Latest reports, citations, and penalties from CMS data
The resident, identified as CR #1, was admitted with multiple serious conditions including heart failure, diabetes, morbid obesity, and atrial fibrillation....
## Food Storage Violations Put Residents at Risk The inspection revealed several concerning food safety practices in the facility's kitchen....
Federal inspectors found the COTA was still scheduled to work as late as the day before the inspection, despite having an expired license....
Inspectors found the facility failed to ensure safe smoking practices when smoking residents possessed smoking materials and smoked without supervision....
## Widespread Menu Compliance Failures The inspection revealed systematic failures in following planned menus during the lunch service on August 12, 2024....
These surfaces had not been cleaned despite the obvious contamination....
Video surveillance documented that a CNA brought the resident's food tray to his room at 6:43 pm but left the facility at 7:05 pm....
During five separate observations between March 24-27, inspectors found the resident reclined in the Broda chair either at the nursing station or in her room....
## Medical Implications of the Transfer Accident The resident's medical history made this incident particularly dangerous....
Inspectors found that Heritage Park Care Center failed to meet these basic care requirements for vulnerable residents....
When questioned about cleaning protocols, the nurse stated she sanitized the glucometer only at the beginning and end of her shift, not between residents....
The resident clearly communicated his wishes during the inspection, stating **he wanted to be resuscitated and wanted to be Full Code**....
The resident, who had been admitted less than 24 hours earlier, was lying in bed when the aide attempted to transfer her....
Four residents specifically identified in the report experienced gaps in critical care that could have resulted in severe health consequences....
The resident received Entresto and carvedilol despite blood pressure readings as low as 103/74 and 106/46....
This represents a fundamental breakdown in the facility's internal quality control mechanisms designed to prevent medical errors and ensure resident safety....
These medications are specifically designed as extended-release formulations that should never be crushed or opened....
Inspectors identified issues with how the facility handled medication supervision and self-administration protocols....
Dietary Aide #23 was observed rinsing dirty dishes, washing plates and trays while wearing gloves and an apron that contacted contaminated surfaces....
The resident, identified as R1 in the inspection report, subsequently died at the hospital after sustaining injuries from the fall....