Heritage Park Rehabilitation and Skilled Nursing C

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 14, 2025

  Based on observation, interview and record review the facility failed to ensure that the resident environment remains as free of accidents and hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 resident ( Resident #1) reviewed for adequate supervision. The facility failed to ensure Resident #1 was not left unattended on 10/10/2025 at an off-site medical appointment that was an unfamiliar location. Resident #1 had neither appropriate supervision nor arrangements for return transportation. Resident #1 was left alone in an unfamiliar place, with diminished cognition and altered physical ability. An Immediate Jeopardy (IJ) situation was identified on 10/11/2025. […]

• Immediate jeopardy, isolatedF689Nov 8, 2024

  Based on observations, interviews, and record reviews, the facility failed to the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for elopement. The facility failed to put interventions in place to prevent Resident #1 from eloping from the facility after she broke her window and attempted to leave through her window on 10/29/24. Resident #1 broke her window again and successfully eloped from the facility on 11/01/24. An IJ was identified on 11/06/24. The IJ template was provided to the facility on [DATE] at 4:45 PM. […]

• Immediate jeopardy, isolatedF689Mar 27, 2024

  Based on interview and record review the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1) reviewed for accidents and hazards. The facility failed to identify Resident #1 as an elopement risk from his admission paperwork or complete a wandering/elopement assessment within 24 hours of admission. On 02/08/24 he eloped from the facility for approximately three hours and was located 1-2 miles from the facility at a busy intersection of a street and a highway. The noncompliance was identified as PNC. The IJ began on 02/08/24 and ended on 02/15/24. […]

• Actual harm, isolatedF689Jul 15, 2025

  Based on interview and record review, the facility failed to ensure the residents' environment remained as free of accident and hazards as is possible and ensure each resident received adequate supervision for 1 (Resident #1) of 10 residents reviewed for accidents and hazards. The facility failed to ensure CNA B and CNA C appropriately utilize the mechanical lift on 06/11/2025 while transferring Resident #1 to her wheelchair causing her foot to get trapped underneath her in the wheelchair and fractures to her lower leg. This failure could place residents at risk of harm, injury, fractures, and hospitalization. […]

• Actual harm, isolatedF689Oct 31, 2023

  Based on observations interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one resident (Resident #1) out of five residents reviewed; and that each resident (Resident #1) received adequate supervision and assistance devices which would have prevented accidents. The facility failed to ensure that Resident #1 did not have access to an open stairwell in her environment where she fell down the stairs in her wheelchair, suffered an abrasion to her right knee which had scabbed, and complained of pain. […]