Resident #4 scored 11 on the facility's wandering risk assessment, marking them as high risk to wander.
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on August 12, 2025, when inspectors opened the cooler and saw a hard plastic container filled halfway with shredded cheese.
Only a concerned family member's phone call hours later prompted nurses to review her condition and discover the critical signs.
That is what federal inspectors found at Heritage Manor, a nursing facility at 610 North Garfield Avenue, during a complaint inspection on August 14, 2025.
Federal inspectors found every single resident room they checked exceeded the facility's own temperature policy during an August inspection.
The resident, identified in inspection records as Resident #5, told the aide the arrangement was uncomfortable.
When asked what the medications were, the resident couldn't identify any of them.
Nobody had written that down anywhere enforceable.
The finding, the most serious classification available to federal inspectors, applied to at least one resident.
Morning Star Post Acute staff held Resident 5's eye pressure medications on July 19 because the pharmacy had not delivered them.
She scratched her chest, abdomen, legs, arms, palms, flanks and back as she spoke.
Resident 1 arrived at the facility on August 2, 2025, around 3:00 p.m.