Heritage Park Nursing Center

Inspectors wroteBased on interview, and record review, the facility failed to protect against physical abuse for one of three sampled residents (Resident 1) when a Certified Nursing Assistant (CNA 1) forcefully sat Resident 1 in the wheelchair by Resident 1's pants, then pushed the wheelchair into the room and closed the door behind Resident 1. This failure had the potential to cause physical injury, emotional distress, and a decline in Resident 1's sense of safety and well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy for Psychotropic (drugs that affect the mind, emotions, and behavior) Medication Use was implemented for one of two residents reviewed for unnecessary medications (Resident 38). This failure had the potential to place Resident 38 at risk of staff not identifying the effectiveness of the psychotropic medication and missing potential side effects placing Resident 38 at risk for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication administration policies and procedures when: 1. A Licensed Vocational Nurse (LVN 2) administered Metoprolol (medication used to lower blood pressure) Extended Release (ER- type of medications designed to be swallowed whole to allow the medication to work gradually over time) crushed to Resident 34. 2. The controlled drug inventory (when a nurse signs verifying that the nurses performed controlled medication counts during shift change- system in place used to prevent discrepancies in narcotic medication counts) had missing signatures on multiple shifts for two carts on Unit 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when a License Vocational Nurse 2 (LVN 2) did not wear PPE (Personal Protective Equipment, such as gloves and gowns) as required under EBP (Enhanced Barrier Precautions, used to prevent the spread of resistant infections) while providing treatment to a resident in EBP isolation (Resident 117). This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to another 65 vulnerable residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure for investigating an allegation of suspected physical abuse for one of three sampled resident (Resident 3), when the facility did initiate an investigation for the incident within specified timeframes after Resident 3 reported an alleged abuse by another resident to the Administrator on April 2, 2025. This failure has the potential to jeopardize Resident ' s 3 health, safety, and well-being at risk and the other vulnerable population of 69 residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of a Level I preadmission screening and resident review (PASRR) for 1 (Resident #51) of 6 sampled residents reviewed for PASRR requirements. Specifically, Resident #59 had a diagnosis of schizoaffective disorder and major depressive disorder; however, the resident's Level I PASRR screening indicated the resident did not have a mental disorder.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged sexual abuse for one of three sampled residents (Resident 2) by another resident to the local, state and agencies. This failure had the potential to place a clinically compromised resident (Resident 2)'s health, safety and well-being at risk.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) who eloped (leaving a safe area without authorization and/or appropriate supervision from the facility) was assessed to prevent or/and to minimize the risk for recurrence of elopement. This failure had the potential to cause a delay in identifying care and support needs which could place Resident 3 at risk for recurrence of elopement and at risk for injuries related to elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their closed observation protocol (a protocol for observing residents who are at risk for harm every fifteen minutes) documentation was complete in accordance with the facility ' s policy and procedure (P&P) for one resident (Resident 1) when Resident 1 returned to the facility after he eloped on January 7, 2024. This failure has the potential to result in Resident 1 to be at risk for further elopement without supervision of his whereabouts which could increase Resident 1 ' s risk for harm.

Inspectors wroteBased 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.

Inspectors wroteBased 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 life sustaining measures to be rendered against what Residents 156, 33, and 46 wanted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for two of six residents (Resident 4 and Resident 7) reviewed for urinary catheter (flexible tube inserted into the bladder to drain urine) when: 1. Resident 4's urinary catheter bag was not covered by a privacy bag (bag used to cover catheter bag). 2. Resident 7's urinary catheter bag was not covered by a privacy bag. These failures had the potential to compromise Residents 4 and 7's dignity and violate their rights to privacy, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their splint (device applied to prevent or reduce contractures) application policy and procedure was implemented for one resident (Resident 23) reviewed for range of motion (ROM- full movement potential of a joint) when Resident 23's multiple splint application refusals were not addressed from December 2021 through October 2022. This failure placed Resident 23 at risk of further deformities and having decline in ROM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety policies and procedures were implemented for one of three residents (Resident 29) reviewed for accidents when the facility did not provide Resident 29 floor mats as per physician's orders. These failures have the potential to increase the risk of further falls, injuries, and unmet care needs, which could threaten the welfare, health, and safety of Resident 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in accordance with the physician's orders and facility's policies and procedures for one resident (Resident 156) reviewed for respiratory care when Residents 156's nasal cannula (a device which delivers oxygen utilizing a tube) was not labeled. This failure had the potential to place Resident's 156 at risk for developing a respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure medications and medication carts (used to transport medications from resident rooms; often come equipped with locking drawers, adjustable height) were properly secured when one of six medication carts (IV [Intravenous- method of putting fluids, including drugs, into the bloodstream] medication cart) was found unlocked and unattended by a licensed nurse. These failures had the potential to compromise the security of medication for potentially unauthorized staff and resident around the area could access it in a highly vulnerable population of 64 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly and in accordance with their policy and procedure when garbage was found on the ground by the garbage storage area . This failure had the potential for the harborage or breeding place of insects and rodents that could affect the health and safety of a highly vulnerable population of 64 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 virus (a highly infectious respiratory disease) and other communicable diseases when one unvaccinated staff (Licensed Vocational Nurse - LVN 2) did not wear a respirator mask (a filtering facemask used to protect the wearer from fine particles including viruses) on November 3, 2022. This failure had the potential to cause harm to the 64 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus.