Heritage Manor of Mandeville

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#5) resident out of a total of 23 sampled residents. The facility failed to ensure Resident #5 was coded accurately for fall with major injury. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Muscle Weakness, Lack of Coordination, Abnormalities of Gait and Mobility. Review of Resident #5's Annual Minimum Data Set (MDS) dated [DATE] revealed Section J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), Section C: Major Injury - bone fractures, joint dislocations, close head injuries with altered consciousness, subdural hematoma was coded as 2. Two or more. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the services provided met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 1 (#8) of 2 (#8 and #81) residents reviewed for insulin administration. Review of the Novolog insulin pen manufacturer's insert revealed the following, in part:Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units. Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #8's current Physician Orders revealed the following, in part:Order date: 07/09/2025; [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure adequate monitoring for side effects with the use of psychotropic medication was completed for 1 (#65) of 5 (#3, #9, #14, #65 and #98) residents reviewed for unnecessary medications. Review of Resident 65's current Physician Orders revealed orders the following: 8/25/25- Escitalopram Oxalate Tablet 20mg give 1 tablet via PEG-Tube one time a day09/20/2025-Buspirone HCL Tablet 7.5 mg give 1 tablet via PEG-Tube three times a day09/20/2025-Clonazeepam Tablet 0.5mg give 1 tablet via PEG-Tube two times a day09/22/2025-Depakote Sprinkles Capsule Delayed Release Sprinkle 125mg give 1 capsule via PEG-Tube two times a dayReview of Resident #65's current medication administration record revealed Resident #65 had received the above medications as ordered for 09/01/2025- 09/23/2025. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure medications were properly stored in 1 (Med Cart 2) of 3 (Med Cart 2, Med Cart 3, and Med Cart 4) medication carts observed for medication storage. Review of the Humalog medication insert revealed in part, the following:Storage information:Opened: Total of 28 days. An observation was made on 09/22/2025 at 8:45 a.m. of Med Cart 2 with S3LPN. Observed 1 opened Humalog insulin pen for Resident #81, with a written opened date of 08/09/2025. An interview was conducted on 09/22/2025 at 8:46 a.m. with S3LPN. She confirmed the open date on Resident #81's Humalog insulin pen read 08/09/2025. She stated opened insulin pens should be discarded after 28 days. She confirmed Resident #81's Humalog insulin pen should have been discarded and was available for resident use. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure adequate monitoring for side effects with the use of psychotropic medication was completed for 1 (#65) of 5 (#3, #9, #14, #65 and #98) residents reviewed for unnecessary medications. Review of Resident #47's clinical record revealed resident was admitted to the facility on [DATE]. Review of Resident #47's Plan of Care Task revealed the following:Start Date- 01/06/2025- Assist Resident with inserting hearing aids in the morning and removing at night to put on charger. Further review revealed Resident #47 was assisted with placement of hearing aids on 09/01/2025, 09/08/2025, 09/12/2025, 09/17/2025, 09/21/2025, 09/22/2025 and 09/23/2025. On 09/24//2025 at 12:32 p.m., an interview was conducted with S3LPN. She stated Resident #47 was hard of hearing and did not wear hearing aids. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted timely for 2 (#27 and #101) of a total of 31 sampled residents reviewed for Resident Assessment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident's MDS assessments accurately reflected the resident's status for 5 (#17, #22, #26, #99, and #114) out of 31 residents reviewed in the final sample. The facility failed to ensure: 1. Resident #17 and Resident #22 were accurately coded for PASRR (Pre-admission Screening and Resident Review); 2. Resident #26 was not coded for anticoagulant use; 3. Resident #99 was coded correctly for Diabetic foot ulcers; and 4. Resident #114 was coded correctly for discharge.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident identified with a qualified mental disorder was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#48) of 5 (#17, #22, #30, #48 and #59) residents reviewed for PASARR.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident's plan of care was revised when code status was changed from full code to Do Not Resuscitate (DNR) for 1 (#18) of 31 sampled residents reviewed for care plans.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with accepted principles for 1 (Cart A) of 3 (Cart A, Cart B and Cart C) medication carts and 1(Medication Room A) of 1 medication room observed. The facility failed to ensure expired medications were not available for administration to residents.

Inspectors wroteBased on interviews and record review, the facility failed to employ staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to: 1. Maintain documentation of daily temperature and chemical sanitation checks for the dishwasher; and 2. Maintain documentation of freezer and refrigerator temperatures checks. This deficient practice had the potential to affect 109 residents who were served meals from the facility's kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 1 (#69) of 1 (#69) sampled residents reviewed for compression stockings.

Inspectors wroteBased on interviews and record review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies for 2 (#27 and #101) of a total of 31 sampled residents reviewed for Resident Assessment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#57) of 6 (#57, #62, #65, #102, #108, and #315) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing peri-care to a resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and sanitary environment for residents and staff. The facility failed to ensure the walk-in cooler was free from pooling water. The facility had 109 residents who received meals out of the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly labeled and dated; and 2. Food was not expired. There were a total of 103 facility residents who were provided meals and beverages from the facility's kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to ensure alleged violations of physical abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to other officials in accordance with State law for 2 (Resident #2 and #3) of 4 (Resident #1, #2, #3 and #4) residents reviewed for abuse.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was palatable to residents in taste and consistency for 4 (#R6, #R7, #R8, and #R9) of 8 (#1, #2,#3,#4,#R6, #R7, #R8, and #R9) residents reviewed for food. There were 103 residents that were served food from the kitchen.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 2 (#2 and #3) of 8 ( #2, #3, #4, R1, R2, R3, R4, and R5) residents reviewed for incontinent care.

Inspectors wroteBased on interviews and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure respiratory treatments were documented for 1 (#1) of 2 (#1 and #4) residents reviewed for respiratory treatments.

Inspectors wroteBased on record reviews and interview, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#4) of 4 (#1, #2, #3 and #4) sampled residents reviewed for hydration.

Inspectors wroteBased on record reviews and interview, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 3 (#1, #2 and #3) of 3 (#1, #2 and #3) sampled residents reviewed for ADL Care.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure respiratory treatments were transcribed and administered as ordered for 1 (#3) of 2 (#1 and #3) residents reviewed for respiratory treatments.

Inspectors wroteBased on record review and interview, the facility failed to provide Physical Therapy services according to a resident's comprehensive plan of care for 1 (#1) of 3 ( #1, #2, and #3) sampled residents reviewed for rehabilitation services.

Inspectors wroteBased on record review and interviews, the facility failed to develop a plan of care for 2 (#86 and #108) of 23 sampled residents reviewed for care plans. The facility failed to ensure residents' diagnosis of Pneumonia was reflected in the plan of care.