Portland Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Portland Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 29, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure residents' change of condition was assessed timely for 2 of 2 residents (#s 8 and 22) reviewed for skin conditions. This failure resulted in Resident 8 experiencing untreated and significant pain, sustaining multiple fractures and receiving treatment at the hospital. Findings include: 1. Resident 8 was readmitted to the facility in 10/2018 with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial loss of strength on one side of the body) following a stroke. a. […]

• Actual harm, isolatedF689Oct 29, 2024

  Based on observation, interview and record review it was determined the facility failed to assess for care plan effectiveness, identify and implement new fall interventions or provide adequate supervision needed to prevent falls for 3 of 3 sampled residents (#s 40, 48 and 108) reviewed for falls. This failure resulted in Resident 108's hospitalization and placed residents at risk for falls and injury. Findings include: 1. Resident 108 was admitted to the facility in 9/2023 with diagnoses including cancer, severe protein-calorie malnutrition, abnormal weight loss, chronic fatigue, and weakness. […]

• No harm, potential for more than minimal, widespreadF727Feb 9, 2024

  Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day seven days per week for 4 of 68 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 12/1/23 through 2/6/24 revealed on 12/10/23, 1/2/24, 1/5/24 and 1/11/24, RN coverage was not provided for at least eight consecutive hours per day. On 2/9/24 at 9:55 AM Staff 19 (Staffing Coordinator) acknowledged the facility lacked RN coverage on the identified days. On 2/9/24 at 12:01 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of this investigation. […]

• No harm, potential for more than minimal, widespreadF725Apr 22, 2021

  Based on observation, interview, and record review it was determined the facility failed to ensure adequate staffing was maintained for 3 of 3 halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: 1. Resident 11 readmitted to the facility in 4/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 11's current care plan indicated the resident required two-person staff assistance with transfers using a mechanical lift. On 4/15/21 Resident 11's call light was initiated on South hall at 12:46 PM, the light was answered by Staff 16 (CNA) and Staff 20 (CNA) at 1:09 PM, 23 minutes later. Resident 11 was overheard telling staff she/he wanted to get out of bed. […]

• No harm, potential for more than minimal, patternF565Feb 27, 2026

  Based on interview and record review, it was determined the facility failed to effectively respond to resident council concerns expressed at 3 of 3 resident council meetings reviewed for facility response to Resident Council concerns. This placed residents at risk for unmet needs concerning issues of resident care and lessened quality of life. Findings include: The facility's 1/2017 Resident Council Policy revealed the facility was expected to communicate a response and/or decisions to the Resident Council by the next meeting.During the 2/25/26 at 11:08 AM Resident Council meeting the residents stated they did not feel heard about their concerns or suggestions. […]