Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Park during CMS and state inspections, most recent first.
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.
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.
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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 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 | ★★★★★ | 9 | 0 |
| Windsor Hills Nursing Center | 1.4 mi | ★★★★★ | 12 | 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 July 2026) and official state health department websites.