Heritage Manor West

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF580Jul 16, 2026

  Based 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.Findings:Review of facility's Change in Resident Medical Status Policy (latest revision date 9/17) revealed in part: A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment.Facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s),A need to alter treatment significantly (that is a need to discontinue or change an existing treatment due to adverse consequences, or to commence a new form of treatment).Review of… […]

• No harm, potential for more than minimal, patternF726Jul 16, 2026

  Based 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. Findings:Review of facility's Wound/Skin Documentation policy (latest revision date 4/25) revealed in part;Wound/skin evaluation is utilized to document and trend the status of pressure ulcers, other ulcers, (diabetic, arterial, and venous ulcers), surgical wounds, open lesions and other skin issues.Documentation shall occur on admission, on discovery, weekly and when significant changes to the wound… […]

• No harm, potential for more than minimal, patternF656Mar 11, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF677Mar 11, 2026

  Based 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. Findings:Review of Resident #91's Medical Diagnoses revealed the following but not limited to dysphagia following cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and dementia. Review of Resident #91's Quarterly MDS dated [DATE] was assessed to have a BIMS of 03 out of 15 indicating severely impaired cognition. Observation on 03/09/2026 at 1:00 p.m. […]

• No harm, potential for more than minimal, patternF698Mar 11, 2026

  Based 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. Findings: Review of Resident #5's Medical Diagnoses revealed the following but not limited to end stage renal disease and dependence on renal dialysis.Review of Resident #5's March 2026 Physician Orders revealed an order dated 12/17/2025 for Hemodialysis on Monday, Wednesday, and Friday at 9:30 a.m. […]