Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Signature Health Of Portland Rehab & Wellness Cent during CMS and state inspections, most recent first.
A resident with impaired mobility and a left knee immobilizer was readmitted without the facility implementing the immobilizer-related skin monitoring orders. Staff failed to document daily skin checks under the device, and a reddened area above the left lateral ankle was later found where the immobilizer had rubbed the skin. The area progressed to an unstageable pressure injury with slough and infection, and the DON, ADON, and LPN acknowledged gaps in assessment, staging, and documentation.
The ADON failed to perform proper hand hygiene and failed to use appropriate PPE during wound care for two residents with pressure ulcers. One resident had a pressure ulcer to the left lower leg and the ADON washed hands for only a few seconds before and after the dressing change. Another resident had pressure injuries to both heels, and the ADON entered without PPE, changed gloves between wounds, and washed hands for only a few seconds after the treatments. Facility policy, EBP guidance, and CDC guidance required hand hygiene and gown/glove use during wound care.
A resident with multiple medical conditions and moderate cognitive impairment experienced a severe weight loss of over 7% in one week. Despite facility policies requiring monitoring and intervention for significant weight changes, there was no evidence that the RD or staff implemented or documented any interventions or follow-up after the weight loss was identified. Staff interviews confirmed that the expected process for addressing nutritional risk was not followed, resulting in actual harm.
A resident with paraplegia and a neurogenic bladder suffered third-degree burns after urine from self-catheterization contacted a power strip placed in the bed by the administrator. Despite staff awareness of the resident's incontinence, use of multiple electronics in bed, and safety concerns, there was no documented assessment, care plan intervention, or consistent monitoring to address the risks. The lack of appropriate actions and oversight led to the resident sustaining severe electrical burns.
A resident with a history of respiratory failure and COPD, who had clearly documented full code status and a preference for resuscitation, was found unresponsive by nursing staff. Despite being aware of the resident's wishes and physician orders, staff did not initiate CPR, citing the resident's physical appearance. This failure to provide BLS/CPR as required led to a citation for substandard quality of care.
The facility failed to provide adequate supervision and maintain a safe environment, resulting in serious incidents including a resident being electrocuted by a power strip in bed and another resident suffering a fatal fall after being left unattended. Multiple residents were found with electrical devices and cords in their beds, and staff reported unclear procedures and insufficient training regarding electrical safety. The facility lacked proper documentation and protocols for testing and maintaining patient care-related electrical equipment, contributing to ongoing accident hazards.
A resident suffered third-degree electrical burns after urine contacted an energized power strip in bed, requiring emergency evaluation. The QAPI committee did not maintain documentation or monitor the effectiveness of interventions following the incident, and ongoing noncompliance with electrical safety practices was observed, including residents with charging cords in bed and a lack of care plan interventions.
A resident with paraplegia and a neurogenic bladder, who self-catheterized and had a history of incontinence, sustained third-degree electrical burns after urine leaked into a power strip placed in bed. The facility did not assess the resident's ability to use the power strip safely, failed to include necessary interventions in the care plan, and did not report the incident of neglect with physical harm to the State Survey Agency as required.
A resident with complex medical and behavioral needs was not permitted to return to the facility after hospitalization for acute confusion and infection. Despite stabilization and no evidence of ongoing aggression, the administrator informed hospital staff and the resident's family that the resident would not be allowed back, contrary to facility policy and regulatory requirements. Staff interviews indicated the resident's behaviors were related to his medical condition, and the resident was not given the option to return.
A resident with paraplegia suffered second-degree burns in a shower room due to a malfunctioning hot water heater that had been leaking steam and hot water. Despite multiple reports from staff about the issue, the shower room remained in use, and the Administrator's instructions to manage the problem were inadequate. The resident, unable to feel below the waist, was unaware of the danger until injured, highlighting a significant neglect in ensuring resident safety.
A resident with paraplegia sustained second-degree burns on the left foot due to a malfunctioning hot water heater in the shower room, which reached temperatures of 169°F. Despite prior reports of steam and hot water leaks, the facility failed to address the issue, leading to Immediate Jeopardy. Staff were instructed to manage the situation by turning on faucets in adjacent rooms, rather than shutting down the malfunctioning shower room.
A facility's administration failed to address a malfunctioning hot water heater, resulting in a resident suffering a major burn injury. Despite multiple reports from staff about the hazard, the Administrator did not take appropriate action to ensure safety, leading to Immediate Jeopardy citations for substandard care.
Failure to Monitor Skin Under Immobilizer Led to Pressure Injury
Penalty
Summary
The facility failed to provide care and services to prevent the development of a pressure ulcer/injury for one sampled resident with impaired mobility who was readmitted with a left lower leg immobilizer. The resident had diagnoses including a left patella fracture, disorders of bone density and structure, dementia, and osteoarthritis. Hospital documentation stated the resident was to continue wearing the knee immobilizer and could bear weight as tolerated only while wearing it. The facility did not implement the immobilizer-related orders on readmission and did not assess, monitor, or document the skin underneath the immobilizer on multiple days between readmission and the discovery of the wound. Facility policies required proper application, monitoring, maintenance, and documentation of splints and braces, and required ongoing documentation of impaired skin integrity. The record showed one nursing note stating the skin underneath the immobilizer was within normal limits, but daily skilled notes repeatedly lacked documentation that the skin under the immobilizer had been assessed on several dates. The DON stated the standing orders for monitoring should have been entered at readmission but were missed and not entered until the reddened area was discovered. The ADON acknowledged she was notified when the wound was found but did not document her findings, and the LPN who found the wound stated she was not comfortable staging it. On discovery, the resident had a quarter-sized reddened area above the left lateral ankle where the immobilizer had rubbed the skin. The wound later progressed to an unstageable pressure injury with slough and drainage, and the wound culture showed heavy growth Staphylococcus aureus. Subsequent notes described the wound as infected and the resident received doxycycline. The Medical Director stated documentation of how the wound was progressing would have been expected, and the DON stated the wound should have been staged when first found. The facility’s failure to assess the skin under the immobilizer on a daily basis resulted in actual harm to the resident when the reddened area developed into an unstageable pressure ulcer that became infected.
Hand hygiene and PPE not used during wound care
Penalty
Summary
The facility failed to ensure infection prevention and control during wound care when the ADON did not perform hand hygiene and did not use appropriate PPE while treating two residents with pressure ulcers. Facility policy required hand hygiene before and after resident contact, before aseptic tasks, and after removing gloves. The facility’s Enhanced Barrier Precautions policy also identified residents with chronic wounds as indicated for EBP, with gown and gloves used for high-contact resident care activities. CDC guidance reviewed in the report stated that gown and gloves are indicated for nursing home residents with wounds during high-contact care activities. Resident #4 was admitted with diagnoses including fracture of the left patella, dementia, protein-calorie malnutrition, and chronic pain. Her annual MDS showed a BIMS score of 15, indicating she was cognitively intact. Her care plan identified a pressure ulcer to the left lower leg, and the physician ordered daily wound care to cleanse the left lower lateral leg dressing. During observation in the resident’s room, the ADON removed the old dressing, went to the sink and washed her hands for 4 seconds, applied new gloves, and completed the dressing change. After finishing, the ADON returned to the sink and washed her hands for 3 seconds. Resident #18 was admitted with diagnoses including fracture of the left femur, protein-calorie malnutrition, depression, dementia, and kidney failure. Her annual MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and she was coded as having a pressure ulcer. Physician orders required daily wound care for pressure injuries to both heels. During observation, the ADON entered the room without donning PPE, applied gloves, cleansed the left heel, removed gloves, applied another set of gloves, applied medication and a dry dressing, then repeated the process for the right heel. The ADON then washed her hands for 5 seconds. The DON stated that hand hygiene should be performed before starting patient care, after removing a dirty dressing, before applying a new dressing, when done, and after glove changes, and stated that EBP should be followed during a dressing change.
Failure to Address Severe Weight Loss and Nutritional Risk
Penalty
Summary
The facility failed to assess and address the nutritional status of a resident who experienced a severe weight loss of 7.07% within a one-week period. The resident, who had multiple diagnoses including metabolic encephalopathy, neurogenic bladder, BPH, diabetes, and a urinary tract infection, was moderately cognitively impaired and required assistance with eating. Despite a significant weight loss being documented, there was no evidence that the registered dietitian (RD) or facility staff implemented or documented any interventions to address the weight loss or prevent further decline. Facility policies required regular monitoring of weights, prompt notification of significant changes, and individualized nutritional interventions. The resident's weight dropped from 230.5 lbs to 214.2 lbs in one week, and subsequent laboratory results showed low total protein and albumin levels, indicating poor nutritional status. There was no documentation of RD follow-up or progress notes after the initial evaluation, and no evidence of reweighing or new interventions following the significant weight loss. Interviews with staff confirmed that the expected process for addressing significant weight changes was not followed, and the RD was not notified or did not document any follow-up actions. Staff interviews revealed that while CNAs reported poor intake to nurses and offered snacks, and nurses were aware of the need to monitor and report weight changes, the required escalation to the RD and implementation of further interventions did not occur. The DON and other staff confirmed that there was no RD documentation after the weight loss was identified, and the process for monitoring and addressing nutritional risk was not followed as outlined in facility policy. This failure resulted in actual harm to the resident.
Neglect Resulting in Severe Electrical Burns Due to Unsafe Use of Power Strip
Penalty
Summary
A deficiency occurred when a resident with paraplegia, bilateral leg amputations, and a neurogenic bladder sustained third-degree burns to 4% of his body after urine from a self-catheterization or incontinence episode contacted an energized power strip that was positioned in his bed. The resident, who was functionally dependent for many activities and had a history of incontinence, was provided a power strip by the facility administrator after his extension cord was removed. There was no documented assessment of the resident's ability to safely use the power strip, nor was there any care plan addressing the risks associated with electrical devices in the bed, despite the resident's known incontinence and use of multiple electronic devices in bed. Staff interviews and medical record reviews revealed that the resident frequently kept electronics, charging cords, and other items in his bed, and staff were aware of his incontinence and the risk of spillage during self-catheterization. Multiple staff members, including CNAs and nurses, observed the power strip in the bed and reported safety concerns to administration, but there was no evidence of consistent monitoring, intervention, or documentation of the resident's refusals or noncompliance. The care plan did not include interventions related to the safe use of electrical devices, noncompliance behaviors, or monitoring of self-catheterization competency, even though the resident was receiving medications that could cause drowsiness and further increase risk. On the day of the incident, the resident self-catheterized and subsequently experienced an electric shock, resulting in severe burns. The power strip was found melted and deformed, and the resident required emergency medical attention. Staff confirmed that no education or monitoring regarding the safe use of electrical devices in bed had been provided prior to the incident. The facility's failure to assess, monitor, and implement appropriate interventions to prevent physical harm constituted neglect and resulted in actual harm to the resident.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate and provide Basic Life Support (BLS), including Cardiopulmonary Resuscitation (CPR), to a resident who was designated as full code status. According to the facility's policies and the resident's documented preferences, staff were required to perform CPR unless there was a written physician order to the contrary. On the date of the incident, nursing staff found the resident unresponsive, without respirations or a palpable pulse, but did not attempt to perform BLS/CPR as required by both the resident's wishes and physician orders. The resident involved had a medical history that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and pneumonia. The resident was admitted and readmitted to the facility, with documentation confirming full code status and a clear preference for resuscitation efforts in the event of cardiac or respiratory arrest. The medical record, care conference notes, and the Tennessee Physician Orders for Scope of Treatment (POST) form all indicated the resident's desire for full code status, which was discussed and confirmed with both the resident and their representative. On the morning of the incident, the registered nurse assigned to the resident found them unresponsive during routine medication administration. Despite being aware of the resident's full code status, the nurse did not initiate CPR, citing the resident's physical appearance, such as blue fingers and discoloration of the lower extremities, as the reason. Another staff member was told by the nurse that the resident was a Do Not Resuscitate (DNR), which was not accurate. Interviews with other staff and the resident's family confirmed that the expectation was for life-saving measures to be performed in accordance with the resident's wishes. The facility's failure to provide BLS/CPR as required resulted in a citation for substandard quality of care.
Failure to Prevent Accidents and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in avoidable accidents involving five residents. One resident, a bilateral amputee with paraplegia and neurogenic bladder, was electrocuted while lying in bed after urine contacted an energized power strip that had been provided by the Administrator and placed in the resident's bed. This incident resulted in third-degree burns to 4% of the resident's body. Staff and other residents reported that the resident frequently kept electronic devices and cords in bed, and concerns about safety had been voiced to administration, but no effective interventions were implemented to prevent the accident. Staff interviews revealed a lack of clear procedures for approving and monitoring electrical devices, and maintenance did not keep logs or have a set schedule for checking cords and devices. Another resident, who was cognitively impaired, legally blind, and at high risk for falls, was left unattended in the bathroom after being assisted there by staff. The resident stood up and fell, sustaining a left pubic root fracture that resulted in a fatal hemorrhage. The cause of death was documented as blunt force injury of the pelvis. The resident's care plan identified a high risk for falls and required staff assistance with transfers, but staff failed to provide the necessary supervision at the time of the incident. The resident had a history of falls and required substantial assistance with mobility and activities of daily living. Additional residents were observed with electrical devices and charging cords in their beds or attached to bed rails, despite care plans noting noncompliance with electrical device safety. Staff and residents reported that concerns about electrical hazards were not addressed until after state surveyors were present. Facility documentation revealed a lack of policies and procedures for testing patient care-related electrical equipment according to NFPA standards, and numerous devices with deficiencies were identified without records of repair. Staff education on electrical safety was inconsistent or lacking, and there was no evidence of systematic monitoring or enforcement of safety protocols related to accident hazards.
Failure to Implement and Monitor QAPI Interventions for Resident Safety
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee implemented and monitored effective interventions to maintain a safe environment for residents. Despite having a policy in place requiring systematic monitoring and evaluation of resident care, the QAPI committee did not maintain documentation of meeting minutes or evidence of monitoring the effectiveness of interventions following a serious safety incident. Staff interviews and observations revealed inconsistent compliance with education and monitoring related to electrical safety, and there was a lack of consistent oversight for electrical devices and power cords used by residents. An event occurred in which a resident was found in bed with third-degree electrical burns after urine contacted an energized power strip positioned in the bed. The resident required transfer to the emergency room for evaluation. Subsequent observations during the survey found ongoing noncompliance, with residents having charging cords in bed or attached to handrails without appropriate care plan interventions. The Maintenance Director confirmed inconsistent monitoring of electrical devices, and the Administrator was unable to provide QAPI meeting minutes or evidence of performance improvement evaluation related to the incident.
Failure to Report Neglect Resulting in Resident Injury
Penalty
Summary
The facility failed to report an incident of neglect with physical harm to the State Survey Agency as required by federal and state law. A resident with paraplegia, neurogenic bladder, and bilateral above-knee amputations, who was cognitively intact and performed self-catheterization, sustained third-degree electrical burns after urine leaked into a power strip that had been placed in the bed. The administrator had previously removed an extension cord from the resident's room and provided a power strip, but there was no documentation of an assessment to ensure the resident could use the power strip safely, nor was there a care plan addressing the safe use of electrical devices or education provided to the resident about the risks involved. Medical records indicated the resident had a history of incontinence and required assistance with personal hygiene and toileting. Despite this, the care plan did not include interventions for intermittent catheterization or address the resident's refusal of care. Staff documented episodes of incontinence, and the resident was known to keep electronics in bed. After the incident, the resident was sent to the emergency room and admitted for treatment of the burns, which covered approximately 4% of the body surface area. Interviews with facility staff, including the former assistant director of nursing, former director of nursing, and the administrator, confirmed that the incident was not reported to the State Survey Agency. Staff also acknowledged that the resident's competency in self-catheterization was not observed or documented, and that no interventions or education regarding the safe use of electrical devices were implemented prior to the incident. The administrator admitted to not reporting the accident as required by regulations.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, in violation of its own policy and federal regulations regarding resident rights to remain in the facility unless specific criteria for discharge are met. The resident in question had a complex medical history, including osteomyelitis, paraplegia, anxiety disorder, and an ileostomy, and was admitted and readmitted to the facility prior to the incident. Documentation showed that the resident experienced an acute episode of confusion, agitation, and combative behavior, which coincided with a urinary tract infection, sepsis, and metabolic encephalopathy. Staff documented that the resident was resistant to care, removed his colostomy bag, and swung a trapeze bar, but interviews with staff indicated that he had not been physically aggressive toward other residents and that his behavior was likely related to his acute medical condition. On the day of the incident, the resident was sent to the hospital for evaluation due to increased confusion and agitation. The facility completed an involuntary discharge notice, citing safety concerns and an inability to meet the resident's needs. The administrator delivered the resident's belongings and attempted to have the resident sign discharge paperwork at the hospital, despite being informed by hospital staff that the resident was not cognitively able to understand or sign the documents. Hospital case management notes and interviews confirmed that the administrator stated the resident would not be allowed to return to the facility, and this was communicated to both the hospital and the resident's family member. Multiple interviews with facility staff, hospital staff, the ombudsman, and the resident himself revealed that the resident was not offered the opportunity to return to the facility after his medical condition stabilized. The administrator maintained that the resident refused to return, but both the resident and his family member stated they were not given the option. The facility's actions were not consistent with its policy or regulatory requirements, as the resident's acute behavioral episode was related to a treatable medical condition, and there was no evidence that the facility could not meet his needs after stabilization.
Neglect Leads to Resident Burns Due to Malfunctioning Hot Water Heater
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in second-degree burns due to a malfunctioning hot water heater in the Station 2 shower room. The resident, diagnosed with paraplegia and requiring substantial assistance for showers, was exposed to scalding water when the hot water heater began gushing hot water and steam onto the floor. Despite multiple reports of the malfunctioning heater, the shower room remained in use, leading to the resident's injury. Staff, including CNAs and LPNs, had repeatedly observed and reported the hot water heater's issues, such as steam and hot water leaking into the shower room. The Director of Nursing and other staff members had informed the Administrator about the problem, but the shower room was not taken out of service. The Administrator instructed staff to manage the situation by turning on a faucet in an adjacent room, rather than addressing the root cause or closing the shower room. The resident, who had no feeling below the waist, was unaware of the scalding water until it caused burns. The incident was preventable, as staff had been aware of the ongoing issues with the hot water heater. The facility's failure to act on these reports and ensure a safe environment for the resident resulted in Immediate Jeopardy and actual harm to the resident.
Resident Burned Due to Hot Water Heater Malfunction
Penalty
Summary
The facility failed to maintain a safe environment for its residents, as evidenced by dangerously high hot water temperatures in the Station 2 shower room. This failure resulted in a vulnerable resident with paraplegia sustaining second-degree burns on the left foot. The incident occurred when the hot water heater malfunctioned, causing scalding water to spray onto the floor where the resident was seated. The water temperature was measured at 169 degrees Fahrenheit at the time of the incident. Interviews and documentation revealed that the facility had been aware of issues with the hot water heater prior to the incident. Staff reported multiple episodes of steam and hot water leaking from the heater, which had been occurring for several months. Despite these warnings, the facility did not take adequate measures to address the problem. The Administrator and Director of Nursing were informed of the malfunctioning heater, but the issue was not resolved, and the shower room continued to be used. The facility's inaction and improper handling of the hot water heater issue led to Immediate Jeopardy, as the malfunction posed a significant risk to resident safety. Staff were instructed to manage the situation by turning on faucets in adjacent rooms to relieve pressure, rather than shutting down the malfunctioning shower room. This inadequate response contributed to the resident's injury and highlighted a lack of effective communication and problem-solving within the facility.
Failure to Address Malfunctioning Equipment Leads to Resident Injury
Penalty
Summary
The facility administration failed to provide adequate oversight and supervision, resulting in a serious incident involving a malfunctioning hot water heater in the Station 2 shower room. Despite being notified of the issue on multiple occasions, the administration did not take appropriate action to address the hazard. The Director of Nursing (DON) and other staff members were aware of the malfunction, which caused scalding hot water to leak onto the floor, yet the shower room continued to be used for resident care. This negligence led to a major burn injury to a resident's left foot, highlighting a significant lapse in ensuring a safe environment. Interviews with staff revealed that the malfunctioning hot water heater had been reported to the Administrator and Maintenance Director prior to the incident. The DON acknowledged receiving a text message about the issue, and Licensed Practical Nurses (LPNs) reported observing steam and hot water leaking from the shower room. Despite these warnings, the Administrator dismissed concerns, suggesting that the water was not hot enough to cause harm and instructed staff to temporarily alleviate the issue by draining hot water from the heater. The Administrator's failure to take decisive action, such as shutting down the malfunctioning shower room, directly contributed to the resident's injury. The facility was cited for Immediate Jeopardy due to this oversight, with deficiencies noted under F-835, F-689, and F-600, indicating substandard quality of care. The report underscores the administration's responsibility to maintain a safe environment and protect residents from neglect and avoidable accidents.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Gallatin Center For Rehabilitation And Healing | 9.1 mi | ★★★★★ | 0 | 0 |
| The Waters Of Gallatin | 9.7 mi | ★★★★★ | 14 | 0 |
| White House Health Care Inc | 10.8 mi | ★★★★★ | 11 | 0 |
| Nhc Place Sumner | 11.7 mi | ★★★★★ | 3 | 0 |
| Westmoreland Care & Rehab Ctr | 13.6 mi | ★★★★★ | 9 | 0 |
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