Heritage Park Rehab & Skilled Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: Refer to F 677 Activities of Daily Living Care for Dependent Residents, Scope and Severity = D Refer to F 684 Quality of Care, Scope and Severity = D Refer to F 689 Free of Accident Hazards, Scope and Severity = G The facility policy and procedure titled Emergency Staffing with a review date of October 2025 documented when the facility was at a crisis level impeding…

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 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)). The findings include: The facility policy and procedure titled Formation of the Resident Care Plan, dated [DATE] documented the comprehensive care plan will be developed within seven (7) days after the comprehensive assessment and will be prepared by an interdisciplinary team that includes, but was not limited to: Attending Physician, a…

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, 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. The findings include:The facility policy Food Safety Requirements revision/review date 04/12/2024 documented it is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food 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.

Based 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. In addition, the facility did not follow their plan of correction from their Standard survey 04/03/2026 to provide education to staff in the areas of Activities of Daily Living Care Provided for Dependent Residents (F677); and Infection Control (I210). The findings include: Refer to: F 604- Right to be Free from…

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 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. The findings include: The facility policy and procedure titled Restraints and Safety Devices dated 10/07/2014 documented the objective of the policy was to maintain dignity of the resident at all times and promote greater functional independence. The policy documented that residents shall not be restrained unnecessarily or for…

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 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. The findings include: The facility policy and procedure titled Care of Incontinent Resident dated 10/07/2014 documented that providing incontinent care was to keep a resident with problems of involuntary elimination, clean and dry to promote cleanliness, comfort and to prevent skin issues. An incontinent resident in bed should be checked and change incontinence product as per care plan The facility policy and procedure titled Activities of Daily Living dated 01/14/2015 documented the nursing staff will assist the resident with any of the activities that they were unable to…

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 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.The findings are:Review of the Dear Administrator letter 23-11 dated 06/30/23 sent to the nursing home administrators informing them that starting 04/01/2022 nursing homes were required to have an average daily staffing of 3.5 hours of care per resident per day with 2.2 hours for Certified Nurse Aides and 1.1 hours for Licensed Practical Nurses or Registered Nurses.The Facility Assessment, review dated 01/30/2025, documented the assessment is required by the nursing home Requirements of Participation to identify and analyze the…

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 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. Review of the Facility Assessment completed in January 2024 revealed that the assessment did not include minimum staffing numbers. During an interview on 2/29/24 at 8:57 AM, Scheduler #1 stated they were instructed by administration to have…

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, 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. The findings are: The undated policy and procedure titled Refrigerated Food Storage Labeling and Dating documented coolers will be maintained below 41 degrees Fahrenheit. All opened and prepared food items will be covered, labeled and dated so as to indicate a consume by or expiration date. Once the product is opened or prepared, keep it a maximum of four days (with today as day one). Exceptions to this are refrigerated staples/ condiments, which may include catsup, mustard, relish, pickles, salad dressing, jelly, syrup, dried or candied fruit, salsa, horseradish,…

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 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. Any suspected abuse must be reported immediately. Immediately, in this context, means after ensuring the resident has been removed from any possibility of harm…

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, 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: Review of policy and procedure titled Cleansing Inner Cannula (a tube within the outer tube that can be removed and cleaned easily without having to change the whole (outer) tracheostomy tube) of Tracheostomy Tube/Trach Care tube revised on 4/27/17, documented that the care should provide wiping and washing of the neck around and under the cannula with a gauze. Review of policy and procedure titled Procedure for Handwashing review date 12/22/14, documented that hands should be…

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 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: The facility policy and procedure (P&P) titled Hemodialysis dated 1/14/15 documented the hospital supplies a Nursing Home/Dialysis Communication sheet that is filled out and sent with the resident for every appointment. The hospital in turn completes their section and returns it after each visit. Upon return the nurse reviews the…

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.