Oak Grove Center
OAK GROVE CENTER in WATERVILLE, ME — inspection on January 29, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 [R1]).Finding: On 1/28/26 at 1:12 p.m., in a telephone interview, R1's Public Guardian Representative stated the facility's primary provider increased 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 R1's clinical record noted a copy of a court's decision, dated 10/31/18, appointing the
provider orders noted that on 9/30/25, the provider increased 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. R1's care plan, last revised 9/11/25, included the focus area, 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 R1 is at risk for complications related to the use of psychotherapeutic medication.
Interventions included provide informed consent to R1 or healthcare decision maker. A review of email correspondence between the facility and 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 R1's Lithium was changed and I was not previously made aware of this, nor was I asked for consent on this and, 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.
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.
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