Heritage Park Healthcare and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 2, 2024

  Based on observation, interview, and record review, the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of property and exploitation. Specifically, for 5 out of 50 sampled residents, three female residents had incidents of sexual abuse by two male residents. Resident identifiers: 12, 33, 42, 52, 63, 85, and 167. Findings included: 1. A. Resident 63 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, mood disorder, anxiety disorder, chronic pain, lumbar region intervertebral disc degeneration, and dysphagia. Resident 63's medical record was reviewed from 6/24/24 through 7/2/24. […]

• Actual harm, isolatedF689Jul 2, 2024

  Based on observation, interview, and record review, the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 50 sampled residents, a resident sustained a burn after spilling coffee on himself and a resident eloped from the facility. Resident identifiers: 21 and 166. Findings included: 1. Resident 21 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, dementia, cerebral infarction, dysphagia, type 2 diabetes mellitus, chronic kidney disease, and mood disorder. Resident 21's medical record was reviewed from 6/24/24 through 7/2/24. […]

• Actual harm, isolatedF689Nov 15, 2022

  Based on interview and record review, it was determined, the facility did not ensure that the resident's environment remained as free of accident hazards as was possible. Specifically, for 2 out of 36 sampled residents, a resident sustained a scrotal laceration during a transfer with a mechanical lift. The deficient practice identified was found to have occurred at a harm level. Additionally, a resident sustained a fall during a one person assistance with a slideboard transfer. Resident identifiers: 73 and 77. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF880Apr 8, 2021

  Based on observation, interview and record review it was determined, for 12 of 50 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of a staff reconnecting a ventilator tubing to a resident's [CONDITION(S)] connector barehanded after it had fallen to the floor, new admissions were not quarantined and isolated on contact/droplet precautions, a resident exposed to a positive COVID-19 infection was not quarantined and isolated on contact/droplet precautions, a hoyer lift used in a contact precautions isolation room was not disinfected prior to use with… […]

• No harm, potential for more than minimal, patternF609Jul 2, 2024

  Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury. Specifically, for 3 out of 50 sampled residents, the facility did not report an allegation of mental/verbal abuse until seven days after the incident occurred, the facility did not report an allegation of sexual abuse until five days after the incident occurred, and the facility did not report an additional allegation of sexual abuse to Adult Protective Services (APS) or the police within… […]