Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 Park during CMS and state inspections, most recent first.
Failure to maintain a licensed administrator. The facility's governing body did not appoint a properly licensed administrator to manage the facility, and no licensed administrator had been in place since the previous administrator became the administrator of record at another facility. The CFO stated he was not a licensed administrator and did not go into the building, and the DON stated she expected the facility to have a licensed NHA.
Failure to ensure staff were fit-tested for N-95 respirators. The RNC stated the facility had no policy for N-95 fit testing and no recent testing had been completed, with no documented evidence of testing. A CNA, a CMA, and the DON all reported they had not been fit-tested, and the Previous Administrator stated they had not been tested and was unsure of the requirements.
Failure to Protect Residents from Abuse by Another Resident: A resident with documented poor impulse control and a history of slapping others physically and verbally abused multiple residents, including pulling one resident from a chair, slapping another resident in the face, snatching a bingo card and using a vulgar slur toward a resident during an activity, and hitting another resident on the shoulder. Several of the affected residents had severe cognitive impairment, and the DON stated the facility did not conduct thorough investigations for the incidents.
Failure to Timely Report Abuse Allegations: The facility did not ensure abuse allegations were reported to the state survey agency within the required 2-hour timeframe. Incidents involved a resident with a history of aggression and poor impulse control who pulled another resident by the arm, slapped one resident, snatched a bingo card and used a vulgar slur toward another resident, and hit a fourth resident on the shoulder. Staff reported some incidents to the ADM or DON, but one was not reported at all before survey, one was reported the next day, and another was not submitted until days later.
Failure to Thoroughly Investigate Alleged Resident Abuse: The facility did not thoroughly investigate multiple allegations of verbal and physical abuse involving one resident and several other residents. Witnesses, including an LPN, Activity Director, and another resident, described incidents such as slapping, pulling a resident by the arm, snatching a bingo card, and hitting a shoulder, but the investigative files lacked witness statements and other documentation showing a complete review. The involved residents had varying cognitive status, including severe cognitive impairment in several victims and intact cognition in others, and the DON and previous ADM acknowledged the investigations were incomplete.
Incomplete ADL Documentation in Resident Records: Surveyors found missing EHR charting for bathing and incontinence care for multiple residents. Residents with diagnoses including diabetes, MS, schizoaffective disorder, paraplegia, and chronic respiratory failure had care plans requiring bathing or incontinence assistance, but staff did not document whether care was provided or refused on multiple occasions. CNAs, LPNs, the ADON, and the DON all stated that ADL care was supposed to be documented in the record.
A resident with bipolar disorder, depression, anxiety, and other psychotic disorder, and with moderate cognitive impairment, received psychotropic medications including an antipsychotic, an SSRI, and an antidepressant without documented informed consent from the resident or responsible party. Staff stated informed consent was required for psychotropic medications and should be obtained and scanned into the EHR, but no consent was found for the resident, and the RNC and DON confirmed the documentation was missing.
Medication Error and Failure to Follow Physician Orders: A resident with MS had an order for oxycodone-acetaminophen PRN for pain, but staff gave the wrong medication instead of the ordered dose. The CMA notified the nurse, and the error was documented; the resident was alert and oriented with no signs or symptoms of distress, and the physician, DON, Administrator, and family were notified.
The facility failed to provide residents access to their trust account money during nights and weekends. The policy requires proper management of the trust fund, but residents reported they could not access funds on weekends and had to request money on Fridays. The BOM confirmed that funds were only accessible during weekdays, limiting residents' access to their money.
The facility failed to notify residents when their trust account balances were within $200 of the Medicaid resource limit of $2,000. Four residents had balances exceeding or nearing this limit, yet no notifications were provided. Interviews confirmed that residents were unaware of their financial status, indicating a lapse in compliance with notification requirements.
The facility failed to monitor a resident's fluid intake despite a fluid restriction due to kidney issues, and did not provide prescribed nutritional interventions for two residents experiencing weight loss. Observations showed these residents were not receiving double portions or health shakes as ordered. Staff confirmed the lack of adherence to care plans and physician orders.
A facility failed to complete pre and post dialysis assessments for a resident with end-stage renal disease and acute kidney failure. Despite having orders for dialysis services three times a week, documentation showed that necessary assessments were not consistently completed. Interviews with staff confirmed the deficiency, with an LPN and the ADON acknowledging the lack of completed assessments as required by the facility's policy.
The facility failed to maintain a medication error rate below five percent. One resident did not receive their prescribed Colace due to a pharmacy error, while another resident with hypertension was incorrectly administered carvedilol despite their diastolic blood pressure being below the specified parameter. These incidents highlight the facility's failure to ensure medications were administered correctly.
The facility did not include the medical director in its QAPI program, as required by policy and contract. The QAPI plan and committee list lacked a physician or medical director, and QA meeting sign-in sheets from January to October 2024 showed no medical director participation. The administrator confirmed the absence of the medical director in the committee throughout 2024, with the last involvement in December 2023.
The facility did not provide residents with information on how to file a complaint with the State agency. Observations revealed no such information in resident areas, and the resident council confirmed they were not informed of their rights. The administrator admitted the information was not posted, despite previous claims.
The facility did not ensure that the most recent survey results were accessible to residents. Binders with past survey results were found, but the latest results were missing. Residents were unaware that survey results were supposed to be posted, and the administrator admitted they were not reposted after painting.
A resident with intact cognition and medical conditions including cardiomyopathy and acute respiratory failure expressed concerns about the unfinished repairs in their room, specifically the wall spackle and screw anchors. Despite procedures for maintaining a homelike environment, the wall remained in disrepair since the resident moved in. Staff interviews indicated that maintenance was notified, but the repairs were not completed.
The facility did not complete a discharge summary for a resident who passed away after being taken over by emergency services. The policy required a recapitulation of the resident's stay and a final summary at discharge, but this was not documented. The DON and ADON confirmed the absence of the discharge summary, noting the resident was in the hospital at the time of death.
The facility did not serve pureed meals at the correct consistency for residents requiring such diets. The DM prepared a meal with meat loaf, potato salad, and cabbage, adding water, but the food was not smooth and contained fine chunks. This was confirmed when dietary staff served four trays with the incorrect consistency. The DM acknowledged the issue, noting the meal was grainy and had fine chunks.
The facility failed to follow the prescribed pureed diet menus for four residents during a meal service. The dietary manager prepared meals without including all required items, such as bread and pineapple cake, and substituted potato salad for scalloped potatoes. The manager acknowledged the omission and substitution, admitting that not all menu items were provided as required.
A resident with multiple sclerosis reported a persistent fly problem in their room, which was confirmed by observations. Despite the facility's pest control policy, staff were unaware of the issue, and the maintenance department experienced high turnover, leading to inaction on the pest problem.
Failure to Maintain a Licensed Administrator
Penalty
Summary
The facility's governing body failed to appoint a properly licensed administrator to manage the facility, and the report states that no licensed administrator had been accountable for the facility since 05/07/2026. A letter from the Oklahoma State Department of Health to another facility, dated 06/18/2026, showed that the facility's previous administrator became the administrator of record at another facility beginning 05/07/2026. During an interview on 07/04/2026, the CFO stated that the last day the facility had a licensed administrator was 05/07/2026, that the facility did not currently have a licensed administrator, and that he was not a licensed administrator and did not go into the building. On 07/08/2026, the DON stated that she expected the facility to have a licensed nursing home administrator.
Failure to Ensure N-95 Fit Testing for Staff
Penalty
Summary
The facility failed to ensure that all staff were fit-tested for an N-95 respirator mask in accordance with CDC and OSHA requirements. The report states that OSHA requires users of tight-fitting respirators to pass a fit test before use and that fit testing must be completed annually and repeated when changes occur that could affect respirator fit. During interview, the Regional Nurse Consultant stated the facility did not have a policy regarding N-95 fit testing and that no recent fit testing had been completed. She also stated she did not know when the last fit testing was done and that there was no documented evidence that N-95 fit testing had been completed. Staff interviews confirmed the lack of fit testing at the facility. A CNA hired in June 2026 stated they had not been fit-tested for an N-95 mask. A CMA hired in September 2024 stated they had not been fit-tested for an N-95 mask since working at the facility. The DON stated she had been employed since April 2026, had not received an N-95 fit test when she started, and there had been no N-95 fit testing since she had been there. The Previous Administrator stated they were not involved in N-95 fit testing, had not been tested while working at the facility, and was not sure about the requirements for N-95 fit testing.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by another resident, Resident #33, who had a history of severe major depressive disorder with psychotic symptoms and anxiety disorder and was documented as having poor impulse control and a pattern of slapping other residents when angry. The care plan identified that Resident #33 needed staff to immediately intervene for aggressive behavior, monitor and report signs of danger to self or others, and intervene before agitation escalated. Despite these documented behaviors and interventions, multiple incidents involving Resident #33 and other residents occurred over several months. On 07/29/2025, a nurse observed Resident #33 pulling another resident by the arm in an attempt to get the resident off a couch so Resident #33 could sit down. The nurse later stated that Resident #33 pulled the resident out of the seat against the resident’s will. The resident involved was identified as Resident #56, who had severe cognitive impairment with a BIMS score of 1 and diagnoses including Alzheimer’s disease, dementia, anxiety disorder, and depression. Facility records showed no evidence that this incident was investigated or reported to the state survey agency before the survey, and the previous ADM stated she was unaware of the incident until the survey period. Additional incidents involved Resident #33 slapping Resident #51 on the face after being told to leave them alone, snatching a bingo card from Resident #39 and calling Resident #39 a vulgar slur during a facility activity, and hitting Resident #35 on the shoulder after a chair incident in the dining room. Resident #51 had severe cognitive impairment with a BIMS score of 2 and diagnoses including violent behavior, mood disorder, and bipolar disorder. Resident #39 had severe cognitive impairment with a BIMS score of 3. Resident #35 had intact cognition with a BIMS score of 15 and diagnoses including schizophrenia, bipolar disorder, and anxiety. The DON stated the facility failed to conduct thorough investigations for the incidents on 07/29/2025, 01/20/2026, 01/23/2026, and 06/04/2026, and stated that thorough investigation could have identified interventions that might have prevented additional incidents of abuse from Resident #33.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the state survey agency within two hours after the allegation was made. The deficiency involved four residents reviewed for abuse and centered on multiple incidents in which Resident #33, who had diagnoses including severe major depressive disorder with psychotic symptoms, anxiety disorder, and poor impulse control, was involved in resident-to-resident altercations. Resident #33’s care plan identified that the resident had a history of slapping other residents when angry and directed staff to intervene immediately for aggressive behavior and report to the charge nurse as needed. On 07/29/2025, LPN #3 observed Resident #33 pull another resident by the arm in an attempt to move the resident off a couch so Resident #33 could sit down. LPN #3 stated she immediately separated the residents, documented the incident, and informed the DON at the time. Facility records showed no evidence that this allegation was reported to the state survey agency before the survey. The previous ADM stated she was unaware of the incident until the survey date and confirmed it was not reported. On 01/20/2026, Resident #33 slapped Resident #51 in the face after Resident #51 told the resident to leave them alone. LPN #5 stated she immediately separated the residents and notified the ADM. Although the facility did report the allegation, the facsimile receipt showed the report was submitted the next day at 12:24, which was beyond the required two-hour timeframe. The previous ADM stated the report should have been submitted within two hours and had no excuse for the delay. On 01/23/2026, Resident #33 took a bingo card from Resident #39, called the resident a vulgar slur, and slapped the resident’s hand. The Activity Director stated she witnessed the incident and reported it to the Administrator. The facility completed an incident report, but there was no indication it was submitted to the state survey agency, and the previous ADM stated she was not sure when or whether it was submitted timely. On 06/04/2026, Resident #33 hit Resident #35 on the shoulder after Resident #35 accidentally bumped Resident #33 with a chair. The ADON and DON stated abuse allegations were to be reported immediately and within two hours, but the facsimile receipt showed the report was not submitted until four days later. The DON stated she was not aware of the incident when it occurred and only submitted the report after hearing staff discuss it days later.
Failure to Thoroughly Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate alleged incidents of verbal and physical abuse involving Resident #33 and five other residents. The facility policy required all allegations of abuse to be thoroughly investigated, including review of documentation and evidence, review of medical records, observation of the alleged victim, interviews with reporting persons, witnesses, the resident or representative as appropriate, staff on all shifts, family members or visitors, and complete documentation of the investigation. The report identified that the facility did not complete thorough investigations for incidents occurring on 07/29/2025, 01/20/2026, 01/23/2026, 03/22/2026, and 06/04/2026. Resident #33 was admitted on 11/30/2022 and had diagnoses including severe major depressive disorder with psychotic symptoms and anxiety disorder. The resident’s annual MDS dated 12/09/2025 showed a BIMS score of 14, indicating intact cognition. The care plan identified poor impulse control, difficulty controlling anger in social settings, and a history of slapping other residents when angry. Interventions directed staff to immediately intervene for aggressive behavior, report to the charge nurse, monitor and document signs of danger to self or others, and intervene before agitation escalated. For the 07/29/2025 incident, LPN #3 stated she saw Resident #33 tell another resident to move from a seat in the TV room and then pull the resident by the arm when the resident did not move. She said she separated the residents, documented the event, and informed the DON, but the facility had no evidence the incident was investigated before the survey. The state incident report identified the other resident as Resident #56, who had severe cognitive impairment with a BIMS score of 1 and diagnoses including Alzheimer’s disease, dementia, anxiety disorder, and depression. For the 01/20/2026 incident, Resident #33 slapped Resident #51 in the face after an interaction in the dining room. Resident #51 had diagnoses including violent behavior, mood disorder, and bipolar disorder, and a BIMS score of 2. LPN #5 stated she separated the residents and notified the ADM. The facility’s investigative documents did not include witness statements or documentation showing what was done to investigate the incident, and the previous ADM stated that reviewing camera footage alone was not a thorough investigation. For the 01/23/2026 incident, Resident #33 snatched a bingo card from Resident #39, used a vulgar slur, and slapped the resident’s hand during an activity. The Activity Director witnessed the event and reported it to the ADM. Resident #39 had severe cognitive impairment with a BIMS score of 3. The facility’s investigative documents did not include witness statements or documentation of the investigation, and the previous ADM stated she was not fully trained on the abuse policy and should have obtained statements from staff, victims, and families. For the 03/22/2026 incident, an incident report stated that another resident witnessed Resident #33 slapping Resident #36’s hand, but the report did not include the time of the incident. Resident #36 had severe cognitive impairment with a BIMS score of 3. The record contained no progress note, witness statements, or other documentation describing the incident or investigation. The previous ADM stated she reviewed video footage, did not see physical contact, and did not investigate further, but later stated she should have obtained statements from staff, the victim, and family and reviewed Resident #33’s prior behavior. For the 06/04/2026 incident, Resident #35 accidentally bumped Resident #33 with a chair in the dining room, and Resident #33 retaliated by hitting Resident #35 on the shoulder. Resident #35 had diagnoses including schizophrenia, bipolar disorder, and anxiety, and a BIMS score of 15. Resident #11 witnessed the event and described Resident #33 hitting Resident #35 after the chair incident. The facility’s investigative documents did not include witness statements or documentation of the investigation. The ADON and DON both stated the incident was not thoroughly investigated, and the DON stated she did not believe she documented interviews with residents or staff.
Incomplete ADL Documentation in Resident Records
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for documentation of ADL care for three residents. Facility policy required all services provided to a resident, including changes in condition and progress toward care plan goals, to be documented in the medical record. Surveyors found missing documentation for bathing and incontinence care in the electronic record for the residents reviewed. Resident #13 was admitted with diagnoses including type 2 diabetes mellitus, severe protein-calorie malnutrition, and depression, and had moderate cognitive impairment with substantial/maximal assistance needed for bathing. The care plan required one-person assistance with bathing, and the June 2026 ADL task record showed multiple scheduled bath days with no documentation indicating whether the bath was offered or provided. Staff interviews reflected that bathing care should be documented in the electronic record whether provided or refused, and the DON stated there was no documentation at the end of June for bathing and that if it was not documented, it could not be proven it was done. Resident #12 was admitted with diagnoses including multiple sclerosis, adult failure to thrive, and schizoaffective disorder, and had moderate cognitive impairment with dependence on staff for bathing. The care plan required one-person assistance with bathing, but the June 2026 documentation survey showed multiple bath days with no documentation that the bath was offered or provided. Staff interviews again confirmed that bathing care was expected to be documented, and the DON stated there was no documentation and there should have been. Resident #29 was admitted with diagnoses including incomplete paraplegia, chronic respiratory failure, and major depressive disorder, and had intact cognition but was dependent on staff for toileting hygiene and personal hygiene and was always incontinent of bowel and bladder. The care plan directed staff to provide incontinence care as needed, but the June 2026 ADL documentation showed multiple days with no charting of bowel and bladder care. CNAs stated that incontinence care was required to be documented each shift and that blanks should not be present, while the ADON and DON stated that ADL documentation was mandatory and should be completed in the EHR every shift.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure there was documentation that a resident or responsible party was informed of the risks and benefits of psychotropic medications and gave informed consent before those medications were administered to one resident. The resident had diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, and other psychotic disorder, and a BIMS score of 8 indicating moderate cognitive impairment. The resident’s care plan noted behaviors and resistance to care, including medications, and directed staff to allow the resident to make decisions about the treatment regimen and to educate the resident, family, or caregivers about the possible outcomes of not complying with treatment or care. The resident’s active medication orders included aripiprazole for bipolar disorder, citalopram for depression, and mirtazapine for major depressive disorder. During interviews, facility staff stated that informed consent was required for psychotropic medications and should be obtained by the admitting nurse or charge nurse and scanned into the electronic health record, but no informed consents were found for this resident. The regional nurse consultant stated she had completed an audit for informed consents and believed this resident was one still needing follow-up, but there was no documentation of contact with family. The DON stated she expected informed consent for all psychotropic medications and did not believe it met expectations for the resident to receive those medications without any informed consent.
Medication Error and Failure to Follow Physician Orders
Penalty
Summary
The facility failed to follow physician orders for one resident when staff did not administer the resident’s medication as ordered. Resident #12 was admitted with a history of multiple sclerosis and had an order for oxycodone-acetaminophen 7.5 mg/325 mg, one tablet by mouth every four hours as needed for pain. On 10/29/2025, a Certified Medication Aide notified the nurse that the resident had received the wrong medication, and the medication error was documented in an incident report and progress note. The incident report stated that the resident’s physician, DON, and Administrator were notified of the medication error. The nursing note documented that the resident denied shortness of breath, nausea, or vomiting and was alert and oriented with no signs or symptoms of distress. During interviews, the DON stated that residents were expected to receive the right medication and the right dose, and the Previous Administrator stated that a CMA made the medication error with Resident #12 and was not allowed to return to work at the facility.
Lack of Access to Resident Trust Funds on Nights and Weekends
Penalty
Summary
The facility failed to ensure that residents had access to their trust account money during nights and weekends, affecting three residents who were reviewed for this issue. The facility's policy on the management of the resident trust fund, last updated in March 2024, requires that proper accounting principles be followed in accordance with state and federal regulations. However, a review of the trust account ledgers for the affected residents showed no entries of money being withdrawn at night or on weekends. Interviews with residents revealed that they could not access their funds on weekends and had to request money on Fridays if they needed it for the weekend. The Business Office Manager (BOM) confirmed that they worked only Monday through Friday and that resident funds were kept in a safe in the administrator's office, with access limited to the administrator and the BOM. Consequently, residents were unable to access their funds during nights and weekends.
Failure to Notify Residents of Trust Account Balances Near Medicaid Limit
Penalty
Summary
The facility failed to notify residents when their trust account balances were within $200 of the Medicaid resource limit of $2,000. This deficiency was identified for four residents who were reviewed for notifications of trust balances. The Business Office Manager (BOM) acknowledged that 33 residents had money in the trust account, but there was no documentation indicating that notifications were provided to the residents when their balances approached the Medicaid resource limit. Specifically, the trust account ledgers for four residents showed balances exceeding or nearing the $2,000 limit, yet no notifications were given. Resident #5 had a balance of $2,444.21, Resident #10 had $2,152.88, Resident #9 had $2,446.25, and Resident #26 had $1,853.72. Interviews with the BOM and residents confirmed that notices were not provided, and residents were unaware of their financial status in relation to the Medicaid limit, indicating a lapse in the facility's compliance with notification requirements.
Failure to Monitor Fluid Intake and Provide Nutritional Interventions
Penalty
Summary
The facility failed to adequately monitor and manage the fluid intake and nutritional needs of several residents, leading to deficiencies in care. Resident #93, who was on a fluid restriction due to end-stage renal disease and acute kidney failure, was not monitored for fluid input and output as required by their care plan. Despite having a small refrigerator with over thirty cans of drinks in their room, the facility did not document or inquire about the resident's fluid consumption. Both the LPN and ADON confirmed that no monitoring was being conducted for this resident's fluid intake. Additionally, the facility did not provide the necessary nutritional interventions for Residents #3 and #5, who were both on pureed diets with orders for double portions and supplemental shakes due to weight loss. Observations revealed that these residents were consistently served single portions without the prescribed shakes. Staff interviews confirmed that the dietary orders were not being followed, with the dietary manager admitting that health shakes were not provided due to a shortage. The ADON acknowledged that the care plan interventions and physician orders for these residents were not being adhered to.
Failure to Complete Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to complete pre and post dialysis assessments for a resident who required dialysis services. The resident, who was admitted with diagnoses including end-stage renal disease and acute kidney failure, had orders for dialysis services three times a week. However, documentation revealed that the necessary assessments were not consistently completed. Specifically, a dialysis communication form dated 10/03/24 did not document a post-assessment, and there was no documentation for a form on 10/05/24. Additionally, forms dated 10/17/24, 10/19/24, and 10/22/24 did not have all areas of the pre and/or post assessments completed. Interviews with facility staff confirmed the deficiency. An LPN stated that the resident was the only one receiving dialysis and was supposed to be checked before and after dialysis, including vital signs and the graft/fistula site. The ADON acknowledged that the facility used communication forms for monitoring dialysis residents and admitted that the pre and post dialysis assessments had not been completed as required. This lack of documentation and assessment indicates a failure to adhere to the facility's policy on dialysis care.
Medication Error Rate Exceeds Acceptable Levels
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication pass observation. One incident involved a resident with a diagnosis of neurogenic bowel who had a physician's order for Colace, a laxative, to be administered twice daily. Despite the order being active in the facility, the medication was not administered because it was mistakenly discontinued by the pharmacy. The Certified Medication Aide (CMA) acknowledged the issue and noted that the medication was expected to be delivered during the evening shift, but it was not available at the time of administration. Another incident involved a resident with hypertension who had a physician's order for carvedilol, a medication to be held if the resident's diastolic blood pressure was 60 or below. During the medication pass, the Assistant Certified Medication Aide (ACMA) administered the carvedilol despite the resident's diastolic blood pressure being below the specified parameter. The ACMA later admitted to misinterpreting the order, thinking it referred to the pulse rate instead of the diastolic blood pressure. These incidents contributed to the facility's failure to maintain the required medication error rate.
Medical Director Absence in QAPI Program
Penalty
Summary
The facility failed to ensure that the medical director was part of the Quality Assurance and Performance Improvement (QAPI) program, as required by their policy and the medical director's contract. A review of the facility's QAPI plan and committee member list revealed that all department heads, the administrator, and the Director of Nursing (DON) were included, but a physician or medical director was not. Additionally, sign-in sheets for Quality Assurance (QA) meetings from January 2024 to October 2024 showed no evidence of the medical director's participation. The administrator confirmed that the medical director had not participated in the committee throughout 2024, with the last involvement being in December 2023. This oversight indicates a failure to comply with federal, state, and local regulatory requirements for the QAPI program.
Failure to Provide Complaint Filing Information
Penalty
Summary
The facility failed to ensure that residents were provided with contact information for filing a complaint with the State agency. During an observation on October 21, 2024, it was noted that there was no information available in the resident halls or main living area regarding how to file a complaint. In a confidential interview with the resident council group, they confirmed that they had not been informed of their rights or given information on how to formally complain to the State about their care. The facility administrator initially claimed that the information was posted near the ombudsman sign but upon inspection, acknowledged that it was not currently posted, although it used to be.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible to the residents. During an observation on October 21, 2024, it was noted that binders containing survey results from 2018, 2019, and 2022 were located on the wall between the medication storage room and the administrator's office. However, the survey results from the most recent survey were not present. In a confidential interview with the resident council group, it was revealed that the State survey results were not available for residents to read without having to ask, and the residents were unaware that the results were supposed to be posted. The administrator acknowledged that the latest survey results were supposed to be posted but had not been put back after painting was completed.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident #10, who had diagnoses including cardiomyopathy and acute respiratory failure with hypoxia. The resident's cognition was documented as intact. During an observation, the resident expressed concerns about the condition of their room, specifically mentioning wall spackle and the top of their wall. The resident stated that they had paid a lot of money to live at the facility and expected it to look good. Upon inspection, the wall next to the resident's television was found to have two areas of white plaster-like material and five plastic screw anchors, which had been in that condition since the resident moved in. Interviews with facility staff revealed that there were procedures in place to maintain a homelike environment, such as tidying up and notifying maintenance for repairs. A CNA mentioned that they would ensure items were put away and notify maintenance if repairs were needed. An LPN also stated they would notify maintenance for room repairs. The maintenance staff member responsible for repairs observed the wall in Resident #10's room and noted that it appeared someone had started repairs but did not finish them. This observation was made before the current maintenance staff member took on their role.
Failure to Complete Discharge Summary for Deceased Resident
Penalty
Summary
The facility failed to complete a discharge summary with a recapitulation of the resident's stay for one of the two closed records reviewed. The undated policy on Discharge Summary and Plan required that a discharge summary include a recapitulation of the resident's stay and a final summary of their status at discharge. An incident progress note documented that emergency services arrived on a specific date and took over care after the resident coded. The discharge assessment indicated that the discharge was due to a death in the facility, and the census report confirmed the discharge date. However, there was no documentation of a completed discharge summary for the resident. When asked, the DON and ADON acknowledged the absence of the discharge summary, stating that the resident was in the hospital when they passed away.
Improper Consistency of Pureed Meals
Penalty
Summary
The facility failed to ensure that pureed meals were served at the correct consistency for residents requiring such diets. During an observation, the Dietary Manager (DM) was seen preparing a pureed meal that included meat loaf, potato salad, and cabbage. The DM added water to these items, but upon tasting, both the DM and the surveyor noted that the pureed food was not smooth and contained fine chunks of meat, cabbage, and potatoes. This inconsistency was confirmed when dietary staff served four pureed trays with the incorrect consistency. The DM later acknowledged that the pureed foods should have been smooth, but the Sunday noon meal was grainy and had fine chunks.
Failure to Follow Pureed Diet Menus
Penalty
Summary
The facility failed to ensure that menus were followed for pureed diets during a meal service. The dietary manager (DM) identified four residents with diet orders for pureed meals. According to the menu extension dated 10/20/24, the noon pureed meal was supposed to include baked meat loaf, scalloped potatoes, a dinner roll, and pineapple cake. However, during the meal preparation on 10/20/24, the DM was observed pureeing only single portions of meat loaf, potato salad, and cabbage, without including bread or pineapple cake. Subsequently, four pureed trays were served without the bread or pineapple cake. The DM acknowledged that the current diet orders were on each meal ticket and that all residents were supposed to receive their diet order and all menu items. The DM admitted that the pineapple cake was not made and no substitute was provided. Additionally, the DM stated that there was no bread as required by the menu, and the potato salad was used as a substitute for scalloped potatoes because the residents had scalloped potatoes the previous night. The DM admitted to not providing all the menu items as required.
Pest Control Deficiency in Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from pests, specifically flies, in the room of a resident diagnosed with multiple sclerosis. The resident reported having three or four flies in their room during the day or evening and stated that they had informed the staff multiple times, but no action was taken. Observations confirmed the presence of flies in the resident's room, including on the window and pillow. The facility's pest control policy indicated that pest control services were conducted monthly and as needed, with staff instructed to report any pest issues to the Maintenance Director or Administration immediately. Interviews with staff revealed a lack of awareness and action regarding the pest issue. A CNA was unsure of the pest control policy and did not consider flies a significant issue until recently. An LPN confirmed the monthly pest control service and the option to call for additional services if pests were identified. However, the Maintenance/Housekeeping staff was unaware of the fly problem in the resident's room until it was pointed out during the survey. The staff turnover in the maintenance department was noted, with only one staff member having more than two weeks of experience, which may have contributed to the oversight.
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 198 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — 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 Bethany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grand At Bethany Skilled Nursing And Therapy | 0.7 mi | ★★★★★ | 8 | 0 |
| Windsor Hills Nursing Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Heritage Manor | 2 mi | ★★★★★ | 15 | 0 |
| North Winds Living Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Warr Acres Nursing Center | 3.3 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 October 2026) and official state health department websites.