Heritage Park

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Apr 30, 2021

  Based on interview, and record review the facility failed to prevent, and identify wounds prior to the stage being unidentifiable, and failed to ensure worsening of wounds were monitored, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in [CONDITION(S)], and hospitalization for Resident B. The immediate jeopardy began on February 10, 2021 when the facility failed to prevent and identify wounds prior to stage being unidentifiable and failed to monitor worsening of wounds with update or treatment in wound regimen. The Regional Director of Clinical Services, Senior Director of Clinical Services, Regional Vice President of Operations, and Director of Nursing Services were notified of the immediate jeopardy at 2:15 p.m., on [DATE]. […]

• No harm, potential for more than minimal, patternF698Feb 20, 2026

  Based on interview and record review, the facility failed to ensure accurate assessments and communication with the off-site dialysis center for 4 of 7 resident reviewed (Resident 1, Resident 6, Resident 23 and Resident 109).Findings Include:1.Resident 1's record was reviewed on 02/17/2026 at 1:50 PM. Diagnosis included metabolic encephalopathy, end stage renal disease, dependence on renal dialysis, arteriovenous fistula, acquired and kidney transplant failure.A review of Resident 1's physician's orders, dated 2/16/2026 at 3:37 PM, indicated for the dialysis access site, left upper arm fistula, to monitor access site and effected extremity for signs and symptoms of infection, edema, pain, numbness, bleeding and leaks. […]

• No harm, potential for more than minimal, patternF761Feb 20, 2026

  Based on observation and record review, the facility failed to ensure proper labeling was completed for insulin pens related to open dates and expiration dates. For 5 of 5 residents reviewed (Resident 10, Resident 56, Resident 94, Resident 130 and Resident 132) Findings include:During an observation on 2/18/26 at 8:38 AM with Registered Nurse (RN) 2 on the 300-medication cart, inside the following opened medications were observed: Resident 10 had a Lantus insulin Pen with no open or expiration date documented. Resident 56 had a Basaglar insulin pen with no open or expiration date documented. Resident 94 had a Lantus insulin pen with no open or expiration date documented. […]

• No harm, potential for more than minimal, patternF677Feb 28, 2024

  Based on observation, interview, and record review the facility failed to provide personal care and hygiene to dependent residents for 4 of 34 residents reviewed. (Resident 122, Resident 27, Resident 72, and Resident 113). Findings include: 1) During an observation and interview, on 2/22/24 at 10:08 A.M., Resident 122 in her room indicated she had a very hard time getting her teeth brushed. She indicated staff were too busy to assist her with brushing her teeth at night and reluctant to do it during the day. Resident 122 was observed dressed in a hospital gown. She indicated if she were able to dress herself there was no way she would be dressed in a hospital gown, but she had no choice and being dressed in the gown was the least of her concerns. […]

• No harm, potential for more than minimal, patternF565Jan 13, 2023

  Based on interview and record review, the facility failed to ensure Resident Council grievances were resolved in a timely manner for 5 of 7 months reviewed. Finding include: On 1/11/23 at 3:59 P.M., the Resident Council President was interviewed. During the interview, he indicated there had been several grievances brought up by members of the Resident Council during the past several months. The concerns had not been resolved. The grievances included, cold food on room trays, long call light response times, and lack of linens. […]