Heritage Manor Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 4, 2026

  This citation pertains to intake number 2723282.Based on observation, interview, and record review, the facility failed to protect R201's right to be free from physical and mental abuse by Housekeeper D and Housekeeping Manager C, when Housekeeping Manager C sprayed a chemical (bleach cleaner) into the eyes of R201 while Housekeeper D held R201's wheelchair in place. This deficient practice caused chemical damage to R201's eyes and subsequent pain.Findings include: On 1/14/2026 at 8:51 AM, the State Agency (SA) received a Facility Reported Incident (FRI) with an allegation of staff to resident abuse.On 2/4/2026 at 10:00 AM, R201 was observed in bed and was interviewed about the reported incident to the SA. R201 stated, Some staff sprayed a chemical in my eyes. […]

• Actual harm, isolatedF689Apr 24, 2024

  This citation pertains to intake MI00143878. Based on interview and record review, the facility failed to implement interventions and provide sufficient staff for supervision to prevent falls for one (R921) of four residents reviewed for accidents and supervision resulting in R921 being found unresponsive on the floor with a pool of blood around the resident's head. Findings include: The State Agency received a Facility Reported Incident (FRI) on [DATE] for an incident that occurred on [DATE]. The FRI reported that R921, a Hospice patient (receiving palliative care) was observed on the floor by Certified Nursing Assistant (CNA) C on [DATE] at 7:50 AM with an injury of unknown source with serious bodily injury. […]

• Actual harm, isolatedF697Nov 18, 2021

  This citation pertains to intake: MI 567 Based on observation, interview, and record review, the facility failed to ensure pain medication was consistently available and administered in one of one resident (R115) reviewed for pain, resulting in R115 not having his pain consistently controlled as evidenced by moaning, facial grimacing, and clenching his fists during care. Findings include: During an observation on 11/15/21 at 10: 40 AM, R115 was being repositioned in bed by Certified Nursing Assistant (CNA) L. R115 was clenching his fists and moaning out loud. R115 was alert with facial grimacing but unable to coherently verbalize due to cognitive impairments. […]

• Actual harm, isolatedF697Mar 10, 2021

  This citation pertains to Intake/FRI MI 0. Based on observation, interview, and record review the facility failed to ensure a resident's pain management was addressed prior to the receipt of personal care, affecting one sampled resident (# 806), resulting in verbalized pain, discomfort, and anxiety during personal care. Findings include: On 3/9/23 at 9 a.m. a review of an investigation and other pertinent documents regarding a Facility Reported Incident (FRI) revealed the incident occurred on 2/26/21 at 3:00PM. The resident reported two female CNAs was rough with her during care causing pain in both legs. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to: 1. Ensure the use of hair restraints of staff working in the kitchen; 2. Effectively clean multiple surfaces in the kitchen (walls, ice machine, ice scoop holder, reach-in cooler floor, reach-in cooler storage racks); 3. Ensure cleaned pans and dishes were allowed to air dry before stacking; 4. Ensure surfaces inside the kitchen were smooth and easily cleanable (insulated foam board); and 5. Ensure cleaned ladles were properly stored. Findings include: On 3/3/26 at 8:40 AM during a tour of the kitchen with Dietary Manager (DM) Q, the following items were noted: Dietary Aid (DA) U was observed operating the dish machine. DA U's facial hair was not covered with a beard guard. […]