Oak Grove Center
Inspection Findings
F-Tag F0551
F 0551
Give the resident's representative the ability to exercise the resident's rights.
Level of Harm - Minimal harm or potential for actual harm
Based on interviews and record reviews, the facility failed to ensure that the current resident representative was notified of a change in the resident's medication regimen for 1 of 3 residents having court appointed guardianship (Resident #1 [Resident R1]).Finding: On 1/28/26 at 1:12 p.m., in a telephone interview, Resident R1's Public Guardian Representative stated the facility's primary provider increased Resident R1's dose of Lithium (a mood stabilizer and antimanic agent) without obtaining the Guardian's consent. On 1/29/26 at 9:45 a.m., in an
interview with a surveyor, the facility's social worker described the process for notification of changes to court appointed guardians. The social worker stated for any change in condition or need to send a resident out, nursing is to call and get approval of the guardian, specifically for anything requiring a decision. On 1/29/26, a review of Resident R1's clinical record noted a copy of a court's decision, dated 10/31/18, appointing the Department of Health and Human Services as a full public guardian and conservator for Resident R1. A review of provider orders noted that on 9/30/25, the provider increased Resident R1's Lithium from 300 mg. (milligrams) twice daily to 450 mg. twice daily for increased hallucinations and delusions. The record lacked evidence that this increase in dosing was discussed with or consent obtained from the guardian. Resident R1's care plan, last revised 9/11/25, included the focus area, Resident R1 has a court appointed conservator or guardian of person. Interventions included State guardian will be involved with decisions being made. In addition, another focus area stated Resident R1 is at risk for complications related to the use of psychotherapeutic medication. Interventions included provide informed consent to Resident R1 or healthcare decision maker. A review of email correspondence between
the facility and Resident R1's guardian revealed on 10/2/25, the guardian discussed the facility's failure to obtain consent for treatment and medication changes. The guardian noted a phone call with a voicemail or email notification of what is going to be done does not constitute consent. Further, the guardian stated I found out today that Resident R1's Lithium was changed and I was not previously made aware of this, nor was I asked for consent on this and, Resident R1 is unable to provide his/her own consent which is why the State of Maine is his/her guardian. On 2/24/26 at 3:30 p.m., in a telephone discussion with the facility's Administrator, the surveyor discussed the finding.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
OAK GROVE CENTER in WATERVILLE, ME inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WATERVILLE, ME, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAK GROVE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.