Heritage at Turner Park Health & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for accident, hazards and supervision. The facility failed to maintain the resident environment as free of hazards as possible and failed to ensure each resident received adequate supervision when Resident #1, who was known to be non-compliant with his NPO status, entered the employee breakroom, which was not secured, used a microwave to heat water and sustained second degree burns to his hand after spilling the hot liquid. Staff were unaware of the incident or injury until they were notified by a hospice nurse. This failure could place residents at risk of serious injury or harm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 for two (Resident #30 and Resident #33) of twelve residents observed for infection control. RN A failed to sanitize shared use equipment (blood pressure device and wrist cuff) before and after resident use with Resident #30 and Resident #33 on 07/30/2025. This failure could place residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on interview and records review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of six residents reviewed for pain medication. LVN A failed to administer Resident #1 pain medicine for a complaint of pain intensity level 4 (moderate pain) out of 10 on 01/04/25; pain intensity level 4 (moderate pain) out of 10 on 01/05/25; pain intensity 5 (moderate pain) out of 10 on 01/06/25; pain intensity 5 (moderate pain) out of 10 on 01/07/25; pain intensity 7 (severe pain) out of 10 on 01/10/25, and a pain intensity 6 (moderate pain) out of 10 on 01/10/25 (intensity levels are interpreted as 0: no pain; 1 - 3: mild discomfort; 4 - 6: moderate pain; 7 - 10: Severe discomfort/pain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. The facility failed to ensure LVN A provided physician ordered wound care for Resident #1 on 01/04/25 - 01/07/25. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one (Resident #1) of three residents reviewed for nursing services. The facility failed to ensure LVN A did not falsely document that she provided physician ordered wound care for Resident #1 on 01/04/25 - 01/07/25. This failure could place residents at risk for not receiving ordered wound care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #4) reviewed for physical environment. The facility failed to ensure the call light was within reach for Resident #4. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for one of three residents (Resident #1) observed for infection control. The facility failed to ensure the ADON wore the appropriate PPE while measuring and assessing foot wounds for Resident #1. These failures could place residents at risk of transmission of multidrug-resistant organisms.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and the environment was free from accident hazards for one (Resident #2) of four residents reviewed for supervision. Inside the facility the courtyard could not be viewed due to the blinds being closed and there was no camera monitoring of the courtyard. The facility failed to adequately supervise Resident #2. On 08/17/24 RN B was making rounds around 6:40 AM and Resident #2's roommate reported her missing. RN B stated he and staff searched the facility for Resident #2. He stated the Administrator, police, and ADON were notified. Resident #2 was able to exit the dining room and enter the courtyard. The alarms to the doors had been removed (08/09/24 by the Maintenance Supervisor) prior to the incident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment. The facility failed to ensure Resident #1's walls in his room were in good repair. The facility also failed to ensure Resident #1's air conditioning unit was properly installed in his room. The failures could place residents at risk for a diminished quality of life due to the lack of a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #30) reviewed for abuse. The facility failed to ensure LVN A did not verbally abuse Resident #30 on 6/4/24 during lunch service when LVN A had a witnessed, verbal altercation with Resident #30. The altercation occurred in the presence of other residents. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to transmit resident assessments within the required time frame for 3 of 3 discharged residents (Resident #1, #3, #59) reviewed for data encoding and transmission to CMS that: The facility failed to ensure the resident's assessments were encoded and transmitted timely. Resident #1 ARD was due on 5/3/2024 according to the resident's individual ARD- Assessment Reference Date. Resident #3 ARD was due on 5/3/2024 according to the resident's individual ARD- Assessment Reference Date. Resident #59 ARD was due on 5/2/2024 according to the resident's individual ARD- Assessment Reference Date. This failure placed residents at risk for not having their MDS Assessments transmitted in a timely manner.

Inspectors wroteBased on observation and interview, and record review, the facility failed to provide adequate supervision and ensure the resident environment remains free of accident hazards as is possible for 2 of 2 (male unit and female unit) secure units reviewed for accidents and hazards. 1. The facility failed to ensure the emergency exit door was locked. Resident #1 was able to exit from the back door and then fell outside while she ran from staff from the secure unit. Resident #1 subsequently had a serious injury to the forehead which resulted in her having three stitches. 2. The facility failed to have a monitoring system for residents who wanted to go outside in the courtyard from the dining room exit door to the outside smoke area in the secured unit. These failures could place residents at risk of accidents, injury, or being left outside exposed to physical environment elements.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of (Halls 500 and 600) six halls and 3 (Residents #1, #2, and #3) of 9 residents reviewed for safe environment in that, 1. The facility failed to provide hot water on Halls 500 and 600 2. The facility failed to provide linens free from stains and holes for Residents #1, #2, and #3. These failures could place residents at risk for a diminished quality of life due to an unhomelike and uncomfortable environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one (Men's Secured Unit) of two (Men's Secured Unit and Women's Secured Unit) resident secured units reviewed for sufficient staff. The facility failed to have sufficient staff available to provide resident care and supervision for the men's secured unit on the 10:00PM to 6:00AM shift beginning on 03/11/24 and ending on 03/12/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 4 of 5 medication carts (Halls 100, 200, 300 hall nursing carts, and Medication Aide cart) and 1 of 1 treatment cart reviewed for drug storage. LVN A left 4 medication carts and 1 treatment cart unlocked and unattended in the hallway near the 300 Hall nursing station for an unknown amount of time . These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications.

Inspectors wroteBased on observation, interview and record review the facility failed to incorporate the recommendations from the PASRR report for 1 of 2 resident (Resident #1) reviewed for PASRR services. The facility did not submit a request for approval for Resident #1's CMWC in the LTC Online Portal within 20 business days after the date of the IDT meeting. NFs have 20 business days from the IDT meeting to enter a request for NF Specialized Services. This failure could place residents with a positive PASRR evaluation at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of six residents (Resident #25) observed for infection control. CNA P failed to perform hand hygiene during while providing incontinence care to Resident # 25. This failure could place the residents at risk for infection.