Heritage Manor West

Inspectors wroteBased on record review and interviews the facility failed to notify the resident's (RP) responsible party of a change in plan of care for 1 (#1) of 3 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure nursing staff provided nursing services to assure residents maintained the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by assessments and individual plans of care. The facility failed to complete a full body assessment for 1 (#1) of 3 sampled residents upon admission.

Inspectors wroteBased on record review, observations, and interviews the facility failed to follow physician orders for 1(#87) of 1 resident reviewed for tube feedings. The facility failed to administer medications to Resident #87 as ordered by physician prior to bolus feeding. Review of Resident #87's medical diagnoses revealed the following but not limited to moderate protein-calorie malnutrition, dysphagia, oropharyngeal phase, encounter for attention to gastrostomy, pneumonitis due to inhalation of other solids and liquidsReview of Resident #87's March 2026 Physician Orders revealed:11/05/2025: Carafate Oral Tablet 1 GM (Sucralfate); Give 1 tablet via PEG tube four times a day related to anemia; give down tube 30 minutes prior to bolus feeding. 09/15/2025: Tube feeding formula: Isosource 1.5 carton bolus. [...]

Inspectors wroteBased on record reviews, observations, and interview, the facility failed to ensure residents who were unable to complete their Activities of Daily Living received the necessary services to maintain grooming for 1 (Resident #91) of 1 resident reviewed for Activities of Daily Living. The facility failed to ensure nail care was provided for Resident #91.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#5) of 1 resident reviewed for dialysis by failing to communicate and collaborate with the dialysis facility. The facility failed to complete the dialysis communication sheet and monitor Resident #5 for complications after each dialysis treatment.

Inspectors wroteBased on record reviews and interview the facility failed to provide the resident and the resident's representative with the facility bed hold policy at the time of transfer as required for 1(#16) of 2 residents reviewed for hospitalization.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident assessments were transmitted within the required timeframe for 1 (#48) of 1 resident reviewed for resident assessment. FindingsReview of Resident #48's medical record revealed an admission date of [DATE]. Further review revealed Resident #48 expired and was discharged on [DATE]. Review of Resident #48's MDS assessment revealed a discharge date of [DATE]. Further review of Resident #48's discharge MDS assessment revealed a signed date of [DATE]. During an interview on [DATE] at 8:10 a.m., S7MDS Nurse reported Resident #48 was discharged on [DATE]. S7MDS Nurse further reported Resident #48's discharge MDS assessment was not transmitted until [DATE]. During an interview on [DATE] at 8:10 a.m., S5RN, Medicare Case Manager confirmed Resident #48's discharge MDS assessment was not transmitted until [DATE]. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise the plan of care after a change in condition for 1(#14) of 3 (#13, #14, #18) residents reviewed for accidents. The facility failed to revise Resident #14's plan of care to reflect the removal of a wander/elopement alarm. Review of Resident #14's medical record revealed an admit date of 07/19/2022 with a diagnosis of but not limited to dementia in other diseases, unspecified anxiety disorder and Alzheimer's disease. Review of Resident #14's Quarterly Minimum Data Set revealed Resident #14 was assessed to have a Brief Mental Status Interview Score of 6 indicating severely impaired cognition. Review of Resident #14's comprehensive plan of care revealed Resident #14 had an intervention/approach of, wander/elopement alarm in place on left ankle. Observation on 03/11/2026 at 2:45 p.m. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident's narcotic record was maintained and reconciled for 1 (#30) of 1 resident individual narcotic record reviewed. Review of the facility's Drug-Controlled Substances Policy dated 09/2025 revealed the following: Controlled medications are to be signed out on Individual Resident Narcotics Record at the time they are administered. Observation on 03/11/2026 at 9:05 a.m. with S4 LPN revealed Resident #30's Individual Narcotic Record for Pregabalin 25 milligrams had a documented count of 47. Review of Resident #30's narcotic card of Pregabalin 25 milligrams revealed an actual count of 46. During an interview on 03/11/2026 at 9:05 a.m. S4 LPN reported she had given Resident #30's Pregabalin but failed to sign it out on Resident #30's Individual Narcotic Record. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure all corridors were equipped with a complete and secure handrail. The facility failed to ensure handrails were complete and secure on 1(Hall A) of 6 resident hallways observed. Findings Observation on 03/09/3026 at 3:00 p.m. with S9 Service Tech, revealed the handrail on Hall A did not have an end cap, leaving a sharp metal piece exposed and was not secured to the wall. During an interview on 03/09/26 at 3:00 p.m., S9 Service Tech confirmed the handrail did not have an end cap and was unsecure. During an interview on 03/11/2026 at 3:56 p.m., S1Administrator confirmed Hall A handrail should have been repaired.

Inspectors wroteBased on observations and interviews the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#15, #80) of 2 (#15, #80) residents' rooms observed for environment. The facility failed to ensure: 1. Resident #15's wheelchair was clean and sanitary 2. Resident #80's restroom was clean and sanitary.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident's plan of care was implemented for 1 (#15) of 1(#15) resident out of total of 34 sampled residents. The facility failed to ensure Resident #15's lab work was done as ordered.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each resident received the care and services in accordance with professional standards of practice for 1 (#2) of 1 sample resident reviewed for skin conditions (non-pressure). The facility failed to ensure resident #2, with a diagnosis of diabetes was provided necessary care and services for her feet.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide preventive care, and treatment consistent with professional standards of practice, for 1 (#151) of 3 (#15. #35 and #151) residents reviewed for positioning/mobility. The facility failed to ensure residents who were at risk for development of pressure injuries was provided necessary care to avoid a pressure injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's MDS (Minimum Data Set) assessment was transmitted to CMS (Centers for Medicare and Medicaid Services) within the required timeframe for 1 (#74 ) of 1 (#74 ) resident who was reviewed for Resident Assessment.

Inspectors wroteBased on record reviews, observations, and interviews, and the facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding for 3 (#2, #4, #5) out of 6 (#1, #2, #3, #4, #5) residents reviewed. The facility failed to change enteral feeding bags at appropriate interval and label the enteral feeding bag and syringe.

Inspectors wroteBased on observations and interviews, the facility failed to ensure dependent residents were provided Activities of Daily Living for 2 (#2, #5) out of 5 (#2, #3, #4, #5, #6) residents observed. The facility failed to trim Resident #2 and Resident #5's fingernails.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents on dialysis received services consistent with professional standards of practice for 1 (#62) of 3 (#44, #55, #62) sampled residents receiving dialysis. The facility failed to monitor dialysis access site for Resident #62.

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practiced for 2 (#14, #55) of 3 (# 14, #55, #62) residents reviewed for respiratory care. The facility failed to ensure the oxygen tubing and humidification bottles were changed and dated weekly and oxygen and nebulizer tubings were bagged when not in use.