Heron's Key

In the surveyor’s words

From the most serious findings on record at Heron's Key, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 31, 2023

  Based on interview and record review, the facility failed to implement the planned preventative measure of two person assist when using mechanical devices to ensure safety and prevent falls for 1 of 3 residents (Resident 1) reviewed for accident hazards. This failure resulted in harm to Resident 1 who experienced pain and sustained a left upper arm fracture when they were transferred with one person assist rather than two person assist as they were assessed to require. This failure also placed other residents at risk for falls, injury, and diminished quality of life. Findings included . […]

• Actual harm, isolatedF689Jan 4, 2022

  Based on observation, interview and record review, the facility failed to prevent and immediately assess and treat a burn injury when one of four residents (Resident 1) reviewed for accidents spilled hot soup at lunch time. This failure resulted in harm to Resident 1 when assistance during mealtime was not provided per assessment, the resident sustained a blistering burn injury, and the nurse was not notified immediately so that the resident could be assessed for injury and provided with first aid and pain management in a timely manner. Findings included . Resident 1 was admitted [DATE] with diagnosis of Alzheimer's Disease. […]

• No harm, potential for more than minimal, widespreadF572Nov 15, 2024

  Based 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. Findings included . During an interview on 11/12/2024 at 9:15 AM, Staff A, Administrator (ADM), stated they did not have a Resident Council President. […]

• No harm, potential for more than minimal, widespreadF812Nov 15, 2024

  Based 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. Findings included . <Kitchen Observation> Observation on 11/13/2024 at 11:25 AM showed a peroxide cleaning spray hanging from food shelfing containing raw bananas and tortillas. Observation on 11/13/2024 at 11:28 AM showed Staff K, Cook, had an uncovered beard and was cutting pieces of pie at a preparation station. […]

• No harm, potential for more than minimal, patternF623Nov 15, 2024

  Based 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 . Findings included . Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and heart failure. Resident 1 was able to make needs known. Review of Resident 1's EHR showed a hospitalization on [DATE], and readmission to the facility on [DATE]. […]