Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 3 | 0 |
| Pilgrim Manor | 1.9 mi | — | 0 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 2.7 mi | — | 0 | 0 |
| Apple Rehab Middletown | 3.1 mi | — | 0 | 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 August 2026) and official state health department websites.