Heritage Park Rehabilitation and Skilled Nursing C

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services timely to maintain good grooming and personal hygiene for two of seven residents (Resident #128, Resident #135) reviewed for ADLs. The facility failed to ensure Resident #128 and Resident #135 fingernails were trimmed and maintained. This failure could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the open date for insulin and secured med cart for 2 (med cart #2 and med cart #1) of 6 med carts reviewed for medication storage. The facility failed to ensure that Resident #195 and Resident #75's insulin pens were labeled with an open date on med cart #2. The facility failed to ensure that med cart #1 was locked when RN was not present. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of their medications, a decline in health status, and adverse effects if they had access to an unlocked MC.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 10 residents (Resident #20) reviewed for rights. The facility failed to ensure CNA B closed Resident #20's door while providing incontinent care. The deficient practice could place residents at risk of feeling embarrassed and diminish the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 6 medication carts (2200/2500-hall med cart) in the facility effecting 2 residents (Resident #156 and Resident #71) reviewed for pharmacy services. The facility failed to ensure LVN G accurately reconciled Resident #156 and Resident #71's narcotic medication log when she administered but did not sign for Resident #156's Hydrocodone APAP 5-325mg (controlled medication used for pain) 1 tablet and for Resident #71's Hydromorphone Hch 2mg (controlled medication used for pain) 1 tablet on 02/20/2026 between 6:00 a.m. and 10:00 a.m. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure the cook performed hand hygiene while preparing puree foods. This deficient practice could place residents who were served from the kitchen at risk for foodborne illnesses. Findings Included:Observation of puree being prepared by the [NAME] on 02/19/2026 at 9:55 a.m., revealed she had gloves on. She put the meat and potatoes in the puree machine. She then put the meat and potatoes in a pan. She tasted the puree, threw the spoon away, covered the meat and potatoes, and put the puree meat on the steam table. She opened a heated cabinet and got the beans. She checked the temperature, wiped the thermometer with an alcohol wipe. [...]

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 1 of 3 residents (Resident #164) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed when CNA D and CNA E performed peri care for Resident #164. This deficient practice could place residents at risk for the spread of infection.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 4 (Resident #3, Resident #4, Resident #5 and Resident #6) of 7 residents reviewed for environment. The facility failed to ensure Resident #3, Resident #4, Resident #5 and Resident #6's linens were free of tears, free of holes or not stained on 08/07/2025. These failures placed residents at risk of discomfort, embarrassment and diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is a deterioration in health, mental or psychosocial s tatus in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 7 residents reviewed for physician notification, in that: The facility failed to notify Resident #1's physician when she developed a rash on 07/26/2025 and no skin assessment was conducted for Resident #1 on 07/26/2025 after the rash was found and there was no notification to physician to obtain orders for treatment. The facility failed to notify Resident #1's family when she refused showers regularly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to assess Resident #1 and report a new rash to the physician on 07/26/2025. There were no orders added for rash/skin treatments from 07/26/2025 to 08/07/2025 for Resident #1. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control effectively treat the building for cockroaches. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices cleaning the ice machine, cleaning the cooktop range drip pans, utilization of an ice scoop receptacle that was not cracked and broken on the bottom were used. 2. The facility failed to label and date all food items in the kitchen. 3. The facility failed to refrigerate products after opening per the manufacturer label. 4. The facility failed to ensure food items were covered, secured and stored properly. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective ongoing pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control effectively treat the building for insects. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 9 of 9 (Resident #292, Resident #12 Residents #6, 17, #22, #27, #60, #93, and 103's) residents reviewed for dignity. 1. The facility failed to ensure Resident #292, and Resident #12 had a privacy cover on their urinary catheter bag. 2. The facility failed to promote Residents #6, 17, #22, #27, 60, #93,103's dignity while dining when staff did not serve the residents their lunch tray at the same time as other residents at the same table for lunch on 11/12/2024 and Resident #6 for lunch on 11/14/2024. These failures could affect the resident's dignity and affect their quality of life and contribute to poor self-esteem and unmet needs.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for 12 of 12 residents 9 confidential residents and 3 of 3 residents (Residents #128, Resident #140, Resident #101) reviewed for resident rights. 1. The facility failed to ensure the SS did not search residents' wheelchairs and belongings (Resident #128, #101, and #140) for contraband without their permission. 2. The facility failed to ensure an unidentified staff did not conduct random searches on residents' rooms (Residents #128, Resident #140, 9 confidential residents) on undisclosed dates without residents' permission or remove items from their rooms without permission. This failure could place all residents at risk of emotional distress, feelings of disrespect, lack of dignity, and could decrease residents' self-esteem and/or quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for the rooms of 4 of 20 residents (Resident room [ROOM NUMBER], #43, #106, and #176) reviewed for cleanliness and sanitization. The facility failed to ensure that the rooms of Residents #12, #43, #106, and #176 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 9 residents (Residents #33, 151, and 176) reviewed for care plans. The facility failed to ensure Resident # 33's care plan addressed her oxygen orders. The facility failed to ensure Resident # 151's care plan addressed his dental needs and food allergies. The facility failed to ensure Resident # 176's care plan addressed her present on admission diagnosis of PTSD-Post Traumatic Stress Disorder needs. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of ten residents (Resident #142, Resident #54, Resident #39 and Resident #60) reviewed for quality of life. The facility failed to ensure Resident #142, Resident #54, Resident #39 and Resident #60 received regular showers. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 16 residents (Residents #9, 58, and 130) reviewed for activities. The facility failed to ensure Residents #9, 58, and 130 received activities according to their preference on their comprehensive assessments. This failure placed residents at risk of boredom and diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by staff in the direct care of 5 of 15 residents (Resident #6, Resident #48, Resident #64, Resident #108, and Resident #292) reviewed for infection control in that: 1. CNA V did not sanitize or wash hands in between giving Resident # 48, Resident # 64 and Resident #108's meal trays, placing residents at risk of getting sick from food contamination. 2. CNA O failed to perform proper hand hygiene practices during peri care for Resident #6 3. The facility failed to ensure Resident #292 received indwelling urinary catheter care to maintain his catheter free of a moderate build-up of a dark brown colored substance. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the required 80 square foot per resident in 5 of 5 resident rooms (room numbers 201, 404, 504, 2405, and 2505), reviewed for environment. The facility failed to provide 80 square feet per resident in 5 shared resident rooms. This failure could affect residents who resided in the facility and could result in inadequate space for resident's activities of daily living in their rooms.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to provide personal privacy for of closing privacy curtains during pericare for resident ( Resident # 92) reviewed for privacy. 1 of 1 resident was observed. Resident #92's privacy curtain was not closed all the way while receiving incontinent care. This failure could place residents at risk not having personal privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for 1 (Residents #6) of 37 residents reviewed for restraints. The facility failed to ensure that wedges (triangle plastic pads used to position residents with pressure ulcers) were not used on the side of Resident # 6's bed without the resident having been evaluated for the medical need. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 10 residents (Resident #176) reviewed for baseline care plans. The facility failed to ensure Resident #176's baseline care plan dated 10/21//2024 included instructions to address her present on admission diagnosis of PTSD-Post Traumatic Stress Disorder (a mental health condition that can develop after someone experiences or witnesses a traumatic event) within 48 hours of admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents environment remained as free of accident and hazards as possible for 1 of 3 residents reviewed for accidents and hazards (Resident #13). The facility failed to ensure soap was secured in labeled container in Resident #13's room. This failure could result in residents experiencing accidents and possible illness, injury, and hospitalization by inadvertently consuming unknown substances.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounted for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #176) of 3 resident reviewed for quality of care. The facility failed to ensure that Resident #176's potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 7.69 % based on 2 errors out of 26 opportunities, which involved 2 of 4 residents (Resident #1 & #156) and 2 of 2 staff (MA R and MA T) reviewed for medication errors, in that: MA R administered a whole Metroprolol ER (Extended release or slow release) gel pill and the Resident #1 had orders to crush all medications. MA T administered 1 medication (Metroprolol) which was ordered to be given if blood pressure reading was within the parameters. Orders indicated to hold (do not give to resident) if blood pressure reading is outside of the parameters. The blood pressure was outside of the parameters. These failures could place residents at risk of medication errors that could cause a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 (Resident#156) of 4 resident reviewed for pharmaceutical services. The facility failed to follow prescriber's orders and professional standards and principles which apply to professionals providing services for Resident #156's scheduled medications. MA T administered 1 medication (Metroprolol) which was ordered to be given if blood pressure reading was within the parameters. Orders indicated to hold (do not give to resident) if blood pressure reading is outside of the parameters. The blood pressure was outside of the parameters. This failure could place residents at risk of discomfort or jeopardizes his or her health and safety.

Inspectors wroteIn accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. 2 of 4 medication carts reviewed in that: The medication cart for the 2400 hall and one cart by the front entrance on the lower level were not locked. During a medication review, MA T walked away and left the medications out with the surveyor, instead of locking the medications back up. These deficient practices could affect residents and result in a drug diversion due to medications not being properly disposed and secured.

Inspectors wroteBased on interviews and record review the facility failed to provide diagnostic services to meet the needs of its residents in a timely manner for 1 of 9 (Resident # 153) residents reviewed for radiology services. The facility failed to ensure Resident # 153 was taken to their imaging appointment in a timely manner to ensure their appointment was not canceled due to being late for the appointment. This failure could place residents at risk of delayed diagnosis and medical treatment to prevent complications and injuries.

Inspectors wroteBased on interviews and record review the facility failed to assist residents in arranging transportation to and from dental services location to meet the needs of 1 of 6 (Resident # 151) reviewed for dental services. The facility failed to assist Resident # 151 with arranging transportation to and from dental services location to complete his dental appointment for castings to be made for dentures. This deficient practice could affect residents by placing them at risk of not receiving dental care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for one (1) of ten (10) residents (Resident # 151) reviewed for food allergies. The facility kitchen failed to honor Resident # 151 food allergies according to his meal ticket and served him beets which his meal ticket stated he had an allergy to. This failure placed the resident at risk of consuming a food allergen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical records are accurately documented for 1 of 5 residents (Resident #13) reviewed for clinical records. The facility failed to ensure Resident #13's admission Agreement dated 8/26/24 signed electronically after consent received during phone conversation was witnessed by 2 people. These failures could result in inaccurate records, errors in care, decline in health and quality of life. Findings Include: Review of Resident #13's face sheet revealed an 80-years-old male with admission date of 8/24/24 with a discharge date of 10/18/2024. Diagnoses included: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations were reported immediately or not later than 24 hours for 1 (Resident #1) of 6 residents reviewed for elopement. The facility failed to report to the SA an incident where Resident #1 eloped from the facility on 11/01/24. This deficient practice could place residents at risk of abuse, neglect, elopement, injury, and death.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 facilities reviewed for pests control The facility failed to ensure the facility was free from pests/insects in multiple areas including resident rooms, shower room, dining room and kitchen. This failure could place residents at risk for insect borne illnesses, and cause residents to live in an uncomfortable and non-homelike environment free of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service in that: The facility failed to label and date items in the freezer. This failure could put residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 8 residents reviewed for resident rights and dignity. CNA B failed to provide privacy and dignity to Resident #1 by closing the door and/or privacy curtain leaving the resident exposed during incontinent care. This failure could place residents at risk for a loss of dignity, decreased self- worth, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs were stored in locked compartments with access by authorized personnel only for 1 of 3 medication carts (300 hall cart) reviewed for storage of drugs and biologicals. RN A failed to secure the 300 hall medication cart leaving it unlocked and unsupervised. This failure could result in staff, visitors, or residents accessing medications not prescribed to them.

Inspectors wroteBased 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. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased 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. This failure could result in acute or permanent injury or death for residents who are wheelchair dependent or unable to navigate the stairs safely.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for 3 (Resident #20, #65, and #395) of 169 residents reviewed for resident rights and ensure each resident was provided a safe, clean, comfortable, and homelike environment in that: 1. Staff did not check on and make sure Resident #20 was fully clothed. 2. Resident #395's urinal was out in plain sight, emptied, and cleaned. 3. Resident #65 repeatedly urinated in resident common areas, threw, and damaged facility property placing residents in an uncomfortable, unsanitary, and non-homelike environment. These deficient practices placed residents at risk of a decline in their sense of dignity and self-worth and diminished their right to feel safe, secure, and live in a clean homelike environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident had a right to a safe, clean, comfortable and homelike environment for 4 (Resident #41, #129, #141, and #395) of 169 residents reviewed for environment. 1. Resident #41, #129, #141, and #395's rooms had a urine odor. 2. The facility's memory care unit had a urine odor and sticky floors. These deficient practices placed residents at risk of discomfort and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective ongoing pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control treat the building for insects. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside the facility for one (Resident #103) of seven reviewed, in that: The facility failed to provide a communication aide (examples being paper and writing implement or white board) for Resident #103 after a diagnosis of hearing loss. This failure placed residents at risk of a lack of a dignified existence, self-determination, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one (Residents #78) of one of one reviewed, from verbal abuse, in that: The facility failed to ensure Resident #78 was not verbally abused by Resident #90. This failure could most likely place residents at risk of fear, depression, intimidation, and a diminished quality of life due to verbal abuse.

Inspectors wroteBased on observation, interview and record review, 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 (Resident #102 and Resident #182) of eight residents reviewed for activities of daily living. The facility failed to ensure Resident #102 received nail care. The facility failed to ensure Resident #182 received shaving care. These failures placed residents at risk of diminished support with activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide or obtain routine dental services to meet the needs of each resident for one (Resident #36) of eight residents reviewed for dental services. SW A failed to obtain financial consent or declination for recommended dental services for Resident #36. This failure placed residents with dental issues at risk of diminished ability to chew, decreased intake and weight loss.