Heritage Manor Health & Rehab

Inspectors wroteBased on observation and interview the facility failed to ensure the most recent survey results were readily accessible to the residents, family members or anyone to review.

Inspectors wroteBased on record reviews and interviews, the facility failed to:1.) Provide written notice to residents and/or their RP (Responsible Party) which specified the reason for transfer, effective date, location and statement of the resident's appeal rights and duration of the bed hold for 1 (#38) of 4 residents reviewed for hospitalizations.2.) Update the emergency transfer log (Notice of Discharge to the Ombudsman) for 3 (#8, #38, and #55) of 4 residents reviewed for hospitalizations.

Inspectors wroteBased on record reviews and interview, the facility failed to refer 1 (#49) of 1 (#49) resident with a newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a plan of care had been implemented for 1 (#30) of 17 sampled residents whose care plans were reviewed. The facility failed to administer Resident #30's neuropathy medication as ordered by the physician.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure 2 (#8, #15) out of 2 residents who need respiratory care, including tracheostomy care and tracheal suctioning, are provided such care, consistent with professional standards of practice. The facility failed to:Store Resident #8 suctioning equipment to prevent contamination; and Change Resident #15's nasal cannula and humidifier weekly and clean and store BIPAP equipment according to policy and procedure.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure 2 (#15, #26) of 7 reviewed for unnecessary medications were monitored for edema while receiving a diuretic.

Inspectors wroteBased on observations and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the walk-in refrigerator and freezer leaking water and in need of repair. This deficient practice has the potential to affect any of the 50 residents consuming food from the kitchen according to S9Dietary Manager.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 5.41 % medication error rate with 2 medication errors out of 37 opportunities.

Inspectors wroteBased on record review and interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day, 7 days a week, for 5 days throughout dates 02/22/2026 through 03/24/2026.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents had a safe, functional, sanitary, and comfortable environment by failing to provide clean bath towels and bed linen for Residents at all times. This deficient practice had the ability to affect the census of 58 Residents that resided in the facility.

Inspectors wroteBased on record review and interviews the facility failed to implement a comprehensive person-centered care plan which met the needs of 1 (#1) of 4 sampled residents reviewed for falls. The facility failed to ensure Resident #1 received one on one monitoring at all times as ordered.

Inspectors wroteBased on record review and interviews, the facility failed to develop a Comprehensive Person Centered Care Plan, which met the needs of 1 (#1) of 3 sampled residents. The facility failed to ensure physician recommendations were followed and interventions were in place for a subacute-chronic olecranon fracture.

Inspectors wroteBased on record review and interviews, the facility failed to ensure 2 (#3, #5) out of 5 sampled residents were free from abuse resulting in resident to resident interactions. The facility failed to develop and implement ongoing monitoring to ensure resident safety.

Inspectors wroteBased on record review and interviews, the facility failed to provide needed care and services, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The facility failed to ensure 1 (#4) out of 5 sampled residents received medication ordered upon re-ademission to the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility failed to document 1 (#1) out of 2 residents discharge from the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan for 1 (#1) out of 5 sampled residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure 5 (#1, #6, #7, #8, and #49) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medications were informed of the risks, benefits, and side effects of psychotropic medication, and allowed to choose the treatment option they preferred prior to the start of the medication.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents received services with reasonable accommodation of resident needs. The facility failed to ensure:1. Resident #54's call light functioned properly and Resident #54's calls for assistance were answered in a timely manner.2. The emergency call light in the hall bathroom between room A and room B had a pull cord in place.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents who received psychotropic drugs were free from unnecessary drugs for 1 (#7) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medication. The facility failed to ensure:1. Pharmacy GDR (gradual dose reduction) requests were conducted and communicated to the physician for consideration.2. Psych NP (Nurse Practitioner) recommendation was communicated to the physician for consideration.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide to the resident and/or resident representative written notice which specified the reason for transfer, effective date, location, statement of the resident's appeal rights, and duration of the bed hold policy and failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 4 (#2, #56, #58, #62) of 4 (#2, #56, #58, #62) sampled residents reviewed for discharge and transfer requirements.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident assessments accurately reflected the residents' status for 2 (#8, #34) of 22 sampled residents reviewed for accurate assessments. The facility failed to accurately assess Resident #8 for insulin administration via injection, and failed to complete Resident #34's discharge assessment.

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident's plan of care was implemented for 1 (#49) of 5 (#1, #6,#7, #8, #49) residents reviewed for unnecessary medications. The facility failed to ensure resident #49's laboratory tests were done as ordered.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 (#54) of 3 (#37, #54, #62) residents reviewed for ADLs (activities of daily living). The facility failed to ensure Resident #54 received nail care and a shave.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure residents received treatment and care and services in accordance with professional standards of practice for 2 (#6, #8) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medications. The facility failed to ensure medications were administered, assessments were conducted, and monitoring was performed as ordered.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#8, #26, and #59) of 4 (#8, #26, #44, and #59) residents reviewed for respiratory care. The facility failed to ensure oxygen supplies were dated, humidification bottles were not empty, and oxygen concentrator filters were clean.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to (1) document least restrictive approaches before installation of bed rail/side rail, (2) obtain a written order from the physician for bed rails/side rails use, (3) obtain an informed consent from resident from resident or resident representative prior to installation (4) ensure resident care plan included a focus for bed rails/side rails, and (5) ensure maintenance of bed rails/side rails for 1 (#37) out of 1 residents reviewed for accidents. Review of facility's Bed Rail Policy (undated) revealed in part:Purpose: Ensure correct installation, use and maintenance of bed railsProcedure: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure there were a sufficient number of personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 1 of 14 days reviewed.

Inspectors wroteBased on record review and interview the facility failed to ensure residents' drug regimen was free of unnecessary medications for 2 (#8, #49) of 5 (#1, #6, #7, #8, #49) residents reviewed for unnecessary medications. The facility failed to monitor for behaviors and side effects of psychotropic medication.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to maintain a facility medication error rate of less than 5% by failing to give 3 medications as ordered for 3 (#27, #31, and #36) residents observed during medication administration. A total of 31 opportunities were observed which included 3 medication errors for a medication error rate of 9.68%.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to follow the prescribed diet for 1 (#1) of 1 (#1) residents reviewed for Food/Nutrition.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure:1. Food was stored in accordance with professional standards for food service safety. 2. High Temperature Dishwasher met wash cycle and rinse cycle temperature recommendations. This deficient practice had the potential to affect the 54 residents who received meals on 08/04/2025 as per S12Dietary Manager.

Inspectors wroteBased on record review and interview the facility failed to ensure a water management program had been implemented to minimize the risk of Legionella and other opportunistic pathogens.

Inspectors wroteBased on record review and an interview, the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 1 (#37) of 2 (#2, #37) residents reviewed for advanced directives.

Inspectors wroteBased on observation and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the walk-in refrigerator and freezer leaking water and in need of repair. This deficient practice has the potential to affect any of the 51 residents consuming food from the kitchen according to S3 Dietary Manager.

Inspectors wroteBased on record reviews and interviews the facility failed to conduct a significant change MDS (Minimum Data Set) for 1 (#1) of 3 (#1, #2, #3) sample residents after changes were noted that had an impact on the resident's health status and required interdisciplinary review and revision of the care plan.

Inspectors wroteBased on record reviews and interview the facility failed to ensure standing orders were implemented for 1 (#3) of 3 (#1, #2, #3) residents reviewed. The facility failed to ensure S5 Physician's standing orders for a chest x-ray were completed.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 3 (#1, #2, #3) sample residents. This is evidenced by the facility failing to continue monitoring and assessment of a resident (#1) after a fall to identify any complications or changes in the resident condition.

Inspectors wroteBased on record reviews and interviews the facility failed to complete required reporting to the State Survey and Certification Agency in accordance with State law in a timely manner for 1 (#2) of 3 (#1, #2, and #3) sampled residents incidents that required reporting to be submitted. The facility failed to report an allegation of an inappropriate sexual relationship between a staff member and a resident in a timely manner to the State Survey and Certification Agency.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 resident (#3) of 2 residents (#1, #3) reviewed with pressure ulcers. The facility failed to ensure pressure ulcer treatments were performed as ordered and failed to measure and stage pressure ulcers according to professional standards of practice.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to: 1. provide the minimum required staffing hours for 20 of 37 days reviewed and 2. ensure a licensed nurse was designated as a charge nurse for each shift.

Inspectors wroteBased on record review and interviews, the provider failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 2 of 37 days reviewed for RN hours, and failed to have a DON (Director of Nursing) for 33 consecutive days. This deficient practice had the potential to affect any of the 59 Residents residing in the facility according to the facility's detailed census report.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement a comprehensive, resident centered plan of care for 2 (#3, #4) out of 5 (#1, #2. #3, #4, #5) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (#4, #5) of 5 (#1, #2, #3, #4, #5) sampled residents with peg tubes (a feeding tube inserted through the abdomen and into the stomach). The facility failed to ensure accurate skin assessments that reflected a peg tube site for Residents #4 and #5.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#3) of 5 (#1, #2, #3, #4, and #5) sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure appropriate care and services had been provided for 1 (#3) of 1 (#3) residents reviewed for Dialysis out of a total of 5 sampled residents. The facility failed to ensure Resident #3 was accurately assessed and monitored for the care of his dialysis access site.

Inspectors wroteBased on interviews and record review, the facility failed to ensure medical records were accurately documented for 2 (#3, #5) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure accurate documentation of weekly skin assessments for Resident #3 and #5, and accurate documentation of dressing changes for Resident #5.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and control program help prevent the development and transmission of communicable diseases and infections for 2 (#3 and #4) of 5 (#1, #2, #3, #4, and #5) sampled residents as evidenced by failing to ensure: 1. Staff wore appropriate PPE (Personal Protective Equipment) when providing high contact patient care for Resident #3, and #4 who were had Enhanced Barrier Precautions (EBP) in place; 2. Followed appropriate hand hygiene during wound care and incontinence care for Resident #3; and 3. Followed accepted infection control principals during wound care and incontinence care for Resident #3.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's advanced directive was honored for 1 (#1) of 5 ( #1, #2, #3, #4, and #5) sampled residents.

Inspectors wroteBased on record review and interviews the facility failed to ensure quarterly statements were provided for 2 (#1, #3) of 5 (#1, #2, #3, #4, #5) residents whose personal funds accounts were reviewed. The facility failed to provide quarterly statements to residents and their responsible parties.

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to accommodate the needs of 5 (#23, #29, #31, #50, & #54) of 29 sampled residents. The facility failed to ensure: (1) Two (#31, #50) residents call lights were in reach. (2) One (#54) resident call light was functioning. (3) Incontinence briefs were readily available for 2 (#23, #29) residents

Inspectors wroteBased on record reviews and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice had the potential to affect the total census of 58 residents in the facility according to Long-Term Care Facility Application for Medicare and Medicaid dated 07/14/2024.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents were provided information regarding formulation of advance directive upon their admission for 4 (#8, #17, #23, #50) of 24 initial pool residents.

Inspectors wroteBased on record reviews and interviews the facility failed to thoroughly investigate, document findings, and follow up within 3 working days per facility grievance policy for 1 (#51) out of 1 (#51) resident reviewed for personal property.

Inspectors wroteBased on record review and interview the facility failed to ensure a criminal background check and sex offender registry check had been conducted prior to hire for 1 (S14 CNA[Certified Nursing Assistant]) of 5 (S12 CNA, S13 CNA, S14 CNA, S15 CNA, and S16 CNA) CNA personnel records reviewed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a comprehensive, person-centered care plan had been developed and implemented for 4 (#6, #23, #30 and #54) of 29 sampled residents. The facility failed to ensure: 1. Resident #6 was monitored for anticoagulant use and AV (Arteriovenous) shunt was monitored. 2. Resident #23 was care planned for oxygen 3. Resident #30 was care planned for oxygen, nebulizer treatment minutes were documented and abdominal binder was in use 4. Resident #54 was care planned for having a PICC (peripherally inserted central catheter) line.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure 1 (#53) of 2 (#6, #53) residents reviewed for nutrition received care as ordered by the physician and as stated in the facility policy. Resident #53 did not have weekly weights as ordered and the registered dietician's recommendations were not implemented.

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to provide appropriate treatment and services for 2 (Resident #30 and #257) of 3 (#24, #30 and #257) residents reviewed for tube feeding. The facility failed to ensure the tube feeding bottles were labeled properly.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for 3 (#23, #30, #46) of 3 (#23, #30, #46) residents with an order for oxygen and/or respiratory treatments. The facility failed to ensure: (1) Oxygen tubing and humidification bottle were changed weekly for Resident #23 and Resident #30 and the oxygen tubing was stored properly for Resident #23. (2) Nebulizer mask was stored properly for Resident #46.

Inspectors wroteBased on record review and interview the facility failed to ensure nursing and related services were provided to assure resident safety and maintenance of highest practicable physical, mental, and psychosocial well-being for 1 (#54) of 29 sampled residents. The facility failed to ensure Resident #54's PICC (peripherally inserted central catheter) line dressing changes had been conducted weekly.

Inspectors wroteBased on record reviews and interview the facility failed to ensure a licensed pharmacist had conducted a review of residents' drug regimen at least once a month for 5 (#1, #5, #17, #30 and #42) of 5 (#1, #5, #17, #30 and #42) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary services were provided in a sanitary environment for the 56 residents receiving a meal tray from the kitchen as reported by S5 Dietary Manager. The facility failed to ensure opened food items were labeled and dated; failed to ensure the sugar scoop was not stored in the sugar bin; failed to ensure a soda bottle was not stored in the ice machine; and failed to ensure the refrigerator and freezer were monitored at the proper temperature to prevent potential food borne illness.

Inspectors wroteBased on record review and interview, the facility failed to conduct (QAA) Quality Assessment and Assurance meeting was held at least quarterly.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for 4 (#6, #17, #24, and #30) of 29 sampled residents.

Inspectors wroteBased on personnel record reviews and interview, the facility failed to ensure provision of at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired for 5 (S12 CNA [Certified Nursing Assistant], S13 CNA, S14 CNA, S15 CNA, and S16 CNA) of 5 CNA personnel records reviewed.

Inspectors wroteBased on record review and interview the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#44) of 2 (#1, #44) residents reviewed for accidents. The facility failed to ensure the post-fall assessment was accurately completed for fall risk.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure a resident who was unable to complete their ADLs (activities of daily living) received the necessary services to maintain proper grooming for 1 (#29) out of 1 (#29) residents reviewed for ADLs. The facility failed to ensure Resident #29 received nail care.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (Resident #1, #2, #3, and #4) of 4 (Resident #1, #2, #3, and #4) sampled residents. The deficient practice resulted in an Immediate Jeopardy on 05/17/2024 when the facility's HVAC (Heating, Ventilation, and Air Conditioning) system, which regulated the temperature for the front section of the facility, failed. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #1 lying in bed with oxygen infusing per nasal cannula with a personal fan in use and her face appeared flushed. Further observation failed to reveal a pitcher of ice water. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #2 sitting upright in bed with red cheeks, appearing uncomfortable with personal fan blowing at highest speed at close proximity to her face. [...]

Inspectors wroteBased on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 4 (#1, #2, #3, and #4) of 4 residents (#1, #2, #3, and #4) sampled residents. The facility failed to ensure a system was in place to assess residents for heat related issues and monitor room temperatures to maintain environment at a comfortable level when the HVAC (Heating, Ventilation, and Air Conditioning) system failed. The deficient practice resulted in an Immediate Jeopardy on 05/17/2024 when the facility's HVAC system, which regulated the temperature for the front section of the facility, failed. Observation on 05/22/2024 at 8:05 a.m. [...]