Heritage Park Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 17, 2025

  Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards (refer to elements of the resident environment that have the potential to cause injury or illness) for one of three sampled residents (Resident 1) when Resident 1 ingested a cleaning solution left by a housekeeper (HSK 1) in Resident 1's room on March 2, 2025. This failure resulted in Resident 1 to be transferred to the General Acute Care Hospital (GACH) for higher level of care and suffered from additional health issues. […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: a. Stacked cups were stored wet. b. The ice machine had black build up in the ice chute (where ice exits the area where its formed and drops into the ice bin). These failures had the potential for bacteria to growth and cause foodborne illness in a highly susceptible population of 57 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview, with the Dietary Supervisor (DS), on November 1, 2022, at 8:10 AM, inside the kitchen, there were stacked cups stored wet. […]

• No harm, potential for more than minimal, patternF641May 16, 2024

  Based on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected preadmission screening and resident review (PASRR) information for 3 (Residents #2, #26, and #61) of 6 residents reviewed for PASRR requirements. Findings included: A facility policy titled, Minimum Data Set (MDS) - Resident Assessment Instrument (RAI), dated 11/2017, revealed, 1. […]

• No harm, potential for more than minimal, patternF610Feb 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure immediate measures were put into place to provide protections to one of three sampled resident (Resident 3) when a License Vocational Nurse (LVN) and a Program Counselor (PC) were not suspended immediately after an alleged abuse to Resident 3 was reported on February 14, 2024. This failure had the potential for further abuse, neglect, exploitation, or mistreatment in a vulnerable population of 68 residents as the alleged perpetrators, LVN and PC, continued to have access to the alleged victim, Resident 3, and to other residents while the investigation was still in process. […]

• No harm, potential for more than minimal, patternF578Nov 4, 2022

  Based on observation, interview, and record review, the facility failed to ensure information whether or not the resident has executed an advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) was displayed prominently in the medical record for three of six residents (Residents 156, 33, and 46) reviewed for advance directives. This failure had the potential to result in a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. During an observation, on November 1, 2022, at 10:38 AM, Resident 156 was in her room, lying down in bed. […]