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Mayfield, KY – Resident Found Dead with Rigor Mortis; Facility Violated Monitoring Orders


Located: 401 INDIANA AVE, MAYFIELD, KY 42066

HERITAGE MANOR HEALTH CARE CENTER was cited in February of 2014 by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies relating to {Level of harm – Immediate jeopardy}.

The following highlighted quoted text is only a portion of the report/survey. The full report/survey can be found here.


Provide necessary care and services to maintain the highest well being of each resident


Based on interview, record review, and review of the facility’s Condition Change of a Resident policy, and the Hospital Office Follow-up Report, it was determined the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one (1) of seven (7) sampled residents (Resident #1).

Continuing: On [DATE] at 5:29 PM, the facility documented the resident’s temperature of 100.5 degrees F; however, there was no documented evidence of a resident assessment or administration of medication for the increased temperature at that time. In addition, there was no documented evidence the licensed staff had conducted ongoing assessments of Resident #1 for the remainder of that shift, until 11:00 PM; and on the next shift (,[DATE] AM on [DATE]). Resident #1 was found in bed deceased , on [DATE] at 8:00 AM, with signs of lividity, blood pooling in lowest parts of his/her body with darkening of the skin in the independent parts of the body, and rigor set in as illustrated by the fixed position of the resident’s extremities. (Refer to F282) The facility’s failure to ensure each resident received necessary care and services related to the failure to provide an on-going assessment of Resident #1 after a change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident

Continuing: LPN #2 revealed she entered Resident #1’s room at 8:00 AM, and knew immediately that the resident was deceased . She revealed the resident was laying on his/her right side facing the door. The resident had no pulse, blood pressure, was not breathing, and had no heartbeat, and the resident was extremely cold and stiff. Interview with the resident’s Oncologist, on [DATE] at 4:40 PM, revealed he would have expected vital signs every shift with routine monitoring of Resident #1, per the facility’s change in condition policy. Interview with the Director of Nursing (DON), on [DATE] at 3:50 PM, revealed the resident was in reverse isolation precautions as a nursing intervention. She stated she expected nursing to document an assessment every shift on Resident #1 as he/she was having side effects from the [MEDICAL CONDITION] treatment. She revealed an assessment should have included skin color, warmth, respirations, and abdominal distention. She revealed there was no specific facility policy related to nursing assessments.

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

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18 Responses to “Mayfield, KY – Resident Found Dead with Rigor Mortis; Facility Violated Monitoring Orders”

  1. sandy brundige says:

    this is yhe worst place ever i cried the whole time i was there

  2. Glenda Morris says:

    I can’t believe that you had a sick resident with a temp of 100.5 and nobody went into that room to check on them again not even recheck a temp
    I have done or did this work for 33 years and a nurse never ever had to tell me to recheck a temp or check on a resident or patient!!! Their doors should be SHUT DOWN for ever!!!! No exceptions. Makes me deeply sick!!

    • gwen says:

      I don’t understand. first, they do bed checks evey 2 hrs. or did when i worked as aide. and someone had to be in that room checking. Also, if they were facing the hall, someone had to notice that gray or green is not a normal color. duh. wrong.

  3. Yea that was not right for any staff to not do their job properly. I think they should be imediate shut dowwn to Herritage. Checking temperature is suppose to be done on a regular basis in a nursery home.

  4. Ashley says:

    This is completely insane and uncalled for. I was a CNA for fours and never once left a patient unattended. This facility should be shut down for good. And whom ever the CNA was on the floor and whom ever the nurse was should lose their license. Healthcare is for those who care about their patients not for those who dont. Stay out of this profession if you dont care their are people with good hearts that do.

  5. shawnta todd says:

    Just want to say that is so sorry if it was my family member I would sue them. That’s why when my granny was down there seem like she was not getting better but worse. So our family moved her out of there. See the ppl they got working down there is so lazy there was times my granny was wet or messed on herself n she would tell them n when they tried to cum do it we said we do it they are very sad down there I can tell more but it’s a lot i can tell about my granny. And my aunt that just passed away this month. They lazy n dnt do there jobs.

  6. Geni Lankford says:

    I was going to put my grandma in there. But she did not make it. Im glad she didnt go there.

  7. Geni Lankford says:

    We was going to put my grandma in there. But she passed away. Im glad it didnt happen,

  8. I worked in a nursing home for 18 years. Our charge nurses made sure that Residents that were extremely ill in anyway were checked on by themselves or a nurse aide at proper intervels, and if the situation warranted the Resident was transported to hospital. This situation is a perfect example of neglect.

  9. David says:

    Well my mother and my wife was a cna and they was that for a long time.and this makes me sick knowing they killed this person they never check on this person through the night and found this person dead. They new of his temp of 100.5 and they didn’t do nothing the cna and the nurse on that hall should be fired and not paid and the place should be shutdown and the cna should loose there nursing license thats how i feel this is sad to the family

  10. Allen says:

    The federal and state government have made operating a nursing home so difficult due to well intentioned laws and regulations they can’t afford to staff appropriately and stay in business. My guess is that this scenario is not uncommon. The same problem exists in acute care facilities also. I doubt this facility “needs to be closed down”. They need relief from a suffocating government.

  11. Jennifer Burris says:

    This is disgusting! The whole thing makes me irate that you work in healthcare with the elderly and yet you show no concern. Not only do I feel that the facility needs to be shut down. I also think these people should be flagged so that they can not work with the elderly again. They need to be held accountable.

  12. Bobby Sadler says:

    About time. Chech the rest of them.

  13. tanya says:

    no excuse for this

  14. kay says:

    As a former employee i agree it does need to be shut down. They are extremely understaffed. Most people in that building are there just for the paycheck. The ED, office workers and paperwork nurses are worthless. They dont care about the residents. As for floor nurses and aides we do as much as we can because we alwaysshort staff. Its hard to provide excellent care when u have 40 patients give or take to 1 nurse and 1 aide. Most nurses there refuse to help aides because “They didnt go to school to do aide work.” Most wont even answer a call light because its an aides job. As for the staff on duty the night of the incident, in my opinion are good and caring. The resident was checked on througt the night. Resident even hit call light multiple times that night. When god is ready for you hes ready point blank period!

  15. brandi says:

    I would just like to say that I know a person there and she has worked there fir 20. years she was not the One over the deceased but I do not believe they should shut this facility down.. I feel that they should be more strict and have more people working… the One was in charge of the deaseaed was fired and just because One person did something doesn’t mean they all should be put out of a job… and its not right for them to shut this down… they just hired the wrong person… so think about the. people That actually do thier job other than the ones that don’t…

  16. frances says:

    I worked there and hated what I saw on a daily basis. The office staff for the most part didn’t come out of hiding unless someone of importance was there or the State. One member of the office staff spent her time walking the halls looking for the snack cart, going to the kitchen for tea or coffee and grabbing the Paducah Sun to carry back to her office to read. The facility was very much understaffed and even had a legally blind aide on one of the halls that was good to the patients but useless in case of an emergency when she would have required help herself. Other aides would kick in and do some of her job responsibilities for her or cover for her. It was terrible to see her get paid more per hour than the ones busting their rumps and doing three times more work. Never did understand why this was allowed. The nurses would not answer call lights and a few was quick to tell you that they did not go to school to do aide work. Not all of them were like that but to many of them were. It was very hard to keep good dependable employees due to the abrupt schedule changes, people calling in and creating twice a much workload, low pay, and not being treated as an equal for what should have been everyone working together to take care of patients.


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