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 Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Two residents in an LTC facility experienced safety incidents due to inadequate supervision and environmental hazards. One resident with severe cognitive impairment sustained a burn from hot coffee served without a lid, while another resident, identified as a high elopement risk, managed to leave the facility unsupervised. The facility failed to maintain safe coffee temperatures and did not implement consistent monitoring for the elopement risk, leading to these deficiencies.
The facility failed to protect residents from sexual abuse, as evidenced by incidents involving inappropriate contact between residents. A resident with Alzheimer's was involved in several incidents where male residents engaged in inappropriate touching. Another resident with a history of sexually inappropriate behavior was not consistently monitored, leading to multiple incidents of inappropriate contact with female residents. Staff interviews revealed a lack of awareness and communication regarding these behaviors.
The facility failed to report abuse allegations within the required timeframe for three residents. A resident with dementia experienced delayed reporting of sexual abuse, while another resident with Alzheimer's faced delayed reporting of verbal abuse. Additionally, a third resident was involved in two incidents of sexual abuse, both reported late. Staff interviews indicated a lack of adherence to reporting protocols despite training.
The facility failed to serve meals at safe and appetizing temperatures, as reported by several residents and confirmed by a test tray evaluation. Residents frequently received cold meals, and this issue was documented in resident council minutes. Despite audits and measures like batch cooking and plate warmers, the problem persisted.
The facility failed to meet professional standards of food service safety, with food items left open to air in storage areas and an unclean kitchen environment. Observations revealed unlabeled dry storage bins, broken tiles, and food debris under equipment. Interviews indicated that audits and cleaning logs were maintained, but the Dietary Manager was unaware of some issues, and cleaning behind ovens was infrequent.
A resident with multiple medical conditions reported missing personal items, including a jacket, which were not located or replaced in a timely manner. The facility lacked consistent procedures for addressing missing items, and no grievance was filed. Despite discussions among staff, the issue remained unresolved, leading to a deficiency in maintaining a safe and homelike environment.
A facility failed to transmit a resident's MDS data to CMS within the required timeframe. The resident, with multiple serious health conditions, had a Death in Facility MDS assessment completed, but it was not submitted due to an error in the electronic medical record system. The MDS Coordinator confirmed the oversight.
A resident with a history of chronic pain conditions did not receive adequate pain management due to the unavailability of prescribed medication, Cyclobenzaprine HCl, from 6/27/24 to 6/30/24. Despite a care plan in place, the resident was observed in significant pain, with a reported pain level of 10 out of 10, affecting sleep and daily activities. Interviews with nursing staff revealed a failure to reorder medication in a timely manner, leading to the deficiency.
Two residents in the facility did not receive their prescribed medications due to delays in the ordering and delivery process. One resident, with chronic pain, missed doses of Cyclobenzaprine, while another, with psychoses and dementia, did not receive Quetiapine for two days. Interviews with nursing staff and the DON revealed procedural lapses in reordering medications, leading to these deficiencies.
Two residents received medications outside of physician-ordered parameters, leading to unnecessary drug administration. One resident was given Midodrine and Novolog insulin despite not meeting the conditions for administration, while another received Midodrine when it should have been held. Staff interviews revealed a lack of adherence to medication orders, indicating systemic issues in the facility's practices.
A resident with multiple medical conditions experienced delays in receiving necessary lab results due to the facility's failure to provide timely laboratory services. The Depakote test was delayed by 10 days due to an unsuitable gel barrier tube, and the CBC test was delayed by seven days due to an insufficient specimen. The facility did not follow its protocol of checking lab results daily and contacting the lab if results were not received within three days.
A CNA failed to perform hand hygiene while assisting multiple residents with dining, touching environmental surfaces and resident objects without sanitizing hands in between. Interviews with staff confirmed that hand hygiene should be performed between serving meal trays and when touching surfaces that could lead to cross-contamination.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. Resident 21, who had severe cognitive impairment and required assistance for eating, sustained a burn after spilling hot coffee on himself. The incident occurred when Resident 21 was served coffee without a lid, despite staff having identified a new tremor in his hands that increased the risk of spilling. The coffee was served at a temperature higher than the facility's policy allowed, contributing to the severity of the burn. The facility's dietary staff were not consistent in monitoring and documenting coffee temperatures, which led to the coffee being served at unsafe temperatures. Resident 166, who had severe cognitive impairment and a history of wandering, eloped from the facility. Despite being identified as a high elopement risk, the resident's wander guard was removed after it caused agitation, and the facility did not implement consistent 15-minute checks as required for high-risk residents. The resident managed to leave the facility and was found walking towards a gas station. The facility's failure to maintain adequate supervision and monitoring allowed the resident to elope, posing a significant safety risk. Both incidents highlight the facility's deficiencies in maintaining a safe environment and providing adequate supervision for residents with cognitive impairments. The lack of proper temperature control for hot beverages and insufficient monitoring of residents at risk of elopement contributed to these safety incidents. The facility's inaction in addressing known risks and implementing necessary precautions led to these deficiencies.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, as evidenced by multiple incidents involving inappropriate sexual contact between residents. Specifically, three female residents experienced incidents of sexual abuse by two male residents. Resident 63, who has Alzheimer's disease and dementia, was involved in several incidents where male residents engaged in inappropriate touching. Despite being dependent on staff for care and having limited communication abilities, Resident 63 was found in situations where male residents had their hands down her pants or were touching her inappropriately. Resident 12, who also has Alzheimer's disease and dementia, was involved in multiple incidents of sexually inappropriate behavior towards female residents. His medical records indicate a history of such behaviors, including attempts to grab female residents' breasts and making inappropriate comments. Despite these behaviors, there was a lack of consistent monitoring and documentation of his actions, and staff were not adequately informed about the need to keep him separated from female residents. The facility's investigation into these incidents revealed that staff were aware of the inappropriate behaviors but failed to implement effective measures to prevent further occurrences. Interviews with staff indicated a lack of awareness and communication regarding residents with a history of sexual behaviors. The facility's failure to adequately monitor and separate residents with known inappropriate behaviors contributed to the ongoing risk of abuse and exploitation among residents.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, exploitation, or mistreatment within the required timeframe for three out of fifty sampled residents. Resident 85, who has diagnoses including hemiplegia, dementia, and anxiety, was involved in an incident of sexual abuse that was reported to the State Survey Agency (SSA) two days late, and notifications to Adult Protective Services (APS) and the police were also delayed. Similarly, Resident 21, with Alzheimer's Disease and other conditions, was subjected to mental/verbal abuse, but the incident was reported to the SSA seven days late, and there was no documentation of APS notification. Resident 63, diagnosed with Alzheimer's disease and other conditions, was involved in two separate incidents of sexual abuse. The first incident was reported to the SSA and APS five days late, and the second incident was reported to the SSA over 24 hours late, with no documentation of APS notification. Interviews with staff revealed that while abuse training was provided, there was a lack of adherence to the reporting timeframe, and staff often reported incidents to nurses rather than directly to the Administrator, who was responsible for timely reporting.
Food Temperature Deficiency
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 5 out of 50 sampled residents. Residents reported that their meals were often served cold, and this issue was documented in the resident council minutes. Specific residents, identified as 25, 37, 72, 268, and 274, expressed dissatisfaction with the temperature of their food during interviews. The resident council notes revealed ongoing concerns about food temperature, with repeated mentions of food not being served hot on hall carts and trays. A test tray evaluation further confirmed the deficiency, as the food items were found to be below the appropriate serving temperature. The barbeque chicken was 89 degrees Fahrenheit, the pasta salad was 67.5 degrees Fahrenheit, the mushroom salad was 64.4 degrees Fahrenheit, and the ice cream was 21.2 degrees Fahrenheit, indicating that the meals were not served at safe and appetizing temperatures. The Registered Dietitian and Dietary Manager acknowledged the issue, with the RD conducting audits and the DM implementing measures like batch cooking and using plate warmers, but the problem persisted.
Food Service Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during multiple walkthroughs of the kitchen. During these inspections, it was noted that various food items in the dry storage room, walk-in refrigerator, and walk-in freezer were left open to air, which included oats, chocolate powder, sugar, flour, cake mix, potato chips, bacon, biscuit dough, beef patties, gluten-free sausage links, frozen peas, frozen vegetables, tilapia filets, and gluten-free elbow pasta. Additionally, the dry storage bins were not labeled, and the kitchen was found to be unclean, with food debris under and behind the grill and ovens. Broken tiles were also observed near the ice cream freezer and between the ovens, with dirt and dried food particles present. Interviews with the Registered Dietitian (RD) and the Dietary Manager (DM) revealed that kitchen audits were conducted every other month, and cleaning logs were maintained for each shift. However, the DM was unaware of the broken tiles and stated that cleaning behind the ovens was done only once a month. The DM also mentioned that food items should be wrapped and sealed when returned to the refrigerator or freezer to prevent contamination or freezer burn, and that bulk storage bins should be labeled and dated. Despite these procedures, the facility failed to ensure that these standards were consistently met, leading to the observed deficiencies.
Failure to Protect Resident's Property
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's property, leading to a deficiency in maintaining a safe and homelike environment. Resident 65, who had multiple medical conditions including chronic respiratory failure and major depressive disorder, reported that personal items, including a jacket, went missing. The resident expressed concerns about housekeeping staff entering the room and misplacing items, including personal papers that were discarded. Despite these concerns, no grievances were filed, and an inventory list for the resident was not available. Interviews with facility staff revealed a lack of consistent procedures in addressing the missing items. The Resident Advocate (RA) acknowledged that a grievance form was not completed for the missing jacket, as the issue was discussed in meetings and actively searched for by staff. The RA and the prior Administrator were uncertain about replacing the jacket, and the matter was left unresolved with the transition to a new Administrator. The Housekeeping and Laundry Supervisor confirmed that the jacket was reported missing shortly after the resident's admission, but efforts to locate it were unsuccessful, and the item was not replaced. The Administrator confirmed that the resident refused to fill out an inventory list upon admission, complicating efforts to verify the missing item. Attempts to obtain an inventory list from the resident's previous facility were also unsuccessful. The RA noted that the resident had changed the description of the missing jacket over time, further complicating the resolution. Despite ongoing discussions and attempts to address the issue, the facility did not take timely action to replace the missing item, resulting in a deficiency in protecting the resident's property.
Failure to Transmit MDS Data to CMS
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within the required 14 days of completing a resident's assessment. This deficiency was identified for one resident out of a sample of 50. The resident, who had been admitted and readmitted with multiple diagnoses including end stage renal disease and chronic respiratory failure, had a Death in Facility MDS assessment completed. However, the assessment was incorrectly marked as not required for submission to CMS due to an error in the electronic medical record system. The MDS Coordinator acknowledged that the assessment should have been transmitted but was not due to the incorrect selection in the system.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 9, who required such services. Resident 9, who had a history of paraplegia, cirrhosis of the liver, hepatic encephalopathy, psychosis, and hypertension, was observed to be in significant pain on multiple occasions. Despite having a care plan that included administering analgesic medication and monitoring pain levels, the resident's prescribed pain medication, Cyclobenzaprine HCl, was not available from 6/27/24 to 6/30/24. The resident was observed to be in distress, exhibiting facial grimacing and crying, and reported a pain level of 10 out of 10, which affected his sleep and daily activities. Interviews with the nursing staff, including RN 1 and the Director of Nursing (DON), revealed that the medication was not administered due to it being unavailable from the pharmacy. RN 1 acknowledged that the resident could experience increased pain due to tense muscles and that the resident's pain levels fluctuated. The DON stated that medications should be reordered three to four days before they run out, but this protocol was not followed, resulting in the resident not receiving the necessary pain management. The failure to ensure the availability of pain medication and to follow the care plan led to the deficiency in providing appropriate pain management for Resident 9.
Medication Unavailability for Residents
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the unavailability of prescribed medications for two residents. Resident 9, who was admitted with multiple diagnoses including paraplegia and chronic pain syndrome, did not have Cyclobenzaprine available for several days. This medication was prescribed to manage pain related to muscle spasms. Despite the resident's visible signs of pain and discomfort, the medication was not administered from June 27 to June 30, 2024, due to delays in receiving the medication from the pharmacy. Interviews with the nursing staff and the Director of Nursing (DON) revealed that there were procedures in place for reordering medications, but these were not effectively followed, resulting in the resident's pain management being compromised. Resident 111, diagnosed with conditions such as amyotrophic lateral sclerosis and anxiety disorder, also experienced a lapse in medication administration. The resident did not receive Quetiapine, prescribed for psychoses and dementia, for two consecutive days. The medication was noted as unavailable, and although it was reordered, it was not delivered in a timely manner. Interviews with Licensed Practical Nurses (LPNs) and the DON indicated that there were multiple methods for reordering medications, but the process was not executed efficiently, leading to the resident missing critical doses of their medication. The facility's failure to ensure the timely acquisition and administration of medications highlights a significant deficiency in their pharmaceutical services. The staff interviews revealed inconsistencies in the medication ordering process and communication with the pharmacy, which contributed to the delay in medication delivery. The DON acknowledged the expectation for medications to be delivered promptly, yet the system in place did not prevent the interruption in medication administration for these residents.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of medications outside of the physician's ordered parameters. Specifically, Resident 35, who had multiple diagnoses including hypotension and type 2 diabetes mellitus, was administered Midodrine and Novolog insulin when the parameters for holding these medications were not met. The Midodrine was given even when the systolic blood pressure (SBP) was above 90, contrary to the physician's order to hold it if SBP was greater than 90. Similarly, Novolog insulin was administered when the resident's blood sugar was below 120, against the physician's directive to hold it under such conditions. Interviews with the nursing staff revealed a lack of adherence to the prescribed medication parameters. RN 1 admitted to administering Midodrine and Novolog without consistently checking if the conditions for holding the medications were met. The Director of Nursing (DON) acknowledged the challenges in maintaining Resident 35's blood pressure due to frequent dialysis but did not ensure compliance with the medication orders. The staff's failure to follow the physician's orders resulted in the unnecessary administration of medications, potentially affecting the resident's health. Resident 65 also experienced similar issues with the administration of Midodrine. Despite having a physician's order to hold the medication if SBP was greater than 90, the medication was administered when the SBP exceeded this threshold. RN 1 was unaware of the hold parameters and admitted to persuading the resident to take the medication even when it was not necessary. This oversight indicates a systemic issue in the facility's medication administration practices, leading to the use of unnecessary drugs for the residents involved.
Delayed Laboratory Services for a Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident, resulting in significant delays in obtaining necessary lab results. The resident, who had multiple medical conditions including a fracture of the right femur, hypertension, and dementia, was supposed to have a Depakote level and a Complete Blood Count (CBC) test conducted. However, the Depakote test was not performed initially due to an unsuitable gel barrier tube, and the CBC test was not completed due to an insufficient specimen. These issues led to delays of 10 days for the Depakote test and seven days for the CBC test. The Director of Nursing (DON) acknowledged that the facility did not follow up with the laboratory in a timely manner. The facility's process required staff to check lab results daily and contact the lab if results were not received within three days. However, this protocol was not followed, contributing to the delay. The DON indicated that the Unit Manager should have followed up with the lab sooner, but this did not occur, resulting in the resident's lab tests being delayed and not meeting the needs of the resident in a timely manner.
Inadequate Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during a breakfast meal observation. CNA 6 was observed assisting multiple residents with dining without performing hand hygiene after touching environmental surfaces and resident objects. Specifically, CNA 6 served food to resident 84, passed a stool over resident 24's meal, cleaned spilled milk off the floor, and then continued to assist residents 40, 24, 63, and 21 with their meals without sanitizing their hands in between these actions. Additionally, CNA 6 touched her eyeglasses repeatedly while assisting the residents, further compromising hand hygiene. Interviews conducted with other staff members, including CNA 8 and the CNA Coordinator, confirmed that the expected protocol was to perform hand hygiene between serving meal trays and when touching any surfaces that could lead to cross-contamination. The CNA Coordinator specifically stated that hand hygiene should be performed if a CNA touches a resident's straw that has come into contact with the resident's mouth before assisting another resident. These observations and interviews highlight a deficiency in the facility's infection prevention and control practices, as proper hand hygiene was not maintained during resident meal assistance.
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Illustrative
What surveyors actually found near you
We read the 85 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Terrace Transitional | 4.2 mi | ★★★★★ | 0 | 0 |
| Mt Ogden Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Stonehenge Of Ogden | 4.4 mi | ★★★★★ | 0 | 0 |
| South Ogden Post-acute (cascades At South Ogden) | 5.2 mi | ★★★★★ | 14 | 0 |
| Rocky Mountain Care- Clearfield | 5.4 mi | ★★★★★ | 6 | 0 |
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