Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Park Nursing Center during CMS and state inspections, most recent first.
A CNA physically abused a resident with paranoid schizophrenia by grabbing the resident by the back of the pants, forcefully sitting the resident in a wheelchair, pushing the wheelchair into the resident’s room, and closing the door. The incident occurred during a period of yelling and redirection near medication administration and cigarette break, and the Admin later stated the CNA’s actions met the facility’s finding of physical abuse.
A resident with multiple medical conditions was prescribed Trazodone for insomnia without documented orders to monitor for side effects or sleep patterns, and no care plan was initiated to address the medication use. Facility leadership confirmed that required monitoring and care planning per policy were not followed.
A nurse crushed and administered an extended-release blood pressure medication to a resident with multiple chronic conditions, contrary to facility policy. Additionally, required signatures were missing from controlled drug inventory forms for two medication carts, with staff confirming that documentation procedures were not followed.
A nurse failed to wear required PPE, specifically an isolation gown, while providing care to a resident on Enhanced Barrier Precautions for a gastrostomy tube. Despite clear physician orders and posted signage, the nurse performed treatment without proper PPE, contrary to facility policy and infection control protocols.
A resident with schizoaffective disorder and major depression reported to the Ombudsman that another resident had sexually assaulted her. Despite facility policy requiring immediate investigation of abuse allegations, leadership did not initiate or document an investigation after the report, and no interventions were recorded to address the resident's safety. Facility leaders acknowledged the failure to follow policy during interviews.
A resident with multiple serious health conditions accidentally ingested a cleaning solution left in an unlabeled disposable cup by housekeeping staff, mistaking it for water. The resident experienced mouth and throat irritation and was transferred to a hospital for evaluation. The incident occurred because facility staff failed to follow policies requiring proper labeling and storage of hazardous chemicals.
The facility failed to accurately code MDS assessments for PASRR information for three residents with serious mental illness or intellectual disabilities. Despite having Level II PASRR determinations indicating the need for specialized services, the MDS assessments did not reflect this status. Interviews revealed that the MDS Nurse did not verify Level II determinations, leading to incorrect coding, and the DON acknowledged the expectation for accurate MDS assessments.
A resident with schizoaffective disorder and major depressive disorder was inaccurately screened in the PASRR Level I process, which failed to identify their mental disorders. The admitting nurse did not catch the error, and the Director of Nursing and Administrator expected the nurse to ensure accuracy and report discrepancies, which did not occur.
The facility failed to report an alleged sexual abuse incident involving a resident with schizoaffective disorder, major depressive disorder, and hypertension. The incident was not reported to the appropriate agencies, and there was no 5-day investigation summary available. This failure placed the resident's health, safety, and well-being at risk.
Physical Abuse During Resident Redirection
Penalty
Summary
The facility failed to protect a resident from physical abuse when a CNA forcefully sat the resident in a wheelchair by grabbing the resident by the back of the pants, then pushed the wheelchair into the resident’s room and closed the door behind the resident. The resident had diagnoses including paranoid schizophrenia, and the incident occurred during a period of escalating yelling and redirection in the hallway near medication administration and cigarette break activities. A mental health worker stated the resident was yelling, standing up, and arguing with others when the CNA made comments about the resident being “babied” too much, then grabbed the resident by the pants and forcefully put the resident back into the chair. The CNA’s written statement described the resident as repeatedly becoming upset around cigarette break, standing up and cussing at others, and stated the CNA grabbed the back of the resident’s pants, sat the resident down in the wheelchair, turned the wheelchair, and backed it into the room. The Administrator stated the investigation found the CNA physically abused the resident by forcefully sitting the resident in the wheelchair by the pants.
Failure to Implement Psychotropic Medication Monitoring and Care Plan
Penalty
Summary
The facility failed to implement its policy regarding psychotropic medication use for one resident. The resident was admitted with diagnoses including an intracapsular fracture of the left femur, acute respiratory failure with hypoxia, and major depressive disorder. A physician order was in place for Trazodone 100mg at bedtime for insomnia, but there were no documented orders to monitor for adverse side effects or to track the resident's hours of sleep. Additionally, the resident's care plan did not include any interventions or monitoring related to the use of Trazodone. During interviews and record reviews, both the Assistant Director of Nursing and the Director of Nursing confirmed the absence of monitoring orders and a care plan for the resident's use of Trazodone. Review of the facility's policy on psychotropic medication use indicated requirements for adequate indications, monitoring for efficacy and adverse consequences, and interdisciplinary management, which were not followed in this case. The Director of Nursing acknowledged that the policy and procedure were not adhered to.
Failure to Follow Medication Administration Policy and Incomplete Controlled Drug Inventory Documentation
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow the facility's medication administration policies by crushing and administering Metoprolol Extended Release (ER) to a resident with diagnoses of anemia, hypertension, and multiple sclerosis. During medication administration observation, the LVN prepared and crushed all of the resident's medications, including Metoprolol ER, and administered them. Upon review, the LVN acknowledged that Metoprolol ER should not have been crushed, as confirmed by the facility's policy, which states that medications should only be crushed when appropriate and safe, and that long-acting medications should not be crushed. Additionally, the facility failed to maintain accurate controlled drug inventory records for two medication carts on one unit. Controlled Drug Inventory (CDI) forms for multiple shifts were missing required signatures from both off-going and oncoming nurses, as observed and confirmed by staff. The facility's job description for charge nurses requires accurate narcotic records for each shift, but this was not followed, as acknowledged by the Director of Nursing.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to follow required infection control practices while providing care to a resident under Enhanced Barrier Precautions (EBP) isolation. The resident had been admitted with a history of digestive system surgery and required ongoing care for a gastrostomy tube, with physician orders specifying the use of gloves and gown during high-contact care activities. Despite clear signage indicating EBP isolation and explicit orders for PPE use, the LVN entered the resident's room and performed treatment without donning the required isolation gown. During interviews, the LVN acknowledged the failure to wear the appropriate PPE and recognized the lapse in protocol. The Infection Preventionist Nurse confirmed that all staff are expected to use PPE when caring for residents under isolation precautions, and the Director of Nursing reviewed the facility's policy, which mandates gown and glove use for residents under EBP. The facility's policy was not followed during this incident, as confirmed by the DON.
Failure to Initiate Timely Investigation of Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for investigating an allegation of suspected physical abuse involving a resident who reported being sexually assaulted by another resident. The incident was reported to the facility Administrator on April 2, 2025, but there was no documented evidence that an investigation was initiated within the specified timeframes. The facility's policy requires that all allegations of abuse, neglect, exploitation, or theft/misappropriation of resident property be thoroughly investigated and documented, with findings reported to the appropriate agencies. However, interviews with facility leadership, including the Program Director, Director of Nurses, and Administrator, confirmed that the investigation was not started as required by policy. The resident involved had a history of schizoaffective disorder and major depression and was assessed as cognitively intact with a BIMS score of 14. The allegation was reported to the Ombudsman, who then informed facility staff, but the clinical record review from April 10 to April 16, 2025, showed no evidence of an investigation or interventions to address potential harm or prevent recurrence. Facility leadership acknowledged during interviews that the investigation should have been initiated immediately according to policy, but this did not occur.
Resident Ingests Cleaning Solution Due to Improper Chemical Storage
Penalty
Summary
A deficiency occurred when a housekeeper left a cleaning solution in an unlabeled, clear disposable cup on a resident's bedside table. The resident, who had diagnoses including end-stage renal disease, heart failure, and a recent non-ST elevation myocardial infarction, returned to his room after being outside and drank from the cup, believing it contained water. Upon tasting the liquid, the resident immediately recognized it was not water, attempted to induce vomiting, and called for assistance. The cleaning solution was a heavy-duty multi-surface cleaner, which, according to its safety data sheet, can cause serious eye damage, skin irritation, and gastrointestinal symptoms if ingested. The incident was confirmed through multiple sources, including the resident's own account, nursing notes, emergency department records, and interviews with facility staff. The housekeeper admitted to pouring the cleaning solution into a disposable cup due to the lack of an appropriate bottle and left it unattended on the bedside table. The facility's policies required chemicals to be stored in properly labeled containers and prohibited the use of unlabeled containers for hazardous substances. However, the housekeeper was not trained on this policy until after the incident, and the required labeling and storage procedures were not followed at the time of the event. As a result of ingesting the cleaning solution, the resident experienced mouth and throat irritation, tingling, and discomfort, and was transferred to a general acute care hospital for evaluation and treatment. The resident reported ongoing symptoms, including blisters and irritation when swallowing, and was referred for an ENT consult. The facility's failure to ensure chemicals were stored and labeled according to policy directly led to the resident's accidental ingestion and subsequent health complications.
Inaccurate MDS Coding for PASRR Information
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected Preadmission Screening and Resident Review (PASRR) information for three residents. The facility's policy required comprehensive assessments using the Resident Assessment Instrument (RAI) as specified by the Centers for Medicare and Medicaid Services (CMS). However, the assessments for Residents #2, #26, and #61 did not accurately reflect their Level II PASRR status, which indicated serious mental illness or intellectual/developmental disabilities. Resident #2 was admitted with a history of paranoid schizophrenia, unspecified dementia, and anxiety disorder. Despite a Level II PASRR determination indicating the need for specialized services, the admission MDS did not reflect this status. Similarly, Resident #26, with a history of schizoaffective disorder and major depressive disorder, had a significant change in status MDS that failed to acknowledge the Level II PASRR findings. Resident #61, diagnosed with schizophrenia and major depressive disorder, also had an admission MDS that inaccurately coded their PASRR status. Interviews with the Director of Nursing (DON) and MDS Nurse #2 revealed that the MDS assessments were not accurately coded due to a failure to review the Level II PASRR determination letters. The DON acknowledged the expectation for MDS assessments to reflect the residents' PASRR status accurately. MDS Nurse #2 admitted to not verifying the Level II determinations when positive Level I PASRRs were present, leading to incorrect coding. The facility administrator also emphasized the responsibility of MDS staff to ensure accurate coding of assessments.
Inaccurate PASRR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure the accuracy of a Level I Preadmission Screening and Resident Review (PASRR) for a resident with a diagnosis of schizoaffective disorder and major depressive disorder. The resident's PASRR Level I screening incorrectly indicated that the resident did not have a mental disorder, despite having active diagnoses of non-Alzheimer's dementia, depression, and schizophrenia, and being on antipsychotic medication. This discrepancy was identified during a review of the resident's admission records and care plan, which clearly documented the presence of these mental health conditions. The admitting nurse, RN #1, acknowledged the oversight during a telephone interview, admitting that she did not notice the error in the PASRR screening. The Director of Nursing (DON) and the Administrator both stated that it was the responsibility of the admitting nurse to ensure the accuracy of PASRR screenings and to notify them if any inaccuracies were found. However, in this case, the admitting nurse failed to correct the PASRR screening or inform the DON or Administrator of the error, leading to the deficiency.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving a resident with schizoaffective disorder, major depressive disorder, and hypertension. The incident was not reported to the local, state, and federal agencies as required by the facility's policy. During interviews, the Director of Nursing (DON) stated that investigations and reports are usually handled by the Administrator, but all licensed staff and department heads are responsible for reporting. The Administrator admitted that a report was filled out but could not be found, and there was no 5-day investigation summary available for the alleged incident. The facility's policy, dated September 2022, mandates that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property be reported to the appropriate agencies and thoroughly investigated. The policy also requires a follow-up investigation report within five business days of the incident. The failure to adhere to these procedures placed the resident's health, safety, and well-being at risk.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Upland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Upland Rehabilitation And Care Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Villa Mesa Care Center | 0.7 mi | ★★★★★ | 19 | 0 |
| Ontario Grove Healthcare & Wellness Centre, Lp | 1 mi | ★★★★★ | 1 | 0 |
| Las Colinas Post Acute | 1.2 mi | ★★★★★ | 24 | 0 |
| Community Extended Care Hospital Of Montclair | 2.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.