Heritage Park Care Center

In the surveyor’s words

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

• Actual harm, isolatedF692Aug 29, 2024

  Based on observation, record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for weight loss out of 28 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. Resident #24 was admitted on [DATE] with a diagnosis of Alzheimer's disease, dysphagia (difficulty swallowing), prediabetes and chronic kidney disease stage 3. On 7/16/24 the resident weighed 197 pounds (lbs) and on 8/29/24 the resident weighed 185 lbs. The resident lost 5.1% (10 lbs) of her body weight in 29 days. […]

• Actual harm, isolatedF600Jul 5, 2023

  Based on observations, interviews and record review, the facility failed to ensure five (#1, #2, #3, #4 and #5) of seven sample residents remained free from abuse from staff or other residents. Specifically, Resident #1 was involved in five abuse incidents within three months. One incident involved her mistreatment by registered nurse (RN) #2 on 5/15/23, and four incidents involved Resident #1 abusing Resident #4 on 3/31/23, Resident #2 on 5/26/23, Resident #3 on 5/26/23 and Resident #5 on 6/9/23. All the residents lived in the secure unit at the time of the abuse incidents. Resident #1 was being combative to staff on 5/15/23. […]

• Actual harm, isolatedF689Feb 9, 2023

  Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#39) of four residents reviewed for accident hazards out of 26 sample residents. The facility failed to ensure appropriate and effective measures were in place to prevent Resident #39 from repeated falls. Resident #39 fell out of bed on 9/7/22 and again on 1/17/23. Both falls for Resident #39 resulted in a hematoma and lacerations to her head after she hit her head on the bed frame. Resident #39 had to go to the hospital for an evaluation and sutures after the fall on 1/17/23. […]

• No harm, potential for more than minimal, widespreadF867Aug 29, 2024

  Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address multiple concerns related to quality of care. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) Plan, revised 1/18/24, was provided by the nursing home administrator (NHA) on 8/26/24 at 1:00 p.m. […]

• No harm, potential for more than minimal, widespreadF880Feb 9, 2023

  Based on observations, record review and staff interviews, the facility failed to ensure infection control practices were maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and possible transmission of Coronavirus (COVID-19) infection. Specifically, the facility failed to: -Follow proper infection control practices following an employee who exhibited signs/symptoms of COVID-19, entered the facility and began working, then was later confirmed to have COVID-19 from a positive COVID-19 antigen test; and, -Practice proper hand hygiene during meal service with resident assistance. Findings include: I. Infection control practices regarding a COVID-19 positive staff member A. […]