Heritage Hall-Blackstone

In the surveyor’s words

From the most serious findings on record at Heritage Hall-Blackstone, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF582May 17, 2023

  Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide notice of Medicare non-coverage for two of three beneficiary protection notification resident reviews, Residents #50 and #62. The findings include: 1. For Resident #50 (R50), the facility staff failed to provide the resident and/or the responsible party with an ABN (advance beneficiary notice) to allow them to make an informed decision regarding their care. R50's last covered day of Medicare part A services was 2/28/2023. R50 was admitted to the facility on [DATE]. R50's diagnoses included but were not limited to congestive heart failure, type two diabetes mellitus and cerebral infarction. […]

• No harm, potential for more than minimal, patternF756May 17, 2023

  Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the monthly drug regimen reviews for one of 48 residents, Resident #66. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: CVA (cerebral vascular accident), dysphagia, anxiety disorder, cognitive communication deficit, unspecified dementia without behavior/psychosis/mood/anxiety behaviors. A review of the comprehensive care plan dated 3/20/23, which revealed, PROBLEM/NEED: Psychotropic drug use APPROACHES: evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. […]

• No harm, potential for more than minimal, patternF759May 17, 2023

  Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a medication error rate less than 5% for three of five residents in the medication administration observation, Residents #76, #84 and #132. The findings include: 1. For Resident #76 (R76), the facility staff failed to administer Lasix (1) as ordered by the physician. On 5/16/2023 at 8:09 a.m. an observation was made of LPN (licensed practical nurse) #4 administering medications to Resident #76. […]

• No harm, potential for more than minimal, patternF761Nov 17, 2021

  Based on observation, staff interview and facility document review it was determined the facility staff failed to secure Medications in a safe and secure manner according to professional standards in three of three medication carts, (Wing 100-medication cart-two, Wing 200-medication cart-one and Wing 200-medication cart-two). The findings include: One whole pill and two half-loose unidentified pills were observed in the second drawer of the Wing 100-medication cart-two. Three half unidentified pills were observed in the second drawer of the left side of Wing 200-medication cart-one and an opened bottle of pills without a cap was observed in the third drawer on the right side of Wing 200-medication cart-one. […]

• No harm, potential for more than minimal, patternF812Nov 17, 2021

  Based on observation, staff interview and facility document review, it was determined that facility staff failed to store, and prepare food in in accordance with professional standards for food service safety. Facility staff were observed drying clean dishes using a cloth and paper towels and a fan with coated with gray dust and lint on the front and back blade guards was found blowing air over the area where dishes were washed and racked to dry. The findings include: On 11/16/2021 at approximately 9:35 a.m., an observation of the facility's dish room revealed OSM [other staff member] # 2, dietary aide removing and wiping dry clean trays, plates from the dishwashing racks on the clean dish line. […]