Heritage Manor of Mandeville

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 16, 2023

  Based on observations, record review, and interviews, the facility failed to ensure a cognitively impaired resident, who exhibited exit-seeking behaviors, was adequately supervised to prevent unsafe wandering and elopement for 1 (#1) of 4 (#1, #3, #4, and #6) residents reviewed. This deficient practice resulted in an immediate jeopardy situation for Resident #1, who had severe cognitive impairment and a history of exit seeking behavior, on 06/28/2023 at 8:22 p.m. after Resident #1 was observed on video surveillance entering another resident's room and did not exit the room. Resident #1 had eloped from the facility premises, and was found wandering across a four-lane roadway yelling for help. A concerned citizen contacted the facility and asked if they were missing a resident. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2024

  Based on observations, interviews, and record review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly labeled and dated; and 2. Food was not expired. There were a total of 103 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of Facility's Policy titled Storage of Refrigerated Food revealed the following, in part: Procedure: 5. All non-hazardous opened foods are labeled with name of food, date stored. 11. Food shall be stored base on use-by expiration date and facility recommended food storage chart. 1. On [DATE] at 9:15 a.m., a tour of the facility's kitchen was conducted with S6DM. […]

• No harm, potential for more than minimal, patternF640Oct 9, 2024

  Based on record review and interviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted timely for 2 (#27 and #101) of a total of 31 sampled residents reviewed for Resident Assessment. Findings: Resident #27 Review of Resident #27's Clinical Record revealed he was admitted to the facility on [DATE]. On 10/07/2024, review of Resident #27's Quarterly MDS with an ARD of 09/03/2024 revealed the MDS assessment was incomplete and had a status of: In progress. On 10/08/2024, review of Resident #27's Quarterly MDS with an ARD of 09/03/2024 revealed a completion date of 10/08/2024, signed by S6MDS. Resident #101 Review of Resident #101's Clinical Record revealed he was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF641Oct 9, 2024

  Based on interviews and record reviews, the facility failed to ensure resident's MDS assessments accurately reflected the resident's status for 5 (#17, #22, #26, #99, and #114) out of 31 residents reviewed in the final sample. The facility failed to ensure: 1. Resident #17 and Resident #22 were accurately coded for PASRR (Pre-admission Screening and Resident Review); 2. Resident #26 was not coded for anticoagulant use; 3. Resident #99 was coded correctly for Diabetic foot ulcers; and 4. […]

• No harm, potential for more than minimal, patternF609Mar 7, 2024

  49343 Based on record review and interviews, the facility failed to ensure alleged violations of physical abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to other officials in accordance with State law for 2 (Resident #2 and #3) of 4 (Resident #1, #2, #3 and #4) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse/Crime Reporting revealed the following, in part Policy dated 07/2011: The law stipulates that staff members who witness suspicious activity that could result in serious bodily injury shall report that suspicion immediately but not later than two (2) hours after forming the suspicion. […]