Porthaven Post Acute

In the surveyor’s words

From the most serious findings on record at Porthaven Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 7, 2024

  Based on interview and record review it was determined the facility failed to implement policies and procedures for the prevention of sexual abuse for 2 of 2 sampled residents (#s 1 and 2) reviewed for abuse. This failure, determined to be an immediate jeopardy situation, placed residents at risk for sexual abuse when staff witnessed repeated nonconsensual sexual activity without putting interventions in place. Findings include: A 1/2023 facility abuse policy indicated the following. - A thorough investigation is completed through a systematic collection and review of evidence/information that describes and explains an event or series of events. It seeks to determine if abuse occurred, and how to prevent further occurrences. […]

• Actual harm, isolatedF600Apr 16, 2025

  Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 resident (#2) reviewed for physical abuse. This resulted in physical injury and prolonged pain which required increased pharmaceutical interventions. Findings include: Resident 2 was admitted to the facility in 4/2023 with diagnoses including multiple spinal fractures and mild cognitive impairment. The 1/9/25 Quarterly MDS, revealed Resident 2 had severe cognitive impairment and was independent with mobility. […]

• Actual harm, isolatedF689Jan 4, 2024

  Based on interview and record review it was determined the facility failed to ensure a resident was provided supervision and positioning assistance with eating and follow a resident's care plan related to bed mobility and bathing for 2 of 3 sampled residents (#s 5 and 11) reviewed for accidents. This resulted in Resident 5 aspirating while eating without supervision and positioning assistance. Findings include: 1. Resident 5 was admitted to the facility in 2023 with diagnoses including difficulty swallowing following a stroke and respiratory failure. Resident 5's Care Plan initiated on 7/11/23 indicated the resident required one-on-one staff supervision while eating. […]

• No harm, potential for more than minimal, widespreadF880Aug 16, 2024

  Based on observation, interview, and record review it was determined the facility failed to follow infection control standards for 2 of 4 halls (East and Annex Halls), 1 of 1 dining room, and 2 of 4 sampled residents (#s 28 and 37) reviewed for dining and skin conditions. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. The Centers for Disease Control and Prevention website, section titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers, when shared. […]

• No harm, potential for more than minimal, widespreadF725Mar 19, 2021

  Based on interview and record review it was determined the facility failed to ensure call lights were answered timely for 1 of 3 sampled residents (#1) reviewed for call lights. This placed residents at risk for unmet needs. Findings include: Resident 1 was admitted to the facility in 10/2020 with [DIAGNOSES REDACTED]. The 10/20/20 Admission MDS Assessment indicated Resident 1 required staff to manage, monitor and empty the resident's ileal conduit drainage bags. According to 10/22/20 intake interview for a public complaint called into the State Survey Agency Resident 1 used the call light for assistance with her/his [MEDICAL CONDITION] bag and waited hours for a response from staff. […]