The most recent inspection on October 30, 2025, identified deficiencies related to medication administration records, including missing documentation and failure to report a medication error for one resident. Earlier inspections showed a pattern of medication management issues, including a prior complaint investigation in September 2023 that confirmed incorrect transcription and administration of Morphine, as well as a March 2023 finding where a resident missed doses of pain medication leading to emergency care. Complaint investigations conducted throughout 2024 were generally unsubstantiated or found substantial compliance, with no enforcement actions or fines listed in the available reports. The main themes of deficiencies involved medication documentation and administration procedures. The facility’s inspection history suggests ongoing challenges with medication management, with no clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The biennial survey was conducted to assess compliance with the Assisted Housing Program Licensing Rule and Residential Care Facilities regulations.
Findings
The facility was found non-compliant due to deficiencies in medication/treatment administration records, specifically missing documentation for medication administration and failure to record medication errors in incident reports for one resident.
Severity Breakdown
Class III: 1Class II: 1
Deficiencies (2)
Description
Severity
Medication Administration Record (MAR) lacked documentation of whether a medication was administered or refused for Resident #4.
Class III
Failure to record a medication error of omission incident report for an unexplained blank entry on Resident #4's MAR.
Class II
Report Facts
Residents reviewed: 6Unexplained blank entries: 1Date completed: Nov 6, 2025
Employees Mentioned
Name
Title
Context
Renee Hanscom
Executive Director
Administrator and person responsible for plan of correction
The visit was a biennial survey to assess compliance with the Assisted Housing Program Licensing Rule for Residential Care Facilities.
Findings
The facility was found not in compliance due to deficiencies in medication administration records (MAR), specifically a missing documentation entry for a medication administered to one resident, and failure to record a medication error incident report for this omission.
Severity Breakdown
Class III: 1Class II: 1
Deficiencies (2)
Description
Severity
Medication Administration Record (MAR) lacked documentation of whether a medication was administered or refused for one resident, with one unexplained blank for Morphine Sulfate oral tablet 15 mg scheduled daily at 2200.
Class III
Failure to record a medication error of omission incident report for the unexplained blank entry on the resident's MAR.
The inspection was conducted as a case investigation for regulatory compliance of Woodlands Assisted Living of Waterville, a Level IV PNMI Residential Care Facility.
Findings
The facility was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities and Infection Prevention and Control.
The inspection was conducted as a complaint investigation for Woodlands Assisted Living of Waterville under complaint numbers 2024-AHP-39803 and 2024-AHP-39785.
Findings
Woodlands Memory Care of Waterville, a Level IV PNMI Residential Care Facility, is in substantial compliance with the regulations governing assisted housing programs and infection prevention and control.
Complaint Details
Complaint investigation for two complaint cases (2024-AHP-39803 and 2024-AHP-39785) with findings indicating substantial compliance.
Employees Mentioned
Name
Title
Context
Olivia Labrecque
Administrator
Named as the facility administrator in the complaint investigation report.
The inspection was conducted as a complaint investigation for multiple complaint cases numbered 2024-AHP-38507, 2024-AHP-38969, 2024-AHP-39182, and 2024-AHP-39203.
Findings
Woodlands Assisted Living of Waterville was found to be in substantial compliance with the regulations governing Level IV PNMI Residential Care Facilities and Infection Prevention and Control.
Complaint Details
The visit was complaint-related involving four complaint investigations as listed in the report.
This document is a statement of deficiencies and plan of correction for Woodlands Assisted Living of Waterville, related to a case investigation completed on 2024-09-18.
Findings
Woodlands Assisted Living of Waterville is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities and Infection Prevention and Control.
The inspection was conducted as a complaint investigation covering multiple complaint investigations numbered 2024-AHP-36958, 2024-AHP-36984, 2024-AHP-37096, 2024-AHP-37114, and 2024-AHP-37115.
Findings
Woodlands Assisted Living of Waterville, a Level IV PNMI Residential Care Facility, is in substantial compliance with the regulations governing the licensing and functioning of assisted housing programs and infection prevention and control.
Complaint Details
The document references multiple complaint investigations but does not provide substantiation status or specific complaint details.
This document is a statement of deficiencies and plan of correction related to case investigations 2023-AHP-35531 and 2023-AHP-35757 for Woodlands Assisted Living of Waterville.
Findings
Woodlands Assisted Living of Waterville, a Level IV PNMI Residential Care Facility, is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.
Employees Mentioned
Name
Title
Context
Olivia LaBrecque
Administrator
Named as administrator of the facility in the report
The document is a statement of deficiencies and plan of correction related to case investigations 2023-AHP-34088, 2023-AHP-34095, and 2023-AHP-34122 for Woodlands Assisted Living of Waterville.
Findings
Woodlands Assisted Living of Waterville, a Level IV PNMI Residential Care Facility, is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.
The inspection was conducted following receipt of two Resident Incident/Accident Reports regarding a medication transcription and administration error involving Morphine at the facility.
Findings
The facility failed to use safe and acceptable procedures when receiving, documenting, and administering medication to a resident, resulting in an incorrect transcription and administration of Morphine dosage. This is a repeat deficiency from a prior inspection dated 7/14/2023.
Complaint Details
The complaint investigation was triggered by two incident reports received on 8/29/2023 concerning medication errors dated 1/24/2023 and 8/20/2023. The investigation confirmed the transcription error and incorrect administration of Morphine to Resident #1. Interviews with the Administrator and Program Coordinator confirmed these findings.
Deficiencies (1)
Description
Failure to use safe and acceptable procedures when receiving, documenting, and administering medication to a resident, specifically involving incorrect transcription and administration of Morphine dosage.
Report Facts
Total Capacity: 58Incident Report Dates: 2Medication Dosage: 5Medication Dosage: 5
Employees Mentioned
Name
Title
Context
Olivia LaBrecque
Acting Administrator
Confirmed findings related to medication error during interviews
The document is a Statement of Deficiencies and Plan of Correction for Woodlands Assisted Living of Waterville, related to licensing and certification compliance.
Findings
Woodlands Assisted Living of Waterville is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities.
The document is a statement of deficiencies and plan of correction for Woodlands Assisted Living of Waterville, a Level IV PNMI Residential Care Facility, related to regulatory licensing and certification oversight.
Findings
Woodlands Assisted Living of Waterville is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.
This document is a statement of deficiencies and plan of correction for Woodlands Assisted Living of Waterville, a Level IV PNMI Residential Care Facility, related to licensing and certification oversight.
Findings
Woodlands Assisted Living of Waterville is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.
The document is a statement of deficiencies and plan of correction for Woodlands Assisted Living of Waterville, related to regulatory oversight of a Level IV PNMI Residential Care Facility.
Findings
Woodlands Assisted Living of Waterville is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.
The document is a statement of deficiencies and plan of correction for Woodlands Assisted Living of Waterville, related to licensing and certification compliance for a Level IV PNMI Residential Care Facility.
Findings
Woodlands Assisted Living of Waterville is in substantial compliance with the regulations governing the licensing and functioning of Level IV PNMI Residential Care Facilities.
The inspection was conducted to investigate compliance with regulations governing assisted housing programs, specifically regarding medical and health care standards for residents.
Findings
The facility failed to promptly access appropriate services for a resident whose pain medication order had no refills and whose medication inventory had expired, resulting in the resident being transferred to the emergency department. The resident missed multiple doses of prescribed Oxycontin, leading to emergency care due to chest pains and anxiety.
Deficiencies (1)
Description
Failure to promptly coordinate and assist in accessing appropriate services for a resident whose pain medication order had no refills and expired inventory, resulting in emergency department transfer.
Report Facts
Total Capacity: 58Medication Inventory Count: 0Medication Inventory Count: 60
Employees Mentioned
Name
Title
Context
Kendall Bailey
Acting Administrator
Confirmed findings at time of survey and exit interview
Palliative Care Nurse Practitioner
Interviewed regarding Resident #1's medication and condition
The document is a statement of deficiencies and plan of correction related to case investigations 2023-AHP-32639 and 2023-AHP-32634 for Woodlands Assisted Living of Waterville.
Findings
Woodlands Assisted Living of Waterville, a Level IV PNMI Residential Care Facility, is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV PNMI Residential Care Facilities, Part of 10-144, Chapter 113.