Heritage Manor Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the use of hair restraints of staff working in the kitchen; 2. Effectively clean multiple surfaces in the kitchen (walls, ice machine, ice scoop holder, reach-in cooler floor, reach-in cooler storage racks); 3. Ensure cleaned pans and dishes were allowed to air dry before stacking; 4. Ensure surfaces inside the kitchen were smooth and easily cleanable (insulated foam board); and 5. Ensure cleaned ladles were properly stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handling of clean linen resulting in the potential for infection among all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the reach-in juice cooler, the inside of the walk-in cooler and the walk-in freezer were properly maintained and in good working order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the walls and cove base outside of the walk-in cooler were in good condition and cleanable and the leak in the janitor's closet was repaired correctly and timely.

Inspectors wroteBased on interview and record review the facility failed to deposit the resident personal funds (resident trust fund) in an interest-bearing account that is separate from the facility's operating account and credit all interest earned on the resident funds to that account. This deficient practice has the potential to affect R90 and 27 of 36 residents that had over $100.00 in the facility's resident trust fund account in the month of January 2026. On 3/4/26 at 1:44 PM, R90 reported that they received their $60.00 a month but it is always late. According to R90's Electronic Health Record (EHR), R90 admitted on [DATE] with multiple diagnoses that included congestive heart failure. R90 had a court appointed Legal Guardian. R90's annual Minimum Data Set (MDS) dated [DATE] identified R90 to be cognitively intact and totally dependent on staff for all activities of daily living. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain a separate accounting system for the resident trust fund account and use generally accepted accounting principles for 35 residents utilizing the facility's resident trust fund account. This deficient practice has the potential for the misappropriation of resident's funds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide periodic reviews and to adequately update information on Advance Medical Directives (AMD- the written instruction relating to the provision of health care) for five (R5, R6, R55, R45, and R25) of thirteen residents reviewed for advanced directives.

Inspectors wroteThis citation pertains to intake 2792738. Based on interview and record review, the facility failed to ensure money was safe from misappropriation for one resident (R110) of two residents reviewed for abuse, resulting in missing resident funds.

Inspectors wroteThis citation pertains to intake 2792738. Based on interview and record review, the facility failed to ensure staff reported an allegation of misappropriation of resident property (MARP) to the State Agency in a timely matter for one resident (R110) out of two residents reviewed for abuse, which could result in additional missing resident funds.

Inspectors wroteThis citation pertains to intake 2792738. Based on interview and record review, the facility failed to conduct a thorough investigation of misappropriation of resident property (MARP) for one resident (R110), out of two residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a supra-pubic (s/p, a tube inserted through the abdomen directly into the bladder to drain urine) indwelling urinary catheter care plan for one (R9) of two residents reviewed for urinary catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a wheelchair dependent resident (R35), reliant on the use of the elevator to smoke, of one resident reviewed for smoking resulting in missed opportunities for smoking.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate indwelling urinary catheter care for one (R9) of two residents reviewed for urinary catheter care resulting in discomfort and irritation at R9's supra-pubic catheter (s/p, a tube inserted through the abdomen directly into the bladder to drain urine) insertion site along with the potential for infection and catheter dislodgement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare vegetables to the proper food consistency for four residents receiving pureed textured meals in the facility.

Inspectors wroteThis citation pertains to intake number 2723282. Based on observation, interview, and record review, the facility failed to protect R201's right to be free from physical and mental abuse by Housekeeper D and Housekeeping Manager C, when Housekeeping Manager C sprayed a chemical (bleach cleaner) into the eyes of R201 while Housekeeper D held R201's wheelchair in place. This deficient practice caused chemical damage to R201's eyes and subsequent pain.

Inspectors wroteThis citation pertains to 1220384, 1220412, and 2569363. Based on interview and record review the facility failed to ensure that one resident (R406) of five residents reviewed was free from abuse and exploitation of personal funds resulting in certified nursing assistant (CNA) A using a R406's debit card to make purchases totaling $1,900.

Inspectors wroteThis citation pertains to intake MI00153787 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 107 residents who consume food products, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteThis citation pertains to intake MI00153787 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteThis citation pertains to intake MI00153011. Based on interview and record review the facility failed to document complete transfer and discharge information for one (R510) of two residents reviewed for the transfer/discharge process resulting in the potential for the receiving health care provider to be unaware of all the resident's healthcare needs.

Inspectors wroteThis citation pertains to intake MI00148648. Based on observation, interview, and record review the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs (a drug that the government regulates for possession and use, i.e. narcotics) in the facility's back-up box (secured storage unit of controlled drugs), resulting in the facility being unable to account for the receipt of, disposition of, or discrepancies of controlled drugs in the facility's back-up box with the potential for drug diversion and controlled drugs being unavailable to administer to residents as prescribed.

Inspectors wroteBased on interview and record review the facility failed to obtain and address Medication Regimen Review (MRR) recommendations timely for two residents (R35 and R54) of five residents reviewed for medication regimen review, resulting in the continuance of unnecessary medications and a lack of communication of recommended medication changes between pharmacist and physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident (R9) was free from significant medication errors out of six residents reviewed for medication administration when only two doses of an antibiotic eye solution (Erythromycin Ophthalmic solution) was administered to the resident of the 56 doses prescribed, resulting in potential for prolonged signs and symptoms of a right eye infection.

Inspectors wroteBased on interview, and record review the facility failed to maintain a complete and accurate Antibiotic Stewardship Program, resulting in R9's antibiotic usage for an eye infection not being identified, monitored, or administered as prescribed. This deficient practice has the potential to affect all residents receiving antibiotics in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure they consistently screened, educated, offered, and administered influenza vaccines for five (R4, R9, R40, R52, and R57) of five residents reviewed for vaccinations/immunizations resulting in R57 consenting to receive the influenza vaccine but not receiving it and the lack of vaccine screening, education, and offering to receive the vaccine for residents R4, R9, R40, and R52.

Inspectors wroteThis citation has two deficient practice statements. Deficient Practice #1 Based on observation and interview the facility failed to effectively clean and maintain the physical facility in good repair affecting 25 residents on the third floor, resulting in an unpleasant, non-homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the standards of practice for medication administration when 1.) an insulin pen was not primed (remove air bubbles from needle and cartridge) prior to administration of insulin to R53, 2.) medications through a PEG (feeding tube that is surgically placed through the abdominal wall directly into the stomach) were not individually crushed and separately flushed through the PEG tube for R9 and 3.) a physician's order for an anti-hypertensive medication was incorrectly transcribed on the Medication Administration Record (MAR) for R9, resulting in the potential for an inaccurate amount of medication to be administered and decreased efficacy of the medications.

Inspectors wroteBased on observation, interview and record review the facility failed to provide hair care for two residents (R5 and R7) and a shave for one resident (R16) out of a sample of 14 residents reviewed for activities daily living (ADL's), resulting in unmet hygiene needs, loss of dignity and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate supra-pubic catheter care for one (R37) of two residents reviewed for catheter care, resulting in discomfort at the insertion site, the potential for dislodgment of the catheter, and urinary tract infection.

Inspectors wroteBased on interview and record review, the facility failed to justify the use of a PRN (as needed) antianxiety medication and document the rationale for open ended use for one resident (R54) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to one Resident (R5) of two reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided to the resident.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure enhanced barrier precaution were implemented for two residents (R1 and R9) out of twenty four residents reviewed for infection control, resulting in the potential for the transmission of infectious t organisms.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents call lights were properly functioning for one of four units, resulting in a potential for a delay in responding to care needs of the residents that resided on the unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review or revise the care plan following falls for two residents (R701 and R704) out of three reviewed for fall care plan interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an intervention from the care plan for one resident (R702) out of three reviewed for fall care plans.

Inspectors wroteThis citation pertains to intake MI00144280. Based on observation, interview, and record review the facility failed to implement interventions to obtain resident weights for two residents who refused to be weighed (R902 and R903) out of three residents reviewed for nutrition, resulting in significant weight changes to go undetected.

Inspectors wroteThis citation pertains to intake MI00143878. Based on interview and record review, the facility failed to implement interventions and provide sufficient staff for supervision to prevent falls for one (R921) of four residents reviewed for accidents and supervision resulting in R921 being found unresponsive on the floor with a pool of blood around the resident's head.

Inspectors wroteThis citation pertains to intakes: MI00140904, MI00141103, MI00141276, MI00143450, MI00141973, and MI00142724 Based on observation, interview and ecord review, the facility failed to provide a functional call system that provides direct communication from the residents via the 2nd floor with no call light station, Resident rooms 215, 307, 312, 2nd floor shower room, 3rd floor shower room, and 4th floor shower rooms. This deficient practice had the potential to affect all residents that utilize the shower rooms and residents in rooms 215, 307 and 312.

Inspectors wroteThis citation pertains to the intakes: MI00140904, MI00141103, MI00141276, MI00141360, MI00141973, MI00142127, and MI00143303 Based on observation, interview, and record review the facility failed to maintain general repair and cleanliness of the resident rooms, and common areas with potential for avoidable contamination, injuries, and decrease in satisfaction of living affecting all 97 residents.

Inspectors wroteThis citation pertains to intakes: MI00143303 and MI00143980 Based on interview and record review the facility failed to assist Resident Council to meet for monthly meetings consistently and failed to promptly follow up and resolve concerns and follow up consistently.

Inspectors wroteThis citation pertains to intake MI00143232. Based on interview and record review, the facility failed to promptly conduct a thorough investigation for allegations of abuse/neglect, including an injury of unknown origin for seven (R910, R911, R915, R916, R917, R918, and R921) of 10 residents reviewed for abuse/neglect.

Inspectors wroteThis citation pertains to intakes: MI00143303 and MI00143980 Based on observation, interview, and record review, the facility failed to follow-up on grievances expressed by two (R912 and R919) of four Residents reviewed for grievances resulting in frustration and ongoing communication concerns. Findings Include: R912 R912 was admitted to the facility on [DATE]. R912's admitted diagnoses included Major depressive disorder, schizoaffective disorder, anxiety disorder and heart failure. Based on assessment dated [DATE], R912 had Brief Interview for Mental Status score of 14/15, indicative of intact cognition. An observation was completed on 4/24/24 at approximately 2:00 PM. During the observation R912 reported that they were missing a bag with their personal belongings that included some important receipts, debit card, and clothes. [...]

Inspectors wroteThis citation pertains to intake MI00143878. Based on interview and record review, the facility failed to immediately report an injury of unknown origin to the Nursing Home Administrator and/or the State Agency (SA) for one ( R921) of 10 residents reviewed for abuse/neglect.

Inspectors wroteThis citation pertains to intake MI00142890. Based on observation, interview, and record review, the facility failed to prevent employee to resident abuse for one resident (R602) of four residents reviewed for abuse, resulting in R602 being hit in the face and sustaining a laceration and hematoma (bruising).

Inspectors wroteThis citation has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview, and record review the facility failed to administer and document wound care treatments consistently for two residents (R1 and R72) out of three residents reviewed for skin care, resulting in the potential for spread of infection and worsening of wounds.