Porter Hills Health Center

Based on observation, interview, and record review the facility failed to ensure personal resident information was kept private for 20 (Resident #5, #19, #32, #22, #37, #21, #20, #28, #10, #26, #14, #34, #12, #36, #9, #27, #29, #38, #17, & #8) of 37 residents reviewed for privacy resulting in the feeling of being uncomfortable with others having access to their personal information and the potential for further personal information to be accessed by unauthorized persons. Findings include:Resident #5:Review of Resident #5's brief interview for mental status, dated 6/19/25, was scored 15 which reflected intact cognition. During an observation and interview on 07/22/2025 at 10:34 AM, in Resident #5's room there was an approximately 8 inches by 11 inches piece of paper, untitled and undated, with various pieces of information on 20 residents (Resident #5, #19, #32, #22, #37, #21, #20, #28, #10, #26, #14, #34, #12, #36, #9, #27, #29, #38, #17, & #8) facing up with the information visible. This document was on an approximately thigh high table next to the window in Resident #5's room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents who consume food from the kitchen. Findings include: During a tour of the facility, starting at 9:40 AM on 7/30/24, an interview with Chef Manager U found that the facility does not cool much, but they do maintain a log for cooling. During a tour of the walk-in cooler, at 9:46 AM on 7/30/24, it was observed that three 1/8th pans of leftover breakfast puree items were found in the walk in cooler warm to the touch and covered in saran wrap. When asked about the items, Chef Manager U stated they don't typically keep those items. During a revisit to the kitchen, at 3:12 PM on 7/30/24, it was observed that a 1.5 gallon container of Corn chowder soup was found in the walk in cooler covered with saran wrap. A temperature of the soup was taken at this time and was found to be 107ºF in the middle. An interview with [NAME] V and Dining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments in 2 of 12 residents (Resident #18 & #33) reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's status. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 3 Section O: Special Treatments, Procedures, and Programs, revealed .The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods .The treatments, procedures, and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life .Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update/revise a comprehensive care plan after a change in resident condition in 3 of 12 residents (Resident #18, #8, & #37) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to thoroughly assess, investigate and prevent falls, in one of three residents reviewed for falls (Resident #37), resulting in likelihood of additional falls and injuries. Findings include: Resident #37 (R37) On 7/30/2024 at 9:56 AM, R37 was observed lying in bed and stated he fell from his wheelchair recently attempting to reach for his call light and had scraped his back. In review of R37's Minimum Data Set (MDS) with assessment reference date of 6/11/2024, he was admitted at the facility on 2/29/2024; had a Brief Interview for Mental Status (BIMS, a short cognitive screener) score of 13 (13-15 Cognitively intact). The same MDS indicated R37 had a diagnosis of dementia and had a history of a stroke with weakness/paralysis on one side of his body. Incident Report dated 3/07/2024 at 9:45 AM revealed R37 fell in his room and called a family member for help. The same report revealed R37 was observed lying on his left side next to the bed in his room and stated to staff he was reaching for his cell phone with his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive vaccination if eligible for 2 (Resident #9 and #18) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Resident #9 Review of an admission Record revealed Resident #9 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes. Review of Resident #9's Immunization Record indicated that Resident #9 received a PCV13 (pneumococcal vaccination) on 5/2/2017. During an interview on 7/31/24 at 2:35 PM, Director of Nursing (DON) B reported that she was responsible for ensuring all residents were screened for vaccination eligibility and administration. DON B was unable to report when Resident #9 was last reviewed for pneumococcal vaccination eligibility. In a communication via email on 7/31/24 at 5:10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assure a Registered Nurse was on duty for eight consecutive hours a day seven days a week, resulting in the potential for inadequate coordination of emergent or routine care with negative clinical outcome affecting all residents in the facility. Findings include: Review of the Payroll Based Journal (PBJ) report revealed: the facility triggered for No RN Hours .four (4 ) or more days within the quarter with no RN hours. for the Fiscal Year (FY) Quarter 2 2023 ([DATE] - [DATE]) On the following dates: No RN Hours Triggered for 1/2/23 (Mon); 1/7/23 (Sat); 1/8/23 (Sun); 1/15/23 (Sun); 1/21/23 (Sat); 1/22/23 (Sun); 2/4/23 (Sat); 2/11/23 (Sat); 2/12/23 (Sun); 2/25/23 (Sat) . During an interview on 6/14/23 at 12:30 PM., Nursing Home Administrator (NHA) A reported during the beginning of the year (January and February 2023) their (the facilities) weekend Registered Nurse (RN) that typically worked the weekend shifts had broken her ankle. NHA A reported she had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a home exercise program (HEP also known as restorative exercise program) per physician order for 1 (Resident #18) of 1 resident reviewed for rehabilitation and restorative services resulting in the potential for decline in range of motion and mobility and increased weakness. Findings include: Resident #18 Review of a Face Sheet revealed Resident #18 was a male, with pertinent diagnoses which included: weakness; primary osteoarthritis, left shoulder; and primary osteoarthritis, right shoulder. Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 4/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #12 was cognitively impaired. In an interview on 6/12/23 at 11:40 AM, Resident #18 reported would like to have more therapy. Resident #18 reported had been receiving therapy 2-3 times per week to work on his arms but thought therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform proper hand hygiene during wound care dressing change for 1 resident (Resident #185) reviewed for wound care resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: Resident #185 Review of an admission Record revealed Resident #185, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: lymphedema (Tissue swelling caused by an accumulation of fluid, most commonly occurring in the arms and legs) Review of a Minimum Data Set (MDS) assessment for Resident #185, with a reference date of 5/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #185 was cognitively intact. During an observation on 06/13/23 at 10:57 AM., Licensed Practical Nurse (LPN) O entered Resident #185's room, applied gloves, and did not perform hand hygiene. LPN O removed a plastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.