Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Heritage Manor during CMS and state inspections, most recent first.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to ensure a licensed nurse was in charge on each shift, as required.
The facility did not maintain 24-hour licensed nursing staff coverage for eight days in the first quarter of fiscal year 2024. The CASPER report showed 20 days without licensed staff, and the DON attributed this to payroll software issues. However, payroll records confirmed gaps of six hours or more on specific night shifts, and no information on the software problem was provided.
A facility failed to perform an elopement risk assessment for a resident with severe cognitive impairment and a history of wandering. Despite having a care plan and provider orders for a wanderguard, the resident's medical record lacked an elopement risk assessment. The DON acknowledged the oversight, noting that a trial removal of the wanderguard was done without a new assessment, contrary to the facility's policy.
A resident with severe cognitive impairment and multiple diagnoses, including dysphagia, was not positioned correctly during tube feedings, as required by their care plan. Observations showed the head of the bed was consistently lower than the specified 45 to 60 degrees, increasing the risk of aspiration. Staff interviews revealed a lack of awareness and adherence to the required positioning, despite clear orders and policy guidelines.
A facility failed to change a resident's oxygen tubing weekly as required, despite physician orders and facility policy. The resident, with multiple health conditions, had undated oxygen tubing observed on two occasions, and records showed no changes in April or May. Interviews with a CNA and LPN confirmed the responsibility for changing the tubing, while the DON expected care to be completed and charted per shift.
A resident with dementia and hemiplegia was not properly positioned in their wheelchair as per occupational therapy orders, which required two lateral side wedges to prevent leaning. Observations showed the resident frequently leaning without the prescribed supports, and staff interviews confirmed the orders were not consistently followed.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain 24-Hour Licensed Nursing Staff Coverage
Penalty
Summary
The facility failed to provide licensed nursing staff on a 24-hour basis for eight days in the first quarter of fiscal year 2024. The CASPER report identified 20 days between October 1, 2023, and December 31, 2023, when there was no licensed nursing staff present. During an interview on May 17, 2024, the Director of Nursing (DON) stated that the facility was currently well-staffed and attributed the gaps in the CASPER report to a malfunction in their payroll software. However, the facility's payroll records confirmed specific dates with gaps of six hours or more without licensed nursing staff coverage, particularly on night shifts. Information regarding the payroll software issue was requested but not provided.
Failure to Conduct Elopement Risk Assessment
Penalty
Summary
The facility failed to perform an elopement risk assessment for a resident with severe cognitive impairment, Alzheimer's disease, dementia, and major depressive disorder with psychotic symptoms. The resident's quarterly Minimum Data Set (MDS) identified these conditions, and provider orders required staff to check the placement and function of a wanderguard on the resident's right ankle each shift. The resident's care plan also noted a risk for wandering, with interventions including the use of a wanderguard, moving the resident closer to the nurse's station, and encouraging participation in activities during peak wandering times. Despite these measures, the resident's medical record lacked an elopement risk assessment. During an interview, the Director of Nursing (DON) acknowledged that the only elopement risk assessment found in the resident's record was initiated in August 2023. The DON admitted that a trial removal of the wanderguard was conducted without a subsequent assessment, even after the resident attempted to walk away in the common area. The facility's elopement policy, dated August 2022, required an assessment on admission and whenever a resident was identified at risk for elopement, which was not adhered to in this case.
Failure to Maintain Safe Positioning for Resident with Feeding Tube
Penalty
Summary
The facility failed to maintain safe positioning for a resident with a feeding tube, leading to a deficiency in care. The resident, who had severe cognitive impairment and multiple diagnoses including Parkinson's disease, respiratory failure, and dysphagia, was dependent on staff for mobility and oral hygiene. The resident's care plan and provider orders specified that the head of the bed (HOB) should be elevated between 45 to 60 degrees during feedings to prevent aspiration. However, observations revealed that the resident's HOB was consistently lower than the required elevation, ranging from 10 to 20 degrees, while the tube feeding was running. Interviews with staff indicated a lack of awareness and adherence to the specified HOB elevation. A nursing assistant was unsure of the required HOB position, and a licensed practical nurse confirmed that the HOB was not at the correct elevation, despite the orders being clearly posted. The director of nursing also acknowledged the importance of maintaining the correct HOB elevation to prevent aspiration. The facility's policy on enteral feeding tube usage required at least a 30-degree elevation, yet this was not consistently followed, contributing to the resident's risk of aspiration.
Failure to Change Oxygen Tubing Timely
Penalty
Summary
The facility failed to ensure timely changes of oxygen tubing for a resident, identified as R17, who required respiratory care. R17 had a significant change Minimum Data Set (MDS) with diagnoses including heart failure, anxiety, type 2 diabetes, and a thyroid disorder. Physician orders dated 12/20/23 specified that oxygen tubing should be changed weekly on Monday night shifts. However, observations on 5/14/24 and 5/17/24 revealed that the oxygen tubing lacked a date, and the treatment record indicated that the tubing was not changed in April or May. Interviews with a certified nursing assistant (CNA) and a licensed practical nurse (LPN) confirmed that nurses were responsible for changing the tubing per orders, yet the tubing remained undated. The director of nursing (DON) stated that staff were expected to complete and chart resident care during their shifts. The facility's Oxygen Administration policy, dated 9/12/23, required that tubing and cannula or mask be labeled with a date and changed weekly.
Failure to Implement Wheelchair Positioning Orders
Penalty
Summary
The facility failed to implement occupational therapy (OT) orders for proper wheelchair positioning for a resident identified as R31. R31, who has diagnoses including dementia, generalized muscle weakness, and hemiplegia, was severely cognitively impaired and required substantial assistance with daily activities. The care plan dated 6/23/22 specified the use of side supports in the wheelchair to prevent leaning to the left. A therapy progress note from 3/6/24 indicated that lateral side wedges were provided to further prevent leaning, with orders to place them on both sides while the resident was in the wheelchair. Observations from 5/14/24 to 5/17/24 revealed that R31 was frequently seen leaning to one side in the wheelchair, often without the prescribed lateral side wedges in place. Interviews with staff, including an occupational therapist, a nursing assistant, a registered nurse, and the director of nursing, confirmed that the orders for two lateral side wedges were communicated but not consistently implemented. The director of nursing acknowledged the expectation that care plans and therapy orders should be followed, yet there was no recollection of R31 using two lateral side wedges as ordered.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 45 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chisholm
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cornerstone Villa | 4.3 mi | ★★★★★ | 4 | 0 |
| Guardian Angels Health & Rehab Center | 5.3 mi | ★★★★★ | 1 | 0 |
| The Waterview Pines Llc | 15 mi | ★★★★★ | 18 | 1 |
| Essentia Health Virginia Care Cent | 15.2 mi | ★★★★★ | 4 | 0 |
| The Waterview Woods Llc | 15.6 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.