Inspection Reports for Porter Place
17833 S Harlem Ave, Tinley Park, IL 60477, United States, IL, 60477
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Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple facility reported incidents and complaint investigations related to resident care and medication management.
Findings
The facility failed to ensure a resident received assistance with bathing as required and failed to properly document showers. Additionally, the facility failed to keep medications locked and inaccessible to residents and did not properly dispose of controlled substances for residents who had expired.
Complaint Details
Multiple complaint investigations were conducted, all noted as unsubstantiated except for specific regulatory violations related to bathing assistance and medication storage and disposal.
Severity Breakdown
Type 3 Violation: 1
Type 2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident received assistance with bathing and proper documentation of showers. | Type 3 Violation |
| Failure to ensure medications were kept locked and inaccessible to residents and failure to dispose of controlled substances after resident discharge or death. | Type 2 Violation |
Report Facts
Residents reviewed for bathing: 3
Residents reviewed for medication storage: 7
Residents with medication storage issues: 2
Dates missing shower documentation: 3
Medication quantities: 20
Medication quantities: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Assistant Director of Nursing | Provided shower sheets and explained documentation process |
| E5 | Resident Care Manager | Explained controlled substances storage and destruction procedures |
| E2 | Clinical Services Director | Noted medication cart was unlocked and medications of discharged residents were improperly stored |
| E1 | Executive Director | Commented on medication cart security and controlled substance destruction procedures |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 11, 2024
Visit Reason
Annual licensure survey to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations during this annual licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 27, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (Complaint #IL181402 and FRI #IL179578, #IL175513, #IL174256, #IL173985) regarding service plan deficiencies and abuse/neglect concerns at Porter Place.
Findings
The facility failed to develop and implement individualized service plans with goals and interventions to prevent repeated falls for 4 of 6 residents sampled, resulting in a substantial probability of severe harm. Additionally, the facility failed to investigate unexplained bruising and injury for one resident, lacking a complete written investigation into the cause of injuries.
Complaint Details
Complaint #IL181402 was unsubstantiated. The investigation revealed failures in service plan revisions and abuse/neglect reporting and investigation requirements.
Severity Breakdown
GENERAL VIOLATION: 1
TYPE 3 VIOLATION: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement individualized goals and interventions to address resident falls and aggressive behavior for multiple residents. | GENERAL VIOLATION |
| Failure to investigate unexplained bruising and injury for a resident and provide a complete written investigation report. | TYPE 3 VIOLATION |
Report Facts
Resident falls: 10
Resident falls: 16
Resident falls: 14
Resident falls: 3
Cognitive assessment score: 12
Cognitive assessment score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Unable to provide evidence of a complete written investigation into the cause of resident R3's injuries on 5/20/24 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 27, 2024
Visit Reason
The Illinois Department of Public Health conducted an investigation of self-reported incidents and a complaint investigation at the facility to determine the validity of allegations related to resident abuse, neglect, and service plan deficiencies.
Findings
The investigation substantiated four Facility Reported Incidents (FRIs) and found one complaint unsubstantiated. The facility was cited for one General Violation related to failure to develop and implement individualized service plans addressing resident falls and aggressive behavior, and one Type 3 Violation for failure to investigate unexplained bruising and injury to a resident. A fine of $1,000 was imposed.
Complaint Details
Complaint #181402 was investigated and found to be unsubstantiated. Four Facility Reported Incidents (#173985, #174256, #175513, #179578) were substantiated. The investigation included review of resident records, interviews, and on-site analysis.
Severity Breakdown
General Violation: 1
Type 3 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement individualized goals and interventions to address resident falls and aggressive behavior, affecting 4 of 6 residents sampled. | General Violation |
| Failure to investigate unexplained bruising and injury for one resident (R3). | Type 3 Violation |
Report Facts
Fine amount: 1000
Resident falls: 10
Resident falls: 16
Resident falls: 14
Investigation timeframe: 14
Notification timeframe: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamika Henry | RN (Clinical Services Director) | Held in-service training on 12/18/24 regarding plan of correction |
| Laporsha Chavers | Executive Director | Interviewed regarding investigation and inability to provide evidence of complete written investigation |
| Edward Pitts | RN-BSN, PSA | Author of the complaint investigation letter |
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