Portland Care & Rehab Centre, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Residents #3, 33 and 12) reviewed for unnecessary medications, for Resident #3 and 33, the facility failed to ensure monthly pharmacy medication regimen reviews were completed for 5 of the 12 months reviewed and for 1 of 5 residents Resident #12 the facility failed to ensure monthly pharmacy medication reviews were completed 11 of 12 months. The findings include: 1. Resident #3 was admitted to the facility in December 2023 with diagnoses that included thrombophilia, severe dementia with mood disturbance, and hypothyroidism. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and was receiving antipsychotic, hypnotic, and anticoagulant medications. The care plan dated 3/10/26 identified Resident #3 was taking an anticoagulant medication, with interventions that included reviewing the medication list for adverse interactions and was taking an antipsychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility documentation, facility policies, and interviews, the facility failed to ensure food service staff were wearing hair restraints while preparing food and failed to ensure a low temperature dishwasher was operating in accordance with the manufacturer's recommendation. The findings include: 1. [NAME] #1 was hired in October 2012.Dietary Aide #1 was hired in November 2023.Observation on 3/8/26 at 9:00 AM, in the first-floor dining room, identified Dietary Aide #1, serving breakfast from the steam table, without the benefit of a hair guard.Interview with Dietary Aide #1 on 3/8/26 at 9:08 AM identified that she was aware that she should be wearing a hair net while serving food, but today she had arrived late and they were short staffed, so she forgot to put it on. Dietary Aide #1 indicated that she always wears a hair net.Observation on 3/9/26 at 11:40 AM identified [NAME] #1, in the kitchen, temping food on the steam table, without the benefit of a beard guard.Interview with [NAME] #1 on 3/9/26 at 11:40 AM identified that he always puts on a beard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility documentation and interviews the facility failed to ensure a clean and homelike environment. The findings include:Observation on 3/10/26 11:37 AM with the facility Administrator/Owner identified 3 of 4 upholstered chairs in the solarium (sitting room) and 5 of 10 upholstered chairs in the dining room were marked with heavy brown/black staining on the seat, and back of chairs.Interview with the Administrator on 3/10/26 11:37 AM identified he was aware the chairs were heavily soiled and had recently been researching replacements indicating they were costly. The Administrator further identified although his efforts were ongoing, he was unable to provide any documentation regarding progress towards replacement.Although requested, a policy on maintaining a clean homelike environment was not provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #12) reviewed for accidents, the facility failed to ensure a resident with a customized wheelchair was re-assessed for safe transfers after implementing a new standing mechanical lift and sling harness resulting in staff having to lower the resident on a firm surface near the floor. The findings include:Resident #12 was admitted to the facility in December 2024 with diagnoses that included morbid obesity and osteoarthritisPhysical Therapy Evaluation dated 6/24/25 identified Resident #12 was assessed with the use of a mechanical stand lift assist and was able to stand 1-3 minutes with total dependence.The quarterly MDS dated [DATE] identified Resident #12 was cognitively intact and required two person assist with transfers, utilized a motorized wheelchair for mobility and had not experienced any falls since admission.The care plan dated 9/23/25 identified Resident #12 was non ambulatory,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the tour of the Dietary Department, staff interview, and facility documentation, the facility failed to ensure open food items were dated, failed to ensure canned foods in the emergency stock were not expired, and failed to ensure food was served under sanitary conditions. The findings included: During a tour of the Dietary Department on 6/10/24 10:31 AM with the Dietary Director the following was identified: a. 2 ceiling fans directly over the prep area were noted to be oscillating with a heavy accumulation of dust. A dietary worker was cutting a cake directly under one of the fans. In addition, the ceiling fan in the dish room was noted with a heavy accumulation of dust. b. An uncovered pan of gravy and flour mixture was observed to be on top of the preparation (prep) table. The side and underneath area of the prep table were noted to have a heavy accumulation of dirt and debris. c. The pipes behind the conventional convection oven and the flooring behind the oven was observed with a heavy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #5) reviewed for oxygen use, the facility failed to ensure oxygen tubing was connected to the concentrator providing oxygen on 2 occasions. The findings include: Resident #5's diagnoses included chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, obstructive sleep apnea, and chronic pain syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was severely cognitively impaired and required total assistance with bathing and dressing, set up assistance with eating, partial moderate assistance with bed mobility, and total assistance with transfers and mobility. The Resident Care Plan dated 5/3/24 identified oxygen therapy since 2019, chronic respiratory failure with long term oxygen use, choosing to remove oxygen and Chronic Obstructive Pulmonary Disease (COPD). Interventions included to remind to keep oxygen on, monitor for signs or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy for 1 of 5 sampled residents (Resident #14) reviewed for unnecessary medications, the facility failed to attempt a Gradual Dose Reduction (GDR) for a psychotropic medication. The findings include: Resident #14 was admitted on [DATE] with diagnoses of major depressive disorder and personal history of other mental and behavioral disorders. A physician order dated 1/25/23 directed the administration of Lexapro (an antidepressant medication) 20 milligrams daily. An admission MDS dated [DATE] identified Resident #14 had intact cognition, was independent with eating, required supervision with oral hygiene, and partial to moderate staff assistance with transfers. Additionally, Resident #14 had a diagnosis of depression and received an antidepressant. The Resident Care Plan dated 5/1/23 identified Resident #14 was on an antidepressant, interventions included monitoring ongoing signs and symptoms of depression and monitoring side effects and effectiveness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews for 1 of 5 sampled residents (Resident #1) reviewed for the environment, the facility failed to maintain adequate temperatures for a resident refrigerator on the 2nd floor. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses of anxiety, dysphagia, and gastro-esophageal reflux disease. Observation of resident rooms on 6/13/24 identified Resident #1's refrigerator tempeature guage read 50 degrees and the following foods were stored in the refrigerator, yogurt and leftover food from dining service. Additionally, the temperatures recorded on a log for June 2024 ranged between 48 and 50 degrees Fahrenheit (F) (normal at or below 41 degrees F). Interview with the Director of Maintenance on 6/13/24 at 11:00 AM identified the refrigerators belonged to the facility and that housekeeping was responsible to check the temperatures of the refrigerators. If the temperatures were out of range, the facility would replace the malfunctioning refrigerator with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, and interviews for one of two dining rooms observed, the facility failed to ensure that adaptive dining equipment was in place for one observed resident (Resident #12) during a meal in accordance with the resident plan of care. The findings include: Resident #12's diagnoses included Alzheimer's Dementia, failure to thrive, Macular Degeneration and bilateral cataracts. Occupational Therapy treatment note dated 7/22/2021 directed use of a non-slip mat under dishes, a lip plate, and Nosey Cup for drinks, and noted orders were written for staff to provide feeding equipment at all meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 had moderate cognitive impairment and required supervision (oversight, encouragement, or cueing) with eating. The Resident Care Plan (RCP) dated 1/18/2022 identified Resident #12 was at risk for weight loss due to dementia. Interventions directed use of a Nosey Cup or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and facility policy review, the facility failed to ensure the laundry room and linens were maintained in a clean manner. The findings include: Observations with RN #2 on 4/13/2022 at 2:03 PM in the facility laundry area, identified a heavy accumulation of white, fluffy debris on the laundry room walls, tops of the laundry machines, tops of the soap dispenser, water pipes, door hinges, ceiling, and on the top of a wall mounted heater. Strands of the white, fluffy debris were observed hanging downward approximately three (3) to six (6) inches from the ceiling and door closure arm. A large industrial-sized fan was observed located on a green plastic chair. The fan was observed to have a large accumulation of white, fluffy debris on the grill cover in front of the fan blades. The fan was turned on and blowing toward a hanging rack with clean clothing and linens and toward folded, clean laundry located on a multi-level linen cart with the protective cover left open, and clean blankets on a table next to the linen cart. Additional linens were observed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.