Oak Grove Center, Waterville, ME · The Vardell Report

The Essentials

Summary

Across 6 inspections from February 2024 to June 2026, state surveyors documented 59 findings at Oak Grove Center; 59 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections: 6; 2024–2026, standard and complaint
Findings: 59; Deficiencies cited by state inspectors
Corrected: 59; Of 59 findings, with a recorded correction date
Penalties: 3; 1 fine; payment not published, 2 closed

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2024	3	32	1
2025	1	18	0
2026	2	9	0

What the Record Shows

59 of 59 findings have a recorded correction date.
CMS lists 3 enforcement actions in the window: 1 fine of $14,056, its payment not published; denial of payment imposed March 27, 2024, ended July 3, 2024; denial of payment imposed May 29, 2024, ended September 27, 2024.
6 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, June 4, 2026, recorded 8 findings (most serious: Level E).

What to Ask About

Infection Control, Cited in Five Inspections
Medical Records, Cited in Four Inspections
A Clean, Homelike Setting, Cited in Three Inspections
Care Plans, Cited in Three Inspections
Accident Hazards and Supervision, Cited in Three Inspections
Nursing Staff Levels, Cited in Three Inspections
Citation F625, Cited in Two Inspections
Pharmacy Services, Cited in Two Inspections

Report at a Glance

Facility: Oak Grove Center
Address: 27 Cool St, Waterville, ME 04901
CMS Certification Number: 205091
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 90
Ownership: For profit - Corporation
Record Window: February 1, 2024 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Jun 42026
Standard health inspection
8 findings
The same visit included a complaint investigation.
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Jul 13, 2026
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jul 13, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jul 13, 2026
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jul 13, 2026
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Jul 13, 2026
- F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Level DNo actual harm, potential for moreCorrected Jul 13, 2026
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 13, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 13, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jan 292026
Complaint investigation
1 finding
- F551Give the resident's representative the ability to exercise the resident's rights.Level DNo actual harm, potential for moreCorrected Mar 24, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Mar 242025
Standard health inspection
18 findings
The same visit included a complaint investigation.
- F584Honor 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.Level ENo actual harm, potential for moreCorrected May 7, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jun 19, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected May 7, 2025
- F699Provide care or services that was trauma informed and/or culturally competent.Level ENo actual harm, potential for moreCorrected May 7, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected May 7, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 7, 2025
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jun 19, 2025
- F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected May 7, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jun 19, 2025
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Jun 19, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 19, 2025
- F578Honor 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.Level DNo actual harm, potential for moreCorrected May 7, 2025
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected May 7, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 7, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 7, 2025
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Jun 19, 2025
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level BPotential for minimal harmCorrected May 7, 2025
- F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level BPotential for minimal harmCorrected May 7, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 292024
Complaint investigation
16 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Sep 27, 2024
- F865Have a plan that describes the process for conducting QAPI and QAA activities.Level ENo actual harm, potential for moreCorrected Sep 27, 2024
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel ENo actual harm, potential for moreCorrected Sep 27, 2024
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jul 9, 2024
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Level ENo actual harm, potential for moreCorrected Sep 27, 2024
- F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level ENo actual harm, potential for moreCorrected Sep 27, 2024
- F946Provide training in compliance and ethics.Level ENo actual harm, potential for moreCorrected Sep 27, 2024
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
- F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
- F646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
- F843Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.Level DNo actual harm, potential for moreCorrected Sep 27, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 9, 2024
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Level DNo actual harm, potential for moreCorrected Sep 27, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 272024
Complaint investigation
1 finding
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 26, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 12024
Standard health inspection
15 findings
The same visit included a complaint investigation.
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 13, 2024
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Mar 13, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Mar 13, 2024
- F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Mar 13, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Mar 13, 2024
- F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Mar 13, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Mar 13, 2024
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 13, 2024
- F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Mar 13, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 13, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 13, 2024
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Mar 13, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 13, 2024
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Mar 13, 2024
- F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level BPotential for minimal harmCorrected Mar 13, 2024
Enforcement Action
Denial of payment imposed March 27, 2024. Status: Closed, July 3, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 1, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $14,056 imposed May 29, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 1, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed May 29, 2024. Status: Closed, September 27, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 1, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Infection Control, Cited in Five Inspections
Inspectors cited F880 in February 2024, February 2024, May 2024, March 2025 and June 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F880 across all 6 inspections, oldest to newest
2
Medical Records, Cited in Four Inspections
Inspectors cited F842 in February 2024, May 2024, March 2025 and June 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F842 across all 6 inspections, oldest to newest
3
A Clean, Homelike Setting, Cited in Three Inspections
Inspectors cited F584 in February 2024, March 2025 and June 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F584 across all 6 inspections, oldest to newest
4
Care Plans, Cited in Three Inspections
Inspectors cited F656 in February 2024, May 2024 and March 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F656 across all 6 inspections, oldest to newest
5
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in February 2024, May 2024 and March 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F689 across all 6 inspections, oldest to newest
6
Nursing Staff Levels, Cited in Three Inspections
Inspectors cited F725 in February 2024, March 2025 and June 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F725 across all 6 inspections, oldest to newest
7
Citation F625, Cited in Two Inspections
Inspectors cited F625 in February 2024 and March 2025. The agency describes it this way: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F625 across all 6 inspections, oldest to newest
8
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in March 2025 and June 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
242424252626F755 across all 6 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in five inspections, most seriously at level E.
02
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in four inspections, most seriously at level E.
03
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in three inspections, most seriously at level E.
04
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in three inspections, most seriously at level E.
05
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level K.
06
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Nursing Staff Levels: cited in three inspections, most seriously at level E.
07
What changed after F625 was cited, and how do you check it now?
Citation F625: cited in two inspections, most seriously at level B.
08
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level E.
09
What led to the 2024 fine, and has it been paid?
A $14,056 civil money penalty was imposed May 29, 2024. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Maine state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maine state survey agency
Inspection Feb 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maine state survey agency
Inspection Feb 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maine state survey agency
Inspection May 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maine state survey agency
Inspection Mar 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maine state survey agency
Inspection Jan 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maine state survey agency
Inspection Jun 4, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 205091
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowFebruary 1, 2024 – October 1, 2026

CMS publishes about three inspection cycles; inspections before February 2024 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.

Oak Grove Center

The Vardell Report.Oak Grove Center

Findings by Year

What the Record Shows

What to Ask About

Report at a Glance

Standard health inspection

Complaint investigation

Standard health inspection

Complaint investigation

Complaint investigation

Standard health inspection

Infection Control, Cited in Five Inspections

Medical Records, Cited in Four Inspections

A Clean, Homelike Setting, Cited in Three Inspections

Care Plans, Cited in Three Inspections

Accident Hazards and Supervision, Cited in Three Inspections

Nursing Staff Levels, Cited in Three Inspections

Citation F625, Cited in Two Inspections

Pharmacy Services, Cited in Two Inspections

Coverage

What This Report Cannot Tell You