Average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Living Center during CMS and state inspections, most recent first.
A resident with CHF, COPD, diabetes, and an indwelling Foley catheter developed confusion, hallucinations, multiple large loose tarry stools, and refusal of intake and ER transfer. Staff notified the on-call provider, but the record lacked evidence of ongoing RN/LPN assessment or documented vital sign monitoring during the evening and night shifts after the acute change, and the resident was later transferred to the hospital with severe hypotension.
A resident with severe cognitive impairment, dementia, and ongoing mouth pain repeatedly hollered loudly for long periods in common areas and during meals, despite multiple interventions such as pain meds, ice, an oral soothing device, essential oils, repositioning, and staff reassurance. Staff described the behavior as the resident’s norm and did not consistently assess the underlying cause or incorporate the observed effective interventions into an individualized approach. Another resident with PTSD and loud-noise triggers was repeatedly distressed by the noise, yelled shut up from behind a closed door, and complained that the hollering was nonstop, day and night, but staff did not consistently intervene or redirect either resident.
Significant morphine dose error: An RN administered 0.25 mL (5 mg) of morphine sulfate buccally instead of the ordered 0.1 mL (2 mg) dose to a resident with severe cognitive impairment, Alzheimer’s disease, CAD, and dementia. The RN said she followed the medication box label, while the unit manager confirmed the correct dose was on the EMAR. The resident was assessed afterward and remained unchanged.
A resident with severe cognitive impairment and diagnoses including Alzheimer's disease, CAD, and dementia received morphine based on an outdated label that still directed 5 mg (0.25 mL) every four hours, even though the current scheduled order was 2 mg (0.1 mL) every four hours. An RN administered 0.25 mL, then documented 0.1 mL in the narcotic record book, and the unit manager confirmed the dose had recently changed but no sticker or other notice had been placed on the medication to alert staff.
Infection Surveillance System and EBP Noncompliance: The facility did not maintain a facility-wide infection surveillance system that tracked, analyzed, and trended signs and symptoms of possible infections or communicable diseases that did not result in antimicrobial treatment. The DON stated she reviewed antibiotics and gathered infection information for QAPI, but the facility could not provide IDT documentation showing review or trending, and the surveillance line lists only reflected treated infections and viral illnesses were not tracked. The facility also failed to ensure EBP was followed for a resident with an indwelling Foley catheter, wounds, and dependence with ADLs, as RN and hospice aide wore gloves but did not wear gowns while providing bathing, dressing, and wound care despite posted signage requiring gown and glove use.
A resident with dementia, osteoporosis, lower extremity impairments, urinary incontinence, and a history of falls and fractures had care-planned fall interventions including a low bed with a fall mat, use of a mechanical stand for transfers, and gripper socks over compression stockings. In the weeks before the incident, staff noted the resident becoming more impulsive and attempting to get out of bed independently. On the day of the fall, a NA left the resident in bed with the bed in a raised position, no fall mat in place, and only stockings on the feet, contrary to the care plan. The resident attempted to self-transfer, fell between the bed and a recliner, and was found on the floor with a head laceration and a twisted right leg, later diagnosed with a scalp laceration, right tibial plateau and femur fractures, and a bimalleolar ankle fracture.
A resident with significant mental impairment and depression was administered Depakote as a mood stabilizer without documented informed consent. Staff did not obtain consent prior to the first dose because they considered the medication an anti-seizure drug, not recognizing its use as a psychotropic medication required consent. Facility policy required informed consent for psychotropic medications, but this was not followed.
The facility failed to ensure proper labeling and disposal of refrigerated food items, with multiple instances of unlabeled and expired food found across different units. Staff interviews revealed no official process for labeling or checking fridges, and the dietary manager and executive director confirmed the lack of a process to ensure regular checks. The facility's policy required unlabeled or undated food to be discarded but lacked a specific time limit for disposal.
Failure to Monitor Resident After Acute Change in Condition
Penalty
Summary
The facility failed to ensure a resident received ongoing nursing assessment and monitoring after an acute change in condition. The resident had intact cognition, was dependent for most ADLs, had an indwelling Foley catheter, was incontinent of bowel, and carried diagnoses including right above-the-knee amputation, heart failure, COPD, diabetes, anxiety, and a history of TIA and stroke. The care plan directed staff to monitor respiratory status, bowel elimination, and diabetes-related symptoms, and to obtain vital signs weekly and as needed. On 6/28/26, the resident developed a significant change in condition. He was confused, hallucinating, and repeatedly refused vital signs, blood work, oral intake, and transfer to the emergency room. Staff notified the on-call physician, who ordered laboratory testing, but the resident initially refused and later the blood samples hemolyzed. Staff documented that the resident had seven large, loose, tarry stools and continued to refuse hospital evaluation and oral intake during the evening shift. The resident was transferred to the hospital the next morning with increased stools and hypotension; his blood pressure was 55/36, pulse 53 beats per minute, and temperature 99.2 degrees Fahrenheit. The medical record lacked evidence that a licensed nurse assessed the resident or that staff monitored his vital signs and clinical condition during the evening and night shifts after the acute change. Blood pressure documentation was absent for the day of the change and before transfer. Interviews with staff showed conflicting recollections about whether vital signs were obtained, but several staff acknowledged they were not documented, and the DON stated staff were expected to document the care and monitoring provided.
Failure to Individualize and Evaluate Dementia-Related Distress
Penalty
Summary
The facility failed to consistently implement and evaluate individualized interventions for a resident with severe cognitive impairment, Alzheimer’s disease, dementia, delusional disorder, and depression who had persistent yelling and other expressions of distress. The resident’s care plan identified behaviors of yelling out, grabbing at staff, and swearing, with interventions to approach calmly, divert attention, remove the resident to another location as needed, monitor behavior episodes, and leave the resident in a safe space and return later for care when verbal or physical behaviors occurred. The resident also had documented pain concerns, including facial expressions indicating possible pain and scheduled pain medications with non-medication interventions. During observation, the resident was repeatedly heard hollering loudly for prolonged periods in common areas and the dining room, including while seated in front of the TV and during meals. Staff acknowledged the resident was having mouth pain and that they were trying to figure out what to do, and the resident had already received pain medication. The resident continued hollering despite being given an oral soothing device, ice, an ice pack, essential oils, a nutritional shake, and repositioning. Staff repeatedly described the hollering as the resident’s norm and stated the resident hollered every day, all day, but the resident remained in shared spaces where the noise continued for extended periods. A second resident with a history of PTSD and loud-noise triggers was affected by the ongoing hollering. That resident’s trauma-informed care plan identified loud noises as a trigger and noted a preference for a private room and use of a TV or white noise machine to block neighboring sounds. During the observations, the second resident was heard yelling shut up from behind a closed door while the first resident continued hollering nearby, and the second resident stated the noise was nonstop, day and night, and asked why the first resident could not be moved somewhere else. Staff did not consistently approach either resident or redirect the situation, and the facility did not complete an assessment of the first resident’s persistent hollering to determine the underlying cause or contributing factors, including whether it was related to pain, dementia-related distress, fear of being alone, environmental factors, or a combination of factors.
Significant morphine dose error
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an RN administered 5 mg of morphine sulfate instead of the prescribed 2 mg dose. The resident had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia. The physician orders directed morphine sulfate concentrate oral solution 100 mg/5 mL to be given as 2 mg (0.1 mL) buccally every four hours for pain, with a separate PRN order for 5 mg (0.25 mL) buccally every hour as needed for breakthrough pain or shortness of breath. The EMAR showed the resident received the scheduled 2 mg dose at 4:00 p.m. and did not show a PRN 5 mg dose. During observation, RN-B withdrew 0.25 mL of morphine sulfate using the syringe provided with the medication and administered it buccally to the resident, then documented on the narcotic record book that 0.1 mL had been given. RN-B stated she gave 0.25 mL because the medication box label identified 0.25 mL, while RN-A stated the correct dose was 0.1 mL and acknowledged the error after RN-B confirmed the amount administered. The resident was assessed after the error and remained unchanged, with vital signs and condition stable. The DON stated the medication label had been followed instead of the EMAR, and the consultant pharmacist stated the resident could have experienced increased drowsiness from the error.
Medication Label Did Not Match Current Morphine Order
Penalty
Summary
The facility failed to ensure a medication label accurately reflected the current physician-ordered dose for one resident who was reviewed for medication labeling. The resident had severe cognitive impairment and diagnoses including Alzheimer's disease, coronary artery disease, and dementia. The resident's physician orders included morphine sulfate concentrate oral solution 100 mg/5 mL for 2 mg (0.1 mL) buccally every four hours for pain, as well as a separate PRN order for 5 mg (0.25 mL) buccally every hour for breakthrough moderate to severe pain or shortness of breath. During an observation, an RN withdrew 0.25 mL of morphine sulfate and administered it buccally to the resident, then documented 0.1 mL in the narcotic record book. The RN stated she gave 0.25 mL because the medication label identified that dose. The unit manager confirmed the resident's order had recently changed and that 0.1 mL was the correct scheduled dose, but the medication label still directed staff to give 5 mg (0.25 mL) every four hours for pain, and no sticker or other notification was attached to show the change. The DON, administrator, and consultant pharmacist stated staff were expected to follow facility policy, and the facility's medication pass policy required staff to read labels three times and follow the six rights of medication administration, but it did not identify a process for updating labels when orders changed.
Infection Surveillance System and EBP Noncompliance
Penalty
Summary
The facility failed to maintain a facility-wide infection prevention and control surveillance system that identified, collected, analyzed, and trended signs and symptoms of possible infections and communicable diseases, including those that did not result in antimicrobial treatment. The infection surveillance line lists for May, June, and July 2026 documented infections such as lower respiratory infections, cellulitis, oral infection, diarrhea with incontinence, pyelonephritis, yeast infections, wound infection, fungal infection, urinary tract infections, anaplasmosis, and shingles, but the lists did not identify signs or symptoms of possible infections or communicable diseases that did not result in antimicrobial treatment or viral illnesses. The August 2026 surveillance line list was requested but not received. During interview, the DON stated she had served as the facility’s infection preventionist since January 2026 and reviewed antibiotics weekly, then gathered infection information monthly for QAPI. She stated nursing staff were responsible for beginning antibiotic monitoring when antibiotics were initiated, and that nursing progress notes for signs and symptoms of infection were reviewed during IDT meetings. However, the facility was unable to provide IDT meeting documentation showing review, analysis, or trending of infection surveillance information. The DON stated she did not track signs or symptoms of possible infections when they did not result in treatment, such as common cold symptoms, and acknowledged that tracking those signs and symptoms in the moment would allow staff to identify possible infections and take measures to prevent spread. The facility’s Infection Surveillance Overview policy stated surveillance was to identify possible communicable diseases or infections before they could spread, and that the system was to include a systematic method for collecting, analyzing, and interpreting data, with dissemination of information to identify infections, infection risks, and outbreaks. The policy also stated surveillance results were to be used to plan infection control activities, determine corrective action, direct in-service education, and identify resident problems requiring intervention. The administrator stated that tracking and trending infection information in the moment allowed staff to identify infections and prevent spread.
Failure to Implement Care-Planned Fall Interventions Leads to Serious Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure that fall prevention strategies were assessed and implemented for a resident at high risk for falls, resulting in a fall with multiple serious injuries. The resident had dementia, vertebral and sacral fractures, age-related osteoporosis, lower extremity impairments bilaterally, frequent urinary incontinence, and a history of falls and fractures. The resident’s MDS and fall risk assessment identified moderate cognitive impairment, unsteadiness, inability to independently stand, and the need for hands-on assistance and a mechanical stand for transfers. The care plan documented specific fall interventions, including keeping the call light within reach, maintaining the bed in the lowest position with a fall mat in place when the resident was in bed, and ensuring gripper socks were worn at all times. In the weeks preceding the fall, staff observed changes in the resident’s behavior and mobility. Progress notes indicated that the resident had previously fallen while attempting to ambulate independently wearing compression stockings, with the root cause identified as slipping on the floor and an intervention added to place gripper socks over compression stockings. Staff interviews revealed that, although the resident was typically content lying in bed, in the weeks before the incident she had begun making attempts to get out of bed and had been found seated on the side of the bed on several occasions. These observations indicated increased impulsivity and attempts at self-transfer in the context of dementia and impaired safety awareness. On the day of the incident, the resident was placed in bed by a nursing assistant who did not lower the bed or place the fall mat, and the resident was left in stocking feet without gripper socks, contrary to the care-planned interventions. The resident subsequently attempted to get out of bed, fell between the bed and recliner, and was found on her side with her right leg twisted underneath her, her left arm pinned, and a large pool of blood around her head. The bed was observed in a raised position with no fall mat in place. The resident sustained a scalp laceration, right tibial plateau fracture, right femur fracture, and a bimalleolar fracture of the right ankle, and experienced severe pain and swelling in the right leg, requiring evaluation and imaging in the emergency department and hospitalization for management of multiple fractures and acute head injury.
Failure to Obtain Consent Prior to Administering Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering a mood stabilizer, specifically Depakote, to a resident with significant mental impairment and diagnoses including depression and coronary artery disease. The resident's medical record did not contain documentation of consent before the first dose of Depakote was given, despite the medication being ordered for major depressive disorder, recurrent, severe with psychotic symptoms. The facility's policy required that an informed consent discussion and completion of a consent form occur with the resident and/or their representative when starting a psychotropic medication or changing its dose. Interviews with facility staff revealed that the process for obtaining consent was not followed in this instance because staff considered Depakote primarily as an anti-seizure medication, not recognizing its use as a mood stabilizer required consent as a psychotropic medication. Both the LPN and the ADON confirmed that education and consent should be obtained prior to administration, but this step was missed. The consultant pharmacist verified that Depakote, when used as a mood stabilizer, is classified as a psychotropic medication and requires consent before administration.
Deficiency in Food Labeling and Disposal Practices
Penalty
Summary
The facility failed to ensure that refrigerated food items were properly labeled and dated, and did not dispose of expired food items, which could potentially harm residents or visitors using the facility refrigerators. During observations, multiple instances of unlabeled and expired food items were found across different units. These included cold packs without labels, a plastic grocery bag with frozen vegetables, an open box of frozen fruit bars, a vegan pizza past its expiration date, and various containers of leftovers without dates. Interviews with staff revealed that there was no official process for labeling food, and no designated task for checking the refrigerators for expired items. The dietary manager and executive director confirmed the presence of these items and acknowledged the lack of a process to ensure regular checks of the unit fridges. They stated the importance of cleaning out the fridges to prevent harm to residents and families. The facility's policy on food brought in by visitors required that any food not labeled or dated be discarded, but it did not specify a time limit for disposal. This lack of clear procedures and oversight led to the deficiency in maintaining food safety standards.
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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 Park Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Pine Acres Nursing Home | 11.2 mi | ★★★★★ | 6 | 0 |
| Frazee Care Center | 32.8 mi | ★★★★★ | 6 | 0 |
| Perham Living | 32.9 mi | ★★★★★ | 7 | 0 |
| Fair Oaks Lodge | 33.2 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Pine River | 34.2 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.