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, isolatedF689Mar 24, 2025

  On 03/19/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision for Resident #1 who wandered and experienced exit seeking behaviors. An undated elopement policy, read in part, It is the policy of this facility to provide a safe and comfortable environment to prevent resident elopements. Resident #1's Wandering Risk Assessment, dated 02/13/25, showed the resident was a high risk for wandering and was a known wanderer/history of wandering. A nurse note, dated 02/15/25 at 1:03 p.m., showed Resident #1 remains confused trying to exit pushing on north hall door. […]

• Actual harm, isolatedF689May 23, 2024

  Based on observation, record review, and interview, the facility failed to ensure: a. falls were evaluated for cause and interventions implemented to prevent falls with injuries for one (#48) of three sampled residents reviewed for accident hazards and falls. Resident #48 had a fall with a major injury in December 2023 which resulted in staples to the head. The facility did not assess the fall and implement changes in interventions to aide in the prevention of falls. Resident #48 had two additional falls one in March 2024 and one in April 2024 that also resulted in injuries without any implemented changes to interventions to aide in the prevention of falls. b. care plan interventions were implemented for one (#32) of three sampled residents reviewed for accident hazards and falls. […]

• No harm, potential for more than minimal, widespreadF847Nov 21, 2025

  Based on record review and interview, the facility failed to ensure residents or their representatives:Understood what an arbitration agreement was;Understood their right not to sign the agreement as a condition of admission, or as a requirement to continue to receive care at the facility; andWere explicitly granted the right to rescind the agreement within 30 calendar days of signing the document for 8 (#1, 2, 27, 38, 39, 42, 45, and #51) of 8 sampled residents reviewed for arbitration agreements.The administrator identified 51 residents resided in the facility.The social services director stated all 51 residents had entered into a binding arbitration agreement.Findings:On 09/30/25 at 12:15 p.m., the social services director was observed using Docusign to click through the sections of the… […]

• No harm, potential for more than minimal, widespreadF848Nov 21, 2025

  Based on record review and interview, the facility failed to ensure the arbitration agreement provided:the selection of a neutral arbitrator agreed upon by both parties; andfor the selection of a venue that is convenient to both parties.The administrator identified 51 residents resided in the facility.The social services director stated all 51 residents had entered into a binding arbitration agreement.Findings:An undated Dispute Resolution Plan, contained within the Admissions Agreement: Manor, read in part, The parties agree and acknowledge that the business relationship involves interstate commerce and that any such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and… […]

• No harm, potential for more than minimal, widespreadF851May 23, 2024

  Based on record review and interview, the facility failed to submit accurate payroll based journal staffing data to CMS for FY quarter 1 2024. LPN #3 identified 51 residents resided in the facility. Findings: A PBJ Staffing Data Report dated 10/01/24 through 12/31/24, documented the facility did not have RN hours for 10/22, 10/23, 11/03, 11/10, 11/17, 11/30, 12/01, 12/04, 12/07, 12/08, 12/09, 12/10, 12/22, 12/23, 12/24, 12/25, and 12/30/24. The report documented the facility did not have licensed nursing coverage for 24 hours/day for 12/09, 12/10, 12/23, and 12/24/24. On 05/23/24 at 8:31 a.m., Corporate Nurse Consultant #1 stated we had the hours they just didn't get on the report. On 05/23/24 at 1:14 p.m., the Operations Manager provided documentation of coverage for the dates above.