Inspection Reports for The Grande At South Portland
25 Country Club Rd, South Portland, ME 04106, United States, ME, 04106
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Moderate
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Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 21
Capacity: 52
Deficiencies: 3
Mar 19, 2025
Visit Reason
A complaint investigation was conducted due to allegations that the facility was out of compliance with regulations governing assisted housing programs, specifically regarding resident rights and care.
Findings
The facility was found non-compliant with regulations related to resident rights to communicate privately, development and implementation of a comprehensive service plan, and maintenance of ongoing progress notes. Specifically, one resident was not assisted with phone calls, lacked a fully developed service plan addressing all needs, and did not have adequate monthly progress notes documenting implementation and significant changes.
Complaint Details
The complaint investigation 2025-AHP-40514 was substantiated with findings that the facility was out of compliance with regulations governing assisted housing programs, specifically regarding resident communication rights and care planning.
Severity Breakdown
Class IV: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident was not assisted with phone calls, violating the right to communicate privately with persons of choice. | Class IV |
| Service plan did not address all areas in which the resident needed assistance or describe strategies to meet those needs. | — |
| Ongoing progress notes were not maintained at least monthly on implementation of the service plan or significant changes in the resident's life. | — |
Report Facts
Census: 21
Total Capacity: 52
Complaint Investigation Number: 2025-AHP-40514
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Guenette | Assisted Housing Program Manager | Signed letter regarding complaint investigation and plan of correction |
| Caitlin Marsanskis | Administrator | Named in relation to findings and interviewed during investigation |
| Employee #1 | Interviewed regarding resident care and phone assistance | |
| Employee #3 | Interviewed regarding resident isolation and medication safety |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 52
Deficiencies: 3
Mar 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding concerns about resident rights, service plan adequacy, and progress notes for Resident #1 at The Grande at South Portland.
Findings
The facility was found not in compliance with regulations governing resident rights, service plan development, and progress note documentation. Resident #1 was not assisted with phone calls, lacked a fully developed service plan addressing all needs, and did not have ongoing monthly progress notes documenting implementation or significant changes.
Complaint Details
The complaint investigation was initiated due to concerns that Resident #1 was not assisted with phone calls, lacked a comprehensive service plan, and did not have adequate progress notes. Interviews with staff, the administrator, the resident's Power of Attorney, and review of records confirmed these issues.
Severity Breakdown
Class IV: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident #1 was not assisted with phone calls, violating the right to communicate privately with persons of choice. | Class IV |
| Resident #1 did not have a service plan that addressed all areas of needed assistance or described strategies to meet those needs. | — |
| Resident #1 did not have ongoing monthly progress notes documenting implementation of the service plan or significant changes in condition. | — |
Report Facts
Census: 21
Total Capacity: 52
Inspection Date: Mar 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Marsanskis | Administrator | Interviewed regarding Resident #1's phone access and progress notes |
| Employee #1 | Interviewed about Resident #1's phone access and service plan deficiencies | |
| Employee #3 | Reported Resident #1 isolating during visits and medication safety concerns |
Inspection Report
Biennial Survey
Census: 20
Capacity: 52
Deficiencies: 5
Oct 29, 2024
Visit Reason
The inspection was a biennial survey to assess compliance with regulations governing the licensing and functioning of a Level IV Residential Care Facility and Infection Prevention and Control.
Findings
The facility was found non-compliant with several regulatory requirements including incomplete records for Schedule II controlled substances, lack of a current diet manual, unsanitary conditions of kitchen equipment, inadequate dishwasher sanitization temperatures and lack of test kits, and absence of proof of rabies vaccination for a facility cat.
Severity Breakdown
Class II: 1
Class III: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to include prescription number, dosage, frequency, and method of administration in Schedule II controlled substances record for one resident. | Class II |
| Facility failed to ensure there was a current therapeutic diet manual. | — |
| Ice machine in memory care unit kitchen was not maintained in a clean and sanitary manner. | — |
| Facility chemical sanitizing dishwasher did not reach required rinse-water temperature and lacked an approved test kit to measure sanitizer residual. | — |
| Facility failed to provide evidence of current rabies vaccination for a facility cat. | Class III |
Report Facts
Census: 20
Total Capacity: 52
Dishwasher test cycles: 4
Dishwasher temperature: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Marsanskis | Administrator | Named as facility administrator |
| Wellness Director | Reviewed medication record deficiency at exit meeting | |
| Executive Chef | Confirmed lack of current diet manual | |
| Director of Maintenance | Confirmed findings related to ice machine, dishwasher, and rabies vaccination at exit interview |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 52
Deficiencies: 3
Mar 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to compliance with regulations governing assisted housing programs, specifically focusing on medication administration, service plans, and progress notes.
Findings
The facility was found non-compliant with medication administration documentation, service plans lacking goals to improve or maintain resident functioning, and missing monthly progress notes since December 2023. These deficiencies were reviewed with the Administrator and Management Staff at the exit meeting and include repeat deficiencies from a prior report dated 10/18/2022.
Complaint Details
The visit was complaint-related, focusing on medication administration and resident care documentation. The deficiencies were substantiated and included repeat issues from a previous statement of deficiencies dated 10/18/2022.
Severity Breakdown
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Multiple blank boxes on Medication Administration Records (MARs) with no documentation of medication administered; staff did not initial or sign MARs after administering medications. | Class III |
| Service plans for Residents #1 and #2 did not include goals to improve or maintain the resident’s level of functioning. | — |
| No monthly progress notes in the records for Residents #1, #2, and #4 since December 2023. | — |
Report Facts
Census: 22
Total Capacity: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caitlin Marsanskis | Acting Administrator | Named as Administrator involved in review of findings |
| Employee #3 | Confirmed staff did not initial or sign MARs after medication administration |
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