Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Living Center during CMS and state inspections, most recent first.
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 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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Heritage Living Center.
100% money-back within 48 hours.
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.