The protocol requires staff to wear gowns and gloves during high-contact care: bathing, dressing, transfers, hygiene, and toileting.
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The August 28 inspection produced five total deficiencies.
Inspectors classified the violation as an isolated incident with no documented harm to any resident.
Inspectors assigned the deficiency a scope and severity level of D, meaning the problem was isolated and no actual harm was documented.
When residents wanted to eat outside scheduled meal times, suitable and nourishing alternatives were not consistently provided.
That admission came on the morning of August 28, 2025, when inspectors sat down with the administrator identified in the inspection report as S1ADM.
Inspectors who visited Waterville Center for Health and Rehab on August 28 found the facility was not honoring it.
The citation was classified as isolated, meaning inspectors did not find it happening broadly across the facility.
Pressure ulcers, sometimes called bedsores, are among the most closely watched indicators of nursing home quality.
Respiratory care in a nursing home setting is not incidental.
But inspectors determined that the potential for more than minimal harm was real and present.
When they are late, or incomplete, or never formally reviewed by the team of health professionals required to sign off on them, care can drift.