Helen Porter Healthcare & Rehab

Based on interviews and record review, the facility failed to maintain dignity and respect for 1 of 6 residents sampled (Resident #1). Findings include: Per interview on 1/13/26 at 11:20 AM, Resident #1 described their experience during a transfer to bed. According to the resident, as their feet began to slide on the floor, the LNA assisting them said, shh. The resident told the LNA to call for assistance, then yelled out for the staff themselves. After this, the LNA called for help. The resident recalled feeling rushed during the transfer. Once in bed, the staff member asked, Do I have anything to worry about? The resident felt this exchange was disrespectful. Per interview with the Administrator on 1/13/26 at 12:15 PM, she confirmed the resident's perspective of the interaction. Per the facility policy titled Resident Rights, effective date 7/8/24, states, You have the right to be treated with dignity and respect. The facility addressed the noncompliance before the investigation visit. Per the Administrator, a Plan of Correction (POC) was implemented around 12/25/25. The POC…

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 store food in accordance with professional standards for food service safety. Findings include:Per review of the facility's Food Safety Systems: Surveillance, Prevention, and Control policy [last revised 7/2024] states, b. All opened or prepared foods will be stored in an approved container (with the appropriate cover), labeled with a description of the food item and the date prepared or opened.C. Labeling.b. TCS [Temperature Controlled for Safety] foods shall be labeled with common name of the food, date the food was made and use by date.TCS food is discarded if not used within 7 days.Per observation of the kitchen freezer on 8/25/25 at 10:41 AM, there was a five-pound bag of diced strawberries that was opened and undated. There was a bag of cut chicken and a bag of frozen meatballs that were opened and not dated. Per interview with the Dietary Manager on 8/25/25 at approximately 10:43 AM it was confirmed that these items in the freezer…

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 provide treatment and services for 1 applicable resident (Resident #79) diagnosed with post-traumatic stress disorder (PTSD). Findings include:Per record review, Resident #79 has a diagnosis of post-traumatic-stress disorder (PTSD) and, as a result, suffers from nightmares and sleep disturbances. Per review of Resident #79's Plan of care meeting notes dated 7/7/25, it mentions how Patient said [he/she] continues to have nightmares and wants to follow-up with provider. Nursing agreed to direct that concern to provider.Per interview with Resident #79 on 8/25/25 at 12:39 PM, s/he reported that nobody here is following up with him/her for psychological services. S/he reports that they have asked many times to have a psychologist to support them with their PTSD. The Resident reports s/he asks every care meeting to get a psychologist or someone from psych services to talk to, but they have not initiated it. Resident #79 reports s/he has tried…

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 ensure medication error rates were not 5% or greater. The total error rate for all observations was calculated at 6.45%. There were 31 medication administration opportunities observed, resulting in 2 errors for 1 of 5 sampled residents (Resident #71) due to not following administration recommendations and not accurately documenting medication administration. Findings include:Per observation on 8/27/25 at 8:34 AM, a Licensed Practical Nurse (LPN) began the process of administering medications to Resident #71. Five medications were crushed together, poured into a medicine cup with yogurt, and Polyethylene glycol 3350 (MiraLAX, a drug prescribed for constipation) was mixed into a half-full 9-oz cup of water. The mixed crushed medications were administered to the resident, and the resident marginally consumed the Polyethylene glycol 3350 and water mixture. The LPN disposed of the remainder of the Polyethylene glycol 3350 and water mixture. Per interview on 8/27/25 at 8:41 AM, the LPN confirmed Polyethylene glycol…

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 and interview, the facility failed to store medications and biologicals within expiration dates, and safely for 1 of 6 residents (resident #17). Per observation and interview on [DATE] at 11:28 AM of the Medication Storage room on Memory Care Unit, with the Unit Manager, the following items were found and confirmed expired: 28 Vacutainer blood collection tubes (a sterile glass or plastic test tube with a colored rubber stopper facilitating the drawing of blood) expired on [DATE] 15 ESwab collection and transport sampling tubes (is used to collect clinical specimens containing aerobic (are bacteria that can grow and live when oxygen is present), anaerobic (are germs that can survive and grow where there is no oxygen) and fastidious bacteria (are microorganisms that are difficult to cultivate in the lab due to their complex or limited nutritional and/or environmental requirements) from the collection site, and transport them to the testing laboratory) expired on [DATE] 2 Micro-Kill Bleach…

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 ensure that food was stored in accordance with professional standards for food safety by leaving a used ice scoop in the ice machine. The facility also failed to monitor the temperatures of refrigerators and freezers daily and report abnormal values for further intervention. Findings include: During the initial tour of the kitchen on 6/3/24 at 10:32 AM with the lead chef it was discovered that the ice scoop was found lying on the ice in the ice machine that is used for 3 out of 3 kitchenettes. Per facility policy of Storage of Food and Non-Food Items reads, Store scoop in storage bin .Do not store the provided ice scoop in the machine. The lead chef confirmed that the ice scoop was in the ice machine per interview at 10:35 AM and 11:06 AM. On 6/3/24 at 10:47 AM in the main dining room meal service area it was discovered that the refrigerator temperature log for 6/3/24 was documented as 44 [degrees] in the AM temperature log. The AM freezer log temperature was not documented. Per record review of the Recording…

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 staff interviews and record reviews, the facility failed to ensure that residents who are trauma survivors receive trauma-informed care that mitigates triggers that may re-traumatize residents for 3 of 8 sampled residents (Resident #33, #71, and #34). Findings include: 1) Per record review, Resident #33 was admitted to the facility on [DATE] with a diagnosis of PTSD (post-traumatic stress disorder), anxiety, and depression. Resident #33's care plan includes a focus of alterations in mood related to the diagnosis of anxiety, PTSD, and depression, with manifestations that include negative verbalizations about others, tearfulness, sudden mood changes, anger, and self-harming behavior at times. A mental health clinician assessment note dated 1/26/24 mentions details of Resident #33's past trauma. Per review of Resident #33's record, no evidence was found that the resident was assessed for triggers that may re-traumatize the resident. No evidence was found in Resident 33's plan of care regarding the…

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 that each eligible resident receives the COVID-19 vaccine for 2 of 5 sampled residents on the rehabilitation unit (Residents #39 and #60). Findings include: 1. Per record review, Resident #39 was admitted to the facility on [DATE] and has diagnoses that include cerebral palsy (disorder of movement that affects muscle tone, and posture, developed before birth), spinal bifida (failure of the spinal completely close), chronic stage 4 pressure ulcers (deep wounds that may expose bone, tendon or muscle), and osteomyelitis (infection of the bone), The Resident #39 is currently receiving negative pressure wound therapy to treat the stage 4 pressure ulcers. Resident # 39 is considered high risk for COVID-19 complications because of his/her diagnoses. Per record review, Resident #39's last COVID-19 vaccination was administered on 5/21/21 and was not provided the 2023-2024 seasonal COVID-19 immunization. There is no evidence in the record that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to provide care and services according to accepted standards of clinical practice regarding Physician Orders and notification for 1 resident [Res.#83] of 35 sampled residents. Findings include: Per record review, after a stay in the hospital, Res. # 83 was admitted to the facility on [DATE] with acute back pain. The resident was placed on a post-hospitalization nursing unit, where resident's vital signs, including their blood pressure, are measured at least twice a day. Res. #83's blood pressure upon admission to the facility was recorded as 121/75. Physician Orders for Res.#83 upon admission included: Notify provider . for: Systolic Blood Pressure: less than 100 mmHg. Review of Nursing Notes for Res.#83 included the resident's vital signs, including blood pressures. If Res.#83's blood pressure is below 90 systolic [The first (upper) number] the number is preceded by a red !, which per the electronic medical record program indicates abnormal. The…

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 include residents, to the extent practicable, in their care plan meetings and failed to document in the resident's medical record resident participation, or to document if the resident's participation is determined not practical for the development of the resident's care plan, for 3 of 19 residents (Residents #60, #71 and #51). Findings include: #1) On 05/01/23 at 11:11 AM during an interview with Resident #60, when asked if s/he had been included in the resident's care plan meetings, the resident replied that s/he has never heard of a care plan. S/he further stated s/he has no resident representative who would attend a meeting on his/her behalf. This resident was alert and able to voice concerns clearly during the interview. Record review shows Resident #60 was admitted on [DATE] and reveals a BIMS score of 13 (Brief Interview for Mental Status -a tool used to identify a resident's cognitive functioning, with 8-12 indicating moderately impaired…

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.