Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heather Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide complete written notifications to residents and their representatives regarding hospital transfers. Three residents were affected, with notifications missing essential information about appeal rights and Ombudsman contact details. Interviews with the Administrator confirmed the lack of additional information beyond the incomplete documents provided.
The facility failed to follow proper infection control measures for several residents. A resident with an indwelling catheter and another with a gastrostomy tube did not have appropriate signage for Enhanced Barrier Precautions (EBP), and staff did not wear gowns as required. Additionally, a CNA improperly discarded a dirty incontinence brief, and a Treatment Nurse did not perform hand hygiene during wound care. The facility lacked a policy on EBP, contributing to these deficiencies.
A resident's privacy was compromised during incontinence care when a CNA failed to close the blinds, leaving the resident exposed to the parking lot. The resident, who was cognitively intact, was observed with their private areas visible from outside. The DON confirmed that staff should ensure privacy by closing doors, curtains, and blinds during personal care.
A facility failed to provide a written bed hold notification to a resident or their representative before a hospital transfer, as required by policy. The resident, diagnosed with dementia and other conditions, was transferred for behavioral symptoms. The Business Office Manager confirmed no notice was sent due to the resident being in a skilled bed, which the facility does not hold after midnight, contradicting the facility's policy.
A facility failed to ensure gradual dose reductions for psychotropic medications were addressed for a resident with moderately impaired cognition. The resident was using an antipsychotic for behavior management and an anti-anxiety medication for anxiety disorder. The facility lacked documentation from the prescribing physician for continuing the PRN anti-anxiety medication past 14 days and did not complete a required reduction of the antipsychotic dosage due to the absence of an approved diagnosis.
An LPN left a medication cart unattended in the hallway with insulin, wound gel, and an unlabeled cup containing a laxative solution. The LPN admitted to pre-preparing the solution, which was not standard practice, and acknowledged the error. The DON confirmed that medications should be securely stored to prevent unauthorized access, as per facility policy.
The facility failed to ensure proper hand sanitation and food handling practices, maintain kitchen equipment, and store food items correctly. Dietary aides were observed not washing hands before handling food, and dirty dishes were improperly placed in the dishwasher. Kitchen equipment and food storage areas were found in unsanitary conditions, with broken seals, buildup of substances, and improperly stored food items.
The facility failed to treat residents with respect and dignity during meal service. One resident was left with a meal tray and instructed not to feed themselves, while another resident had a breakfast tray left in their room for 5-6.5 hours, potentially compromising food safety. The DON acknowledged these practices were not standard and could affect resident dignity.
The facility failed to ensure that combustible equipment was safely locked away from residents who wander and/or self-propel throughout the facility. Surveyors found two doors labeled 'Oxygen' unlocked, with portable oxygen tanks and supplies inside. Staff confirmed that these doors should have been locked, and the DON acknowledged the importance of securing such equipment. The facility lacked a policy on Accidents and Hazards.
The facility failed to ensure that the storage container for refrigerated controlled medications was permanently affixed. An LPN and the DON confirmed that the storage box, containing Lorazepam syringes, was not attached but was behind two locks, contrary to the facility's policy.
The facility failed to ensure that two residents were not served foods they disliked, despite documented preferences. One resident with mild cognitive impairment was served chicken alfredo, similar to their disliked chicken spaghetti, and another cognitively intact resident was served a meal with lettuce, which they disliked. The Dietary Manager and Director of Nursing acknowledged procedural lapses and the absence of a policy on meal serving.
The facility failed to ensure humidifier bottles and nasal cannula tubing were dated and stored in a sanitary manner for two residents. One resident was observed receiving humidified oxygen with an undated humidifier bottle, while another had undated tubing resting on the floor. The DON confirmed that the equipment should be dated and stored properly to prevent infection.
A resident with Osteomyelitis and a sacral pressure ulcer on contact isolation due to MRSA received IV medications in an unsafe manner. An LPN was observed using a previously uncapped saline flush and failing to wear proper PPE, risking further infection. The DON confirmed the need for proper PPE and new saline flushes, and the facility lacked a specific PICC line policy.
Incomplete Transfer Notifications for Hospitalized Residents
Penalty
Summary
The facility failed to provide complete written notifications to residents and their representatives regarding transfers or discharges to the hospital. This deficiency was identified for three residents who were hospitalized. The notifications lacked essential information, including the residents' appeal rights and contact details for the Office of the State Long-Term Care Ombudsman. These omissions were discovered during a review of the facility's documentation and interviews with the facility's Administrator and Director of Nursing. Resident #69, who was cognitively intact with a BIMS score of 15, was transferred to the hospital on four occasions. The facility's transfer letters for these hospitalizations did not include the required information about the appeals process and how to contact the Ombudsman. Similarly, Resident #76, also cognitively intact with a BIMS score of 14, was transferred for behavioral symptoms, and the notification letter again lacked the necessary details about appeal rights and Ombudsman contact information. Resident #49, with a BIMS score of 12 indicating moderate cognitive impairment, was transferred to the hospital for abdominal pain and other symptoms. The notification provided to this resident also failed to include the required information about the appeals process and Ombudsman contact. Interviews with the facility's Administrator confirmed that no additional information was provided to the residents or their representatives beyond the incomplete documents initially given.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection control measures were followed for several residents. For Resident #11, who had an indwelling catheter and was on Enhanced Barrier Precautions (EBP), Certified Nursing Assistants (CNAs) did not wear gowns while transferring the resident, and there was no signage indicating the need for EBP. The Director of Nursing (DON) was uncertain about the current status of EBP requirements, indicating a lack of clarity and communication regarding infection control protocols. Resident #64, who had a gastrostomy tube and was also on EBP, received medication from a Licensed Practical Nurse (LPN) who did not wear a gown during the procedure. Similar to Resident #11, there was no signage to alert staff about the EBP requirement. The facility lacked a policy on Enhanced Barrier Precautions, contributing to the oversight in infection control practices. For Resident #70, a Certified Nursing Assistant (CNA) was observed discarding a dirty incontinence brief on the floor, contrary to the facility's infection prevention policy. Additionally, during wound care for Resident #53, the Treatment Nurse failed to perform hand hygiene between glove changes, despite the presence of EBP signage and PPE supplies. The facility's handwashing policy did not adequately address hand hygiene during wound care, leading to lapses in aseptic technique.
Privacy Violation During Incontinence Care
Penalty
Summary
The facility failed to ensure privacy and maintain dignity for a resident during incontinence care. The resident, who was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, was observed receiving incontinence care with the blinds partially open. This allowed visibility from the parking lot, compromising the resident's privacy. The resident was occasionally incontinent of bowel and bladder, as noted in their Plan of Care. During the incident, a Certified Nursing Assistant (CNA) provided care without closing the blinds, resulting in the resident's buttocks and genital area being visible from outside. The CNA acknowledged the oversight in an interview, admitting that the blinds should have been closed. The Director of Nursing (DON) confirmed that staff are expected to ensure privacy by closing doors, pulling curtains, and closing blinds during personal care, acknowledging that the failure to do so could be a dignity issue.
Failure to Provide Bed Hold Notification Before Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notification to a resident or their representative prior to a hospital transfer. This deficiency was identified during a review of the medical records and facility policies. The resident in question had a diagnosis of dementia with behavioral disturbances, among other conditions, and was transferred to a hospital for behavioral symptoms. Despite the facility's policy requiring that a bed hold notification be provided before such a transfer, there was no documentation indicating that this notification was given to the resident or their representative at the time of transfer. Interviews with facility staff revealed that the Business Office Manager (BOM) was responsible for sending the bed hold notice. However, the BOM confirmed that no notice was sent because the resident was in a skilled bed, which the facility does not hold after midnight. This oversight was in direct contradiction to the facility's bed hold policy, which mandates that the notification be provided before the transfer occurs. The lack of adherence to this policy resulted in the identified deficiency.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDR) for psychotropic medications were addressed and attempted for a resident, in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as-needed (PRN) medication past 14 days. The resident, who had moderately impaired cognition, was using a brand name antipsychotic medication for behavior management and an anti-anxiety medication for anxiety disorder. The facility did not have documentation completed by the prescribing physician providing a rationale for continuing the PRN anti-anxiety medication past the 14-day limit set by CMS, nor was there a documented explanation as to why a dose reduction attempt would be contraindicated. Additionally, the facility did not complete a required reduction of the antipsychotic medication dosage for the resident, as there was no approved diagnosis documented in the resident's health record. The Director of Nursing confirmed that the facility lacked documentation noting an approved diagnosis or that a reduction was completed for the suggested antipsychotic GDR. The facility's policy on psychotropic medications states that these medications should only be given if necessary to treat a specific condition, as diagnosed and documented in the resident's clinical record, which was not adhered to in this case.
Improper Medication Storage and Unauthorized Access
Penalty
Summary
The facility failed to ensure proper storage of medications, leading to unauthorized access. On multiple occasions, an LPN was observed leaving a medication cart unattended in the hallway with a vial of insulin, a tube of wound gel, and an unlabeled plastic cup containing a clear liquid on top. The LPN admitted to pre-preparing a laxative solution for a resident, which was not standard practice, and acknowledged that medications should not have been left unattended. The Director of Nursing confirmed that medications should be securely stored to prevent access by residents and visitors, as per the facility's policy on medication storage.
Deficiencies in Hand Sanitation, Equipment Maintenance, and Food Storage
Penalty
Summary
The facility failed to ensure proper hand sanitation and food handling practices in the kitchen. Dietary Aide #1 was observed placing her hands under her apron and retrieving her glasses without washing her hands before continuing to set up food for serving. Additionally, Dietary Aide #3 and Dietary Aide #1 were seen touching the inside of meal tray lids and bowl lids, respectively, before placing them on the trays and bowls. These actions could potentially contaminate the food being served to residents. Furthermore, dirty dishes were improperly placed into the dishwasher from the clean dish side by Dietary Aide #2, risking contamination of clean dishes and countertops. The facility also failed to maintain kitchen equipment and food storage areas in a sanitary condition. The seal on the ice machine was held in place by tape, and the walk-in freezer contained sub rolls with ice particles inside the bags. Ice was frozen to the side of the freezer door, interfering with the seal. The vent above the door leading outside had a buildup of a black fuzzy substance, and the stove hood vents were covered in a black sticky substance. Additionally, a rubber spatula with pieces missing from the edges was found on the food preparation table, posing a risk of rubber bits breaking off into the food. The steam table contained murky water with a white foam substance floating on top, and the water level did not reach the bottom of the pans containing the residents' meals. Food storage practices were also found to be inadequate. Several food items in the dry food storage area were open and not sealed, including bags of tortilla chips, boxes of parboiled rice and graham crackers, and containers of lemon juice and peanut butter. Some items were past their expiration dates, and others were not labeled with open dates. Food items were also found in direct contact with the floor, including bread trays, soda cans, and various other food products. The fire alarm pull station by the kitchen back door entrance was covered in a black sticky substance, and the back entrance door was not fully sealed, which could allow pests to enter the kitchen area.
Failure to Maintain Resident Dignity and Proper Meal Service
Penalty
Summary
The facility failed to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of his or her quality of life. Resident #25, who had diagnoses of Paraplegia and Major depression disorder, was observed being treated without dignity during meal service. Certified Nursing Assistants (CNAs) instructed the resident not to feed themselves and left the resident's meal tray in front of them while continuing to serve other residents. The resident had to ask multiple staff members for assistance before receiving help with their meal. The Director of Nursing (DON) acknowledged that this practice was not standard and could affect the resident's dignity. Resident #50, diagnosed with Vascular dementia, Transient ischemic attacks, and Chronic kidney disease, was found with a breakfast tray that had been left in their room for 5-6.5 hours. The resident was observed eating from the tray, which included warm milk and other food items that may no longer have been safe to consume. The CNA and DON confirmed that there was no clear policy on how long meal trays should remain in residents' rooms and acknowledged that the food might not be safe after such a long period. Both incidents highlight a failure to maintain the dignity and quality of life for the residents, as well as a lack of clear procedures for meal service and tray removal. The DON admitted that referring to a resident as a
Failure to Secure Combustible Equipment
Penalty
Summary
The facility failed to ensure that combustible equipment was safely locked away from residents who wander and/or self-propel throughout the facility. On two separate occasions, surveyors found doors labeled 'Oxygen' at the ends of the 200 Hall and 600 Hall unlocked, with portable oxygen tanks, supplies, and other equipment inside. The Admission Coordinator and an LPN confirmed that these doors should have been locked. The Director of Nursing (DON) also acknowledged that rooms containing oxygen tanks and other equipment should be locked to prevent residents from accessing and potentially tampering with the equipment. The facility did not have a policy on Accidents and Hazards at the time of the survey.
Failure to Permanently Affix Storage Box for Refrigerated Controlled Medications
Penalty
Summary
The facility failed to ensure that the storage container used to store controlled medications requiring refrigeration was permanently affixed. During an observation of the medication room, an LPN removed the storage box containing refrigerated controlled medications and placed it on the counter. The storage box contained syringes of Lorazepam for emergency use and prescribed Lorazepam syringes. When asked, the LPN confirmed that the storage box was not permanently affixed and believed it only needed to be under two locks. The Director of Nursing (DON) also confirmed that the storage box was not permanently affixed but was behind two locks. The facility's policy stated that medications listed in Schedules II, III, IV, and V should be stored under double lock, with Schedule II medications kept under double lock and attached to a permanently affixed wall. The failure to permanently affix the storage box for controlled medications requiring refrigeration was a deviation from the facility's policy and accepted professional principles.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that two residents, one with diagnoses of congestive heart failure, acute respiratory failure with hypoxia, and anemia, and another with acute on chronic congestive heart failure, type II diabetes mellitus, and cerebral infarction, were not served foods they disliked. Resident #12, who had a BIMS score suggesting mild cognitive impairment, was served chicken alfredo despite having a documented dislike for chicken spaghetti. The Dietary Manager confirmed that chicken alfredo and chicken spaghetti were made with very similar ingredients, indicating a failure to honor the resident's food preferences. Resident #12 was observed complaining loudly about the meal to the Dietary Manager. Resident #23, who was cognitively intact, was served a meal that included lettuce, despite having a documented dislike for it. The resident expressed dissatisfaction with the meal to a Registered Nurse and chose to leave the dining area instead of accepting an alternative. The Dietary Manager acknowledged the oversight and mentioned that there are procedures in place to check meals before they leave the kitchen, but these procedures were not followed. The Director of Nursing confirmed that there was no policy on the serving of meals, contributing to the failure to prevent residents from receiving foods they disliked.
Failure to Maintain Sanitary Conditions for Respiratory Equipment
Penalty
Summary
The facility failed to ensure humidifier bottles and nasal cannula tubing were dated and stored in a safe and sanitary manner to prevent infection for two residents. Resident #78, who had diagnoses of abnormal findings of lung field and cerebral infarction, was observed receiving humidified oxygen via nasal cannula without the humidifier bottle being dated. The Registered Nurse confirmed that neither the humidifier bottle nor the tubing was dated. The Director of Nursing (DON) acknowledged that the water used for oxygen therapy should be dated to indicate when it was opened. Resident #50, who had diagnoses of vascular dementia, transient ischemic attacks, and chronic kidney disease, was observed with an undated humidifier bottle and nasal cannula tubing resting on the floor. The Licensed Practical Nurse (LPN) confirmed that the tubing should be dated and stored in a plastic bag when not in use to maintain sanitation. The DON confirmed that it was inappropriate for the tubing to be left resting over the concentrator and touching the floor, as it is unclean.
Failure to Administer IV Medications Safely and Maintain Sterility
Penalty
Summary
The facility failed to ensure intravenous medications were administered in a safe and non-contaminated manner for a resident with diagnoses of Osteomyelitis and a pressure ulcer to the sacral region. The resident was receiving Vancomycin and Ceftriaxone intravenously and was on contact isolation due to Methicillin-resistant Staphylococcus Aureus in the wound. During the survey, an LPN was observed uncapping a PICC lumen and a normal saline flush, tossing the caps on the resident's bed, and then using the same saline flush later without ensuring it remained sterile. The LPN also failed to wear proper PPE when re-entering the resident's room to cap the lumen, which was done without gloves and after touching the tip of the lumen cap. The LPN admitted to these actions and acknowledged the potential for causing further infection due to contamination and improper PPE use. The Director of Nursing (DON) confirmed that staff should wear gown and gloves when entering a contact isolation room and that a new saline flush should be used to prevent infection. The DON also acknowledged that the facility did not have a specific policy on PICC lines. The facility's existing policy on isolation precautions required wearing gloves and a disposable gown upon entering a contact precautions room, which was not followed by the LPN in this instance.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hope
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Prescott Rehab & Nursing Center | 15.6 mi | ★★★★★ | 4 | 0 |
| The Springs Of Hillcrest | 16.7 mi | ★★★★★ | 8 | 0 |
| The Blossoms At Stamps Rehab & Nursing Center | 20 mi | ★★★★★ | 3 | 0 |
| The Springs Of Mine Creek | 26.1 mi | ★★★★★ | 1 | 0 |
| The Blossoms At Nashville Rehab And Nursing Center | 26.1 mi | ★★★★★ | 1 | 0 |
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