Portside Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Portside Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 1, 2024

  Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure one resident was safe from falling during ADL Care, which constituted harm for 1 of 8 residents (Resident #4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 2/12/22. The resident was last discharged from the facility to a local hospital after a fall and returned 6/26/24. The resident's diagnoses included left hip fracture, distal right femur periprosthetic displaced comminuted fracture, anemia, muscle weakness, hypertension, and depression. […]

• No harm, potential for more than minimal, patternF641Dec 12, 2024

  Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide an accurate assessment for four of 43 residents, R25, R124, R125 and R10. The findings include: 1. The facility failed to provide an accurate assessment including dialysis treatment for R25. Resident #25 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), Sepsis and bilateral osteoarthritis. […]

• No harm, potential for more than minimal, patternF655Dec 12, 2024

  Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop/implement a baseline care plan for two of 43 residents in the survey sample, Resident #176 (R176) and R177. The findings include: 1. A. The facility failed to develop a baseline care plan to include PTSD (post-traumatic stress disorder) for R176. R176 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), CHF (congestive heart failure) and CVA (cerebrovascular accident). […]

• No harm, potential for more than minimal, patternF656Dec 12, 2024

  Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for four of 43 residents in the survey sample, Residents #15, #75, #8, and #70. The findings include: 1. For Resident #15 (R15), the facility staff failed to implement the resident's comprehensive care plan for anticoagulant therapy. R15's comprehensive care plan dated 8/15/24 documented, (R15) is on Anticoagulant therapy .assess/document/report to nurse/MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle… […]

• No harm, potential for more than minimal, patternF657Dec 12, 2024

  Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to review and/or revise the comprehensive care plan for four of 43 residents in the survey sample, Residents #23, #70, #20 and #89. The findings include: 1. For Resident #23 (R23), the facility staff failed to revise the care plan for the use of bed rails. On 12/9/24 at 8:04 p.m., an observation was made of R23 in bed with bilateral upper bed rails in place. Additional observation on 12/10/24 at 9:39 a.m. revealed R23 in bed with bilateral upper bed rails in place. The comprehensive care plan for R23 documented in part, Problem Start Date: 08/07/2024. […]