Astoria Place of Waterville

In the surveyor’s words

From the most serious findings on record at Astoria Place of Waterville, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Aug 27, 2025

  Based on medical record review, observation, staff interview, county coroner interview, review of the Emergency Medical Services (EMS) run report, review of the death certificate, and review of the facility self-imposed action plan, including in-service records and audits, the facility failed to provide residents food in the correct texture to meet individual needs, failed to ensure residents were provided feeding assistance/supervision as required, and failed to put monitoring systems in place to prevent the same actions, situations, and/or practices from reoccurring. […]

• Actual harm, isolatedF742Jan 8, 2026

  Based on medical record review, staff interview, hospice interview, review of the local weather conditions, emergency medical services (EMS) interview, review of the EMS run report, and review of hospital records, the facility failed to adequately assess, monitor, document, and address a decline in a resident's mental health. This resulted in Actual harm to Resident #09 when on the evening of 01/01/26, the resident did not sleep, appeared to be experiencing hallucinations, and was aggressive toward staff. Facility staff failed to notify the physician or implement any interventions throughout the night. […]

• Actual harm, isolatedF600Sep 30, 2025

  Based on medical record review, staff interview, review of the facility investigation, review of emergency medical service (EMS) and police reports, review of the county coroner case documentation, and review of facility policy, the facility failed to prevent resident to resident abuse. Actual harm occurred on 09/23/25 when Resident #29 was discovered in a resident room behind a closed door and Resident #53 was discovered in the same room behind a drawn privacy curtain laying supine on a sheet on the floor with towels secured tightly around the neck. Resident #53's head was purple in color, skin was cool to touch, with blood in her mouth, petechia to her skin, and no respirations or pulse were present. Resident #29 later admitted strangling Resident #53. […]

• Actual harm, isolatedF689Mar 21, 2025

  Based on review of the medical record, review of a self-reported incident, review of an incident report, review of hospital records, review of staff statements, staff interview, staff job description, and policy review, the facility failed to ensure staff assisted a resident with safe ambulation, report a resident fall, and ensure a resident was assessed for injuries prior to moving the resident after a fall, and ensure the resident's fall was thoroughly investigated. Additionally, the facility failed to implement fall prevention interventions. […]

• Actual harm, isolatedF600Sep 17, 2024

  Based on record review, review of the facility policy, review of the Self-Reported Incidents (SRI) database, facility investigation, review of hospital records, resident interviews, and staff interviews, the facility failed to prevent resident-to-resident physical abuse. This resulted in actual harm when Resident #01, a resident with known history of resident-to-resident abuse incidents, struck Resident #02 in the face causing a hematoma (a pool of clotted blood that forms in the tissue) to her face and a closed fracture of the right orbital floor (one or more bones around the eyeball break, often from a blow to the face). […]