Signature Health of Portland Rehab & Wellness Cent

In the surveyor’s words

From the most serious findings on record at Signature Health of Portland Rehab & Wellness Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 11, 2025

  Based on facility policy review, medical record review, hospital documentation review, facility investigation review, and interviews, the facility failed to protect the resident's right to be free from neglect for 1 of 5 sampled residents (Resident #2) reviewed. On 12/13/2023, Resident #2, a vulnerable, bilateral amputee with a diagnosis of paraplegia and neurogenic bladder sustained 3rd degree burns to 4% of his body when urine from a self-catheterization or incontinent episode contacted an energized power strip positioned in the bed with him. During interview staff confirmed episodes of urine leakage after Resident #2 self-catheterized, Resident #2 was not assessed for competency related to self-catheterization and not monitored for risk of electrocution. […]

• Immediate jeopardy, isolatedF678Apr 11, 2025

  Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to initiate and provide Basic Life Support (BLS) including Cardiopulmonary Resuscitation (CPR) according to the resident's preference and physician order for 1 of 3 sampled residents (Resident #3) reviewed. On [DATE] Resident #3, a resident designated with full code status, was found unresponsive, without respirations and a palpable pulse. Nursing staff made no attempt to perform BLS/CPR in accordance with the resident's wishes/preferences. […]

• Immediate jeopardy, isolatedF689Apr 11, 2025

  Based on facility policy review, medical record review, hospital documentation review, Death Certificate review, facility investigation review, observations, and interviews, the facility failed to provide supervision and ensure the environment remained free of accident hazards to prevent avoidable accidents for 5 of 5 sampled residents (Residents #1, #2, #12, #14, and Resident #15) reviewed for accidents. On [DATE], Resident #2, a vulnerable, bilateral amputee with a diagnosis of paraplegia and neurogenic bladder was electrocuted while lying in bed. Resident #2 sustained 3rd degree burns to 4% of his body when urine contacted an energized power strip (provided by the Administrator) positioned in the Resident's bed with him. […]

• Immediate jeopardy, isolatedF600Aug 23, 2024

  Based on facility policy review, manufacture's guidelines review, printed text message review, medical record review, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 3 (Resident #1) sampled residents reviewed. The facility failed to provide the necessary structure and processes to meet the care needs of Resident #1, a vulnerable resident with a diagnosis of Paraplegia, when on 7/28/2024, 7/29/2024, 8/11/2024, and 8/12/2024 staff observed the hot water heater located in the Station 2 shower room, leaking/gushing hot water/steam from the tank onto the resident care area. […]

• Immediate jeopardy, isolatedF689Aug 23, 2024

  Based on facility policy review, hot water heater service manual review, medical record review, facility investigation review, facility Event Report review, Facility Maintenance Logbook Documentation, and interviews, the facility failed to ensure the residents' environment remained free of accident hazards as evidenced by dangerous hot water temperatures in the Station 2 shower room that were measured at 169 degrees Fahrenheit at the time of the incident for 1 (Resident #1) of 10 sampled residents reviewed for accident hazards. On 8/12/2024, Resident #1, a vulnerable resident with a diagnosis of paraplegia was sitting on a shower chair when the hot water tank sprayed scalding hot water on the floor of the shower room where Resident #1 was sitting. […]