Waterville Center for Health and Rehab

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 4 Units (Harbor, Cove and Memory Care).

Inspectors wroteBased on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the unsecured storage of a container of germicidal disposable wipes for 1 of 4 days of survey. (8/25/25), In addition the facility failed to provide adequate supervision resulting in a resident elopement for 1 of 1 residents reviewed (Resident #3 [R3]).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen/kitchenettes were maintained in a clean and sanitary manner for fans, air conditioners, a food mixer, air vents, and walls. Additionally, the facility failed to ensure that foods were stored, dated and labeled properly for 2 of 6 kitchen/kitchenettes tours (Cove Unit Kitchenette and Kitchen)

Inspectors wroteBased on observations and interviews, 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. (8/25/25, 8/26/25 and 8/27/25)

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 6 of 33 sampled residents (Resident #5 [R5], R7, R13, R4, R86, and R48).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive for 4 of 33 residents reviewed (Residents R43, R74, R73 and R58).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's physician was notified of the discontinuance of a medical device that uses negative pressure to promote wound healing (Wound Vacuum-Assisted Closure [Wound VAC]) for 1 of 1 resident reviewed for notification of change. (Resident #111 [R111]).

Inspectors wroteBased on interviews and record review, the facility failed to develop and/or implement an effective discharge planning process by failing to send referrals to appropriate entities timely, to involve the interdisciplinary team in discharge planning process, and to update the comprehensive care plan with goals and preferences regarding discharge, with referrals to appropriate entities made for this purpose and /or responses to information received from referrals to appropriate entities, for 1 of 4 residents reviewed for Discharge (Resident #88 [R88]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review (PASRR) evaluation and determination for 1 of 1 resident reviewed for PASRR evaluation (Resident #81).

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan in the area of anticoagulant (blood thinner) use for 1 of 5 residents reviewed for unnecessary medications (Resident #48 [R48]). In addition, the facility failed to update a care plan for 1 of 1 residents reviewed for Coronavirus 19 (COVID 19) (Resident #45 [R45]).

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the care plans by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 33 residents reviewed for care planning (Resident #125 [R125], R2, R45, R57, and R1).

Inspectors wroteBased on facility policy review, record review, and interview the facility failed to document and adequately assess and monitor a resident after an unwitnessed fall for 1 of 5 residents reviewed for unnecessary medications (Resident #48 [R48]).

Inspectors wroteBased on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #45 [R45]).

Inspectors wroteBased on record review and interview, the facility failed to monitor for side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident [R] 86).

Inspectors wroteBased on observations, interviews and record reviews, 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 1 of 3 residents reviewed for indwelling urinary catheters (Resident #66 [R66]). Additionally, the facility failed to ensure proper notification was given to resident representatives during 1 of 1 Covid-19 outbreak in the facility.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed during an investigation of a facility-reported incident. (Resident #1)

Inspectors wroteBased on interviews, policy review and record review, the facility failed to ensure a resident's right to remain free from a physical restraint in accordance with §483.12, resulting in an immediate jeopardy situation with psychosocial harm and the risk of physical harm including the potential to cause death [Resident #99 (R99)]. All residents remained at risk as the facility failed to develop and/or implement measures, to protect the residents from further use of unnecessary restraints.

Inspectors wroteBased on interviews, facility policy review, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act, resulting in failure to protect the resident from further potential harm from the perpetrator. In addition, the facility failed to report to law enforcement or the State Survey Agency (SA) an incident of possible abuse including the violation of a resident's right to be free from a physical restraint in accordance with §483.12, which kept the resident from ambulating from a wheelchair [Resident #99 (R99)]. This had the potential to affect all residents in the facility.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to fully investigate an incident involving possible abuse including the use of an unnecessary physical restraint on a resident, which kept the resident from ambulating from a wheelchair (Resident #99 (R99). This had the potential to effect all residents in the facility.

Inspectors wroteBased on record reviews and interviews , the facility failed to protect and promote a resident's right be free from a physical restraint in accordance with §483.12 [Resident #99 (R99)]. A reasonable and prudent person would suffer anxiety, distress, and fear from the involuntary loss of independent movement.

Inspectors wroteBased on record review and interviews the facility failed to provide/obtain Resident and/or Resident's Representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an Advance Directive for 8 of 8 Resident's reviewed for Advance Directives (Resident #26 [R26], R46, R251, R252, R43, R4, R64, and R34).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 4 units (Mountain Top Unit and Harbor Unit) for 3 of 3 facility tours (9/9/24, 9/10/24 and 9/12/24).

Inspectors wroteBased on observations and interviews, the facility failed to provide a sanitary environment to ensure that respiratory equipment was clean to help prevent the development and transmission of disease and infection related to nebulizer and oxygen tubing for 3 of 3 residents reviewed for respiratory care (Resident #251 [R251], R3, and R47).

Inspectors wroteBased on interviews, record review, and staffing schedule review, the facility failed to ensure sufficient staff were scheduled and on duty to meet the needs of resident's (Resident #25 [R25], R64, and R18) with the potential to affect all resident's.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure that two people who are authorized to administer medications signed the Narcotic Bound Book [a logbook used to record medication] Shift Count page indicating that they counted all the controlled substances at the change of shift for multiple shifts on 2 of 3 units observed for medication storage (Cove and Harbor).

Inspectors wroteBased on observations, interviews, record reviews, and policy review, the facility failed to adequately date and properly dispose of biological's according to manufacturer specifications and expired medications on 1 of 1 unit (Cove). In addition, the facility failed to adequately store controlled substances in a permanently affixed compartment and double locked in 2 of 2 medication rooms observed (Cove and Harbor). Furthermore, the facility failed to ensure proper vaccine storage temperatures for 1 of 1 unit (Cove) and failed to monitor and record medication refrigerator temperatures for 3 of 4 medication refrigerators observed (Cove and Harbor).

Inspectors wroteBased on observations, interviews, Resident Council Meeting Minutes and lunch meal test trays, the facility failed to serve hot foods hot, and cold foods cold for 2 of 4 lunch meals (lunch 9/9/24, and lunch 9/10/24) tested for appetizing temperatures (Resident #4 [R4], R5, R16, R34, R47, and R59).

Inspectors wroteBased on observations, interviews, facility logs and the facility's Dish Machine Temperatures policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall mounted fan, food disposals, the dishwasher, the standing floor mixer, ceiling air vents, ceiling tiles, and the walk-in freezer; failed to ensure hair protection was worn by staff; failed to ensure foods were dated/labeled appropriately; failed to ensure kitchen sanitizer was monitored and failed to ensure that kitchen and unit refrigerator/freezer and dishwasher temperatures were monitored appropriately for 1 of 1 kitchen tours (9/9/24) and 2 of 2 kitchen observations (9/9/24 and 9/10/24). This has the potential to affect all residents that eat food prepared by kitchen staff.

Inspectors wroteBased on the cumulative effect of deficiencies cited during the recertification survey from 9/9/24 through 9/17/24, the facility failed to ensure the facility was Administered in a manner that enabled residents to attain or maintain their highest practicable well-being as evidenced by Federal findings listed under §483.10 - Resident Rights (F567, F578, F584); § 483.12 - Freedom from Abuse, Neglect, and Exploitation (F604, F607, F609, and F610); §483.15 - Admission, Transfer, and Discharge (F623, and F625); §483.20 - Resident Assessments (F645); §483.24 - Quality of Life (F675); §483.25 - Quality of Care (F684, F695); §483.35 - Nursing Services (F725, and F730); §483.45 - Pharmacy Services (F755, and F761); §483.60 - Food and Nutrition Services (F804, F810, and F812); §483.70 - Administration (F842); §483.80 - Infection Control (F880, and F883); §483.90 - Physical Environment (F908); [...]

Inspectors wroteBased on observations, and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related to enhanced barrier precautions (EBP's) pertaining to Residents (Resident #70 [R70], R87, and R84) with a wound(s) for 2 of 5 days of survey (9/9/24, and 9/10/24).

Inspectors wroteBased on record review, and interview, the facility failed to ensure Residents were offered pneumococcal vaccinations in accordance with their policy and the Centers for Disease Control and Prevention (CDC) recommendations for 5 of 5 residents reviewed for immunizations (Resident [R] 87, R90, R29, R1, and R70).

Inspectors wroteBased on observations, interviews, the facility's Dish Machine Temperatures, and a food equipment service company work log, the facility failed to ensure that the kitchen high temperature dish machine was maintained in good repair and in safe operating condition for 1 of 1 dish machine observations (9/9/24) and failed to ensure proper cleaning and sanitizing of dishes for 1 of 1 kitchen tours (9/9/24).

Inspectors wroteBased on interviews and record review, the facility failed to provide a resident access to personal funds (Resident #47 [R47]).

Inspectors wroteBased on employee record review, facility policy review, and interview, the facility failed to implement its own Abuse, Neglect and/or Misappropriation of Resident Funds or Property Prohibition policy to ensure Maine background checks were completed for new employees before they were permitted to work for 2 of 12 sampled employees (Certified Nursing Assistant #5 [CNA5] and Registered Nurse #1 [RN1]).

Inspectors wroteBased on record reviews, and interviews, the facility failed to issue a written transfer/discharge notice to a Resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 Resident's reviewed for hospitalization (Resident #68 [R68], and R48).

Inspectors wroteBased on record review and interview, the facility failed to issue written bed hold notices to include cost of care to the Resident and/or legal representative for 2 of 3 sampled Resident's reviewed for transfer to an acute care hospital (Residents #68 [R68], and R48).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents with a specialized mental health diagnosis had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review (PASRR) evaluation and determination for 3 of 3 residents reviewed for PASRR evaluation (Resident #90 [R90], R25, and R11).

Inspectors wroteBased on record reviews, and interview the facility failed to ensure that physician orders were updated and/or followed for 1 of 5 Resident's reviewed for unnecessary medications. (Resident #29 [R29]).

Inspectors wroteBased on performance evaluation review and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #2 [CNA2]).

Inspectors wroteBased on record review, observations, and interview, the facility failed to provide adaptive built-up utensils and Kennedy cups for 1 of 5 residents reviewed for nutrition (Resident #11 [R11]).

Inspectors wroteBased on record reviews, and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 3 of 20 residents reviewed for documentation (Resident #46 [R46], R3, and R47).

Inspectors wroteBased on employee files review and interview, the facility failed to develop and implement an education program that included training on Resident Rights for 1 of 5 Certified Nursing Assistant's (CNA) reviewed (CNA4).

Inspectors wroteBased on review of Certified Nursing Assistant's (CNA) in-service training and interview, the facility failed to ensure that 1 of 1 CNA completed yearly training for Abuse, Neglect, Exploitation and Misappropriation of Property (CNA1).

Inspectors wroteBased on record review and interview, the facility failed to ensure staff received mandatory training on its Quality Assurance and Performance Improvement Program (QAPI), which included the staff's role and communication with the program, for 1 of 5 employee files reviewed (Certified Nursing Assistant #4 [CNA4]).

Inspectors wroteBased on record reviews, review of the facility's Anti-psychotropic Medication Use Policy, and interview, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) test for 1 of 5 residents reviewed for unnecessary medications (Resident # 70).