Heritage Park Care Center: Infection Control Failures - CO
Federal inspectors watched housekeeper after housekeeper ignore the most basic infection control protocols during their August inspection of the 120-bed facility on Village Road.
On August 27, inspectors observed one housekeeper cleaning a resident's room and bathroom. The worker never touched the call light cords in either location. Never wiped down the door handles to the room or bathroom. When questioned afterward, the housekeeper insisted she had cleaned the call light cords.
She hadn't. The director of housekeeping confirmed the worker later admitted she had skipped the resident call lights entirely during the observed cleaning.
Two days later, inspectors watched a second housekeeper clean another resident's room. Same pattern. Call light cords in the room and bathroom went untouched. Door handles remained uncleaned. This housekeeper, interviewed through a Spanish interpreter, acknowledged she had not cleaned the residents' call lights or any door knobs.
The facility's own policies required daily cleaning of these high-touch surfaces. The director of housekeeping told inspectors that call light cords, door handles, drawer handles and cabinet handles should be cleaned every day. She said she had previously spoken to housekeeping staff about the importance of cleaning high-touch surfaces.
But the housekeeping policy itself contained a critical gap. It required maintaining a "sanitary, orderly, and comfortable interior" but never specified that high-touch surfaces needed cleaning.
The infection preventionist and director of nursing both confirmed that resident call lights and door handles should be cleaned daily because they were considered high-touch surfaces that could transmit infections.
Hand hygiene failures compounded the cleaning problems.
On August 28, inspectors watched a registered nurse enter a resident's room, knock on the door, touch the resident's call light, then leave and begin preparing medications for another resident at the medication cart. The nurse never washed her hands before entering the room. Never sanitized after touching the call light. Just moved directly to handling medications for the next patient.
That same day, a certified nurse aide helped a resident to the bathroom but failed to offer the resident hand hygiene afterward. Federal guidelines emphasize that healthcare workers should help residents wash their hands after using the bathroom as part of basic infection control.
On August 29, inspectors observed a nurse aide passing clean water cups to residents throughout the facility. The worker entered multiple residents' rooms, collected used water cups, and replaced them with clean ones. Eventually, the aide performed hand hygiene after visiting several rooms.
But the aide failed to wash hands before entering each room, after exiting each room, or immediately after touching the contaminated water cups. The pattern meant potentially spreading germs from room to room on hands that had touched used cups and doorknobs.
The infection preventionist told inspectors that staff should perform hand hygiene before entering a resident's room, when leaving a resident's room, and between different care tasks in the same room. Staff should offer to wash residents' hands after assisting them to the bathroom. Workers should wash their hands after interacting with anything in a resident's environment.
The director of nursing confirmed that nursing staff should offer hand hygiene to residents after bathroom assistance.
But the facility's hand hygiene policy contained another gap. It specified using alcohol-based hand rub "before direct patient contact and after contact with inanimate objects in the patient's environment" but failed to address the full range of situations where hand hygiene was required.
The infection control failures reflected broader systemic problems at Heritage Park Care Center.
The nursing home administrator acknowledged during her interview that the facility's quality assurance program had failed to identify multiple areas needing improvement, including hand hygiene, infection control, appropriate cleaning of resident rooms, dignity issues, care planning problems, resident positioning, restorative services, weight loss, oxygen equipment, psychiatric medications, screening processes, food quality, and kitchen sanitation.
She said hand hygiene and infection control were "always watched as an area for improvement" but resident hand hygiene and appropriate room cleaning were not identified as problems until the federal inspection.
The administrator blamed leadership turnover for causing "a breakdown in the system." She said the quality assurance team needed to create performance improvement plans and complete audits to better identify problems. The facility completed random spot checks with staff, but she wanted to increase monitoring. She said the facility needed "more eyes on the floor" to identify improvement areas.
The facility focused on bigger concerns while missing smaller problems that could affect resident care, she explained. The quality assurance system worked, she said, but the team needed to re-evaluate their approach to catch all areas of concern, not just the major ones.
Staff training records revealed additional compliance failures.
Of five randomly selected certified nurse aides whose training records were reviewed, two had not received the required 12 hours of annual continuing education. Both workers had completed only 10 hours and 30 minutes of training during their annual training period.
One aide was hired in June 2022, the other in June 2014. Both fell short of federal requirements for annual training that must include dementia management and resident abuse prevention.
The administrator said she maintained training records and verified that staff received appropriate training. She acknowledged recording only 10.5 hours for the two aides, including dementia and abuse training. She said completing annual training was important for aides to stay updated on current bedside skills and education.
She promised to conduct an audit to ensure all staff completed training appropriately going forward.
The facility did not invite floor staff, residents, or family members to quality assurance meetings or seek their feedback, though the administrator said they wanted to include others. She said the facility had not accomplished getting others involved in the meetings.
Heritage Park Care Center's infection control program was supposed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of infectious diseases. Instead, inspectors found housekeepers skipping the surfaces residents touch most and nurses moving between rooms without basic hand hygiene.
The administrator's acknowledgment that leadership turnover caused system breakdowns offered an explanation but not a solution for residents who remained vulnerable to preventable infections from contaminated call buttons and unwashed hands.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Park Care Center from 2024-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HERITAGE PARK CARE CENTER in CARBONDALE, CO was cited for violations during a health inspection on August 29, 2024.
On August 27, inspectors observed one housekeeper cleaning a resident's room and bathroom.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.