Heritage Park Health Center By Harborview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure staff responsible for providing Cardiopulmonary Resuscitation (CPR) demonstrated the competency, knowledge, and skills necessary to perform CPR in accordance with professional standards and facility policy for one resident (#1) of two reviewed for CPR.Findings included: Review of the facility's Nursing Job description revealed the following: Major Duties and responsibilities:Participates in end-of-life care as requiredPromotes teamwork, mutual respect, and effective communicationTreats all residents with dignity and respect. Promotes and protects all residents' rights.Establishes a culture of compliance by adhering to all facility policies and proceduresFulfills responsibilities as assigned during implementation or activation of the facility's emergency plan. On [DATE] at 10:56 AM, during a phone interview, Staff A, Licensed Practical Nurse (LPN)stated on [DATE], Staff B, Certified Nursing Assistant (CNA) notified them Resident #1 was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy, the facility failed to ensure staff administered CPR (Cardiopulmonary Resuscitation) in accordance with professional standards of practice and the facility's CPR policy, for one resident (#1) of two residents reviewed. The facility staff did not call a Code Blue, did not activate EMS (Emergency Medical Service), did not utilize the crash cart or emergency equipment, and did not provide CPR continuously as required for a resident with a full code status. Findings Included: On [DATE] at 10:56 AM, a phone interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A stated on [DATE], Staff B, Certified Nursing Assistant (CNA), advised them Resident #1 was not breathing. Staff A stated upon arriving to Resident #1's room, they checked Resident #1's pulse and, when no pulse was found, they started CPR. Staff A stated the family member said Resident #1 had stopped breathing around 11:12 AM. Staff A stated while they were performing CPR,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility did not ensure Preadmission Screening and Resident Reviews (PASARRs) were completed accurately for five residents (#6, #74 #14, #58, and #66) out of six residents sampled for PASARRs.Findings Included: 1. Record review for Resident #6 revealed the resident was admitted on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Other diagnoses included mood disorder due to known physiological condition with mixed features, schizoaffective disorder, unspecified, unspecified intellectual disabilities, and depression A review of a level I PASARR for Resident #6 dated 6/12/2025 revealed an incomplete Assessment with only the diagnosis of Schizoaffective disorder checked. The PASARR did not show Resident #6 had a primary diagnosis of Dementia. The review showed a level II PASARR was not submitted for consideration following the qualifying diagnoses. 2. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility did not ensure expired medications were discarded in a timely manner and did not ensure proper storage of chemicals and medications in two medications carts (North 100 and North 200) of five carts observed.Findings included: An observation on 4/6/2026 at 2:30 PM of North 100 medication cart revealed a bottle of diphenhydramine with the expiration date worn off. The expiration dates could not be identified. An observation was made of the same cart with an opened vial of insulin that expired on 4/3/2026.An observation on 4/7/2026 at 3:25 PM of the North 200 medication cart revealed a container of bleach wipes stored in the same drawer with oral, topical, and rectal medications. The observation revealed there was no divider/separation in the bottom drawer in which both medications and cleaning chemicals were stored.An interview on 4/7/2026 at 4:45 PM with the Director of Nursing (DON) was conducted. The DON said the expired medications should have been removed from the medication cart. The DON said if the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four (Resident #2, #9, #10, and #18) of 16 residents reviewed were treated with respect and dignity that promoted the resident's quality of life by ensuring staff were able to communicate in a language the residents comprehend. Findings included:An interview was conducted with Resident #2's representative (RR) on 12/15/2025 at 2:59 p.m. Resident #2's RR stated staff did not speak English and Resident #2 did not speak another language. Since the staff did not understand Resident #2's preferences, Resident #2's preferences were not followed. An interview was conducted with Resident #9 on 12/15/2025 at 10:23 a.m. Resident #9 stated the aids speak other languages, and it is difficult to communicate with them.Review of Resident #9's MDS, dated [DATE], Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition not impaired.An interview was conducted with Resident #10 on 12/15/2025 at 10:40 a.m. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment to include resident bathrooms had functioning toilets, and the environment was maintained and sanitary from raw sewage odor in six (A, B, C, D, E, and F) of six-unit zones. Findings included:On 12/15/2025 at 9:10 a.m. upon facility entrance to the facility there was a heavy raw sewage odor.An interview was conducted with Staff I, receptionist, on 12/15/2025 at 9:10 a.m. Staff I confirmed the sewage odor and believed it came from the public bathrooms, located in the lobby area. Staff I said the odor is really bad in the a.m. but later in the day it seems to go away. Staff I stated reporting the odor to the Maintenance Director (DOM). Staff I stated receiving complaints from visitors as well as residents in the building, regarding the odor. Staff I stated not knowing how long the sewage odor had been on, but it has been ongoing since her employment, which was in the beginning of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility record review, the facility failed to ensure; 1. One of one dish washing machine was operating at its low temperature wash and rinse specifications; 2. One of one walk in freezer was free from icing, ice sheeting build up on floors, inside walls, shelving and packaged food items; 3. One of one walk in refrigerator had an internal thermometer to gauge the internal temperatures; and 4. One of one hand washing sink had soap available to wash hands. Findings included: 1. On 10/16/2023 at 9:32 a.m., a kitchen tour was conducted with the Certified Dietary Manager (CDM). There was a hand pump soap dispenser attached to the wall directly above the hand sink. The soap dispenser was empty. The Dietary Manager confirmed the wall mounted soap dispenser was empty and did not know how long it had that way. She further confirmed the sink was where the staff who come into the kitchen washed their hands. She confirmed using an alcohol base sanitizer was not acceptable for her and her staff to use in lieu of washing their hands at the sink with soap…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop care plan problem areas with goals and interventions related to Post Traumatic Stress Disorder (PTSD), for one (Resident #151) of two sampled residents, who had a history of PTSD. Findings included: On [DATE] at 10:15 a.m., Resident #151 was observed in her room with two visiting family members. She was seated on the side of her bed and was dressed for the day and well groomed. Resident #151 was not presenting with any behaviors, pain, or discomfort. She appeared to be comfortable around and with her family members. Resident #151 was interviewed and revealed she felt generally safe at the facility and was happy to have her brother and nephew who visited regularly. She did not have any immediate concerns with her care and services while at the facility. Review of Resident #151's medical record revealed she was admitted to the facility on [DATE] and was at the facility for short term rehabilitation. Review of the advance directives…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure two (Resident #26, and #67) of three sampled residents for quality of care received treatment and care in accordance with professional standards of practice related to 1. Responding to a change in condition timely related to a skin condition for Resident #26, and 2. Monitor and provide care to an occlusive dressing for Resident #67. Findings included: 1. On 10/16/23 at 10:58 a.m., Resident #26 was observed in her room sitting in the wheelchair next to her bed. A tube of [over-the-counter (OTC) medicated ointment, used for skin irritation] was observed sitting on the bedside table. She stated her husband always brought the [OTC medicated ointment] because she wanted to make sure she had it. She had an open area around her anus and in the groin area. Resident #26 stated it was very painful from sitting for so long. The wound care doctor came on Monday, and she needed to see them. She stated it hurt very bad when she urinated. They…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent enteral feeding complications related to not providing the ordered nutrition for one (Resident #28) out of 32 residents sampled. Findings included: Review of Resident #28's face sheet revealed she was admitted to the facility on [DATE]. Resident #28 was receiving hospice services. Her medical diagnoses included but were not limited to dysphagia, gastrostomy status, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, major depressive disorder, and dementia. Review of Resident #28's physician orders revealed an order with a start date of 8/23/23 without an end date for enteral feeding: Formula Jevity, strength 1.5 calorie, Flow rate 70 ml/hr. (milliliters per hour) for 20 hours. Further physician order review revealed an order with a start date of 8/16/23 without an end date for free water flush 250 ml via peg tube every 4 hours. Another order with a start date of 6/20/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the advance directive for a resident was identified in the medical record for one resident (#184) out of the sampled thirty-five residents. Findings included: A review of the Resident Face Sheet revealed Resident #184 was admitted into the facility on [DATE] with primary diagnoses of hypo-osmolality and hyponatremia. A review of the banner on the electronic medical record did not reflect an advance directive for Resident #184. A review of the Physician Order Report dated [DATE] to [DATE] did not reflect an order for an advance directive. A review of the care plans initiated on [DATE] for Resident #184 did not reflect a care plan related to advance directives. On [DATE] at 11:35 a.m., Staff A, Registered Nurse (RN), reported the code status for all residents should be listed on the top of the screen in the electronic health record. She stated that if a resident was coding, she would look at the top of the screen to check the code status. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman of a facility initiated transfer for one resident (#41) of two residents sampled for hospitalizations. Findings included: A review of Resident #41's Resident Face Sheet revealed that Resident #41 was admitted to the facility on [DATE], with a readmission to the facility on [DATE], with diagnoses of bilateral primary osteoarthritis of knee, acute pyelonephritis, and sepsis. Resident #41's Resident Face Sheet also revealed Resident #41 was her own responsible party. A review of Resident #41's Progress Notes revealed a note, dated 07/24/2021 at 5:38 p.m., which documented Resident #41 was transferred to the hospital due to complaints of abdominal pain and decreased bowel sounds. A review of Resident #41's Progress Notes also revealed a note, dated 07/24/2021 at 11:20 p.m., which documented Resident #41 was admitted to the hospital with diagnoses of urinary tract…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy, the facility failed to provide written notice of bed hold upon a facility initiated transfer for two residents (#41 and #72) of two residents sampled for hospitalizations. Findings included: A review of Resident #41's Resident Face Sheet revealed that Resident #41 was admitted to the facility on [DATE], with a readmission to the facility on [DATE], with diagnoses of bilateral primary osteoarthritis of knee, acute pyelonephritis, and sepsis. Resident #41's Resident Face Sheet also revealed Resident #41 was her own responsible party. A review of Resident #41's Progress Notes revealed a note, dated 07/24/2021 at 5:38 p.m., which documented Resident #41 was transferred to the hospital due to complaints of abdominal pain and decreased bowel sounds. A review of Resident #41's Progress Notes also revealed a note, dated 07/24/2021 at 11:20 p.m., which documented Resident #41 was admitted to the hospital with diagnoses of urinary tract infection and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility did not ensure the consultant pharmacist's recommendations were acted upon for one resident (#26) of five residents sampled for unnecessary medications. Findings included: Resident #26 was admitted to the facility with a diagnosis of dementia without behavior disturbance, according to the face sheet in the admission record. Review of the Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 5, indicating cognitive impairment. Further review of the assessment indicated Resident #26 did not have any mood or behavior symptoms at the time of the assessment. A review of the Physician Order Report dated 6/27/21 - 9/15/21 in the medical record revealed the following medications: 6/27/21 Seroquel 25 mg (milligram) give 1/2 tablet (12.5 mg) by mouth at bedtime, with a discontinue date of 6/28/21 6/28/21 Seroquel 25 mg give 1/2 tablet (12.5 mg) by mouth at bedtime Additional review of physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.