Inspection Reports for The Grande At South Portland

25 Country Club Rd, South Portland, ME 04106, United States, ME, 04106

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Inspection Report Summary

The most recent inspection on March 19, 2025, identified deficiencies related to resident communication rights, service plan development, and progress note documentation. Earlier inspections showed similar issues with service plans and progress notes, as well as medication administration documentation and some concerns about kitchen sanitation and record keeping. Complaint investigations substantiated failures to assist residents with phone calls and maintain comprehensive service plans, while the biennial survey noted deficiencies in medication records and facility cleanliness. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern of findings suggests ongoing challenges with documentation and resident care planning, with no clear improvement over time.

Deficiencies (last 2 years)

Deficiencies (over 2 years) 7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

23% worse than Maine average
Maine average: 5.7 deficiencies/year

Deficiencies per year

8 6 4 2 0
2024
2025

Census

Latest occupancy rate 40% occupied

Based on a March 2025 inspection.

Census over time

0 20 40 60 Mar 2024 Oct 2024 Mar 2025 Mar 2025
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)
DescriptionSeverity
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
NameTitleContext
Nicole GuenetteAssisted Housing Program ManagerSigned letter regarding complaint investigation and plan of correction
Caitlin MarsanskisAdministratorNamed in relation to findings and interviewed during investigation
Employee #1Interviewed regarding resident care and phone assistance
Employee #3Interviewed 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, a Level IV Residential Care Facility.
Findings
The facility was found not in compliance with regulations governing assisted housing programs, specifically regarding Resident #1's right to private communication, lack of assistance with phone calls, absence of a comprehensive service plan addressing all resident needs, and failure to maintain ongoing monthly progress notes documenting implementation of the service plan and significant changes in the resident's life.
Complaint Details
The complaint investigation was triggered by reports that Resident #1 was not assisted with phone calls, had a disconnected phone line by the Power of Attorney, and that staff did not facilitate communication with Person #1. Additionally, concerns were raised about the adequacy of the service plan and progress notes. Interviews with staff, the administrator, POA, and review of records confirmed these issues.
Severity Breakdown
Class IV: 1
Deficiencies (3)
DescriptionSeverity
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 their life.
Report Facts
Census: 21 Total Capacity: 52 Inspection date: Mar 10, 2025
Employees Mentioned
NameTitleContext
Caitlin MarsanskisAdministratorInterviewed regarding Resident #1's phone and service plan
Employee #1Interviewed about Resident #1's phone access and service plan deficiencies
Employee #3Reported Resident #1 isolating in room during visits
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)
DescriptionSeverity
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
NameTitleContext
Caitlin MarsanskisAdministratorNamed as facility administrator
Wellness DirectorReviewed medication record deficiency at exit meeting
Executive ChefConfirmed lack of current diet manual
Director of MaintenanceConfirmed 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 medication administration, service plan development, and progress note documentation at Harborchase of South Portland, a Level IV Residential Care Facility.
Findings
The facility was found non-compliant with regulations governing 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.
Complaint Details
The visit was complaint-related, investigating medication administration documentation, service plan adequacy, and progress note maintenance. The report does not explicitly state substantiation status.
Severity Breakdown
Class III: 1
Deficiencies (3)
DescriptionSeverity
Multiple blank boxes in March 2024 Medication Administration Records for Residents #1, #2, and #4 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; repeat deficiency from 10/18/2022.
Report Facts
Census: 22 Total Capacity: 52
Employees Mentioned
NameTitleContext
Caitlin MarsanskisActing AdministratorNamed as Administrator involved in review of findings

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