Heritage Manor South

Inspectors wroteBased on record reviews and interview, the facility failed to develop an individualized care plan for 2 (#4, #5) of 6 sampled residents reviewed. The facility failed:to develop a care plan for urinary tract infections for Resident #4, andto develop a care plan for stage IV pressure ulcer for Resident #5

Inspectors wroteBased on observations, record reviews and interviews the facility failed to ensure residents who were unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 5 (#4, #31, #45, #69, #100) of 5 residents reviewed for activities of daily living out of a total final sample of 37. The facility failed to ensure Residents #4, #31, #45, #69, and #100 fingernails were cleaned and trimmed.

Inspectors wroteBased on record review and interviews the facility failed to ensure assessments were accurate for 1 (#13) of 37 residents reviewed for MDS assessments. The facility failed to ensure Resident #13's medication was accurately assessed.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents received adequate supervision to prevent elopement for 1 (#1) of 3 (#1, #2, #3) sampled residents at risk for elopement. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 12/09/2025. It was determined to be a Past noncompliance Citation.

Inspectors wroteBased on record review and interview the facility failed to ensure a comprehensive person-centered care plan had been developed and implemented for 1 (#3) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure a care plan had been developed and implemented to reflect Resident #1/Resident #1's RP's (Responsible Party) wishes for code status of DNR (Do Not Resuscitate). Review of Resident #3's medical record revealed an admission date of [DATE] with diagnoses including, part, chronic obstructive pulmonary disease (COPD), unspecified severe protein-calorie malnutrition, anemia unspecified, essential (primary) hypertension, anxiety disorder, depression unspecified, and pain unspecified. Review of Resident #3's [DATE] Significant Change MDS (Minimum Data Set) revealed a BIMS (Brief Interview Mental Status) of 99, which indicated Resident #3 was unable to complete the interview. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to ensure a grievance investigation and resolution had been conducted and documented as per facility policy for 1 (#1) of 3 (#1, #2, #3) sampled residents. Review of facility Grievances - Residents policy with latest revision date of 05/2024 revealed, in part:All residents are to be encouraged and assisted (if necessary) in filing grievances to include those with respect to care and treatment, the behavior of staff and other resident's and other concerns regarding their facility stay, in the event that they have a need to make a concern known. The following outlines the process: . Family members, visitors or others may also present grievances on behalf of residents. Grievances may also be made anonymously using the suggestion box. The facility shall make prompt efforts to resolve the grievances. [...]

Inspectors wroteBased on record review, observations and interviews the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#62, #81) out of 30 sampled residents reviewed. The facility failed to develop a care plan for Resident #62's diabetic wound and failed to obtain a physician order for Resident #81 to receive oxygen therapy.

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 1 (#62) of 30 sampled residents by failing to administer a full course of antibiotic as ordered by the physician.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents were free of accident hazards by failing to ensure bed rails were securely attached to the bed for 5 (#70, #54, #49, #40, and #8) of 6 (#70, #54, #49, #40, #8, and #201) residents reviewed for accident hazards.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails. The facility failed to ensure: residents were assessed for risks associated with the use of bed rails (side rails) and/or safety devices, informed consent was obtained from resident/resident representative prior to installation of bed rails, evidence of monitoring and supervision during the use of bed rails, and/or scheduled maintenance was conducted according to manufacturer's recommendations for any bed rails in use for 12 (#5, #8, #14, #29, #31, #40, #49, #54, #57, #64, #70, #201) of 12 residents reviewed for bed rails.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 4 (#28, #34, #79, #87) out of 6 (#28, #34, #49, #70, #79, #87) residents review for unnecessary medications. The facility failed to: 1. Monitor Resident #28 for edema, 2. Monitor Resident #34 for edema and bleeding, 3. Monitor Resident #79 for edema and bleeding, and 4. Monitor Resident #87 for bleeding.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free from unnecessary psychotropic medications for 3 (#34, #79, #87) out of 6 (#28, #34, #49, #70, #79, #87) residents review for unnecessary medications. The failed to monitor Residents #34, #79, and #87 for psychotropic side effects and behaviors.

Inspectors wroteBased on record review and interview the facility failed to inform in writing 1 (#151) of 3 residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Protection Notification of changes in their liability.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the medical record reflected an accurate advance directive preference for 1 (#44) of 1 resident investigated for advanced directives.

Inspectors wroteBased on record reviews, observations, and interview the facility failed to ensure a cover/cap was applied to the male tip of a feeding tube line when removed from a gastrostomy tube for 2 (Residents #2, #76) of 3 (Residents #2, #72, #76) residents reviewed for tube feeding.

Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure a resident's BiPap (bilevel positive airway pressure) machine was in working order for a resident to receive BiPap at bedtime per physician orders for 1 (Resident #29) of 1 (Resident #29) resident reviewed for respiratory care.

Inspectors wroteBased on record review and interviews the facility failed to ensure neurological checks were completed for 1(#41) out of 1 resident reviewed for vision (communication-sensory).