Signature Health of Portland Rehab & Wellness Cent

Inspectors wroteBased on policy review, medical record review, hospital record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer/injury for 1of 4 (Resident #4) sampled residents reviewed for pressure ulcers. On 8/20/2025, Resident #4, a resident with impaired mobility who was at risk for pressure ulcers, was readmitted to the facility with an immobilizer to her left lower leg. The facility failed to assess, monitor, and document Resident #4's skin integrity underneath the immobilizer daily from 8/21/2025 to 9/8/2025, resulting in a pressure injury and an infection to the left lateral (outside portion of leg) ankle which resulted in actual Harm to Resident #4.

Inspectors wroteBased on facility policy review, review of Center for Disease Control (CDC) website guidelines, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 1 staff (Assistant Director of Nursing (ADON)) failed to perform hand hygiene and failed to use appropriate Personal Protective Equipment (PPE) while performing wound care for 2 of 2 (Residents # 4 and #16) sampled residents reviewed.

Inspectors wroteBased on facility job description review, facility policy review, Vitals Report, Patient Weight Reports review, Weight Intervention Audits, Weight (wt.) Loss Documentation Report review, medical record review, and interview, the facility failed to assess and address a resident's nutritional status and implement pertinent interventions when 1 of 16 (Residents #1) sampled residents reviewed for nutritional needs sustained severe weight loss. Resident #1 experienced a severe weight loss of 7.07% from February 12, 2025, to February 19, 2025 (a period of one week). The facility's failure resulted in actual Harm to Resident #1.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. The facility's failure to provide BLS/CPR to Resident #3, a resident identified as a full code, resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). [...]

Inspectors wroteBased 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. Resident #1 was a vulnerable, cognitively impaired, and legally blind resident at high risk for falls. [...]

Inspectors wroteBased on policy review, Quality Assurance and Performance Improvement (QAPI) report, observations, and interview, the QAPI committee failed to ensure systems and processes were in place that implemented and monitored identified interventions for improvement activities to provide a safe environment for residents and failed to provide adequate supervision to ensure staff provided QAPI interventions for a safe environment.

Inspectors wroteBased on facility policy review, facility investigation review, medical record review and interviews, the facility failed to ensure neglect with physical harm was reported to the State Survey Agency (SSA) in accordance with Federal and State law for 1 of 3 sampled residents (Resident #2) reviewed.

Inspectors wroteBased on facility policy review, medical record review, hospital documentation review, and interview, the facility failed to permit 1 of 3 sampled residents (Resident #4) reviewed for discharges to return to the facility after hospitalization.

Inspectors wroteBased 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. The Station 2 shower room remained in use from 7/28/2024 through 8/1/2024 pending repair and on 8/11/2024 and on the morning of 8/12/2024 staff observed hot water and steam leaking/gushing out of the hot water heater located in Station 2 shower room again. [...]

Inspectors wroteBased 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. Resident #1 sustained second (2nd) degree burns to left plantar area of the left foot. [...]

Inspectors wroteBased on the Board of Examiners of Nursing Home Administrators (BENHA) review, job description review, and interview, Administration failed to provide the oversight and supervision of staff to protect the resident's right to be free from neglect and failed to meet the care needs of residents in a safe environment when staff continued to provide Resident #1's showers in the Station 2 shower room which contained a malfunctioning hot water heater. Administration failed to provide oversight and supervision to provide an environment free from hazards and prevent an avoidable accident when the hot water heater in Station 2 shower room experienced a mechanical failure causing scalding hot water to [NAME] onto the floor where Resident #1 was receiving a shower resulting in a major burn injury to Resident #1's left foot. [...]

Inspectors wroteBased on medical record review, observation and interview, the facility failed to handle food in a sanitary manner for 1 (Resident #1) of 2 residents observed on the secure unit, and failed to maintain dietary equipment in a sanitary manner.

Inspectors wroteBased on medical record review and interview, the facility failed to accurately assess a fall with no injury on the Minimum Data Set (MDS) for 1 resident (Resident #60); and failed to accurately identify the discharge location on the MDS for 1 resident (Resident #64) of 33 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review and interview, the facility failed to have a comprehensive care plan related to discharge preferences for 1 (Resident #64) of 33 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation and interviews, the facility failed to obtain a physician's order for Oxygen [02] at 3 Liters [L] per minute for 1 (Resident #36) resident of 24 residents who received respiratory services.

Inspectors wroteBased on facility policy review, medical record review, observation and interviews, the facility failed to properly store and date respiratory equipment to prevent the spread of infection for 3 (Resident #4, #36 and #62) of 24 residents who received respiratory services.

Inspectors wroteBased on observation and interview, the facility failed to maintain the heated plate lowerator in a safe operational condition.

Inspectors wroteBased on facility policy review, manufacturer's guidelines, medical record review, observation and interview, the facility failed to provide supervision to prevent an injury during a transfer with a sit to stand lift resulting in a fracture and (Harm) for 1 Resident (#77) of 6 residents reviewed for accidents.

Inspectors wroteBased on facility policy review, medical record review and interview, Pharmacy Services failed to provide monitoring related to performing Abnormal Involuntary Movement Scale (AIMS) assessments in a timely manner for 11 residents (#1, #15, #26, #39, #49, #51, #68, #79, #232, #235, and #279) of 28 residents receiving Anti-Psychotic medications and 1 resident (#43) of 3 residents receiving neuroleptic medications.

Inspectors wroteBased on facility policy review, medical record review and interview, the facility failed to adequately monitor signs and symptoms of residents prescribed antipsychotics related to performing Abnormal Involuntary Movement Scale (AIMS) assessments in a timely manner for 11 residents (#1, #15, #26, #39, #49, #51, #68, #79, #232, #235, and #279) of 28 residents and 1 resident (#43) of 3 residents receiving neuroleptic medications.

Inspectors wroteBased on medical record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) for 2 (#26, #236) of 7 residents reviewed.

Inspectors wroteBased on facility policy review, observation and interview, the facility failed to lock one unattended medication cart of 6 medication carts observed.

Inspectors wroteBased on facility policy review, observation and interview, the facility failed to update the daily posted staffing from 1/29/19 though 2/4/19 (6 days).