HERITAGE MANOR HEALTH CARE CENTER
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.
WARNING: THE FOLLOWING CAN BE DISTURBING TO SOME READERS
Provide necessary care and services to maintain the highest well being of each resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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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