Below 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 Rehab & Skilled Nursing during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, HTN, and epilepsy sustained a second-degree burn to the hand after hot soup splashed while removing it from a microwave. The resident had a prior microwave-related burn, but the care plan did not address the history or include microwave-related interventions. Staff reported the resident used the microwave routinely, the DON and Acting Administrator called it an avoidable accident, and the Medical Director noted the microwave’s placement allowed resident access without appropriate supervision.
The facility did not maintain its stated minimum RN and CNA staffing levels across multiple shifts, especially evenings and nights. Observations showed residents waiting extended periods for call light response, toileting, repositioning, and incontinent care, while staff and residents reported that low staffing led to delayed meals, missed showers, and residents remaining in wheelchairs or in bed until the next shift. The DON and Acting Administrator acknowledged that staffing below minimums was not ideal and that timely care could not be provided when shifts were short.
Care plans for four residents were not accurately updated to reflect advance directives and code status. Each resident’s care plan listed both DNR and Full Code, while the MOLST documented DNR and Do Not Intubate orders. The RN unit managers, LPN, and DON stated care plans were the unit managers’ responsibility and should match the MOLST and residents’ current wishes.
Food storage and sanitation deficiencies were observed in the kitchen and resident area refrigerators/freezers. Surveyors found sticky spills, dirty ceilings and floors, water-damaged tiles, a broken sink faucet, flies in food prep areas, and an unplugged insect light trap. Multiple refrigerators and freezers contained unlabeled or undated foods, expired dairy items, frozen spills, and hair inside the units, while staff acknowledged some items were not properly labeled and that freezer storage and cleaning issues were ongoing.
QAPI Committee failed to ensure repeated deficiencies were fully addressed and tracked through completion. Surveyors found prior citations in restraints, care planning, food storage, emergency lighting, and fire alarm maintenance remained unresolved, and the facility’s QAPI meeting documentation did not show review of all cited issues, including I210. Interviews with the DON and leadership showed required staff education for F677 and I210 was still incomplete after the deadline, with missing or inaccurate sign-off documentation and uncertainty about who completed some in-services.
Failure to assess and release wheelchair positioning devices used as restraints: A resident with severe cognitive impairment, seizures, and legal blindness was observed in a tilt wheelchair with a seat belt and padded lap tray in place for hours, including during meals, with no documented two-hour releases or restraint reassessments. Staff said they did not know why the devices were used, had not been instructed to release them, and therapy and nursing could not locate restraint evaluations; the MD stated the devices could be considered a restraint if used all the time.
Untimely Incontinent Care for Two Dependent Residents. Two residents with severe cognitive impairment and total or near-total dependence for ADLs were left in the dining room for hours without toileting or check-and-change care, despite care plans calling for incontinent care every 2 to 4 hours and as needed. Staff reported they could not complete the care because of staffing, and when the residents were later placed back in bed, one brief was wet with urine and feces and the other had a strong urine odor and was visibly wet.
The facility did not maintain adequate LPN and CNA staffing levels, resulting in residents with significant care needs being left without timely assistance for eating, toileting, and hygiene. Observations and interviews confirmed that residents often waited long periods for help, missed showers, and were left in soiled briefs, with staff and family members reporting persistent understaffing across all shifts.
Failure to Supervise Microwave Use Resulted in Resident Burn
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent accidents for one resident. On 03/11/2026, Resident #21 sustained an 8.5 cm by 5 cm second-degree burn to the left upper hand after hot soup splashed onto the hand while the resident was removing it from the microwave oven. The resident had diagnoses including Parkinson’s disease, hypertension, and epilepsy, and the MDS dated 02/11/2026 documented the resident was cognitively intact and independent with activities of daily living. The facility did not have a policy or protocol for safe microwave oven operation, and the microwave was located on a counter in the First Floor Dining Room during observations. The resident’s care plan did not document the history of burning self after using the microwave or include interventions related to microwave use. The record showed a prior incident on 12/02/2025 in which the resident had a blister on the left ring finger after heating boil-in-the-bag rice in the microwave, and the resident had been educated to ask staff for assistance with kitchen tasks. During interviews, the resident stated staff had educated them to request help with microwave use, but there was no staff available to assist, so they usually used the microwave by themselves. Staff interviews confirmed the resident used the microwave regularly, and the DON and Acting Administrator stated the burn was an avoidable accident that caused harm. The Medical Director stated the resident had two burns within three months and that the microwave’s placement in the dining room was not appropriate because any resident had access to it.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff on the first, second, and third floor resident care units to meet resident needs and to maintain the facility’s stated minimum staffing levels. The report states that the facility was licensed for 146 beds, had an average daily census of 134, and used staffing expectations based on census and resident needs. The Acting Administrator and DON described minimum staffing expectations for each shift, including one nurse per unit on day and evening shifts and one nurse per unit on the night shift, with CNA staffing also expected to meet unit needs. Review of staffing sheets from 03/25/2026 through 04/25/2026 showed multiple shifts where CNA staffing fell below the facility’s stated minimums, including evening and night shifts, with census during those dates between 113 and 116 residents. The report also documents direct observations of delayed resident care during periods of low staffing. On the third floor, one resident was observed with a call light on and stated they needed their brief changed; the call light had been on for 18 minutes. Another resident’s call light had been on for 34 minutes, and that resident stated they needed to be repositioned and their legs placed back in bed. The call light monitor showed prolonged ringing times before staff responded. During another observation, two residents in the dining room were not offered, encouraged, or provided toileting or incontinent care during the observation period and were later noted to be incontinent during follow-up care observations. Interviews with residents, family, CNAs, LPNs, the RN supervisor, the DON, and the Acting Administrator consistently described staffing shortages, especially on evening and night shifts. Residents reported long waits for call bell response, staff turning off call lights without returning, and meal assistance delays. Staff stated that with only one or two CNAs on a floor, they could not complete toileting, incontinent care, showers, bed-making, or timely transfers, and some residents remained in wheelchairs or in bed until the next shift. The DON and Acting Administrator acknowledged that staffing below the stated minimums was not ideal and that it was not feasible to provide proper and timely care when staffing fell short.
Care plans did not match residents’ DNR status
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including the comprehensive and quarterly review assessments, for four residents. The deficiency involved care plans that did not accurately reflect the residents’ current advance directives and code status. Facility policy stated the comprehensive care plan was to be developed within 7 days of the comprehensive assessment and reviewed at least quarterly by an interdisciplinary team, and the DNR policy described that a DNR order directs staff not to attempt resuscitation if breathing or heartbeat has stopped. Resident #35 had COPD, chronic respiratory failure, and diabetes mellitus, and the MDS documented moderate cognitive impairment. The care plan listed both DNR and Full Code under advance directives, even though the resident’s MOLST, last reviewed and signed by the provider, documented DNR status. During interview, the RN unit manager stated they were responsible for updating care plans, that the resident’s advance directives were documented on the MOLST and care plan, and that if code status changed the care plan needed to be updated. The RN unit manager reviewed the care plan and stated the Full Code status needed to be removed. Resident #20 had dementia and type II diabetes, and the MDS documented severe cognitive impairment. Resident #40 had dementia, type II diabetes, and adult failure to thrive, and the MDS documented severe cognitive impairment. Resident #55 had dementia, a history of breast cancer, and difficulty walking, and the MDS documented severe cognitive impairment. Each of these residents’ comprehensive care plans also listed both DNR and Full Code, while their MOLST forms documented DNR and Do Not Intubate orders. The RN unit manager, LPN, and DON stated that unit managers were responsible for updating care plans and that the care plans should accurately reflect the residents’ care needs and preferences, including advance directives, and match the MOLST orders.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the main kitchen and in the second and third floor resident areas. Surveyors observed multiple sanitation problems in the kitchen, including sticky food spills and residue on the floor, a ceiling tile grid with visible black dust, dirty ceiling tiles, water-damaged floor tiles near the ice machine, a broken faucet at the 3-bay sink, flies in the dishwashing and food preparation areas, and a damaged ceiling light cover held together with duct tape. The kitchen, unit dining room, and activity room coolers, refrigerators, and freezers were also observed to be dirty and to contain multiple food items that were undated, unlabeled, or improperly stored. In the third floor dining room refrigerator, surveyors found an unopened thickened dairy drink past the manufacturer's best-by date, an opened bag of shredded cheese without an opening date, and sticky beverage spills with hair in the refrigerator and freezer. In the second floor dining room refrigerator, a sandwich wrapped in plastic had no date, the freezer contained frozen spills and food crumbs, and later observations found lidded containers of mashed potatoes and cooked vegetables without names or dates, along with a yogurt cup whose manufacturer stamp had already passed. In the second floor activity room refrigerator, surveyors found yogurt cups with manufacturer dates that had passed, another yogurt cup marked sell-by, an undated pitcher of thickened beverage, a leftover container of ice cream and toppings without a name or date, and multiple hairs inside the refrigerator. In the main kitchen, surveyors observed unlabeled and undated food items in stainless steel containers in the walk-in cooler, 22 unlabeled and undated gelatin cups, an uncovered and unlabeled cheese block, and a freezer with a thick layer of frost and multiple unlabeled, undated items. The walk-in freezer was not operating and was being used to store dry goods, while another upright freezer was empty, propped open, and defrosting. The dishwash area also had an uncovered 5-gallon bucket of soy sauce with live flies around it, additional flies in the area, sticky residue on nearby shelving, black discoloration around ceiling vents and tiles, and an insect light trap that was present but not plugged in. Staff interviews confirmed that food items should be labeled and dated, that some items in resident area refrigerators were not labeled as required, and that the facility had ongoing issues with freezer storage, cleaning, and pest control.
QAPI Committee Failed to Track and Complete Corrective Actions
Penalty
Summary
The facility failed to ensure its QAPI Committee developed and implemented effective plans of action to correct repeated quality deficiencies and to regularly review, analyze, and act on available data. During the onsite post survey revisit, surveyors found repeated deficiencies from the prior standard survey in the areas of physical restraints, care plan timing and revision, food procurement and sanitation, emergency lighting, and fire alarm system testing and maintenance. The facility also did not maintain effective systems to remain in compliance with its own QAPI policy, which required ongoing evaluation of services, review of quality measures, plan of correction updates, and reportable events. Record review showed the QAPI meeting on 06/12/2026 documented review of the Statement of Deficiencies, plan of correction, audits, and scheduled education, with education noted for F604, F657, F677, and F689, and review of F812. There was no documentation that I210 was reviewed during that meeting. The survey findings showed the facility had been cited for F604, F657, F812, K291, and K345 on the prior standard survey, and the corresponding plans of correction were due by 06/22/2026 but were not completed. The report also showed the facility did not follow its plan of correction from the prior standard survey for staff education related to F677 and I210. The approved plan required education for nursing staff and CNAs on individualized care plans, timely incontinent care, feeding assistance, hygiene support, documentation, dignity, escalation processes, and for environmental and maintenance leadership on infection prevention and control requirements, vendor oversight, scheduling accountability, and documentation processes. Interviews with the DON, Administrator, and President of Skilled Nursing Operations indicated the education was still being completed after the deadline, some sign-off sheets included per diem or terminated staff, and the facility could not locate documentation for some completed education, including Legionella-related in-service.
Failure to assess and release wheelchair positioning devices used as restraints
Penalty
Summary
The facility failed to ensure that Resident #104 was free from physical restraints that were not clearly evaluated as restraints, were not documented as needing ongoing re-evaluation, and were not released for the required time period. Resident #104 had diagnoses including seizures, intellectual disabilities, and legal blindness, and the MDS documented severe cognitive impairment with dependence for all ADLs. The care plan and ADL care guide described use of a custom tilt wheelchair with a seat belt and padded lap tray to support alignment of the pelvis, trunk, and head, but there was no documented determination that these devices were restraints or documentation of ongoing restraint reassessment. The physician’s orders included use of the wheelchair with chest support, seat belt, and lap tray, but there was no order directing release of the devices. Review of the MARs/TARs and interdisciplinary notes found no documented evidence that the seat belt and lap tray were released every two hours. During a continuous observation, the resident remained in the wheelchair with the padded lap tray and seat belt in place from the morning through early afternoon, including during meals and after being wheeled to the scale and back, with no release observed. Earlier observations also showed the resident in the wheelchair with the lap tray in place, including resting their head on it. Staff interviews showed they did not know why the devices were being used or that they needed to be released every two hours. The CNA stated the resident came to the facility with the devices. The LPN stated the resident had used both devices since admission and that staff were not releasing them every two hours or instructed to do so. Therapy staff stated they had never completed a restraint assessment and had nothing in place to ensure the devices were removed every two hours. The Medical Director stated that if the devices were used all the time, they would be considered a restraint and that a restraint assessment should have been completed. The DON stated no restraint evaluations could be located in the electronic medical record.
Untimely Incontinent Care for Two Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents who were dependent for activities of daily living received timely incontinent care. Both residents had care plans directing staff to provide check-and-change care and toileting/incontinent care every two to four hours and as needed. The report states that the facility policy required incontinent residents to be kept clean and dry, and that nursing staff were to assist residents with activities they were unable to perform. One resident had diagnoses including dementia, hypertension, and chronic kidney disease, with severe cognitive impairment and dependence for toileting transfers and toileting hygiene. On the day of observation, the resident was up in a geri chair in the dining room from the morning through early afternoon, ate breakfast and lunch there, and was not removed from the dining room or provided additional care, including toileting or incontinence checks, during that period. A CNA stated the resident had been washed, dressed, and out of bed early in the morning but had not received incontinent care afterward because the aide was busy with other residents and staffing was limited. When the resident was later placed back in bed, the brief was visibly wet with urine and soiled with feces. The second resident had diagnoses including seizures, intellectual disabilities, and legal blindness, with severe cognitive impairment and dependence for all ADLs. On observation, the resident remained in the dining room in a tilt-in-space wheelchair from the morning until early afternoon, received breakfast and lunch there, and was not provided additional care during that time, including toileting or incontinence checks. A CNA stated the resident had been washed, dressed, and placed in the wheelchair early in the morning but had not received further incontinent care because of staffing. When the resident was later placed in bed and incontinent care was provided, a strong odor of urine was noted and the brief was visibly wet. Staff interviews confirmed that both residents should have been checked and changed sooner, and the DON stated that five to seven hours without incontinent care was untimely and not appropriate.
Failure to Maintain Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as required by state regulations and the facility's own assessment. Staffing reports for multiple days showed that both Licensed Practical Nurse (LPN) and Certified Nurse Aide (CNA) hours per resident per day were consistently below the mandated minimums. The facility assessment indicated the required staffing levels, but actual staffing fell short, with some shifts having only one aide responsible for up to 38 residents. The Director of Nursing and Administrator both acknowledged that the facility had not met minimum staffing levels for an extended period, and that the use of ancillary and agency staff was not sufficient to fill the gaps. Observations and interviews revealed that residents who required assistance with activities of daily living, such as eating and toileting, were not receiving timely or adequate care. Several residents with severe cognitive impairment and physical limitations were observed eating meals in their rooms without staff supervision or assistance, despite care plans indicating they required help. Residents were also observed in soiled incontinence briefs, struggling to access their meals, or unable to get out of bed for activities due to lack of staff. Staff interviews confirmed that showers were often missed, and that aides were unable to provide care to each resident more than once per shift. Multiple residents and family members reported long wait times for call lights to be answered, sometimes exceeding an hour, resulting in incontinence episodes and residents remaining in wet beds overnight. Some residents stated they no longer used their call lights because they did not expect a timely response. Staff consistently reported that the number of aides on duty was insufficient to meet residents' needs, particularly on weekends and night shifts. The deficiency was further corroborated by complaints submitted to regulatory agencies, which described residents left in soiled briefs for extended periods due to inadequate staffing.
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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 Jamestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Green Rehab & Skilled Nursing | 4.3 mi | ★★★★★ | 16 | 0 |
| Heritage Village Rehab And Skilled Nursing Inc. | 11 mi | ★★★★★ | 0 | 0 |
| Rouse Warren County Home | 17.3 mi | ★★★★★ | 2 | 0 |
| Kinzua Nursing And Rehab | 17.6 mi | ★★★★★ | 7 | 1 |
| Warren Manor | 18.2 mi | ★★★★★ | 5 | 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.