Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
The facility failed to provide a resident with the current Combined Federal and State [NAME] of Rights. An admission folder contained an outdated rights notice, while the most current version was dated later. The DON said they did not know how residents received the admission packet, and an RN stated it could be provided in paper or electronic form.
Care plans were not revised to match current assessments, therapy notes, and resident preferences for several residents. One resident’s care plan still showed independence despite MDS findings of severe cognitive impairment, incontinence, and need for assistance with ADLs. Another resident’s plan did not match therapy’s transfer guidance or current feeding tube use, a third resident’s preference for female caregivers was not documented, and a fourth resident’s plan did not reflect therapy’s recommendation to have meals out of bed.
The facility failed to consistently educate, offer, or administer influenza and pneumococcal vaccines for multiple residents. Records for one resident did not clearly show prior vaccine history or eligibility, another resident had no evidence of shared decision making or additional pneumococcal vaccination, and a third resident’s consent was incomplete and lacked documentation of vaccination. The IP nurse stated she handled MIIC review and PCC entry herself and that vaccine review was behind during a period when she was also serving as DON.
A facility failed to maintain an effective compliance and ethics program with adequate monitoring and auditing of MDS data and did not ensure staff could report suspected misconduct without fear of retaliation. Multiple residents had inconsistent or unsupported F33.3 diagnoses added, modified, or removed in the EMR and MDS, while provider notes and orders did not consistently support the diagnosis. Staff reported concerns about altered faxed orders, audit trail changes made by the DON and corporate nurses, and fear of retaliation when raising the issue.
Failure to obtain informed consent for psychotropic medications: two residents were prescribed medications for mental health-related conditions, but the EMR did not show education or consent for all ordered drugs. One resident with intact cognition had orders for Depakote and gabapentin without documented education on risks, benefits, side effects, or alternatives. Another resident with severe cognitive impairment had consent for Celexa, but not for hydroxyzine or risperidone; the DON stated residents and/or families should know the risks and side effects before deciding to take the medication.
A resident with anemia, MS, and a seizure disorder was found with Diclofenac cream, Biotin mouth wash, and Systane eye drops left on the bedside table even though the SAM evaluation and care plan stated the resident could not self-administer medications or keep them at bedside. The active order summary had no bedside-medication orders, and an LPN and RN both acknowledged the medications should not have been left in the room.
Delayed Provider Signature on POLST: A resident with heart failure, dementia, diabetes, hyperlipidemia, and heart disease signed a POLST, but the provider did not sign it until later after the issue was identified. The DON stated the admission coordinator completed the form with the resident or decision maker and then it went into the chart as an order, but could not explain why the POLST was not signed by the provider on admission.
Failure to Provide Notice of Medicare Non-Coverage: A resident did not have clear documentation that she received notice of Medicare non-coverage before services were denied. The resident’s denial forms contained signatures that did not appear consistent with each other or with the admission financial form, and the progress notes did not show the forms were received. When interviewed, the resident did not recall signing any papers about Medicare denial or the right to appeal.
A resident reported being frightened after another resident repeatedly entered the room, grabbed belongings, and acted aggressively, but the concern was not reported to the SA within 2 hours. In a separate incident, a cognitively intact resident returned from the ER with a minor labial tear/perineal laceration and minimal bleeding, yet the DON and administrator did not treat it as reportable abuse or an injury of unknown source and did not investigate it.
Failure to investigate resident-on-resident abuse and unexplained perineal injury: A cognitively intact resident reported being frightened after another resident repeatedly entered her room, grabbed belongings, and snarled at her, but leadership did not complete a formal abuse investigation. The facility also did not investigate a cognitively intact resident’s unexplained labial/perineal tear after an ER visit, despite the injury being documented as a laceration of the perineum and staff acknowledging the concern was discussed but not reported or investigated.
Failure to provide required bed-hold notice before hospital transfer. A resident with intact cognition and diagnoses including hemiplegia/hemiparesis, CHF, and COPD was transferred without documentation of bed-hold information in the progress notes. Staff said the charge nurse would ask the family about bed-hold, document verbal authorization, and social services would later mail the form, but no paperwork went to the hospital with the resident, despite policy requiring the resident and representative be informed of bed-hold rights and the policy accompany the resident for an ED transfer.
The facility failed to complete MDS assessments accurately and on time for multiple residents. One resident’s significant change assessment was late and section GG was not assessed, several residents had unsupported or inconsistent F33.3 diagnosis coding in section I, and other MDSs were left incomplete with missing oral/dental, cognitive, mood, and behavior sections. The MDS coordinator and DON verified the missing and incomplete items were needed for baseline assessment, coding, billing, and care planning.
A resident receiving dialysis had no dialysis-related care plan or dialysis orders in the active record, even though the MDS showed ESRD and dialysis treatment. The resident received dialysis through a perma-catheter, and staff acknowledged that kidney conditions and dialysis should have their own care plans so all staff know how to provide care; the DON stated the care plan should reflect the MDS and include specialized services with measurable goals and interventions.
Failure to Carry Out Lymphedema Treatment Order: A resident with MS, DM, AFib, HTN, HLD, and HF did not receive ordered lymphedema treatment after a family request and provider approval for OT referral. Therapy staff said no lymphedema order was received after the department change, while RN staff confirmed the order had been signed off and the DON stated orders entered as progress notes would not be carried out.
A resident with severe cognitive impairment and mobility problems fell during PT gait training when staff ambulated the resident without the ordered safety supports, and the resident sustained a rib fracture. Another resident was escorted to meals without the ordered gait belt despite PT instructions for SBA/CGA with a FWW and gait belt. In addition, a resident reported a wheelchair brake problem that had been known to staff before a fall, but the equipment concern was not addressed promptly through the facility’s maintenance process.
A resident with dysphagia, severe cognitive impairment, and dependence on staff for ADLs received nocturnal Jevity 1.5 via feeding tube, but the bottle was not dated or timed when opened and the tubing was undated. During observation, the feeding was running on a pump while the resident rested in bed with the HOB elevated, and an LPN and the DON confirmed the dating and timing were missing.
Hygienic care of oxygen and nebulizer equipment was not maintained for a resident with CHF, COPD, a-fib, Parkinsons, and other significant diagnoses. The resident’s oxygen setup included a water bubbler dated months earlier, and the nebulizer mask, chamber, and tubing were left connected at the bedside with liquid and later condensation in the chamber. The resident said he used the nebulizer himself and that staff sometimes did not return to clean it, while an RN said the nebulizer should be cleaned after every use and an LPN confirmed the bubbler and tubing were not being changed as ordered or dated per policy.
Staff did not consistently use PPE in rooms with precautions in place. An LPN and NA entered a resident’s room on EBP without gowns while providing wound care and changing linens, and staff also entered another resident’s room with C. difficile without following the expected precautions, including hand hygiene after leaving the room. Laundry practices were also deficient when wet items were reportedly placed in bins and covered to dry later, and the linen policy did not address wet linen handling.
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.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Provide Current Resident Rights Notice
Penalty
Summary
The facility failed to ensure residents were provided with the current Combined Federal and State [NAME] of Rights. During review of an admission folder related to a concern reported in 2026, R26 stated they felt their rights had been violated during a six-day stay in the facility. The admission packet on file contained a Combined Federal and State [NAME] of Rights dated 2/1/17, while the most current Federal and State [NAME] of Rights was dated 12/22/25. During interviews, the DON stated they did not know how residents received their admission packet, and an RN stated residents could receive the admission packet in paper form or electronically.
Care plans not updated to reflect residents’ current needs and preferences
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect residents’ current needs for 4 of 4 residents reviewed for care planning. For one resident with severely impaired cognition, diabetes mellitus, lung cancer, and bone metastases, the quarterly MDS showed set-up assistance for eating, maximum assistance with toilet hygiene and lower-body dressing, and urinary and bowel incontinence, but the care plan still described the resident as independent with eating, personal hygiene, and oral care, and as able to dress independently. The care plan also described the resident as alert and oriented with intermittent confusion, while the BIMS indicated moderate cognitive impairment. For another resident with intact cognition, encephalopathy, aphasia, and spinal spondylosis, the quarterly MDS showed maximum assistance with showers, transfers, bed mobility, personal and toilet hygiene, dependence for toilet hygiene, and occasional bowel incontinence. The care plan still included interventions for g-tube feedings and transfers using a non-mechanical standing lift or mechanical sling lift, while therapy documentation posted in the resident’s closet indicated a stand-pivot transfer with gait belt and contact guard assist of one. The resident stated he no longer used the feeding tube except for one medication, and staff stated they used the therapy posting and that the resident used the toilet rather than a bed pan as the care plan indicated. For a resident with hemiplegia, dysphagia, aphasia, hypertension, and severe cognitive impairment, the care plan did not identify the resident’s preference for female caregivers only, although a progress note documented no males for personal care and staff and the DON confirmed the preference was known. For another resident with dementia, heart failure, diabetes mellitus, depression, hyperlipidemia, and heart disease, the care plan did not identify that the resident needed to be out of bed for meals, even though therapy documented increased confusion and weakness, inability to hold herself up at the bedside, spilling food while eating in bed, and a recommendation that she be up in a chair for meals. Staff observed the resident eating in bed, and nursing staff stated they were not aware of the therapy recommendation and that the care plan had not been updated.
Failure to Consistently Manage Flu and Pneumococcal Immunizations
Penalty
Summary
The facility failed to consistently educate, offer, or administer influenza and pneumococcal immunizations for 3 of 5 residents reviewed for immunizations. For one resident, the admission record and vaccination consent did not identify whether prior influenza or pneumococcal vaccines had been received or whether the resident wanted or was eligible for the vaccines, and the consent was marked "No!" with a health unit coordinator signature. The resident’s EMR showed prior receipt of Prevnar 13 and influenza vaccine, and the CDC indicated the resident was eligible for shared decision making with the provider regarding PCV20 or PCV21 because more than one year had passed since the Prevnar 13 dose. For another resident, the record did not include evidence of shared decision making or receipt of an additional pneumococcal vaccine. A third resident’s vaccination consent indicated prior pneumococcal vaccines and that the resident would like to receive the vaccine, but the form was not signed by the resident or representative, and the record did not show shared decision making or receipt of vaccination. During interview, the infection prevention and control nurse stated she was responsible for reviewing MIIC reports, uploading them to PCC, and entering immunizations, and that she was the only person doing the vaccine review. She also stated that two of the admissions occurred during a time when she was serving as DON and things were behind. The facility policy required an immunization history on admission, review of MIIC, sharing unknown or noncurrent immunizations with the attending physician, obtaining orders, and documenting immunization history and education in the EMR.
Compliance Program and MDS Documentation Irregularities
Penalty
Summary
The facility failed to implement an effective compliance and ethics program with sufficient monitoring and auditing mechanisms to detect and prevent potential violations and to ensure the integrity of data reported to CMS. The facility also failed to ensure employees could report suspected violations by a high-level leader without fear of retaliation. These failures were associated with documentation and MDS irregularities involving unsupported or inconsistently reported diagnoses for four residents reviewed: R31, R39, R40, and R61. For R31, the admission record identified an admission date of 1/25/23, but the quarterly MDS did not contain diagnosis code F33.3 in Section I. RN-A later modified the MDS to add F33.3, and the diagnosis audit report showed the diagnosis had been added to the EMR with an effective date of 1/25/25. However, a provider progress note from 4/21/26 did not include F33.3 and instead documented severe Lewy body dementia with agitation and depressive disorder in remission. The resident’s progress notes did not reflect supporting documentation for the F33.3 diagnosis, and a provider order for that diagnosis was requested but not received. For R39, the significant change in status assessment MDS completed by RN-A included F33.3, but the history and physical dated 8/13/23 identified late onset Alzheimer’s disease without behavioral disturbance and generalized anxiety disorder, not F33.3. The diagnosis audit report showed F33.3 was added to the record with an effective date of 8/17/23, and a provider order for F33.3 was requested but not received. For R40, the SCSA MDS initially did not identify F33.3, then RN-A added it through a modification and RN-B later removed it. The diagnosis audit report showed F33.3 was added to the EMR with an effective date of 1/15/25. A physician update facsimile dated 8/17/25 referenced use of F33.3 related to behaviors, agitation, and trazodone use, but the provider progress note from 3/24/26 did not include F33.3 and instead documented mild late onset Alzheimer’s dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. NP-F stated she was not aware either R40 or R39 had the diagnosis and confirmed it was not on their current or historical diagnosis lists.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were informed of and consented to medications prescribed and given for mental health intervention for 2 of 5 residents reviewed for unnecessary medications. One resident had a significant change assessment showing intact cognition and diagnoses of Parkinson’s disease, anxiety, insomnia, and bipolar disorder. That resident’s care plan addressed behavior related to bipolar disorder and anxiety, and provider orders included Depakote 250 mg by mouth twice daily for bipolar disorder and gabapentin 300 mg by mouth three times daily for anxiety. The resident’s EMR did not contain evidence that the resident had been educated on the risks, benefits, side effects, and alternatives for either medication. A second resident had diagnoses including Parkinson’s disease, polyneuropathy, depression, and anxiety, and the MDS identified severe cognitive impairment, dependence on staff for activities of daily living, and receipt of antianxiety medications, opioids, and anticonvulsants. The resident’s order summary included Celexa 20 mg daily for major depressive disorder, hydroxyzine 10 mg twice daily for hallucinations/delusions related to Parkinson’s disease, and risperidone 0.25 mg at bedtime for hallucinations related to major depressive disorder. The EMR showed consent for Celexa, but not for hydroxyzine or risperidone. The DON stated that residents and/or their families should know the side effects and risks of the medication to decide if the risk was worth taking the medication.
Failure to Follow SAM Evaluation for Bedside Medications
Penalty
Summary
The facility failed to follow a self-administration of medication (SAM) form that indicated a resident could not self-administer medications and could not keep medications at bedside. The resident had diagnoses including anemia, multiple sclerosis, and seizure disorder. The quarterly MDS indicated no cognitive impairment, and the care plan stated the resident was unable to self-administer medications, with interventions for nursing to document, administer, and store all medications. The resident’s active order summary lacked orders to keep medications at bedside. Despite the SAM evaluation dated 8/21/25 stating the resident could not self-administer medications, a tube of Diclofenac muscle cream, Biotin mouth wash, and Systane eye drops were observed on the resident’s bedside table on 7/27/26 and again on 7/30/26, with no staff present in the room. An LPN stated a SAM assessment and provider orders were needed before leaving medications at bedside and confirmed the medications were left in the room, while an RN reviewed the SAM assessment and acknowledged the resident should not have medications left at bedside. The DON stated staff were expected to ensure the SAM assessment and related paperwork were completed and accurate before leaving medication at bedside.
Delayed Provider Signature on POLST
Penalty
Summary
The facility failed to ensure that 1 of 1 resident's Provider Orders for Life Sustaining Treatment (POLST) was completed timely. The resident had diagnoses including heart failure, dementia, diabetes mellitus, hyperlipidemia, and heart disease, and the admission MDS identified the resident as moderately cognitively intact and requiring partial to moderate assistance with activities of daily living. The resident signed the POLST on 5/6/26, but the provider did not sign it until 7/30/26, after the issue was brought to the facility's attention. During interview, the DON stated the admission coordinator would complete the form with the resident or decision maker and then it would go into the chart as an order, but could not explain why the POLST had not been signed by the provider on admission. The facility's Advance Care Planning policy stated that on admission the resident and/or legal representative would be notified of the need for an order for cardiopulmonary resuscitation and that the POLST would become a medical order.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure a resident received notice of Medicare non-coverage for services covered under Medicare before those services were denied. For one resident, the admission record showed an admission date of 8/21/25 and discharge date of 9/10/25, and the financial questionnaire from admission contained the resident’s signature. The resident’s Medicare denial form (CMS-10123) dated 9/5/25 and managed care denial form (U Care) dated 9/7/25 also contained signatures, but the signatures on the forms did not appear similar to each other, and the signature on the U Care form did not appear similar to the financial questionnaire signature. The resident’s progress notes did not show that the Medicare or U Care denial forms were received, and during an interview on 7/31/26, the resident stated she did not recall signing any papers about Medicare denial and the right to appeal. The resident reported she had been at the facility for 21 days and was home and doing well.
Failure to Report Suspected Abuse and Unexplained Injury
Penalty
Summary
The facility failed to immediately report suspected resident-to-resident abuse to the state agency within 2 hours for a cognitively intact resident who reported being scared of another resident. The resident stated that the other resident had entered the room multiple times during the night, grabbed belongings, snarled at the resident, and left the room. Nursing documentation also showed the resident placed a walker in front of the door on two nights to keep the other resident out and stated, "I'm scared to death of him." The DON was notified of the situation, and staff interviews confirmed the concern was treated as a resident-on-resident altercation with possible abuse, but no state report was made because the facility did not believe it reached the level of potential abuse. The other resident involved had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer's disease. The MDS indicated this resident paced and wandered daily and significantly disrupted the care or living environment of other residents. Progress notes described frequent roaming into other residents' rooms and frequent agitation toward staff and residents. During interviews, staff stated that any nursing staff could file a vulnerable adult report, and the DON acknowledged that a resident-on-resident altercation with concerns of abuse should be reported to the state agency within 2 hours of learning about it. The facility also failed to report and investigate a resident's unexplained perineal injury as potential sexual abuse or an injury of unknown source. The resident was cognitively intact, frequently incontinent, and required substantial to maximum assistance with activities of daily living and peri care. After an emergency room visit, the resident was found to have a very minor labial tear/abrasion at the 12 o'clock position with minimal blood present, and the AVS listed a diagnosis of laceration to the perineum. Staff asked the resident whether anyone had been rough or abusive during care, and the resident denied abuse. The DON and administrator stated they did not consider the injury reportable because they believed it was similar to a prior situation and did not feel the injury of unknown origin needed to be reported or investigated.
Failure to investigate resident-on-resident abuse and unexplained perineal injury
Penalty
Summary
The facility failed to conduct a formal investigation into an allegation of resident-on-resident mental abuse involving a cognitively intact resident who reported being frightened by another resident entering her room repeatedly. The resident stated the other resident had come into her room multiple times, grabbed belongings, snarled at her, and left her scared. Progress notes also documented that she placed a walker in front of her door on two nights to barricade the other resident from entering and stated, "I'm scared to death of him." The resident involved in the behavior had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer's disease, and was documented as pacing, wandering daily, and significantly disrupting the care or living environment of other residents. Staff interviews showed the concern was reported to nursing leadership, but no management member came in that weekend to start an investigation. An LPN stated the DON was notified of the resident-on-resident altercation and that the facility process was for administration to be notified and management to perform investigations when allegations of physical, sexual, or mental abuse were reported. The DON stated she was aware of the situation but was unsure whether any investigation had been completed. The administrator stated a VA had not been filed because the facility did not feel the concern reached the level of potential abuse, and the issue was only discussed in the IDT. The IDT notes for that week were requested but not provided. The facility also failed to investigate a possible sexual abuse or injury of unknown origin when a cognitively intact resident with multiple medical conditions, including ulcerative colitis, cirrhosis of the liver, depression, hypothyroidism, hypertension, edema, osteoarthritis, and a history of malignant neoplasm of the uterus, was found to have an unexplained perineal laceration. The resident was frequently incontinent and required substantial to maximum assistance with ADLs and peri care. The ER record identified a very minor labial tear/abrasion with minimal blood present and listed laceration of the perineum, while the facility note documented that the resident denied being abused when asked. Staff stated they were only told to be more gentle with cares, and several staff reported they had not received specific education about peri care for the resident after the ER visit. The DON and administrator stated they did not report or investigate the injury because they believed it was not reportable, despite acknowledging that abuse, neglect, and injuries of unknown origin should be reported and investigated.
Failure to Provide Bed-Hold Notice Before Hospital Transfer
Penalty
Summary
The facility failed to provide the required written notices before a transfer to the hospital for 1 resident who had intact cognition and diagnoses of right-side affected hemiplegia and hemiparesis, CHF, and COPD. The resident’s significant change in condition assessment MDS identified these diagnoses, but the resident’s progress notes did not include information regarding a bed-hold. During interviews, the RN stated staff would ask the resident or representative if they wanted a bed-hold and then notify social services, and the social services director stated the charge nurse would ask the family about a bed-hold, document verbal authorization in a progress note, and later send the bed-hold form, policy, and return envelope. The social services director also stated no paperwork went to the hospital with the resident and that bed-holds were only done if the resident was admitted. The facility policy stated residents and representatives were to be informed of the right to elect a bed hold during hospitalization or therapeutic leave, and for a hospital leave transfer to the emergency department, the bed-hold policy was to accompany the resident.
Incomplete and inaccurate MDS assessments
Penalty
Summary
The facility failed to ensure minimum data set (MDS) assessments were completed accurately and within required time frames for multiple residents. For one resident with moderately impaired cognition and diagnoses of malignant neoplasm of the lung and secondary neoplasm of bone, the significant change assessment MDS was completed after the assessment reference date, and section GG for functional limitation in range of motion was not assessed. During interview, the MDS coordinator stated there was no date from nursing staff to code section GG and said it was important for baseline information and billing. The facility also failed to ensure the accuracy of diagnosis coding in section I of several MDS assessments for four residents. For two residents, the MDS was modified to add diagnosis F33.3, major depressive disorder with psychotic symptoms, even though the medical records reviewed did not contain supporting documentation for that diagnosis, and provider orders were requested but not received. For two other residents, MDS modifications were made inconsistently, with one modification adding F33.3 and a later modification removing it. Review of progress notes, history and physical documentation, order summaries, and diagnosis audit reports did not show supporting documentation for F33.3 in the records reviewed. The facility also failed to complete required MDS sections for other residents. One resident’s quarterly MDS left section L for oral/dental blank, and another resident’s admission MDS was missing assessments in sections C for cognitive patterns, D for mood, and E for behavior. The MDS coordinator verified the missing information and stated the omitted sections should have been completed for baseline assessment and future comparison. The DON also verified that MDS assessments needed to be completed for coding, billing, and care plan development.
Failure to Include Dialysis in Comprehensive Care Plan
Penalty
Summary
The facility failed to include dialysis in a resident’s comprehensive care plan for a resident who was receiving dialysis while in the facility. The resident’s quarterly MDS indicated the resident was cognitively intact and had diagnoses including anemia, hypertension, and end stage renal disease. The MDS also showed that the resident received dialysis at the facility, but the resident’s active order summary report lacked dialysis-related orders, and the care plan did not include a dialysis-related care plan or interventions until one was initiated later. The resident stated that dialysis was received through a dialysis center in Hibbing, MN on Tuesday, Thursday, and Saturday, and that it was delivered through a perma-catheter in the right chest wall. An LPN stated that resident-specific conditions such as kidney conditions and the need for dialysis should have their own care plans so staff are aware of the condition and how to provide care. An RN reviewed the resident’s MDS and active care plan and acknowledged that the MDS showed dialysis, but there was no active dialysis care plan. The DON stated that RNs should ensure the comprehensive care plan includes all details from the comprehensive MDS assessment, and the facility policy stated the comprehensive person-centered care plan would be completed within 7 days of MDS completion and include specialized services with measurable goals and interventions.
Failure to Carry Out Lymphedema Treatment Order
Penalty
Summary
The facility failed to ensure a provider order was followed as written for a resident with multiple sclerosis, diabetes mellitus, persistent atrial fibrillation, hypertension, hyperlipidemia, and heart failure. The resident’s quarterly MDS identified him as cognitively intact and dependent on staff for assistance with activities of daily living. A family member reported concerns that therapies had not been continued after the new physical therapy department started and stated they believed the provider had reordered therapy, but the resident was not receiving treatment. A physician update showed that the family requested an order for lymphedema treatment and the provider responded that occupational therapy referral for lymphedema treatments was okay. However, the resident’s current orders did not include lymphedema massage, and therapy staff stated they had not received any order for lymphedema therapy after the department change. RN staff confirmed the lymphedema order had been signed off, and the DON stated that provider orders should be entered as orders rather than progress notes because otherwise they would not be carried out. The NP stated the resident would probably benefit from lymphedema treatment and expected orders to be processed as written.
Unsafe ambulation practices and delayed response to wheelchair brake concerns
Penalty
Summary
The facility failed to ensure safe ambulation interventions were followed for two residents. One resident had severe cognitive impairment, diagnoses that included congestive heart failure, respiratory failure with hypoxia, atrial fibrillation, gait and mobility abnormalities, and weakness, and the care plan required supervision with touching assist of one staff member and a front wheeled walker for ambulation. During PT gait training, the resident was ambulated without an assistive device and with standby assist, then fell in the hallway near the nurse’s station. The incident report identified that the resident was being gait trained with therapy staff assist of one, but no gait belt or front wheeled walker was identified. The resident sustained an acute anterior left third rib fracture after the fall. A second resident, who was cognitively intact and had diagnoses including left clavicle fracture, sternum fracture, and hypertension, had care plan instructions allowing independent ambulation with a front wheeled walker in the room, while PT orders directed staff to walk the resident to lunch and supper with a gait belt, front wheeled walker, and standby/contact guard assist of one. During observation, the resident ambulated in the hallway with the walker and was escorted to the dining area without a gait belt. Later, the resident was again walked from the dining table to the room without a gait belt. Staff interviews confirmed uncertainty about the gait belt requirement, and the AD stated the gait belt was forgotten during the escort. The facility also failed to address a resident equipment concern in a timely manner. One resident reported that the brakes on the wheelchair would not lock, causing the wheelchair to roll away when the resident tried to get into bed and resulting in a fall next to the bed. The resident stated maintenance had been aware, staff had left notes and emailed maintenance, and the brake had been fixed by a nursing assistant after the fall but then stopped working again. Staff interviews showed the complaint had been discussed informally, but there was no clear timely work order process followed until later, and the EVS director stated he did not recall when he first heard about the problem and later decided to replace the wheelchair.
Tube Feeding Not Dated or Timed
Penalty
Summary
The facility failed to ensure a tube feeding bottle was dated and timed when opened for one resident receiving enteral nutrition. The resident had diagnoses including hemiplegia/hemiparesis, dysphagia, hyperlipidemia, aphasia, and hypertension. The quarterly MDS identified the resident as having unclear speech, severe cognitive impairment, dependence on staff for activities of daily living, and receipt of tube feedings. The resident had physician orders for nocturnal Jevity 1.5 feedings at 83 ml per hour from 7:00 p.m. to 7:00 a.m. During an observation, the resident was resting in bed with the head of the bed at approximately 30 degrees while Jevity 1.5 was running at 83 ml per hour on a pump. The bottle had no open date or time, and the tubing was not dated. An LPN verified that the bottle was not dated or timed when opened and that the tubing was undated, stating it should be dated and timed to ensure the tube feeding does not hang longer than it should. The DON stated it was her expectation that staff would date, time, and initial the tube feeding bottle and tubing.
Hygienic Care of Oxygen and Nebulizer Equipment Not Maintained
Penalty
Summary
The facility failed to provide hygienic care of oxygen and nebulizer equipment for one resident who had a significant change in status assessment identifying intact cognition, hemiplegia/hemiparesis related to a subarachnoid hemorrhage with the right side affected, Parkinsons, CHF, a-fib, COPD, anxiety, GERD, DM, dysphagia, insomnia, bipolar disorder, acute pain, and anemia. The resident’s care plan addressed oxygen therapy for acute respiratory failure and CHF, with interventions including oxygen therapy, medications as ordered, monitoring for respiratory distress, and oxygen at 2 LPM to keep oxygen saturations above 88%. The provider orders included oxygen at 2 LPM every shift and oxygen at 1 to 4 LPM PRN for shortness of breath. During observation, the resident’s room contained a liquid oxygen container with a water bubbler attached that was dated 4/2/26, and the resident stated he used it at night. The resident also had a nebulizer mask, chamber, and tubing connected and sitting on the bedside table, with liquid and later condensation in the chamber. The resident stated he did the nebulizer himself and that the nurse set it up and sometimes did not come back. An RN stated the resident could administer his own nebulizer but needed the nurse to return to place it back on the machine so it could be cleaned, and stated the nebulizer should be cleaned after every use. An LPN stated tubing and the bubbler were usually changed when they appeared on the TAR, but no order was found to change them, and the bubbler was still dated 4/2/26 with no date on the tubing. The facility policy stated tubing and cannula or mask should be labeled with a date and changed every week.
Inconsistent PPE Use and Improper Laundry Handling
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not consistently use PPE in resident rooms where precautions were in place. One resident had enhanced barrier precautions (EBP) related to a history of ESBL in the urine, with orders and a care plan directing staff to follow EBP. During observation, an LPN entered the room and performed wound care to the resident’s left shin and right toes while wearing gloves but no gown, and a nursing assistant entered the same room to strip the bed, bag soiled linens, and remake the bed without wearing a gown. Both staff later confirmed they had not worn gowns, and the LPN stated the resident did not have an active infection before reviewing the record showing EBP was ordered. A second resident had a diagnosis of C. difficile, was frequently incontinent of bowels, and needed assistance with toileting and hygiene. The care plan included contact precautions for diarrhea related to C. difficile, but it did not include the necessary interventions for enteric precautions, and the provider orders did not contain orders for contact precautions. During observation, a nursing assistant entered the room without an isolation gown or gloves, carried an iPad, spoke with the resident, and took a meal order, then left without cleaning hands and continued to other resident rooms. In another observation, a housekeeper entered the room with gloves but without an isolation gown, removed two yellow trash bags, placed them on top of the dumpster being pushed, and was not observed cleaning hands after exiting. Laundry practices were also not handled hygienically. During a tour of the laundry area, a laundry aide stated wet items were placed in blue bins designated for wet items and then covered with a sheet or something to dry in the morning, and the facility’s linen handling policy did not address handling wet linen. The infection prevention nurse and EVS director stated housekeeping staff were trained through computer-based education or prior paperwork and did not require return demonstrations for PPE use.
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 42 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
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 | ★★★★★ | 15 | 0 |
| 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
Built specifically for Heritage Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.