Waterville Center For Health And Rehab
WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME — inspection on August 28, 2025.
Found 15 citations. 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
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-28.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0580 during a standard health inspection conducted on 2025-08-28.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-08-28.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Care Plan was reviewed and updated.
The summary indicated Referrals are continuing to be completed for other facility options.
The clinical record lacked evidence that R88's comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities.-On 6/24/25, R88's Interdisciplinary Care Meeting indicated that R88's Care Plan was reviewed and updated.
The summary indicated Referrals are continuing to be completed for other facility options.
The clinical record lacked evidence that R88's comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities. On 8/27/25, the facility's policy Discharge of Resident: Home [or] Other Facility dated 6/12/14 was reviewed.
The policy does not address the discharge planning process. On 8/27/25 at 12:40 p.m., during an interview with a surveyor, the Director of Nursing (DON) stated there is not a specific policy for discharge planning regarding a resident's requesting to transfer to another facility.
The DON confirmed that it is the expectation that the facility will make referrals to appropriate entities when requested by residents.
The DON stated that this was made clear to the Director of Social Services.
She stated the Director of Social Services has made referrals to appropriate entities since that discussion (2/24/25). On 8/27/25 at 4:30 p.m., during an interview with the DON and the Administrator, a surveyor confirmed the above findings.
The Administrator stated there is a policy within the Care Plan policy to include transfers to other facilities. On 8/28/25, the facility's policy Care Plans, Comprehensive Person-Centered, Revised December 2024, was reviewed and stated 8.
The comprehensive, person-centered care plan will: . f. include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; . 14.
The interdisciplinary team must review and update the care plan: . b. when the desired outcome is not met; . 16.
Discharge Planning: a.
The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them post discharge.
The clinical record lacks evidence that the comprehensive care plan was updated to include R88's goals and preferences regarding discharge, referrals to appropriate entities made for this purpose and /or updated in response to information received from referrals to appropriate entities. On 8/28/25, the facility's Discharge Planning Protocol, (undated), was reviewed and stated 4. If a resident is requesting to. be transferred to another facility, initiate referral to. facility of choice.
The clinical record lacks evidence that referrals to appropriate entities were made for R88 to transfer to another facility between September 2024 and 2/24/25.
On 8/28/25 at 12:15 p.m., during an interview with the Administrator and the Social Services Director, the Social Services Director confirmed that the facility failed to make referrals to appropriate entities after R88's request to transfer, between September 2024 and 2/24/25. At this time the surveyor confirmed the above finding.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Waterville Center for Health and Rehab
7 Highwood St Waterville, ME 04901
SUMMARY STATEMENT OF DEFICIENCIES
Based 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).Finding:On 8/26/25, clinical record review indicated Resident #81 was admitted to the facility in October of 2024 from a hospital, with a specialized mental health diagnosis.
The clinical record lacked evidence that that the resident had been screened for a PASRR Level I determination and that it was submitted to the State-designated authority prior to admission. On 8/28/25 at 12:23 p.m., in an interview with five surveyors present, the Social Services Director and the Administrator confirmed that Resident #81's clinical record lacked evidence that that the resident had been screened for a PASRR Level I determination and that it was submitted to the State-designated authority when the resident was admitted in October of 2024.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Waterville Center for Health and Rehab
7 Highwood St Waterville, ME 04901
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-28.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
what the acute/chronic pain is related to or the location of the chronic pain. R1’s Care Plan does not address the monitoring and management of afib, or R1’s history of genital herpes and MRSA.
On 8/28/25 at 2:36 p.m., during an interview with a surveyor, the Director of Nursing (DON) and the Administrator, R1's clinical record was reviewed.
The DON stated the last episode of genital herpes resolved in April of 2025 but is unsure why that was removed from the care plan.
She also stated R1 had afib in June of 2025. At this time the surveyor confirmed R1's care plan was not updated to address the monitoring and / or management R1’s diagnoses including afib, Chronic Pain or R1’s history of genital herpes and MRSA.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Waterville Center for Health and Rehab
7 Highwood St Waterville, ME 04901
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-28.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-28.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-08-28.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-28.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-28.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0814 during a standard health inspection conducted on 2025-08-28.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Dispose of garbage and refuse properly.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.
Review of R86’s Interdisciplinary Team (IDT) meeting note, dated 7/17/25, indicates R86’s “…[representative]/POA attended via phone…” and states, .Advanced Directives reviewed, no changes at this time .
Further review of R86’s clinical record lacked evidence of POA documentation or Advance Directive documentation.
On 8/27/25 at 9:10 a.m., the above finding was discussed with the Memory Unit Social Worker (SW). At this time, the SW stated R86's [representative] is not his/her POA, that R86 does not have an Advance Directive, and that the IDT meeting note and care plan are labeled wrong.
- Review of R48’s clinical record revealed a nursing Change in Condition (CIC) Evaluation, dated
8/1/25, that indicated R48 sustained an unwitnessed fall at 4:15 p.m.
The assessment section of the CIC Evaluation indicated the most recent vital signs taken after the change in condition occurred were documented at 4:10 p.m.
Review of R48’s Neurologic Screen Form, dated 8/1/25, indicated that neuro checks were not initiated until 6:00 p.m., however, the vital signs documented under the 6:00 p.m. entry on the Neurologic Screen Form are identical to the vital signs documented at 4:10 p.m. on the CIC Evaluation.
Review of the Incident Report for the above fall, dated 8/1/25 at 6:00 p.m., lacked evidence of the actual time of R48’s fall.
On 8/28/25 between 9:12 a.m.-10:13 a.m., during an interview, the Director of Nursing reviewed R48's entire clinical record and confirmed that it does does not accurately reflect the time of R48’s fall and stated that she cannot determine what time R48 fell or if neurologic checks should have been started at 4:10 p.m. or 6:00 p.m.
Facility ID:
Federal health inspectors cited WATERVILLE CENTER FOR HEALTH AND REHAB in WATERVILLE, ME for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-28.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 15 deficiencies cited during this inspection of WATERVILLE CENTER FOR HEALTH AND REHAB.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-06.