Heritage Manor

In the surveyor’s words

From the most serious findings on record at Heritage Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF808May 19, 2022

  Based on observation, interview, and document review, the facility failed to provide a mechanical altered diet resulting in choking and repeated [MEDICATION(S)] maneuvers to dislodge the food for 1 of 3 residents (R1) reviewed. This resulted in an immediate jeopardy to R1. The immediate jeopardy began on 5/6/22, at 12:00 p.m. when R1 was served a grilled cheese sandwich. R1 had physician's orders to receive minced and moist food. The grilled cheese sandwich was cut up in small pieces and dipped into the soup. Two pieces of the grilled cheese sandwich got lodged in R1's throat. The [MEDICATION(S)] maneuver was performed several times to get the two pieces of the grilled cheese sandwich dislodged. […]

• Actual harm, isolatedF600Jul 31, 2026

  Based on interviews and document review, the facility failed to protect a resident's right to be free from mental abuse for 1 of 4 residents (R71) reviewed for abuse. This led to psychosocial harm when the resident barricaded herself into her room and caused her to discharge early from the facility prior to reaching her maximal level with therapy services.Findings include:R71's admission Minimum Data Set (MDS) dated [DATE], indicated R71 was cognitively intact. Diagnoses included osteoarthritis of the right hip and major depressive disorder.R71's Census List dated 7/30/26, indicated R71 was admitted on [DATE] and discharged from facility on 12/30/25. R71 remained in the same room throughout their stay. […]

• Actual harm, isolatedF684Jun 26, 2025

  Based on interview and document review, the facility failed to track and report lack of bowel movements to provider for 2 of 2 residents (R16, R52) reviewed for bowel tracking. This resulted in actual harm when R16 was hospitalized for constipation and subsequently taken to the operating room for disimpaction. In addition, the facility failed to monitor vital signs and complete weights as ordered for 1 of 1 resident (R52) and follow orders for blood glucose monitoring and insulin administration for 1 of 1 resident (R37).Findings include: R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 had diagnoses which included osteoarthritis of knee, postconcussional syndrome (a set of symptoms that can persist for weeks, months, or years after a concussion or traumatic… […]

• No harm, potential for more than minimal, widespreadF725Jun 26, 2025

  Based on observation, interview and document review the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares including getting residents out of bed when requested for 1 of 2 resident (R36) reviewed for choices, monitoring for and treating constipation for 1 of 2 (R16) and monitoring residents receiving dialysis for 1 of 1 resident (R111) reviewed for dialysis care. This had the potential to affect all residents residing in the facility. Findings include:Staff and Resident Interviews/Observations:On 6/23/25 at 2:53 p.m., R110 stated she had taken herself to the bathroom (said she had already waited 40 minutes) and was fearful of soiling self. […]

• No harm, potential for more than minimal, widespreadF755Jun 26, 2025

  Based on observation, interview, and document review, the facility failed to maintain controlled medication accounting for facility stock medication and for 1 of 1 resident (R262) reviewed for medication side effects. The facility failed to ensure residents were free from medication errors for 1 of 1 resident (R262) who didn't receive their medication as ordered. In addition, the facility failed to remove expired facility stock medication which had to potential to affect any resident needing facility stock medication. […]