Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Park Health Center By Harborview during CMS and state inspections, most recent first.
An LPN failed to demonstrate CPR competency and did not follow code procedures for a full-code resident with dementia, DM, CKD, and HF. After being told the resident was not breathing, the LPN began CPR without calling a Code Blue, stopped CPR to get a CNA to witness and help clean up the resident, then resumed CPR. The CNA said they were not told to call 911 or initiate a Code Blue, other staff were unaware CPR was occurring, the crash cart was not accessed, and the PCP and DON stated the expected process was not followed. The LPN had no CPR training documented.
Failure to provide CPR and activate emergency response for a full code resident. An LPN found a resident unresponsive and without a pulse, but did not call a Code Blue, did not activate EMS, did not use the crash cart or emergency equipment, and stopped CPR after about 15 minutes before resuming it later. Interviews with the CNA, another LPN, the PCP, and the DON confirmed the resident was full code, no DNR was in place, and the facility’s CPR process was not followed.
Incomplete PASARR screening and missing level II reviews were found for multiple residents. Several residents had documented diagnoses such as dementia, bipolar disorder, schizoaffective disorder, depression, anxiety, and intellectual disabilities, but their level I PASARRs were incomplete or failed to mark qualifying MI or suspected MI diagnoses, and no level II PASARR was found for residents who had qualifying conditions. The MDS coordinator stated she reviews PASARRs on admission and had not submitted any level II PASARRs.
Expired meds were found in medication carts, including diphenhydramine with the expiration date worn off and an opened vial of insulin past expiration. In another cart, bleach wipes were stored in the same drawer as oral, topical, and rectal meds with no separation. The DON stated the expired meds should have been removed and the bleach wipes should not have been stored with the meds.
Several residents and a resident representative reported ongoing difficulties communicating with staff who did not speak English or had thick accents, leading to unmet preferences and frustration, particularly among those with cognitive or hearing impairments. Staff interviews confirmed the presence of language barriers, lack of training, and absence of a clear policy to address these issues, despite facility policy requiring communication in a language familiar to residents.
Persistent sewage odors and multiple non-functioning toilets were observed throughout the facility, with staff and visitors confirming ongoing issues. Staff frequently attempted to unclog toilets, often without success, and reported the problems to administration and maintenance, but the issues remained unresolved for months. Documentation showed some efforts to address plumbing, but no current records addressed the ongoing deficiencies.
Failure to Demonstrate CPR Competency and Follow Code Procedures
Penalty
Summary
The facility failed to ensure staff responsible for providing CPR demonstrated the competency, knowledge, and skills necessary to perform CPR in accordance with professional standards and facility policy for one resident. Resident #1 had diagnoses including dementia, diabetes, chronic kidney disease, and heart failure, had a BIMS score of 02 indicating severe cognitive impairment, and was documented as full code in the care plan and orders. Staff A, an LPN, stated that after being told the resident was not breathing, they entered the room, checked for a pulse, found none, and began CPR without calling a Code Blue. Staff A also stated they stopped CPR after about 15 minutes to get a CNA to act as a witness and assist with cleaning up the resident, then resumed CPR, and acknowledged they did not follow facility CPR policy because the family member made them nervous. Staff B, the CNA, stated they told Staff A the resident was not breathing but did not observe CPR being performed, were not instructed to call 911 or initiate a Code Blue, and had not received guidance regarding CPR, code status, or Code Blue procedures. Staff C, an LPN, stated they were not notified until later and no Code Blue announcement was made, with the crash cart remaining in the utility room and no equipment removed. The PCP stated Staff A stepped outside their training and did not follow the expected process for a full code resident, which included checking code status, initiating CPR, calling 911, and continuing compressions until EMS arrived. The DON stated Staff A did not call a Code Blue, no staff were aware CPR was being performed, and the crash cart had not been accessed. Staff A's education transcripts showed no CPR training completed, and the facility did not provide a competency policy.
Failure to Provide CPR and Activate Emergency Response for a Full Code Resident
Penalty
Summary
The facility failed to ensure staff administered CPR in accordance with professional standards of practice and the facility’s CPR policy for one resident who was documented as full code. The resident had diagnoses including dementia, diabetes, chronic kidney disease, and heart failure, and the MDS documented severe cognitive impairment with a BIMS score of 02. The care plan and orders confirmed full code status with no DNR order in place. According to staff interviews, when the resident was found unresponsive and not breathing, Staff A, an LPN, checked for a pulse and began CPR, but did not call a Code Blue, did not activate EMS, and did not use the crash cart or emergency equipment. Staff A stated they stopped CPR after about 15 minutes to get another CNA to witness and help clean up the resident, then later resumed CPR. Staff A acknowledged not following the facility’s CPR policy and stated they did not know why they did not call a Code Blue or why CPR was stopped. Staff B, the CNA, stated they were not instructed to call a Code Blue and did not know who called 911. Staff C, another LPN, stated no Code Blue was heard, the crash cart was not outside the room, and the Ambu bag had not been removed. The PCP stated that for a full code resident, the expected process was to check code status, initiate CPR, call 911, and continue compressions until EMS arrived. The DON and NHA stated Staff A did not follow the facility process, and the DON verified the crash cart had not been opened. The progress note written by Staff A stated CPR was provided for 15 minutes, then restarted, and time of death was called at 12:15 PM. The facility’s CPR policy required basic life support, including CPR, prior to EMS arrival in accordance with the resident’s advance directives or in the absence of a DNR order.
Incomplete PASARR Screening and Missing Level II Reviews
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for five of six residents sampled. Record review showed Resident #6 was admitted with diagnoses including unspecified dementia, mood disorder due to a known physiological condition with mixed features, schizoaffective disorder, unspecified intellectual disabilities, and depression, but the level I PASARR dated 6/12/2025 was incomplete and only schizoaffective disorder was checked; it did not show the resident had a primary diagnosis of dementia, and no level II PASARR was submitted after the qualifying diagnoses. Resident #74 was admitted with bipolar disorder, borderline personality disorder, generalized anxiety disorder, major depressive disorder, anxiety disorder, and primary insomnia, but the level I PASARR dated 6/16/2020 had no diagnoses marked under Section A for mental illness or suspected mental illness, and no level II was submitted. Resident #14 was admitted with anxiety disorder and unspecified bipolar disorder, and the level I PASARR dated 10/17/2025 only marked anxiety disorder under Section A with no other diagnoses checked. Resident #58 was admitted with dementia in other diseases classified elsewhere, major depressive disorder, recurrent, unspecified, and unspecified mood disorder, but the level I PASARR dated 1/21/2026 only marked depressive disorder under Section A, and no level II PASARR evaluation or determination was found in the record or provided by the facility. Resident #66 was admitted with mood disorder due to a known physiological condition with mixed features, anxiety disorder, insomnia, and depression, but the level I PASARR dated 1/27/2025 had Section I decision making for MI or suspected MI left blank. The MDS Coordinator stated she reviews PASARRs on admission, confirms diagnoses, and determines whether a level II is needed, but also stated she had not submitted any PASARRs for a level II and that there were currently no residents who needed a level II PASARR.
Expired Medications and Improper Medication Cart Storage
Penalty
Summary
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 medication carts observed. On 4/6/2026, observation of the North 100 medication cart revealed a bottle of diphenhydramine with the expiration date worn off so the expiration date could not be identified, and an opened vial of insulin that had expired on 4/3/2026. On 4/7/2026, observation of the North 200 medication cart revealed a container of bleach wipes stored in the same drawer with oral, topical, and rectal medications, with no divider or separation in the bottom drawer where both medications and cleaning chemicals were stored. During interview, the DON stated the expired medications should have been removed from the medication cart, that medication with a worn-off expiration date should have been discarded, and that the bleach wipes should not have been stored with the medications.
Failure to Ensure Effective Communication and Dignity Due to Staff Language Barriers
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not providing staff who could effectively communicate in a language understood by the residents. Multiple residents and a resident representative reported difficulties in communication due to staff members, particularly CNAs, not speaking English or having thick accents that made understanding difficult. This language barrier resulted in residents' preferences not being followed and caused frustration among residents, especially those with cognitive or hearing impairments. The issue was noted to be more prevalent during night shifts, and several complaints and grievances had been filed regarding the inability to communicate effectively with staff. Interviews with facility staff, including the LPN, Social Services Director, and DON, confirmed awareness of the language barrier issue. The DON acknowledged that while a language line and bilingual staff were available, there was no documented training or policy addressing language barriers, and some staff members had difficulty understanding English. The facility's own policy required communication of resident rights in a language familiar to the resident, but this was not consistently implemented. The deficiency was identified through interviews, record reviews, and policy examination, highlighting a failure to honor residents' rights to communication, dignity, and self-determination.
Failure to Maintain Sanitary and Functional Resident Bathrooms and Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by persistent raw sewage odors and multiple non-functioning toilets throughout all six unit zones. Upon entrance and during a facility tour, surveyors observed a strong sewage odor in the lobby, corridors, and near resident rooms, particularly in the 200 and 300 halls. Numerous resident bathrooms were found with toilets that were either continuously running, clogged with fecal matter and brown paper towels, or unable to flush after repeated attempts. Staff were observed attempting to unclog toilets with plungers, often unsuccessfully, and confirmed that such issues were ongoing and frequent. Interviews with various staff members, including the receptionist, housekeeping director, LPNs, CNAs, dietary manager, social services, and business office manager, all confirmed the presence of the sewage odor and the recurring problem of clogged toilets. Staff reported that these issues had persisted for months, with complaints from both residents and visitors. Despite staff regularly reporting these problems to the administration and maintenance department, the issues remained unresolved. The maintenance director acknowledged that clogged toilets were a high priority and that work orders were typically submitted, but on the day of the survey, there were no current work orders for the observed toilet clogs. Documentation provided by the facility showed some attempts to address plumbing issues, such as contacting outside commercial plumbing services and ordering toilet wax rings, but there was no current documentation specifically addressing the ongoing sewage odor or the multiple non-functioning toilets. Facility policies on routine cleaning, disinfection, and preventative maintenance did not specifically address persistent sewage odors or frequent toilet clogs, though administration confirmed these issues would fall under existing policies. Photographic evidence was obtained to support the findings.
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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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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Surrey Place Healthcare And Rehabilitation | 0.3 mi | ★★★★★ | 0 | 0 |
| Casa Mora Rehabilitation And Extended Care | 0.3 mi | ★★★★★ | 2 | 0 |
| Inn At Freedom Village, The | 0.4 mi | ★★★★★ | 2 | 0 |
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| Westminster Point Pleasant | 3 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.