Heritage at Turner Park Health & Rehab

In the surveyor’s words

From the most serious findings on record at Heritage at Turner Park Health & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 6, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and the environment was free from accident hazards for one (Resident #2) of four residents reviewed for supervision. Inside the facility the courtyard could not be viewed due to the blinds being closed and there was no camera monitoring of the courtyard. The facility failed to adequately supervise Resident #2. On 08/17/24 RN B was making rounds around 6:40 AM and Resident #2's roommate reported her missing. RN B stated he and staff searched the facility for Resident #2. He stated the Administrator, police, and ADON were notified. Resident #2 was able to exit the dining room and enter the courtyard. […]

• Actual harm, isolatedF689May 5, 2026

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for accident, hazards and supervision. The facility failed to maintain the resident environment as free of hazards as possible and failed to ensure each resident received adequate supervision when Resident #1, who was known to be non-compliant with his NPO status, entered the employee breakroom, which was not secured, used a microwave to heat water and sustained second degree burns to his hand after spilling the hot liquid. Staff were unaware of the incident or injury until they were notified by a hospice nurse. This failure could place residents at risk of serious injury or harm. […]

• Actual harm, isolatedF689Apr 10, 2024

  Based on observation and interview, and record review, the facility failed to provide adequate supervision and ensure the resident environment remains free of accident hazards as is possible for 2 of 2 (male unit and female unit) secure units reviewed for accidents and hazards. 1. The facility failed to ensure the emergency exit door was locked. Resident #1 was able to exit from the back door and then fell outside while she ran from staff from the secure unit. Resident #1 subsequently had a serious injury to the forehead which resulted in her having three stitches. 2. The facility failed to have a monitoring system for residents who wanted to go outside in the courtyard from the dining room exit door to the outside smoke area in the secured unit. […]

• No harm, potential for more than minimal, patternF697Jan 19, 2025

  Based on interview and records review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of six residents reviewed for pain medication. LVN A failed to administer Resident #1 pain medicine for a complaint of pain intensity level 4 (moderate pain) out of 10 on 01/04/25; pain intensity level 4 (moderate pain) out of 10 on 01/05/25; pain intensity 5 (moderate pain) out of 10 on 01/06/25; pain intensity 5 (moderate pain) out of 10 on 01/07/25; pain intensity 7 (severe pain) out of 10 on 01/10/25, and a pain intensity 6 (moderate pain) out of 10 on 01/10/25 (intensity levels are… […]

• No harm, potential for more than minimal, patternF686Jan 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. The facility failed to ensure LVN A provided physician ordered wound care for Resident #1 on 01/04/25 - 01/07/25. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life. […]