Pinnacle Health & Rehab at South Portland

In the surveyor’s words

From the most serious findings on record at Pinnacle Health & Rehab at South Portland, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Sep 17, 2025

  Based on observations and interviews, the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 meals (Bayview and 200 unit) and failed to maintain a homelike environment for 2 of 2 meals observed on 2 of 3 survey days.Findings:1. During a meal observation on the 200 unit on 9/15/25 between 12:24 and 12:43 p.m. the following was observed:Table 1 contained 2 residents. One resident received their meal tray at 12:24 p.m., the staff served multiple other tables before returning to table 1 to give the second resident their meal at 12:34 p.m.Table 2 contained 2 residents. One resident received their meal tray at 12:26 p.m. […]

• No harm, potential for more than minimal, patternF558Sep 17, 2025

  Based on observations and interviews, the facility failed to ensure a residents call bell was within reach for 4 of 25 sampled residents for 2 of 3 days of survey with multiple observations. (Resident #5, #54, #7, and #67).Findings: 1. On 9/16/25 at 9:10 a.m., a surveyor observed Resident #5 seated in his/her Broda chair in his/her room, with the call bell tucked underneath the pillow on his/her bed, out of reach. At this time, Resident #5 stated he/ she was trying to get into bed and that he/she usually has to holler to get help. At 9:11 a.m., a surveyor pressed the call bell, and Certified Nursing Assistant #2 entered the room and stated that Resident #5 usually likes to go back to bed after breakfast and that the call light should not be under his/her pillow and should be within reach. […]

• No harm, potential for more than minimal, patternF578Sep 17, 2025

  Based on record reviews, and interviews, the facility failed to provide evidence to show Advance Directives were offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an Advance Directive, for 8 of 25 residents reviewed for advanced directives (Residents #4, #8, #29, #57, #68, #52, #34, #50).Findings: 1. Resident #4 was admitted to the facility in June 2022. […]

• No harm, potential for more than minimal, patternF584Sep 17, 2025

  Based on observations and interviews, the facility failed to adequately provide maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 3 Units (100's and 200's).Findings: 1. During an initial observation of room [ROOM NUMBER] on 9/15/25 at 9:22 a.m., the footboard on B bed was observed to have missing/peeling areas of luminant, making it an uncleanable surface. On 9/16/25 at 12:51 p.m., during an observation of room [ROOM NUMBER] with Licensed Practical Nurse (LPN) #2 in the presence of Resident #57, LPN#2 observed the footboard and stated that she's never noticed it before, but it definitely needed to be fixed. […]

• No harm, potential for more than minimal, patternF657Sep 17, 2025

  Based on record review and interview the facility failed to hold an Interdisciplinary Team Meeting (IDT) within 7 days of a completed Minimum Data Set (MDS) for 6 of 6 Residents reviewed for Minimum Data Set (MDS) (Resident's #4, #8, #13, #57, #5 and #16).Findings: 1. Review of Resident #4's clinical record revealed the following: -Annual MDS with completion date 6/23/25. Further review of Resident #4's clinical record revealed the IDT meeting was held on 7/7/25 (14 days after completed MDS). -Quarterly MDS with completion date 3/24/25. Further review of Resident #4's clinical record revealed the IDT meeting was held on 4/14/25 (21 days after completed MDS). -Quarterly MDS with completion date 12/20/24. […]