelchair armrests were ripped. The Memory Unit Manager confirmed these findings during the observation. Also on 8/25/25, two surveyors observed food particles and debris in two lower cabinets in the kitchenette on Cove Unit, and the Cove Unit Manager confirmed the findings. On 8/27/25, a surveyor and the Harbor Unit Manager observed two wall fans in Resident room [ROOM NUMBER] that were heavily soiled with dust and blowing on Resident #10, as well as a wall fan at the foot of Resident #6's bed that was heavily soiled with dust. On 8/28/25, during an environmental tour with the Administrator and the Director of Facility Operations, a surveyor observed in Resident room [ROOM NUMBER] six dirty and stained floor tiles under the toilet, a broken metal baseboard heater cover hanging down, and Resident #81's wheelchair brakes with dirty, brownish-stained white tape. The Administrator and the Director of Facility Operations confirmed these findings.
Unsecured Wipes and Resident Elopement Supervision Failure
Penalty
Summary
The facility failed to ensure that a resident area was free from accident hazards when a 1 pound 13 ounce container of Sani-Cloth Germicidal Disposable Wipes was observed stored in a lower, unlocked cabinet in the kitchenette on the Cove Unit. The Safety Data Sheet for the wipes stated that if rash or irritation develops, use should be discontinued, and that eye contact requires flushing with cool water for 15 minutes, while ingestion requires consultation with a physician. Two surveyors observed the unsecured container on 8/25/25 at 12:15 p.m., and the Cove Unit Manager confirmed the finding during an interview shortly afterward. The facility also failed to provide adequate supervision for a resident who was identified as an elopement risk. The resident had diagnoses including dementia, anxiety, and disorganized schizophrenia, and the care plan described the resident as wandering aimlessly and needing interventions such as diversions, structured activities, food, conversation, television, and books. Surveyors observed the resident wandering on the secured Memory Care Unit with a helmet on, and later found the resident in the elevator on the first floor, walking in circles without the helmet. Staff interviews indicated the resident likely entered the elevator after a family member arrived on the unit and did not wait for the doors to close, and staff stated the resident may have been in the elevator for about 10 minutes before being noticed.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to maintain the kitchen and kitchenettes in a clean and sanitary condition. During observations, surveyors found dusty or dirty box floor fans, a dusty or dirty circular fan near a food preparation area, a dusty or dirty ceiling air vent in the dish room, and two wall-mounted air conditioning units by the three-bay sink that were heavily soiled with dust. Surveyors also observed the wall behind the steamer unit to be heavily soiled with dried liquid residue, and the food mixer had chipped or missing paint with dried food particles on the mix arm and base. The facility also failed to store, date, and label food properly in the Cove Unit kitchenette and kitchen. In the Cove Unit kitchenette, opened grape jelly and strawberry preserves that required refrigeration after opening were stored in an upper cupboard instead of being refrigerated, and staff were using paper cups because no drinking cups were available. In the kitchen, eight large bags of cornbread mix in dry storage were not dated, and the walk-in freezer contained a bag of French toast, two packages of hot dog buns, and two packages of Eggos that were not dated and labeled. The Food Service Director and Cove Unit Manager confirmed the findings during interview.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 3 of 4 survey days. On 8/25/25 at 1:00 p.m., a surveyor observed loose trash in a wheeled cart without a lid and a dumpster with the back top lid open, exposing trash, outside the kitchen area. The same conditions were observed again on 8/26/25 at 1:30 p.m. On 8/27/25 at 8:05 a.m., a surveyor and the Food Service Director again observed loose trash in a wheeled cart without a lid and a dumpster with the back top lid open exposing trash outside the kitchen area, and the Food Service Director confirmed the findings during interview.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Complete PASRR Screening for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis was referred to the appropriate state-designated authority for a Pre-admission Screening & Resident Review (PASRR) evaluation and determination. Record review showed that the resident was admitted from a hospital with a mental health diagnosis, but there was no evidence in the clinical record that a PASRR Level I screening was completed or submitted to the state authority prior to admission. This deficiency was confirmed during an interview with the Social Services Director and the Administrator, who acknowledged the absence of required PASRR documentation in the resident's record.
Failure to Timely Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by an interdisciplinary team (IDT), including participation of the resident and/or their representative, within 7 days following each Minimum Data Set (MDS) assessment for multiple residents. Specifically, for several residents, there was either a delay in holding the IDT meeting after the MDS assessment, the meeting was held before the assessment was completed, or there was no evidence that the meeting occurred within the required timeframe. For example, one resident's IDT meeting was held 17 days after the MDS assessment, another's was held 19 days after, and in some cases, the IDT meeting was held prior to the completion of the MDS. Interviews with facility staff confirmed that the scheduling of IDT meetings was based on the Assessment Reference Date (ARD), and not always aligned with the completion of the MDS as required. Additionally, the care plans for some residents were not updated to reflect current diagnoses and care needs. One resident's care plan did not specify the cause or location of chronic pain and failed to address the monitoring and management of atrial fibrillation, a history of genital herpes, and MRSA, despite these being active or relevant diagnoses. The Director of Nursing acknowledged that certain diagnoses had not been included or updated in the care plan, and there was no documentation explaining the omissions.
Failure to Provide Written Advance Directive Information
Penalty
Summary
The facility failed to ensure that the resident and/or resident representative was provided written information concerning the right to formulate an advance directive for 4 of 33 residents reviewed. Resident #43, admitted in July 2025, had no evidence in the electronic record that the facility offered or provided written information about advance directives. Resident #74, also admitted in July 2025, likewise had no record evidence that written information concerning the right to formulate an advance directive was offered or provided. On 8/26/25, during an interview with 5 surveyors present, the Social Services Director confirmed that these residents did not have and/or did not decline an advance directive. The clinical records for Resident #73 and Resident #58 were also reviewed on 8/26/25 and lacked evidence that the facility offered or provided written information concerning the right to formulate an advance directive. During an interview with the Social Services Director on 8/26/25 at 2:03 p.m., the surveyor confirmed the facility failed to offer or provide the residents and/or resident representatives with written information concerning the right to formulate an advance directive.
Failure to Notify Provider of Wound VAC Discontinuation
Penalty
Summary
The facility failed to ensure that a resident's physician was notified when the resident's wound VAC was discontinued. The resident was admitted with an order for a wound VAC, and a Health Status Note documented that the wound VAC canister was full and needed to be changed. When the nurse was unable to replace the canister, she discontinued the wound VAC and applied a wet to dry dressing covered with an abdominal pad and secured with Kerlix. The clinical record contained no evidence that the physician was informed of the discontinuation of the wound VAC, and there was no physician order for the wet to dry dressing that was applied. A Provider progress note documented the wound VAC as still being in place even though it had been removed the prior evening, showing the Provider was not aware of the change in treatment. The resident's primary Provider later stated she was not made aware that the wound VAC had been removed until she saw the resident several days later, and her note from that visit documented the wound VAC was reapplied the evening before. During interview, the DON and Unit Manager confirmed the facility did not have the needed wound VAC supplies to continue treatment, the Provider was not notified of the discontinuance, and a nurse initiated the wet to dry dressing treatment without a physician order.
Incomplete Care Planning for Anticoagulant Use and COVID-19
Penalty
Summary
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured was not done for two residents. R48 had diagnoses including chronic embolism and thrombosis of the right popliteal vein, and an active physician order for Eliquis 5 mg by mouth twice daily for rule out clot, but the comprehensive care plan did not include goals or interventions for anticoagulant use. During interview, the Memory Unit Manager reviewed the care plan and confirmed it did not include the anticoagulant. R45 tested positive for COVID-19 on 2/13/25, but the care plan updated 7/21/25 still stated the resident had a respiratory infection with congested cough and referenced COVID-19 without reflecting the positive test result or the quarantine period discussed by the DON and Infection Preventionist. The DON confirmed R45 had tested positive for COVID-19 and would have been quarantined for up to 10 days, and also confirmed there were no residents in the facility currently positive for COVID-19.
Failure to Document and Monitor After Unwitnessed Fall
Penalty
Summary
The facility failed to document and adequately assess and monitor a resident after an unwitnessed fall. The resident had diagnoses including long term use of an anticoagulant and falls, and sustained an unwitnessed fall on 6/3/25. Review of the Change in Condition Evaluation and SBAR nursing progress note for that event lacked evidence that vital signs were taken at the time of the fall and lacked evidence that the provider was informed the resident was on an anticoagulant. Review of the Neurologic Screen Form also lacked evidence that neurological checks were initiated on the date and time of the fall. The facility policy for Fall Prevention and Response required immediate response actions including a head-to-toe nursing assessment, vital signs, anticoagulant use and last dose review, and neurological monitoring for unwitnessed falls or suspected head impact or anticoagulant use. During discussion with the DON, the facility stated it had a PIP in place for falls, and the surveyor review of the PIP Summary showed it addressed fall prevention and reduction in falls but did not include documentation, assessment, or monitoring.
Delayed Response to Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to consultant pharmacist recommendations for one resident reviewed for unnecessary medications. The resident had diagnoses including dementia, anxiety, and major depressive disorder. A pharmacy consultant report dated 5/22/25 recommended a gradual dose reduction of sertraline to 12.5 mg daily, but the provider response was not documented until 7/20/25, 182 days after the pharmacy review, and stated the dose was not clinically appropriate due to increased anxiety/agitation. Facility policy stated the attending physician should document review of identified irregularities and address them no later than the next scheduled visit, and the DON stated the provider should review pharmacy recommendations within 24-48 hours. A separate pharmacy consultant report dated 1/19/25 recommended a gradual dose reduction of haloperidol 2 mg twice daily, noting the medication had an unfavorable risk profile and that the resident had experienced more than one fall since initiation of haloperidol. The provider response was not documented until 4/30/25, 108 days after the pharmacy review, and stated to discontinue haloperidol; the order was then removed from the medication list. The resident's care plan later reflected psychotropic medication use for aggressive behavior and agitation, and the clinical record showed no evidence that the pharmacy report was reviewed at the 1/29/25 provider recertification note.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to monitor for side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications, Resident 86. Resident 86 had diagnoses including depression and a care plan stating that psychotropic medications were used related to behavior management for depression, with instructions to remain free of drug-related complications and to monitor, document, and report side effects and effectiveness to the MD as needed. The resident had active physician orders for Sertraline HCl 50 mg daily and Venlafaxine HCl ER 75 mg daily for depression. Review of the clinical record showed no evidence that the resident was monitored for side effects of these medications, and the DON confirmed during interview that the resident was not being monitored for side effects of the medications.
Infection Control Program and COVID-19 Notification Failures
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the storage of a urinary catheter drainage bag for one resident with an indwelling suprapubic catheter. The resident had diagnoses including obstructive uropathy, an indwelling suprapubic urinary catheter, and chronic urinary tract infection, and the care plan noted the resident had a suprapubic catheter for obstructive and reflux uropathy and chronic urinary tract infections. On multiple observations, the resident was seen in a wheelchair with the urinary catheter drainage bag hanging below the wheelchair, with the catheter tubing and drainage bag touching or dragging on the floor. During a later observation with the Memory Unit Manager, the drainage bag and tubing were again seen touching the floor before the manager stated there was a spot on the wheelchair to hang the bag and adjusted it. The facility also failed to ensure proper notification was given to resident representatives during a COVID-19 outbreak. The facility’s COVID line list showed that between 1/6/25 and 2/10/25, 18 residents on the Cove unit tested positive for COVID-19, along with 4 residents on Memory Lane, 2 housekeepers, one activities staff member, and one MDS Coordinator. The DON and Infection Preventionist stated the Cove unit was shut down during the outbreak, staff were kept in that area, and only residents and families on the Cove unit were notified. They further stated that a notice of outbreak was posted at the main entrance for visitors, but residents and families on the skilled unit and Memory Lane were not notified of the outbreak.
Incomplete Clinical Records and Monitoring for a Resident
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as evidenced by a review of the resident's care plan and physician orders. The resident, who was admitted with diagnoses including venous stasis ulcers and deep vein thrombosis (DVT), had a care plan indicating a history of DVT and a risk of developing another. However, the active physician orders lacked evidence of monitoring for DVT signs and symptoms. Additionally, daily skilled assessments on specific dates were incomplete, missing cardiovascular and skin assessments, and some assessments were not completed at all. During an interview, the Unit Manager confirmed the absence of documentation for DVT monitoring and incomplete skilled assessments, which did not meet the facility's expectations for comprehensive resident monitoring.
Failure to Ensure Resident's Right to Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure a resident's right to remain free from physical restraints, resulting in an immediate jeopardy situation. An anonymous complaint was received alleging that the facility was short-staffed and CNAs were tying residents to chairs. During the investigation, it was revealed that a resident was found in a wheelchair with a sheet double-knotted around their waist, effectively acting as a restraint. This incident occurred without a physician's order, evaluation, assessment, monitoring, or informed consent, and there was no documentation in the clinical record regarding the medical need for such a restraint. Interviews with staff members revealed a lack of clarity and accountability regarding the incident. The Life Enrichment and Pastoral Care staff member and RN1 were unable to recall specific details about the resident or the staff involved. CNA-M2 mentioned that CNA3 was placed on administrative leave due to the incident but returned quickly, with the belief that the family had restrained the resident. The Director of Nursing, who was not present at the time of the incident, provided partial notes and witness statements from CNA6 and CNA7, confirming the use of a sheet as a restraint. The facility's Restraint Use policy requires specific documentation and consent, none of which were present in this case.
Failure to Report Suspected Abuse and Restraint
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act. This failure resulted in the facility not protecting a resident from potential harm by not reporting an incident of possible abuse, which involved the violation of the resident's right to be free from physical restraint. The incident was not reported to law enforcement or the State Survey Agency (SA) as required by regulations. The facility's policy on abuse, neglect, and misappropriation of resident funds or property required immediate reporting of such incidents to the Administrator or designee, who would then notify the State Agency within 24 hours. However, this protocol was not followed. The incident involved a resident who was allegedly restrained in a wheelchair, which was reported anonymously to the State of Maine, Division of Licensing and Certification. Interviews with staff members revealed a lack of clarity and communication regarding the incident, with some staff members believing the family had restrained the resident. The Director of Nursing and other key personnel confirmed that the incident was not reported to the appropriate authorities. The facility's failure to report the incident within the required timeframe and to conduct a follow-up investigation within five working days resulted in immediate jeopardy for all residents, as the facility did not ensure the implementation of policies to report suspected crimes against residents.
Failure to Investigate Restraint Incident
Penalty
Summary
The facility failed to fully investigate an incident involving possible abuse and the use of an unnecessary physical restraint on a resident, identified as Resident #99 (R99). The incident was reported through an anonymous complaint alleging that CNAs were tying residents to chairs due to short staffing. Interviews with staff members revealed that there was awareness of the incident, but no one could recall specific details about the resident or the staff involved. The facility's policy required a thorough investigation, including interviews with the resident, accused, and potential witnesses, but this was not completed. The Director of Nursing (DON) provided partial notes and a visitor log, but these documents did not clarify who restrained R99 or when the restraint occurred. The notes indicated that R99 was able to transfer independently from bed to chair, and the visitor log showed only one visitor on the day of the incident. Staff interviews revealed that R99 was last seen in a wheelchair without restraint, but later found restrained with a bedsheet. The facility's records lacked documentation of the incident or a comprehensive investigation. The incident was not fully investigated by the Unit Manager, Director of Clinical and Quality Assurance, or the Interim Director of Nursing at the time. The resident had severe cognitive impairment and was unable to be interviewed. The facility's failure to investigate the incident violated the resident's right to be free from physical restraint, as outlined in S483.12, and placed all residents at risk. Immediate jeopardy was identified, and the facility was notified of this status.
Resident Restrained with Bedsheet Leading to Increased Anxiety
Penalty
Summary
The facility failed to protect and promote a resident's right to be free from physical restraints, as required by S483.12. An anonymous complaint was received by the State of Maine, Division of Licensing and Certification, alleging that the facility was short-staffed and CNAs were tying residents to chairs. During the investigation, it was found that a resident, who was admitted on hospice with severe cognitive impairment and multiple diagnoses including dementia and anxiety disorder, was restrained to a wheelchair using a bedsheet tied in a double knot. The incident report indicated that the resident was found restrained at 6:30 p.m. and was observed resisting the restraint by attempting to stand. The Director of Nursing, who was not present at the time of the incident, provided surveyors with documentation including witness statements and a visitor log. The resident, who was able to independently transfer from bed to chair, experienced a change in condition at the time of the incident, leading to increased anxiety and agitation. Hospice was notified, and new medication orders were given to address the resident's severe anxiety. The use of the physical restraint resulted in increased anxiety and distress for the resident, as confirmed by interviews with facility staff and surveyors.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide or obtain written information concerning the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive for eight residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not adhere to its policy of ensuring that residents or their representatives were informed about their rights regarding medical treatment and Advance Directives. The facility's policy requires the Social Service Department to document whether a resident has an Advance Directive and to provide information about Maine's Advance Directive laws if one is not present. The residents affected by this deficiency had various medical conditions, including recent liver transplant, chronic kidney disease, heart failure, diabetes mellitus, COPD, and others. Despite these significant health issues, there was no evidence in their clinical records that the facility provided the necessary information about their rights to accept or refuse treatment or to formulate an Advance Directive. During an interview, the Administrator and Social Worker confirmed the findings, indicating a systemic issue in the facility's admission process and documentation practices.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in two of its units, the Mountain Top Unit and the Harbor Unit, as observed during three facility tours. On the Mountain Top Unit, issues included a pile of wet towels under an ice machine, stripped flooring, and peeling cabinet laminate, with visible mildew on the wall and floor. Additionally, fruit flies were observed in the Blueberry dining room and in a resident's room, with staff confirming these findings. On the Harbor Unit, a fly was observed in a metal container with a partially covered trifle cake during lunch service. Further observations during an Environmental Tour revealed additional maintenance issues. The shower room had non-skid tape peeling up, a resident's bathroom wall had chipped paint, and a wheelchair armrest was torn. Another resident's room had a dusty ceiling vent. These findings were confirmed by the Administrator and the Director of Facilities Operations during the tour.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care equipment, impacting three residents. For Resident #251, a nebulizer was observed on a bedside table with tubing connected to a mask, neither labeled nor bagged, and an oxygen concentrator with nasal cannula/tubing was found lying on the floor, undated and unbagged. There was no evidence of an active order for oxygen or nebulizer use for this resident. During interviews, both a registered nurse and the unit manager confirmed that the equipment was not properly stored or labeled, which was against the facility's expectations. For Resident #3, the oxygen concentrator's filter was heavily soiled, and the oxygen tubing was dated from several weeks prior, with the nebulizer mask and tubing not stored in a sanitary manner. Similarly, Resident #47's concentrator was missing its filter, and the oxygen tubing was labeled with a date from over a month ago. A registered nurse confirmed these findings, noting that the tubing should be changed weekly, but it had not been updated as required. These observations indicate a failure to adhere to the facility's policy on maintaining clean and properly stored respiratory equipment.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, as evidenced by multiple interviews and record reviews. Certified Nursing Assistant #2 reported difficulties in providing timely care due to understaffing, with a nurse covering two floors and a medication assistant present. A resident expressed that they had missed three consecutive baths in the past month due to staff unavailability, despite their care plan indicating a need for extensive assistance with personal hygiene and scheduled showers twice a week. Another resident mentioned missing shower days when only two aides were available for 28 residents, highlighting the challenge of managing care during meal times. Interviews with staff further revealed delays in care, with residents potentially sitting in incontinence for extended periods before receiving assistance. The Cove Unit, in particular, faced challenges due to the high number of residents requiring two-person assistance, including those needing a Hoyer lift. The facility's staffing schedules confirmed that minimum staffing ratios were not met on several occasions, and the Director of Nursing acknowledged the ongoing efforts to address staffing issues. The surveyor confirmed that the facility was not staffing based on the residents' needs, impacting the quality of care provided.
Failure to Document Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that controlled medication counts were conducted and documented by authorized personnel at the change of shifts on two of the three units observed for medication storage, specifically the Cove and Harbor units. The bound controlled medication book labeled Harbor Log #119 showed no evidence of controlled medication counts being conducted by the oncoming nurse on several occasions, including on 8/17/24 at 18:20 and by the outgoing nurse on 8/17/24 at 5:40 a.m., 8/18/24 at 6:00 a.m., and 8/28/24 at 6:00 a.m. These findings were confirmed by a Certified Nursing Assistant-Medications (CNA-M1) during an interview with a surveyor. Similarly, the bound controlled medication book labeled Cove #21 lacked evidence of controlled medication counts being conducted by the oncoming nurse on multiple dates, including 7/26/24 at 18:00, 7/27/24 at 5:30 a.m., and 9/3/24 at 21:00, among others. Additionally, there was no evidence of counts being conducted by the outgoing nurse on several dates, including 7/5/24 at 5:30 a.m., 7/11/24 at 18:00, and 9/4/24 at 5:30 a.m. These findings were confirmed by another Certified Nursing Assistant-Medications (CNA-M2) and the facility's Administrator during a review with a surveyor. The Director of Nursing acknowledged that controlled medication should be counted during each shift change and was aware of the issue due to a previous performance improvement plan that was not followed through.
Deficiencies in Medication Storage and Temperature Monitoring
Penalty
Summary
The facility failed to comply with proper labeling, storage, and disposal of drugs and biologicals, as well as maintaining appropriate storage temperatures for medications and vaccines. During observations, it was found that expired vaccines and medications were stored alongside unexpired ones, making them available for use. Specifically, expired doses of the Moderna and Pfizer COVID-19 vaccines were found in the vaccination refrigerator on the Cove Unit. Additionally, the facility did not store controlled substances in a permanently affixed and double-locked compartment, as required. In the Cove Medication Room, controlled substances like Lorazepam were found in an unlocked, unaffixed metal box, and similar issues were observed in the Harbor Medication Room. The facility also failed to monitor and record medication refrigerator temperatures consistently. Temperature logs for the Cove and Harbor Units revealed significant gaps in daily temperature monitoring, with some refrigerators only having temperatures recorded on a few days each month. This lack of consistent monitoring could lead to improper storage conditions for medications and vaccines, potentially affecting their efficacy. The facility's policies on storage and expiration dating of medications and biologicals were not adhered to, as evidenced by the observations and record reviews conducted during the survey.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate food temperatures, resulting in meals being served at unappetizing temperatures. During observations and interviews, residents consistently reported that their meals were often lukewarm or cold, with some stating that the food had to be reheated before it was palatable. Test trays confirmed these complaints, with hot foods such as potato salad, beans, and hamburgers being served at temperatures significantly below the facility's policy of maintaining food at 140 degrees Fahrenheit. The Interim Food Service Director acknowledged that the temperatures were inappropriate and confirmed that the meals would not be palatable at those temperatures. The issue was further compounded by operational inefficiencies, such as delays in serving meals due to limited staff availability and logistical challenges. For instance, food carts were observed sitting in dining areas for extended periods before being served, leading to further cooling of the meals. Residents and family members expressed dissatisfaction with the quality and temperature of the food, and these concerns were documented in Resident Council Meeting Minutes, indicating that the problem was ongoing and had been previously reported without resolution.
Deficiencies in Kitchen Sanitation and Documentation
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a kitchen tour and subsequent observations. Specific issues included a heavily soiled wall-mounted fan, food disposals with dried food and liquid residue, a high-temperature dishwasher that failed to reach the required 150°F, dusty and dirty ceiling air vents and tiles, and a standing floor mixer with chipped paint. Additionally, the walk-in freezer contained ice build-up on food items, and several food items were found unlabeled and undated. Staff were also observed not wearing appropriate hair protection, which was confirmed by the Kitchen Supervisor and Interim Food Service Director. The facility's documentation practices were also found lacking, with missing records for dish machine temperatures, kitchen and unit refrigerator/freezer temperatures, and sanitizing testing logs over several months. The surveyor requested these logs multiple times before receiving them, and upon review, found numerous days where monitoring and documentation were not completed. The Administrator confirmed the absence of daily monitoring and documentation for these critical areas, which are essential for ensuring food safety and sanitation standards are met.
Multiple Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility failed to administer its operations in a manner that ensured residents could attain or maintain their highest practicable well-being. This was evidenced by multiple deficiencies cited during a recertification survey. The deficiencies spanned various aspects of resident care and facility management, including resident rights, freedom from abuse, neglect, and exploitation, admission and discharge procedures, resident assessments, quality of life and care, nursing services, pharmacy services, food and nutrition services, administration, infection control, physical environment, and training requirements. These failures affected all 91 residents in the facility, as the administration did not follow the facility assessment to ensure staff education, training, and competencies were completed. Specific incidents included the failure to provide a resident access to personal funds, failure to provide residents or their representatives with written information about their rights to accept or refuse medical treatment, and failure to maintain a sanitary and comfortable environment in certain units. Additionally, the facility did not protect a resident from unnecessary physical restraints, which resulted in immediate jeopardy and potential harm to all residents. The facility also failed to conduct required background checks for new employees and did not report or investigate incidents of possible abuse, including the use of unnecessary restraints. Other deficiencies involved the failure to issue proper transfer or discharge notices, ensure specialized mental health evaluations, update physician orders, maintain a sanitary environment for respiratory equipment, and provide sufficient staffing. The facility also failed to ensure proper medication management, serve food at appropriate temperatures, maintain kitchen cleanliness, and complete necessary staff training. These deficiencies highlight significant lapses in the facility's ability to provide safe and effective care to its residents.
Inadequate Infection Control Measures for Residents on EBP
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of enhanced barrier precautions (EBP) for residents with wounds. Over two days of observation, surveyors noted the absence of necessary signage and personal protective equipment (PPE) other than gloves in the rooms of three residents who were on EBP due to their wounds. This deficiency was observed consistently across multiple rooms and confirmed during a tour of the Memory Care Unit with the Unit Manager, who acknowledged the absence of required signage and PPE for these residents.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with their policy and CDC recommendations. The policy required that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and be offered the vaccine within thirty days unless medically contraindicated or previously vaccinated. However, for five residents reviewed, there was no evidence that they were reviewed, offered, or received the pneumococcal vaccine as per CDC guidelines. Specifically, the immunization records for these residents showed lapses in adherence to the vaccination policy. One resident admitted in December 2023 had no evidence of being reviewed or offered the vaccine. Another resident, admitted in August 2024, had a consent signed for vaccination but had not received it by September 2024. Similar issues were found with three other residents, where records did not show compliance with the vaccination policy. An interview with the LPN Memory Care Unit Manager confirmed these findings.
Dish Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen's high-temperature dish machine in good repair and safe operating condition. During a kitchen tour, it was observed that the dish machine was operating at only 110 degrees Fahrenheit, below the required 150 degrees Fahrenheit for proper cleaning and sanitizing. The Kitchen Supervisor acknowledged the machine's issues, including inaccurate temperature readings and water leakage, which required the water to be turned off after each use to prevent flooding. Despite these problems, the dish machine continued to be used by the kitchen staff. Interviews with the Director of Facilities Operations and the Interim Food Service Director revealed that the dish machine had been serviced two weeks prior, but additional parts were needed for full repair. The Interim Food Service Director had instructed staff to wash dishes by hand in a three-bay pot sink, but was unaware that the dish machine was still in use. The Administrator confirmed the ongoing use of the malfunctioning dish machine and stated it would not be used until fixed. A subsequent work log indicated further issues with the machine, including a non-functioning booster and timer.
Failure to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide a resident access to personal funds, specifically for Resident #47 (R47). On two occasions, the facility deducted an incorrect amount for the cost of care, leaving R47 without the $40.00 per month allocated for personal use. This discrepancy was noted when R47 reported not receiving the funds for two months and expressed frustration over the situation. The financial statements showed that the facility deducted $1,291.00 instead of the usual $1,251.00 for the cost of care in August and September, without any explanation for the increased charge. The issue was further highlighted when R47's guardian attempted to access the funds for shopping purposes but found insufficient money in the account. The Nursing and Operations Assistant acknowledged awareness of the error when the guardian raised the concern. An email was sent to the Corporate office to address the error, but compensation was delayed pending a response, resulting in R47 not having access to $80.00 of personal funds that were deducted without explanation.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to adhere to its own policy regarding the prevention of abuse, neglect, and misappropriation of resident funds or property by not completing required Maine background checks for new employees before they began working. Specifically, two employees, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), were allowed to work with residents without having their background checks completed. The CNA was hired and started working on June 12, 2023, but their background check was not completed until July 30, 2023, which was 48 days after their hire date. Similarly, the RN was hired on November 6, 2023, but their background check was only completed on September 13, 2024, 295 days after their hire date. This oversight was confirmed during an interview with the Human Resource Director, who acknowledged that the employees were working with residents prior to the completion of their background checks.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to residents or their legal representatives for facility-initiated transfers to an acute care hospital. This deficiency was identified for two residents during a survey. The first resident, who had diagnoses including dementia, dysphagia, and atrial fibrillation, was transferred to a hospital on September 5, 2024, without receiving the required written notice. The clinical record review confirmed the absence of this documentation. Similarly, the second resident, with diagnoses such as Escherichia coli, dysphagia, hemiplegia, and chronic respiratory failure, was transferred on July 22, 2024, also without a written notice being provided. The administrator confirmed the lack of documentation for both cases during the survey review.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their legal representatives upon transfer to an acute care hospital, as required. This deficiency was identified in the cases of two residents. The first resident, who had diagnoses including dementia, dysphagia, and atrial fibrillation, was transferred to a hospital on September 5, 2024. A review of the resident's clinical record showed no evidence that a written bed hold notice was provided. The facility administrator confirmed this omission during an interview with a surveyor on September 11, 2024. Similarly, the second resident, with diagnoses including Escherichia coli, dysphagia, hemiplegia, and chronic respiratory failure, was transferred to a hospital on July 22, 2024. A review of this resident's clinical record also lacked evidence of a written bed hold notice being issued. The administrator confirmed this deficiency during an interview with a surveyor on September 12, 2024.
Failure to Conduct PASRR Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that residents with specialized mental health diagnoses were referred to the appropriate state-designated authority for Pre-Admission Screening & Resident Review (PASRR) evaluation and determination. This deficiency was identified for three residents reviewed for PASRR evaluation. One resident, who was readmitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and depression, had a PASRR Level I with a Convalescence Categorical exemption, which is a time-limited 30-day exemption. However, the resident's clinical record lacked evidence of a re-evaluation for a PASRR Level II determination after the convalescent period ended. This was confirmed during an interview with the Administrator.
Failure to Update and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that physician orders were updated and followed for a resident reviewed for unnecessary medications. On September 12, 2024, during a clinical record review, it was found that a new physician order dated September 4, 2024, for the resident included discontinuing acetaminophen 650 mg three times daily, starting acetaminophen 1 g three times daily for chronic pain, and initiating physical and occupational therapy evaluations and treatments for decreased mobility. However, the clinical record lacked evidence that these orders were reviewed or updated by a provider. Interviews with staff revealed a lack of awareness and action regarding the new orders. A registered nurse on the Memory Care Unit was unaware of the updated orders and continued administering the previous dosage of acetaminophen. The unit manager confirmed that the orders were filed without being addressed. This oversight resulted in the facility not following the physician's updated orders for medication and therapy, as confirmed by a surveyor during an interview with the unit manager.
Failure to Conduct Annual Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for a Certified Nursing Assistant (CNA) who was hired on July 1, 2021. The deficiency was identified during a performance evaluation review and interview, revealing that the CNA did not receive evaluations for the years 2023 and 2024. This was confirmed by the Administrator during an interview with a surveyor on September 13, 2024.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment and utensils for a resident with specific nutritional needs. The resident, who was admitted with diagnoses including generalized muscle weakness, dysphagia, and protein-calorie malnutrition, had a care plan that required the use of adaptive equipment such as a Kennedy cup, rimmed plate, and built-up utensils during meals. Despite these documented needs, observations over several days revealed that the resident's meal trays consistently lacked the required adaptive equipment. A surveyor noted the absence of these items during multiple meal observations, and an LPN confirmed that the resident had not been using the adaptive dishes as directed by the care plan and dietary communication slip.
Inaccurate Clinical Records and Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for three residents. For one resident, the clinical record lacked evidence of administration or refusal of multiple medications on specific dates, including Bupropion, Famotidine, Apixaban, Carvedilol, Timolol Maleate, Sevelamer carbonate, Tramadol, and Insulin Lispro. The Director of Nursing confirmed these findings during a record review with a surveyor. Additionally, the facility did not maintain accurate documentation for two residents using oxygen concentrators. One resident's oxygen concentrator was heavily soiled, and the tubing was dated incorrectly, with the Registered Nurse confirming that the tubing had not been changed as documented. Another resident's oxygen tubing was labeled with an outdated date, and the filter was missing from the concentrator. The Registered Nurse confirmed that the documentation of tubing changes was inaccurate.
Deficiency in Resident Rights Training for CNA
Penalty
Summary
The facility failed to develop and implement an education program that included training on Resident Rights for one of the Certified Nursing Assistants (CNA) reviewed. CNA4, who was hired on June 27, 2022, had not received the required yearly education on Resident Rights since her hiring date. This deficiency was confirmed during an interview with the Human Resource Director, who acknowledged that CNA4 had not received the necessary in-service training in 2023 and 2024.
Failure to Provide Required Yearly Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) completed the required yearly training for Abuse, Neglect, Exploitation, and Misappropriation of Property. A review of the facility's assessment for 2024-2025 indicated that in-service training for new aides must be sufficient to ensure the continuing competence of nurse aides, with a minimum of 12 hours per year, including dementia management and resident abuse prevention training. Additionally, for nurse aides providing services to individuals with cognitive impairments, the training must address the care of the cognitively impaired. CNA4, who was hired on June 27, 2022, had not received the required yearly education for Abuse, Neglect, Exploitation, and Misappropriation of Property since being hired. This was confirmed during an interview with the Human Resource Director, who acknowledged that CNA4 had not received the necessary in-service training in 2023 and 2024.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on its Quality Assurance and Performance Improvement Program (QAPI). This deficiency was identified during a review of employee files, specifically for a Certified Nursing Assistant (CNA) who was hired on June 27, 2022. The review revealed that the CNA's education records did not contain evidence of receiving the required annual training on the facility's QAPI program. During an interview with a surveyor, the Human Resource Director confirmed that the CNA had not received the necessary in-service training in 2023 and 2024.
What surveyors are citing around you — mapped
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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 89 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) |
|---|---|---|---|---|
| Oak Grove Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Lakewood A Continuing Care Center | 2.7 mi | ★★★★★ | 24 | 0 |
| Woodlawn Rehabilitation & Nursing Center | 14.1 mi | ★★★★★ | 6 | 0 |
| Cedar Ridge Center | 15.3 mi | ★★★★★ | 12 | 0 |
| Maine Veterans Home - Augusta | 15.8 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.