Heron's Key

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess dental status for 1 of 2 sampled residents (Resident 8) when reviewed for dental care. This failure placed the Resident at risk of pain, weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality care related to monitoring of resident skin injuries (bruises), bowel management, and orthostatic blood pressure (blood pressure taken while a person is laying, sitting and standing to monitor for sudden drop in pressure) for 2 of 9 sampled residents (Residents 8 and 11) when reviewed for quality of care. This failure placed residents at risk of injuries, untreated constipation, discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental care for 1 of 2 sampled residents (Resident 3) when reviewed for dental needs. This failure placed the resident at risk for difficulty eating, dental pain, unintended weight loss, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to periodically inform residents of their rights after residents were admitted to the facility for 8 of 8 sampled residents (Residents 1, 3, 6, 9, 13, 14, 15 and 16) when reviewed for resident rights. This failure placed residents at risk of not being informed of their rights and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to sanitarily prepare food in the facility kitchen and failed to monitor resident refrigerators for 1 of 2 resident refrigerators (Front Refrigerator) when reviewed for kitchen. These failures placed residents at risk of consuming contaminated food, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer to the hospital to residents or responsible party for 1 of 1 sampled residents (Resident 1) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility and diminished protection from being inappropriately discharged .

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 1 of 1 sampled residents (Resident 1) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure married residents were provided the right to share a room for 2 of 2 sampled residents (Residents 1 and 4) reviewed for room changes. This failure placed residents at risk for psychosocial stress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to determine if a resident had current advanced directives (AD), and if not, determine whether the resident wished to develop advanced directives for 1 of 4 sampled residents (Resident 9) when reviewed for AD. This failure potentially denied the resident the opportunity to direct their healthcare if they were to become unable to make decisions or communicate their health care preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan about post-traumatic stress disorder (PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event) for 1 of 8 sampled residents (Resident 6) reviewed for care planning. This failure placed the resident at risk for unidentified and unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently implement the bowel program when needed for 1 of 5 sampled residents (Resident 15) reviewed for unnecessary medications. These failures placed the residents at risk for discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe environment was maintained related to a reclining chair for 1 of 2 sampled residents (Resident 14) and common area appliances were safe from resident use for 2 of 2 common area ovens (East and West) when reviewed for accidents. These failures placed residents at risk for avoidable injuries and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed initiate non-pharmacological interventions prior to the administration of as needed pain medication for 1 of 5 sampled residents (Resident 14) reviewed for unnecessary medications. This failure placed residents at risk for receiving unnecessary medications and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary piece of equipment was available to 1 of 2 sampled residents (Resident 6) reviewed for safe and sanitary environment/equipment. This failure placed the resident at risk for infection and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to post actual nurse staffing hours for 11 of 11 months reviewed (01/10/2024 through 11/14/2024) when reviewed for nurse staff posting. This failure placed residents and family at risk of not knowing the actual number of staff working within the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were served meals at appropriate temperatures. This failure placed the residents at risk for food bourne illness, decreased satisfaction with meals and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to adequately monitor for adverse side effects of anticoagulant (blood thinning) medications for 2 of 5 sampled residents (Residents 15 and 9) reviewed for unnecessary medications. This failure placed the residents at risk for unidentified adverse side effects and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled, dated, or discarded in accordance with currently accepted professional standards for 2 of 2 medication carts (1200 and 1300 carts) reviewed for medication storage. This failure placed residents at risk of receiving compromised or expired medications.