Heritage Park

Inspectors wroteBased on interview and document review the facility's governing body failed to appoint a licensed administrator to be accountable and manage the facility since 05/07/2026. The deficient practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure all staff were fit-tested for an N-95 respirator mask (protects residents and staff from the transfer of microorganisms that can cause infectious disease) per the Centers for Disease Control (CDC). This deficient practice had the potential to affect all 43 residents who resided in the facility.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by a resident (Resident #33), which affected 4 (Residents #35, #39, #51, and #56) of 7 residents reviewed for abuse. Specifically, on 07/29/2025, Resident #33 pulled Resident #56 from a chair against their will, open-hand slapped Resident #51 on the face on 01/20/2026, caused Resident #39 to cry on 01/23/2026 when they snatched a bingo card from Resident #39 and called Resident #39 a vulgar slur, and hit Resident #35 on 06/04/2026.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure allegations of abuse were reported to the state survey agency within two hours after the allegation was made, which affected 4 (Residents #35, #39, #51, and #56) of 7 residents reviewed for abuseFindings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 04/2021, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy revealed, 1. [...]

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate alleged incidents of verbal and physical abuse, which affected 5 (Residents #35, #36, #39, #51, and #56) of 7 residents reviewed for abuse. Specifically, alleged incidents of abuse perpetrated by Resident #33 occurred on 07/29/2025, 01/20/2026, 01/23/2026, 03/22/2026, and 06/04/2026 and were not thoroughly investigated.

Inspectors wroteBased on facility policy review, interview, and record review, the facility failed to ensure medical records were complete and accurate related to documentation of the provision of activity of daily living (ADL) care for 3 (Residents #12, #13, and #29) of 4 residents reviewed for ADLs.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure they had record of a resident/responsible party being informed of risks and benefits and receiving informed consent prior to administering psychotropic medications for 1 (Resident #3) of 5 residents whose medication regimen were reviewed.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to follow physician orders for 1 (Resident #12) of 13 sampled residents. Specifically, on 10/29/2025, staff failed to administer Resident #12's medication per physician orders and in accordance with standards of practice.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had access to their trust account money on nights and weekends for three (#9, 10, and #26) of three sampled residents reviewed for access to their trust account money. The BOM identified 33 residents who had money in the trust account.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received notification when they were within $200 of the Medicaid resource limit of $2,000 for four (#5, 9, 10, and #26) of four sampled residents reviewed for notifications of trust balances. The BOM identified 33 residents who had money in the trust account.

Inspectors wroteBased on observation, record review, and interview the facility failed to: a. monitor fluid input and output for one (#93) of one sampled resident reviewed for fluid restrictions; and b. provide nutritional interventions for weight loss of providing nutritional supplements and double portions at meals for two (#3 and #5) of two sampled residents reviewed for nutritional. The DM identified four residents who were on a pureed diet. The ADON identified one resident on a fluid restriction, 13 residents who had physician orders for double portions, and 23 residents who had orders for health shakes with meals.

Inspectors wroteBased on record review and interview, the facility failed to complete pre and post dialysis assessments for one (#93) of one sampled resident reviewed for dialysis services. The administrator identified one resident who received dialysis.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a medication error rate of less than five percent during the medication pass observation. LPN #2 identified 41 residents resided in the facility. The ADON identified 21 residents with ordered blood pressure parameters.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical director was part of the quality assurance program. LPN #2 identified 41 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure contact information for filing a complaint with the State agency was available to the residents. LPN #2 identified 41 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the most recent survey results were readily accessible to the residents. LPN #2 identified 41 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a homelike environment for one (#10) of one sampled resident reviewed for homelike environment. LPN #2 identified 41 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed complete a discharge summary with a recapitulation of their stay for one (#41) two closed records reviewed. LPN #2 identified 41 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pureed meals were served at the correct consistency for one of one pureed meal preparation. The DM identified four residents who had diet orders for pureed meals.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure menus were followed for pureed diets for one of one meal service observed. The DM identified four residents who had diet orders for pureed meals.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the environment was free from pests for one (#13) of one sampled residents reviewed for pests. LPN #2 identified 41 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for six (#20, 29, 10, 40, 4, and #52) of 20 sampled residents reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to perform annual nurse aid performance reviews. The Resident Census and Conditions of Residents form documented 49 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program to prevent the spread of infections. The facility failed to ensure: a. a water management system was in place to detect/prevent Legionella. b. COVID-19 transmission-based precautions were conducted for three (#3, 17, and #42) of four residents reviewed for transmission based precautions. c. COVID-19 testing was performed per policy for one (#3) of four residents reviewed for transmission based precautions. The Resident Census and Conditions of Residents form, documented 49 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who were discharged from Part A skilled services, with benefit days remaining, were issued ABN and/or NOMNC notices for two (#150 and #151) of three sampled residents reviewed for beneficiary notices. The Beneficiary Notice worksheet identified five residents who were discharged from Part A skilled services with benefit days remaining in the previous six months.

Inspectors wroteBased on observation, record review, and interview, the facility failed to update the care plan related to nutrition for one (#46) of one sampled resident whose care plan was reviewed. The Resident Census and Conditions of Residents documented one resident who received tube feedings.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician responded to a pharmacist MRR for one (#32) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 36 residents received psychoactive medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper kitchen sanitation was provided. The facility reported 49 of 49 residents received food from the dietary department.