Pinnacle Health & Rehab at South Portland

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased on observations, record reviews, interviews and the facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 3 residents reviewed for respiratory care (Resident's #31, #19 and #57).

Inspectors wroteBased on record review and interviews, the facility failed to monitor and document targeted behaviors and side effects of psychotropic medication to support the use of psychotropic medications for 3 of 5 residents reviewed for unnecessary medications (Resident #4, #6, and #31).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure expired medications were removed from the supply available for use and failed to ensure that medications were stored properly as per manufacturers' recommendations for 2 of 3 medication rooms reviewed for medication storage (100 unit and 300 unit).

Inspectors wroteBased on facility policy, observation, interviews and record review the facility failed to ensure a smoking assessment of resident capabilities and deficits to determine resident safety was completed for 1 of 1 resident reviewed for smoking (Resident #48).

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's past history of trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include trauma informed care for 1 of 1 residents reviewed for trauma. (#38) A review of the clinical record noted Resident #38 was admitted in May 2025. Medical diagnoses included vascular dementia. A brief trauma questionnaire, completed on 6/9/25, indicated Resident #38 had a history of significant trauma. The questionnaire stated family had identified showers provided by men were a trigger, and that showers should be provided by women only. The record lacked evidence that the results of the brief trauma questionnaire had been communicated to Resident #38's provider. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 1 walk in refrigerators on 1 of 3 survey days.

Inspectors wroteBased on record review and interviews, the facility failed to ensure records were complete and contained accurate information for 1 of 1 resident reviewed for pacemaker (Resident [R]13). FindingsResident [R]13 was admitted in 2022 and was admitted for end of life (Hospice) with diagnoses to include heart dysrhythmia with presence of a pacemaker. Review of R13's care plan updated 7/17/25 states [R13] has a pacemaker r/t Dysrhythmias .Observe for/document/report PRN any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P. Review of R13's active orders lacked evidence that orders were obtained for the pacemaker. During an interview on 9/16/25 at 11:36 a.m. Licensed Practical Nurse (LPN)2 provided document dated 4/29/22 which states Reason for exam Dx: [...]

Inspectors wroteBased on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Complaint Survey Process dated 7/30/24, was effective. The federal citation F880 was cited again during the re-visit to the Complaint Survey, dated 9/25/24.

Inspectors wroteBased on observation, facility policy review, and interviews, a staff member (LPN#1) failed to follow the facility's Infection and Prevention Policy and Update of 7/18/24. to prevent the introduction and spread of Coronavirus Infectious Disease 2019 (COVID-19) in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition on 3 of 3 Units (100s Unit, 200s Unit and 300s Unit), the laundry room and the front lobby sitting area for 1 of 1 Environmental Tour.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 2 of 25 sampled residents (#7, #60).

Inspectors wroteBased on observations, and interview, the facility failed to maintain adequate pharmaceutical services to ensure that outdated medications, and medication no longer in use be removed from availability as discovered in 2 of 3 medication carts and 1 of 3 medication storage rooms.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall mounted fans, a window fan, the hood system, ceiling lights, ceiling tiles and the dry storage room. Additionally, the facility also failed to ensure products in the walk-in refrigerator and walk-in freezer were labeled and dated. Further, the facility failed to label whipped topping with a thaw date.

Inspectors wroteBased on observations, record review and interview, the facility failed to develop/implement a care plan in the area of respiratory and failed to implement the intervention for the care area of physical mobility for 2 of 25 sampled residents. (#7, #39)

Inspectors wroteBased on record review, observation and interview, the facility failed to follow their own policy on Oxygen (O2) therapy and failed to obtain physician orders for oxygen for 1 of 2 residents reviewed for respiratory care. (#7)

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain adequate pharmaceutical services to ensure the removal of controlled medication to avoid misuse and diversion in 1 of 3 medication carts observed. In addition, the facility failed to follow their policy for removal of controlled substances from use.

Inspectors wroteBased on observation and interview, the facility failed to ensure that a patient lift, used for transferring residents, was maintained in good repair and safe operating condition for 1 of 4 days of survey (12/5/22) on I of 3 Units (200 Unit).

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the resident and/or the resident's representative in writing of the transfers/discharges to an acute care hospital for 1 of 3 residents sampled for hospitalizations. (Resident #27)

Inspectors wroteBased on record reviews and interviews, the facility staff failed to develop a care plan to address behaviors and the use of an antipsychotic medication for 1 of 6 residents reviewed for unnecessary medications (Resident #10).

Inspectors wroteBased on record reviews and interviews the facility failed to ensure as needed (PRN) psychotropic medications met the required 14-day limit for 2 of 6 residents reviewed for unnecessary medications (Resident #2 and #14).