Hegg Memorial Health Center

Based on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination and by placing serving utensils on contaminated surfaces then using them. The facility reported a census of 58 residents.Findings include:A continuous observation on 11/5/25 at 9:01 AM of Staff A, [NAME] revealed pureed ham placed in food processor, ham processed, 3 metal steam table containers removed from shelf, containers placed on the table top, ham measured into each container, scoop placed in measuring cup, metal steam table containers placed in oven, green handled scoop removed from drawer, scoop placed on the metal counter where metal steam table containers were previously, pureed asparagus placed in processor, pureed asparagus removed from processor and placed in a measuring cup, obtained 3 metal steam table containers from the shelf, green scoop pushed to the right side of the metal table top, green scoop picked up, green scoop utilized for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notices were signed by residents and or the resident's responsible person when residents transferred out of the facility. The bed hold notice also failed to notify the amount per day the resident or representative agreed to pay for 2 of 2 residents reviewed (Residents #1and #8). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented reentry to the facility for a short term hospital stay. Review of the Clinical Census report for Resident #1 revealed the following information: 1. 3/25/25- entered hospital 2. 3/29/25- end hospital 3. 8/21/25- entered hospital 4. 8/25/25- end hospital Review of the Progress Notes for Resident #1 revealed the following: 1. 3/25/25 at 1:30 AM, Resident admitted due to shortness of breath. 2. 8/21/25 at 10:39 AM, Resident sent to clinic and admitted due to shortness of breath and edema.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Electronic Health Record (EHR) review, document review, staff interview and policy review the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents by not serving residents on International Dysphagia Diet Standardization Initiative (IDDSI) level 5 diet (minced and moist) the appropriate amount of meat according to the menu for 3 of 3 residents reviewed, (Residents #41, #43 and #52). The facility reported a census of 58 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #41 had a Brief Interview for Mental Status (BIMS) of 7 indicating severe cognitive impairment. Review of Resident #41's EHR dated 7/23/25 titled, Diet Orders documented an order for a regular diet with IDDSI 6 meat.2. The MDS dated [DATE] documented Resident #43 had a BIMS of 5 indicating severe cognitive impairment.Review of undated document, Texture Modifications documented Resident #43 was on a regular diet with minced/moist meats.Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that staff practiced safe transfer techniques for 1 of 2 residents. Resident #5 required the use of the mechanical lift for transfers and staff used a sling that was 2-sizes larger than the manufacturer recommended size for her weight. The resident had a decline in condition which changed her ability to tolerate the mechanical lift transfer. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit). She was totally dependent on staff for sit to lying, chair to bed transfers and toileting. Resident #5 was frequently incontinent of urine and bowel and had diagnosis that included; anemia, heart failure, Diabetes Mellitus, malnutrition and anxiety disorder. The Care Plan last reviewed on 9/27/24, showed that Resident #5 was totally dependent on staff to assist with Activities of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, facility policy, and staff interview, the facility failed to provide a process in which grievance may be anonymously submitted. The facility reported a census of 52 residents. Findings include: Tour of the facility's main lobby and each of the 3 neighborhoods on 9/25/23 at 2:31 PM lacked observation of posted information about how to file a grievance or how to file an anonymous grievance. In an Electronic Mail (email) on 9/26/23 at 4:40 PM, the Director of Nursing (DON) reported that no grievances were filed since the last survey (June 2022). In a concurrent facility tour, Grievance Policy review, and interview on 9/27/23 at 3:17 PM, the DON located a binder in the main lobby that contained 2 grievance forms and the grievance policy. Upon review of the Grievance Policy, the DON was unable to locate information about how residents or their representatives could file an anonymous grievance. In the same interview, the DON agreed that there was no way for residents or their representatives to know how to file an anonymous grievance. The Supporting the Right of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews the facility failed to ensure food was discarded after product expiration date. The facility identified a census of 52 residents. Findings include: An initial kitchen tour conducted on 9/25/23 at 1:12 p.m., during the initial tour of the kitchen revealed the following items ready for service in the pantry: a. Two boxes of pancake mix unopened with best by date of 9/11/23. b. One box of pancake mix with an open date of 9/21/23 and a best by date of 9/11/23. c. Mango sauce unopened with an expiration date of 2/23. Dietary Manager (DM) discarded the items immediately except for the Mango sauce as the food representative had just brought the item for the facility to try. Review of the facility provided policy titled Food Storage Guidelines undated revealed it is the policy to ensure safe, sanitary, quality food products as required in Food Code 2017 and Servsafe Essentials. Interview on 9/25/23 at 1:32 p.m., with the DM revealed the items should have been discarded and not in the pantry for use. The pancake mix that was opened after the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #1) reviewed for PASRR requirements. The facility reported a census of 52 residents. Findings include: The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses depression, hypertension and Peripheral Vascular Disease (PVD)The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the MDS dated [DATE] revealed an active diagnosis of depression. Review of the Long Term Care Recertification signed on 9/7/23 revealed a diagnoses of major depression in partial remission. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, facility policy, and staff interview, the facility failed to accurately assess a wound for 1 of 1 residents reviewed (Resident #38). The facility reported a census of 38 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, facility policy, and staff interview, the facility failed to provide restorative therapy for 1 of 1 resident reviewed (Resident #20). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 revealed the resident had severely impaired skills for cognitive daily decision making, had inattention, and disorganized thinking. The MDS revealed the resident had diagnoses of Alzheimer's disease, dementia, anxiety, and depression; required the extensive assistance of 2 staff for bed mobility, transfers, and toileting; required the extensive assistance of 1 staff with eating; did walk in her room or corridor; had functional limitation in range of motion for both lower extremities; was frequently incontinent of urine and bowel; did not have restorative therapy in the last 7 calendar days. The Clinical Record revealed the resident had 4 restorative therapy sessions out of a total of 22 possible sessions for AROM (active range of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and facility policy review, the the facility failed to ensure residents were safe during mechanical lift transfers for 1 of 1 residents reviewed (Resident #1). The facility reported a total census of 52 residents. Findings include: The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses depression, hypertension and Peripheral Vascular Disease (PVD)The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Interview on 9/25/23 at 1:16 p.m., with Resident #1 revealed she does not feel safe when the staff use the EZ stand with her. Resident #1 further revealed the staff does not use the straps or tighten them up when they use the lift with her. Review of Resident #1 ' s Care Plan with a revision date of 8/15/23 revealed the following: a. Resident will often refuse to utilize the strap around her lower extremities. She has been educated on the safety risks. b. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy review and staff interviews, the facility failed to perform proper hand hygiene during routine cares for 1 of 3 residents reviewed (Resident #1). The facility reported a total census of 52 residents. Findings include: The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses depression, hypertension and Peripheral Vascular Disease (PVD)The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Observation on 9/25/23 at 1:36 p.m., of Staff A, Certified Nursing Assistant (CNA) transfer Resident #1 with the sit to stand lift to the restroom. Staff A entered Resident #1 and did not perform hand hygiene applied gloves with no hand hygiene, Staff A removed a soiled brief and placed it in the trash. Staff A removed soiled gloves, placed them in the trash, did not perform hand hygiene. Staff A opened a package of wet wipes and took out wipes and placed them on the top of the package. Staff A without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.