Honorage Nursing Center

In the surveyor’s words

From the most serious findings on record at Honorage Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF625Mar 17, 2022

  Based on record reviews, interviews and review of the facility policy titled, Bedhold Notification/Policy, the facility failed to ensure Resident (R)32, R30, R33 and R51 and/or their responsible party received the Bedhold Notification Policy with the bed hold amount in a timely manner for 4 of 4 residents reviewed for hospitalization s. Findings include: The facility admitted R32 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/15/22 at 1:30 PM of the medical record for R32 revealed confirmation of a hospital stay starting 1/8/22 and returning to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF561May 30, 2024

  Based on record review, interviews, and review of facility policy, the facility failed to honor Resident (R)8's choices for bathing and showering, for 1 of 2 residents reviewed for Activities of Daily Living (ADL). Findings include: Review of the undated facility policy titled, Activities of Daily Living revealed, staff assists or performs activities of daily living (bathing, dressing, grooming, eating, toileting, etc ) as indicated. Review of R8's Face Sheet revealed R8 was admitted to the facility on [DATE], due to system conversion, original admitted was 06/15/23, with diagnoses including but not limited to: heart failure, morbid obesity, muscle weakness, major depressive disorder, Parkinson's Disease and acquired absence of left leg above the knee. […]

• No harm, potential for more than minimal, isolatedF689May 30, 2024

  Based on interviews and record review, the facility failed to provide adequate supervision for Resident (R)50, to prevent potential accidents. Findings include: The facility does not have a policy on Supervision for residents. Review of R50's Face Sheet revealed R50 was admitted to the facility on [DATE], with diagnoses including but not limited to: insomnia, altered mental status, post concessional syndrome, contusion of unspecified part of head, and unspecified dementia. Review of R50's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/24, revealed R50 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating R50 has severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF760Mar 17, 2022

  Based on record reviews, interviews and review of the facility's policy titled, Medication Administration Schedule Policy and Procedure, the facility failed to ensure Resident (R) 32 was free of significant medication errors. R32 did not receive the medication, [MEDICATION(S)] 0.4 milligrams (mg) as ordered for chest pain for 1 of 4 residents reviewed for hospitalization . Findings Include: The facility admitted R32 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/17/22 at 10:42 AM of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review on 3/17/22 at 10:45 AM of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF761Mar 17, 2022

  Based on observations, record reviews, interviews, manufacturer package insert, pharmacy labeling and facility policy, the facility failed to assure that in-use insulin was properly dated as to opening and expiration dates and that expired insulin had been removed from active storage on 1 of 4 medication carts. Findings include: On [DATE] at approximately 10:26 AM, inspection of the East Wing Medication Cart A revealed one opened [MEDICATION(S)] R Insulin vial, 100 U (unit)/ml (milliliter), belonging to Resident (R)43, not dated as to date of opening or expiration and one [MEDICATION(S)] R Insulin [MEDICATION(S)] 100 U/ml, belonging to R29, dated by the facility as opened [DATE] with no expiration date. […]