Blue Heron Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Blue Heron Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 27, 2023

  Based on observation, interview and record review, the facility failed to maintain the kitchen in an clean and sanitary manner. Findings included: During the initial tour of the kitchen on 04/24/23 at 09:20 AM with the Dietary Manager present The following was revealed: -The range hood was noted with grease drippings on light covers. -Debris was noted on top of the dish machine. -Food prep pans were noted to be to be drying face up. -Food storage bins were noted to be drying face up. (Photographic Evidence Obtained) On 04/26/23 at 03:06 PM a Comprehensive tour of the kitchen was conducted with the Dietary Manager and the Assistant Dietary Manager present. […]

• No harm, potential for more than minimal, widespreadF814Apr 27, 2023

  Based on observation, interview and record review, the facility failed to dispose of garbage and refuge in an appropriate manner. Findings included: During the initial tour of the kitchen on 04/24/23 at 09:20 AM with the Dietary Manager present an inspection of the dumpster area was conducted. The dumpster area was noted to have debris and refuge around the trash receptacles. (Photographic Evidence Obtained). Continued inspection of the dumpster areas revealed that there was a used oil receptacle next to the dumpster. The used oil receptacle was noted to have a lid which was uncovered and debris and refuge was noted to be sitting on the inner surface of the opened container. […]

• No harm, potential for more than minimal, patternF644Jul 31, 2025

  Based on record review and interview the facility failed to complete the Pre-admission Screening and Resident Review (PASARR) Level II for residents with qualifying mental health diagnosis for three residents (#17, #16, #8) of five residents reviewed for PASARRS. Review of Resident #17's medical record revealed the resident was admitted to facility on 12/11/2022 with diagnoses to include Alzheimer’s Disease, Unspecified; Dementia in other diseases classified elsewhere, Mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified psychosis not due to a substance or known physiological condition; schizoaffective disorder, unspecified, Encephalopathy. […]

• No harm, potential for more than minimal, patternF561Apr 27, 2023

  Based on observations, record reviews, and interviews the facility failed to ensure three (#196, #54, #349) out of 42 sampled residents were assessed for food and drink preferences, received meals as indicated on menu, and five (#21, #23, #52, #97,and #198) of five residents were offered to have meals in the facility's first floor dining room. Findings included: An observation was conducted on 4/26/23 at 9:45 a.m., of Resident #196 sitting on edge of bed wearing a right arm lower forearm brace as the breakfast tray was delivered. The resident stated that today was the first time that coffee had been offered (not on tray) by the Certified Nursing Assistant (CNA). […]

• No harm, potential for more than minimal, patternF758Apr 27, 2023

  Based on interviews and record review, the facility failed to ensure behavior monitoring was in place related to psychotropic medication use for five residents (#76, #34, #85, #79, #14) out of five sampled residents. Findings included: 1. The admission record for Resident #34 revealed admitted [DATE] and diagnoses that included dementia and depression. The Minimum Data Set (MDS) dated [DATE], Section C, revealed a Brief Interview for Mental Status (BIMS) score of 7 which meant the resident had moderate cognitive impairment. Sections D and E of the MDS revealed no mood disturbance and no presence of behavioral symptoms. Active physician orders revealed medication duloxetine 60 mg (milligrams) at bedtime for depression, start date 10/28/22. […]