Heritage Park Rehab & Skilled Nursing

Inspectors wroteBased on observations, interviews, and record review conducted during survey, the facility failed to ensure that the residents' environment remained as free of accidents as possible, and that each resident receives adequate supervision and assistance devices to prevent accidents for one (1) (Resident #21) of four (4) residents reviewed for accidents. Specifically, on 03/11/2026, the facility failed to assist Resident #21 when they were reheating liquid in the microwave oven, resulting in Resident #21 sustaining an 8.5 centimeter by 5-centimeter second degree burn (damage to both the outer (epidermis) and underlying (dermis) layers of skin, causing blisters, pain, and a shiny moist appearance) to their left upper hand. Additionally, the facility failed to develop the care plan to include Resident #21's history of burning self after heating items in the microwave oven. [...]

Inspectors wroteBased on observations, interviews and record review conducted during survey, the facility failed to ensure sufficient nursing staff to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (First floor, Second floor, Third floor) resident care units. Specifically, the facility did not ensure they met their minimum staffing numbers for each shift and there was a lack of sufficient nursing staff to provide timely care to meet the needs of the residents. This involves Resident's #4, #8, #9, #20, #21, #27, #30, #42, #43, #50, #51 #55, #63, #92, #96, #104, #106 and #119.

Inspectors wroteBased on observation, interview, and record review completed during survey, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for four (4) (Residents #20, 35, 40, and #55) of four (4) residents reviewed. Specifically, comprehensive care plans that did not accurately reflect resident's current Advanced Directives, including their code status (a medical order indicating a patient's preferences for life-saving interventions to guide staff on whether to perform resuscitation- full code (all efforts) or Do Not Resuscitate (DNR)).

Inspectors wroteBased on observations, record reviews, and interviews conducted during the survey, the facility failed to store food in accordance with professional standards for food service safety for one (1) of one (1) kitchen and two (2) (second and third floors) of three (3) resident floors reviewed. Specifically, in the kitchen there were various sticky food spills and sticky residue on the floor, the ceiling tile grid had a visible layer of black dust and there were dirty ceiling tiles, water damaged floor tiles near the ice machine, a broken faucet in the 3-bay sink, flies in the dishwasher and food preparation areas, and a damaged ceiling light cover held together by duct tape. Additionally, the kitchen, unit dining rooms, and activity room coolers/refrigerators/freezers were dirty with liquid spills and contained multiple undated, unlabeled food items.

Inspectors wroteBased on interview and record review conducted during an Onsite Post Survey Revisit #1 completed on 06/25/2026, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance, and there were repeated deficiencies observed from the Standard survey completed on 04/30/2026, in the areas of Right to be Free from Physical Restraints, Care Plan Timing and Revision, Food Procurement, Store/Prepare/Serve-Sanitary, Emergency Lighting, and Fire Alarm System - Testing and Maintenance. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time and document ongoing re-evaluation of the need for restraints for one (1) (Resident #104) of one (1) resident reviewed for physical restraints. Specifically, there were no evaluations completed to determine if Resident #104's lap tray and seat belt devices were restraints or re-evaluations to assess their continued need, staff did not release the seat belt or lap tray devices for over five (5) hours, and there were no provider orders to release the devices.

Inspectors wroteBased on observations, interviews, and record reviews conducted during survey, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (2) (Resident #43 and #104) of eight (8) residents reviewed for activities of daily living (ADLs). Specifically, Residents #43 and #104 were not provided with timely incontinence care.

Inspectors wroteBased on observation, interview and record review conducted during a Complaint investigation (NY00363355-806626 and NY00359730-806683) completed on 09/12/2025, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility did not ensure there was sufficient nurse staffing to meet the needs of the resident in accordance with their preferences and plans of care.

Inspectors wroteBased on interview, and record review conducted during a Complaint investigation (NY00308641) during the Standard survey completed on 3/1/24, the facility did not ensure sufficient nursing staff to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (First floor, Second floor, Third floor) of three resident care units. Specifically, the facility did not ensure they met their minimum staffing numbers. In addition, minimum staffing numbers were not included in the facility assessment. Resident #s 36, 52, 85 and 114 were involved. The finding is: The policy and procedures titled Nursing Policy & Procedure Benefit Improvement and Protection Act (BIPA) revised 8/22/18 and Emergency Staffing Strategies revised 1/6/24 had no documentation regarding minimum nursing staffing numbers. 1a. [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 3/1/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Issues included undated and outdated food in refrigerators, potentially hazardous foods in refrigeration above 41 degrees Fahrenheit, a refrigerator missing a thermometer, and multiple soiled surfaces. This affected two (First Floor, Second Floor) of three resident use floors and the kitchen.

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00332288) during the Standard survey completed on 3/1/24, the facility did not ensure that all alleged violations of abuse, were reported immediately, but not later than two hours after the allegation was made, to the Administrator and other officials including the State Survey Agency for one (Resident #92) of five residents reviewed. Specifically, alleged resident to resident sexual abuse was not reported to the Administrator of the facility and the New York State Department of Health within the required time frame. The finding is: The policy and procedure titled Resident Abuse Prevention Reporting System, revised 1/6/23, documented that it is the responsibility of employees to promptly report to facility management any incident or suspected incident of resident abuse. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 3/1/24, the facility did not ensure a resident who required respiratory care, including tracheostomy (an opening into the trachea (windpipe) to help air reach the lungs) care, provided such care consistent with professional standards of practice for one (Resident #51) of three residents reviewed for respiratory care. Specifically, during an observation of tracheostomy care, the nurse did not perform adequate hand hygiene/glove changes and did not clean the stoma (a surgically made hole) area. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 3/1/24, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected three (First Floor, Second Floor, Third Floor) of three resident use floors and the Basement. The finding is: Observations during the building tour on 2/26/24 from 9:40 AM until 3:00 PM revealed fuel-burning appliances were located in the Main Kitchen on the First Floor and the Laundry Room and Boiler Room in the Basement. [...]

Inspectors wroteBased on observation, interview, and record review completed during the Standard survey conducted from 5/2/22 to 5/6/22 the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #270) of one resident reviewed for dialysis. Specifically, the pressure dressing was not removed from the AV fistula (arteriovenous - a tube or device surgically implanted to create an artificial connection between an artery and a vein) access site for greater than two hours as recommended by the dialysis center. The finding is: [...]