Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Portland Care & Rehab Centre, Inc during CMS and state inspections, most recent first.
Missing Monthly Pharmacy Medication Regimen Reviews: The facility failed to ensure a licensed pharmacist completed and documented monthly medication regimen reviews for multiple LTC residents. Two residents receiving psychotropic, anticoagulant, and other high-risk medications had several months with no documented reviews, and another resident had only one documented review with many months missing. The DNS and supervising pharmacy consultant reported that lost electronic files and computer issues affected the availability of the monthly reviews.
Food service staff were observed preparing and serving food without required hair restraints, including a dietary aide serving from the steam table without a hair guard and another staff member temping food without a beard guard. The facility also failed to keep the low-temp dishwasher at the required minimum wash temp, with repeated readings of 90°F while dishes were being washed and incomplete documentation that required temp and sanitizer levels were met before use.
Soiled Upholstered Chairs in Common Areas: The facility failed to maintain a clean and homelike environment when surveyors observed heavily stained upholstered chairs in the solarium and dining room. The Administrator acknowledged the chairs were heavily soiled and said he had been researching replacements because they were costly, but no documentation of progress toward replacement was provided. A policy on maintaining a clean homelike environment was not provided.
A resident with morbid obesity, OA, and a custom power wheelchair was transferred using a newly purchased stand lift and sling harness without a re-assessment for safe use. During the first transfer, the resident did not clear the wheelchair seat, slipped in the sling, and had to be lowered with a gait belt onto the wheelchair footrests; a small bruise was noted. Interviews showed the new lift and sling were different from prior equipment, the sling was too long, and staff had not demonstrated competency during in-service.
A resident with a history of falls was injured during a transfer when a nursing assistant failed to use a gait belt, as required by facility policy. The resident fell and sustained a hip fracture requiring surgery. The nursing assistant admitted to not using the gait belt, citing the short transfer distance and personal safety concerns. The facility's investigation confirmed the policy was not followed, despite prior training.
The facility failed to maintain proper food safety and sanitation standards, with issues such as dust accumulation on ceiling fans above prep areas, uncovered food items, and dirty equipment. The emergency food supply contained expired items, and the steam table was transported without covering the food. The facility lacked a policy on labeling and dating foods, compromising food safety.
A resident with chronic respiratory conditions, including COPD, experienced two incidents where their oxygen tubing was disconnected from the concentrator, preventing oxygen delivery. The resident, who was severely cognitively impaired, was found with the nasal cannula in place but not receiving oxygen. An LPN suspected the disconnection occurred during mechanical lift transfers, highlighting a failure to ensure proper oxygen delivery as per facility policy.
A facility failed to attempt a Gradual Dose Reduction (GDR) for a resident prescribed Lexapro for major depressive disorder. Despite care plans and progress notes indicating the need for monitoring, no GDR was attempted or documented from January 2023 through June 2024. Interviews revealed a lack of awareness and communication among staff regarding the responsibility for initiating a GDR, contrary to the facility's policy on psychotropic medication management.
A facility failed to maintain adequate temperatures for a resident's refrigerator, which was observed at 50°F, above the normal range. Temperature logs showed consistent readings between 48 and 50°F. Interviews revealed a lack of awareness and communication among staff regarding the correct temperature range, and the facility's policy for addressing out-of-range temperatures was not followed.
Missing Monthly Pharmacy Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly drug regimen reviews for multiple residents and that the reviews were documented in the clinical record. For Resident #3, who was admitted with thrombophilia, severe dementia with mood disturbance, and hypothyroidism, the quarterly MDS identified severely impaired cognition and use of antipsychotic, hypnotic, and anticoagulant medications. The care plan also identified anticoagulant and antipsychotic use with interventions to review for adverse interactions and monitor, record, and report side effects and adverse reactions. The record did not show monthly medication regimen reviews for 9/2025, 11/2025, 12/2025, 1/2026, and 2/2026. For Resident #33, who was admitted with hypertensive heart and chronic kidney disease with heart failure, schizophrenia, and anxiety, the annual MDS identified intact cognition and use of antipsychotic, antidepressant, anticoagulant, diuretic, and antiplatelet medications. The care plan identified anticoagulant and psychotropic/antipsychotic use with interventions to review for adverse interactions and monitor for side effects and adverse reactions. The clinical record did not identify monthly medication regimen reviews for 9/2025, 11/2025, 12/2025, 1/2026, and 2/2026. For Resident #12, who was admitted with COPD, type II diabetes, and chronic kidney disease, the quarterly MDS identified intact cognition and daily medication use for multiple comorbidities. The care plan identified an alteration in endocrine status, anticoagulant use, and antidepressant use, with interventions to administer medications as ordered and monitor effectiveness and side effects. The record showed one pharmacy medication review dated 10/1/25 with no irregularities, but no other documented pharmacy medication reviews from 3/20/25 to 9/2025 and 11/2025 to 2/2026. Interviews with the DNS and Supervising Pharmacy Consultant #1 identified that the consultant pharmacist was responsible for monthly reviews and that computer issues and lost work-related files affected the availability of the reviews for long-term residents.
Failure to Use Hair Restraints and Maintain Dishwasher Temperature
Penalty
Summary
Food service staff were observed preparing and serving food without required hair restraints. On 3/8/26, Dietary Aide #1 was observed serving breakfast from the steam table in the first-floor dining room without a hair guard. During interview, the aide stated she knew she should be wearing a hair net while serving food but had arrived late and, because the unit was short staffed, forgot to put it on. On 3/9/26, [NAME] #1 was observed in the kitchen temping food on the steam table without a beard guard. He stated that he normally puts on a beard guard after his hair net, but the beard guard bag was not available and he forgot to put one on before starting work. The facility also failed to ensure the low temperature dishwasher was operating at the required temperature. On 3/9/26, Dietary Aide #2 was observed washing dirty dishes and utensils in the low temperature dishwasher while the sanitizer reading was within normal limits, but the maximum temperature reached only 90 degrees Fahrenheit. Three additional observations over the next 15 minutes confirmed the dishwasher still only reached 90 degrees Fahrenheit. The Dietary Director stated the dishwasher should operate at a minimum of 120 degrees Fahrenheit and that he notified the Administrator and Director of Maintenance when the temperature was reading 90 degrees Fahrenheit. Review of the March 2026 Dish Machine Temperature and Sanitizing Record showed no documentation that the required temperature and sanitizer levels were obtained before breakfast dishes and lunch dishes were washed on 3/9/26. Dietary Aide #2 stated he checked the dishwasher temperature before washing breakfast dishes and saw 90 degrees Fahrenheit, and planned to recheck it after lunch dishes were washed. The Administrator later stated that adjusting the mixer valve brought the temperature up, and an outside plumber found no mechanical issues, with the water temperature then measuring 125 degrees Fahrenheit. The Low Temperature Dishwasher Machine Operational Requirements directed a minimum wash temperature of 120 degrees Fahrenheit and 50 ppm available chlorine rinse.
Soiled Upholstered Chairs in Common Areas
Penalty
Summary
The facility failed to ensure a clean and homelike environment. During observation with the Administrator/Owner, 3 of 4 upholstered chairs in the solarium and 5 of 10 upholstered chairs in the dining room were noted to have heavy brown/black staining on the seats and backs. The Administrator stated he was aware the chairs were heavily soiled and had been researching replacements because they were costly, but he was unable to provide documentation showing progress toward replacement. A policy on maintaining a clean homelike environment was requested but not provided.
Unsafe Transfer With New Stand Lift and Sling Harness
Penalty
Summary
The facility failed to ensure a resident with a customized wheelchair was re-assessed for safe transfers after a new standing mechanical lift and sling harness were put into use. Resident #12 was admitted with morbid obesity and osteoarthritis, was cognitively intact, non-ambulatory, and required two-person assistance for transfers. Therapy records showed the resident had been using a mechanical stand lift and was able to stand for short periods, and the care plan identified the resident as at risk for falls and dependent on a custom power wheelchair and transfer assistance. On 12/16/25, nursing staff used one of two newly purchased stand lifts for the first time with Resident #12 after in-service training on the new equipment. During the transfer from bed to wheelchair, staff observed that the resident’s lower back and buttocks were hitting the wheelchair seat rather than clearing it as the lift rose to maximum height. The resident then slowly slipped out of the upper body sling harness after no longer being able to hold his/her own weight. Staff used a gait belt to lower the resident, who came to rest on the wheelchair footrests. A body assessment noted a small 1 cm by 1 cm bruise at the right gluteal fold, and the resident denied pain or discomfort. After the incident, rehabilitation later determined that a smaller sling or different connecting point was needed, and physician orders were changed to use a mechanical Hoyer lift for all transfers. Interviews with rehabilitation and nursing leadership indicated the new stand lift and sling harness were different from the prior equipment, the sling was too long, and the resident was not re-assessed for safe use of the new lift and harness before implementation. The Director of Rehabilitation also stated staff were not required to demonstrate competency during the in-service, and no further in-servicing was provided after the incident.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to adhere to its policy of using a gait belt during resident transfers, resulting in a major injury for a resident. The resident, who had a history of falls and was at moderate risk for falling, was being transferred back to bed by a nursing assistant (NA) without the use of a gait belt, contrary to the facility's transfer policy. The resident subsequently fell, sustaining a right hip spiral fracture that required surgery. The nursing assistant admitted to not using the gait belt, citing the short distance of the transfer and concern for personal injury as reasons for the omission. The facility's investigation revealed conflicting accounts from staff, but ultimately determined that the nursing assistant did not follow the care plan or facility policy, which mandated the use of a gait belt for all transfers unless contraindicated. The physical therapist confirmed that the nursing assistant was trained on the policy and should have used a gait belt and a two-wheeled walker, rather than a wheelchair, during the transfer. The Director of Nurses corroborated that the care plan was not followed, and the nursing assistant had been educated on the proper use of gait belts prior to the incident.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in the Dietary Department, as observed during a tour and through staff interviews. Several issues were identified, including heavy dust accumulation on ceiling fans above the prep area, where food was being prepared, and on the fan in the dish room. Uncovered food items, such as a pan of gravy and flour mixture, were left on the prep table, which itself was dirty. The area around the convection oven, including the pipes and flooring, was also heavily soiled, as was the hood vent area. The eye wash station and microwave were noted to be dirty, with the latter having been inadequately cleaned by a staff member. The refrigerator door and handles were similarly unclean, and the beverage cooler had a black substance on its gasket. Additionally, the walk-in freezer contained unlabeled and undated food items, and the dry storage room had several open food items without dates. The facility's emergency food supply was found to contain expired items, and the Dietary Director admitted responsibility for checking these supplies but failed to ensure they were up to date. Furthermore, the steam table used to serve meals was dirty and was transported without covering the food, despite the cook acknowledging that food should be covered during transport. The facility lacked a policy on labeling and dating foods, although the Dietary Director stated that opened food should be dated and discarded by the expiration date. These deficiencies highlight a lack of adherence to professional standards for food storage, preparation, and service, potentially compromising food safety and sanitation.
Oxygen Delivery Failure for Resident with Chronic Respiratory Conditions
Penalty
Summary
The facility failed to ensure proper oxygen delivery for a resident with chronic respiratory conditions, including COPD and chronic respiratory failure. On two separate occasions, the resident's oxygen tubing was found disconnected from the oxygen concentrator, preventing the delivery of prescribed oxygen. The resident, who was severely cognitively impaired and required assistance with daily activities, was observed lying in bed with the nasal cannula in place but not receiving oxygen due to the disconnection. The resident's oxygen saturation levels were recorded at 93% and 94% during these incidents. Interviews and observations revealed that the disconnection of the oxygen tubing might have occurred during mechanical lift transfers, as suspected by an LPN. The facility's oxygen policy requires the attachment of the cannula to the oxygen device and humidifier bottle, with confirmation of oxygen flow through bubbling in the bottle. However, the staff did not ensure the tubing remained connected, leading to the resident not receiving the necessary oxygen therapy as prescribed.
Failure to Attempt Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) for a psychotropic medication for one of the residents reviewed for unnecessary medications. The resident, who was admitted with diagnoses of major depressive disorder and a personal history of other mental and behavioral disorders, was prescribed Lexapro, an antidepressant, at a daily dose of 20 milligrams. Despite the resident's care plan and progress notes indicating the need for monitoring the effectiveness and side effects of the medication, there was no documented attempt to reduce the dosage or explanation for not doing so from January 2023 through June 2024. Interviews with the psychiatric APRN and the Director of Nursing Services (DNS) revealed a lack of awareness and communication regarding the responsibility for initiating a GDR. The psychiatric APRN noted that a GDR should be considered and documented if not attempted, while the DNS was unaware of the need for a GDR for antidepressants and did not know the facility policy. The primary care APRN also indicated that a GDR should be attempted once or twice a year but did not do so because it was not brought to her attention. The facility's policy on psychotropic medication management requires verification of adequate indications for use and monitoring for adverse consequences, which was not adhered to in this case.
Failure to Maintain Adequate Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain adequate temperatures for a resident's refrigerator, which was observed to be at 50 degrees Fahrenheit, above the normal range of at or below 41 degrees Fahrenheit. This deficiency was identified during an observation of resident rooms, where it was noted that the refrigerator contained yogurt and leftover food. The temperature logs for June 2024 showed consistent readings between 48 and 50 degrees Fahrenheit, indicating a persistent issue with maintaining the correct temperature. Interviews with facility staff revealed a lack of awareness and communication regarding the appropriate temperature range for refrigerators. The Director of Maintenance acknowledged that the refrigerators belonged to the facility and were supposed to be maintained between 36 to 42 degrees Fahrenheit, but could not recall any reports of abnormal temperatures. Housekeeper #1, responsible for checking temperatures, was unaware of the correct range and reported temperatures below 50 or 60 degrees Fahrenheit. The Director of Housekeeping confirmed the procedure for reporting out-of-range temperatures but could not explain why the issue in the resident's room was not reported. The facility's policy required adjustments and rechecks of temperatures, with food being moved if necessary, but this protocol was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Cromwell | 1.6 mi | ★★★★★ | 0 | 0 |
| Water's Edge Center For Health & Rehab | 1.8 mi | ★★★★★ | 15 | 0 |
| Pilgrim Manor | 1.9 mi | ★★★★★ | 0 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 2.7 mi | ★★★★★ | 13 | 0 |
| Apple Rehab Middletown | 3.1 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.