Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Park Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer's and dysphagia experienced significant weight loss due to the facility's failure to provide adequate nutrition and hydration. Despite being on a mechanically altered diet and prescribed supplements, the resident was not consistently offered meals or snacks, and her intake was inaccurately documented. Staff failed to implement recommended interventions, such as weekly weight monitoring, and did not inform the resident's representative of the weight loss.
The facility's QAPI program failed to identify and address multiple care deficiencies, including issues with resident dignity, baseline care plans, and infection control. The QAPI committee did not involve floor staff, residents, or family members in meetings, and several specific deficiencies were noted, such as inadequate treatment for activities of daily living, improper respiratory care, and failure to maintain an effective infection control program. The NHA acknowledged the need for a performance improvement plan and audits to better identify areas for improvement.
The facility failed to provide a dignified dining experience for two residents and privacy for another. A resident had meal bowls moved without choice or explanation, while another lacked social interaction during meals, with a CNA observed falling asleep while assisting. A third resident was left exposed while using a urinal, and staff were overheard discussing residents' conditions in public areas.
The facility failed to complete baseline care plans within 48 hours for four residents, as required by policy. This included missing or delayed documentation of advance directives, dietary orders, and therapy services. Staff interviews confirmed the incomplete or delayed care plans, indicating a systemic issue in the admission process.
The facility failed to provide necessary respiratory care for three residents, including timely refilling of portable oxygen tanks and routine changing of oxygen tubing. Staff also neglected to use appropriate PPE while filling oxygen tanks. These deficiencies were observed in residents with conditions such as hemiplegia, COPD, and dementia, highlighting a failure to adhere to facility policies.
The facility failed to serve food at appropriate temperatures and with palatable taste, as reported by several residents. Observations confirmed that meals were often cold or lukewarm, with some dishes being bland or improperly cooked. Despite these issues, the registered dietitian and NHA were unaware of the residents' concerns, and no actions were documented to address previous complaints.
The facility failed to maintain sanitary conditions in the kitchen, with a dietary aide's insulin pen improperly stored in the walk-in refrigerator, inadequate hand hygiene practices during meal service, and dietary staff wearing jewelry while preparing food. These actions violated regulations and facility policies, as confirmed by observations and staff interviews.
The facility failed to maintain an effective infection control program, with housekeeping staff neglecting to clean high-touch surfaces like call light cords and door handles, and staff not adhering to hand hygiene protocols. Observations showed lapses in cleaning and hand hygiene practices, confirmed by staff interviews, highlighting significant gaps in infection prevention measures.
A resident with hearing loss and low vision was not provided with a replacement hearing aid after the facility lost it. Despite the facility's commitment to replace the lost hearing aid, it was not done for over two months, causing the resident difficulty in interacting with others. The NHA cited logistical issues and lack of documentation as reasons for the delay.
The facility failed to conduct timely PASRR for two residents who remained in the facility beyond 30 days with provisional PASRRs. One resident, with diagnoses including anxiety and bipolar disorder, experienced a nine-month delay in receiving recommended therapy and testing. Another resident with severe cognitive impairment also lacked a timely PASRR submission. The social services director cited procedural changes and lack of assistance as reasons for the oversight.
A resident with severe cognitive impairments and mobility issues was not repositioned timely, as required by their care plan, in a LTC facility. Despite needing assistance every two hours to prevent skin breakdown, the resident remained in the same position for over four hours. Staff interviews confirmed the resident's inability to move independently and the need for repositioning, yet the care plan was not followed during the observed period.
The facility failed to ensure timely communication and appropriate care for two residents, leading to deficiencies in their treatment. One resident, with multiple health issues, tested positive for COVID-19 and could not take prescribed medication due to its form. Despite notifying the physician, there was no follow-up, and the resident's condition declined without proper documentation or physician orders. Another resident experienced UTI symptoms, but there was no timely physician response or follow-up, delaying treatment. Staff interviews revealed a lack of adherence to policies regarding physician notification and medication management.
A facility failed to provide appropriate care to maintain or improve a resident's range of motion and mobility. Despite requests from the resident's representative, the resident did not receive passive range of motion exercises and was not on a restorative program. Observations showed a decline in mobility, and staff interviews confirmed the absence of a restorative program and individualized plans for residents.
The facility did not complete an annual performance review or provide in-service education for a CNA hired in 2022. The CNA, who was out of the country for several months, returned to work but had not received the required evaluation or education.
A facility failed to document a physician's rationale for extending the use of PRN lorazepam beyond 14 days for a resident with severe dementia and a history of falling. Despite the resident's care plan including monitoring of anti-anxiety medication, the electronic medical record lacked necessary documentation. The DON was aware of the requirement but did not know the rationale was missing.
The facility did not ensure CNAs received the required 12 hours of annual in-service training, including dementia management and abuse prevention. A review of training records showed two CNAs completed only 10.5 hours of training. The NHA confirmed the shortfall, emphasizing the importance of full training for maintaining updated skills.
The facility did not post updated nurse staffing information daily, as required. Observations showed that the staffing information near the main nurse's station was outdated, last updated over a month ago. The DON confirmed that the central supply staff member responsible for updates was on vacation, leading to the oversight.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure that a resident with Alzheimer's disease, dysphagia, prediabetes, and chronic kidney disease stage 3 received adequate nutrition and hydration, resulting in significant weight loss. The resident, who was independent with eating but required assistance with other activities of daily living, lost 10 pounds, or 5.1% of her body weight, over 29 days. Despite being on a mechanically altered diet and prescribed nutritional supplements, the facility did not consistently encourage or document her meal intake accurately, nor did they monitor her weight weekly as recommended. Observations revealed that the resident was not consistently offered meals or snacks. On one occasion, she consumed less than 25% of her meal without being offered an alternative, and on another, she was not served dinner because it was assumed she preferred to sleep. However, continuous observation showed that she was not offered a snack during this time. Additionally, when the resident expressed hunger and requested food, staff failed to provide her with the requested items, and her intake was inaccurately documented. Interviews with staff and review of records indicated that the facility's interdisciplinary team was aware of the resident's weight loss and poor intake. Despite recommendations for weekly weights and additional nutritional interventions, these were not consistently implemented. The resident's representative was not informed of the weight loss, and there was a lack of documentation regarding the provision of prescribed snacks and supplements. The facility's failure to adhere to its own policies and procedures contributed to the resident's nutritional decline.
Ineffective QAPI Program and Multiple Care Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, which is essential for improving the quality of care for nursing home residents. The QAPI committee did not identify or address multiple concerns related to quality of care, including dignity, baseline care plans, positioning residents, restorative services, weight loss, oxygen canisters, as-needed psychotropic medications, PASRR Level I screens, palatable food, and kitchen sanitation. Additionally, the facility's QAPI plan, which was supposed to be data-driven and proactive, did not involve floor staff, residents, or family members in the QAPI meetings or feedback process, as stated by the nursing home administrator (NHA). The report highlights several specific deficiencies, such as the failure to maintain resident dignity, develop and implement baseline care plans, provide appropriate treatment for activities of daily living, ensure proper range of motion treatment, address weight loss timely, provide proper respiratory care, maintain an effective infection control program, and ensure residents were free from unnecessary psychotropic drugs. Furthermore, the facility did not ensure proper treatment to maintain hearing, complete PASRR Level I screenings within thirty days of admission, or provide food that conserved nutritive value and was served in a sanitary manner. The NHA acknowledged that the QAPI team needed to create a performance improvement plan and conduct audits to better identify areas for improvement, but there was a breakdown in the system due to leadership turnover.
Failure to Ensure Dignity and Privacy for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents. Resident #6, who has severe cognitive impairments and requires assistance with meals, was observed having her meal bowls moved out of reach without explanation or choice by the registered dietitian (RD). This action was not aligned with her care plan, which did not specify such a requirement. Despite the RD's claim that this method reduced agitation, observations did not support this, as Resident #6 was not agitated when all bowls were in front of her. Resident #27, with severe cognitive impairment and multiple diagnoses including Down's syndrome and Parkinson's disease, was not provided with adequate social interaction during meals. The resident's representative noted that he benefited from one-on-one interactions, yet observations showed that staff, particularly CNA #1, did not engage with him during meals. CNA #1 was also observed to be inattentive and appeared to fall asleep while assisting the resident, which the nursing home administrator acknowledged as a risk for choking. Resident #4, who has moderate cognitive impairments and is legally blind, was not provided privacy while using a urinal in his room. The resident was left exposed with the door and window curtains open, despite staff passing by and not addressing the lack of privacy. Additionally, staff were overheard discussing residents' conditions and preferences in the dining room, violating privacy protocols. The RD was noted to speak loudly about residents' dietary needs and personal information, which could be overheard by others in the dining area.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that four residents had a completed baseline care plan within 48 hours of admission, as required by their policy. The baseline care plan is intended to provide an initial set of instructions needed to provide effective and person-centered care. For Resident #241, the facility did not complete a baseline care plan or a comprehensive care plan within the required timeframe. The care plans for medications and dietary needs were delayed, with the dietary care plan not initiated until several weeks after admission. Resident #242's baseline care plan was incomplete, missing critical components such as advance directives, dietary orders, and therapy services. Similarly, Resident #36's baseline care plan failed to document advance directives, dietary orders, and therapy services, with the dietary care plan not initiated until days after admission. Additionally, the baseline care plan did not address the resident's activities of daily living self-care deficit until much later. For Resident #239, a baseline care plan was not completed at all. Although a comprehensive care plan was initiated within 48 hours, it did not include essential elements such as a fall care plan, dietary care plan, and therapy services care plan until much later. Interviews with staff revealed that the baseline care plans were incomplete or not completed within the required timeframe, indicating a systemic issue in the facility's admission process.
Deficiencies in Respiratory Care and PPE Usage
Penalty
Summary
The facility failed to provide necessary respiratory care for three residents, as observed during a survey. The deficiencies included not refilling portable oxygen tanks in a timely manner, not routinely changing and dating oxygen tubing, and not using appropriate personal protective equipment (PPE) while filling oxygen tanks. These failures were observed in three residents who were dependent on oxygen therapy due to various medical conditions such as hemiplegia, chronic obstructive pulmonary disease (COPD), and dementia. Resident #16, who was cognitively intact but physically dependent on staff for daily activities, was found using an empty portable oxygen tank with no date labeled on the oxygen tubing. Similarly, Resident #14, with severe cognitive impairments, was observed with an empty oxygen tank and undated tubing. Resident #17, who had moderate cognitive impairments, was also found with an empty oxygen tank and undated tubing. These observations were made despite the facility's policy requiring oxygen supplies to be changed weekly and labeled with the resident's name and date. Additionally, staff members, including a certified nurse aide (CNA) and the infection control preventionist (IP), were observed filling portable oxygen tanks without wearing the required PPE, which includes goggles, heavy gloves, ear protection, and an apron. The director of nursing (DON) confirmed that proper PPE is necessary for safety when filling oxygen tanks. These deficiencies indicate a failure to adhere to the facility's policies and procedures for safe and appropriate respiratory care.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to consistently serve food that was palatable in taste, texture, appearance, and temperature. Multiple residents reported receiving cold food, with some describing the food as bland or improperly cooked. Resident interviews revealed that meals served in both the dining room and residents' rooms were often cold or lukewarm. A resident group interview further confirmed these issues, with several residents expressing dissatisfaction with the temperature of their meals. Observations by surveyors supported these complaints, as a test tray evaluation showed that the food was not served at appropriate temperatures and lacked palatability. The parmesan crusted tilapia was found to be bland and served at 111.8 degrees Fahrenheit, while the pea salad and tartar sauce were served at temperatures below the recommended levels. Despite these findings, the registered dietitian and nursing home administrator were unaware of the residents' concerns, and there was no documentation of actions taken to address previous complaints about meal temperatures.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as evidenced by several observations and interviews. During an initial tour, a dietary aide's insulin pen was found stored in the walk-in refrigerator alongside residents' food, contrary to regulations that require employee medications to be stored separately in a designated container. The registered dietitian confirmed that personal medications should not be stored in the walk-in refrigerator, indicating a lapse in adherence to proper storage protocols. Additionally, the facility did not ensure appropriate hand hygiene practices during meal service. Observations revealed that residents were not offered hand hygiene after participating in activities and before eating, and dietary aides did not perform hand hygiene between handling drinks and touching residents or their wheelchairs. This lack of hand hygiene was noted over several days, highlighting a consistent failure to follow infection control procedures as outlined in the facility's policy and professional guidelines. Furthermore, dietary staff were observed wearing jewelry while preparing food, which is against the regulations that prohibit wearing jewelry, except for a plain ring, during food preparation. A dietary aide was seen wearing a corded bracelet that came into contact with food items, such as butter packets, during meal service. This breach of protocol was acknowledged by the regional vice president, who was unaware of the practice, indicating a lack of oversight in ensuring compliance with food safety standards.
Infection Control Deficiencies in Housekeeping and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by deficiencies in housekeeping and hand hygiene practices. Observations revealed that housekeeping staff did not clean high-touch surfaces such as call light cords and door handles in residents' rooms and bathrooms. Despite the facility's policy requiring daily cleaning of these areas, housekeepers were observed neglecting these tasks. Interviews with housekeeping staff and the director of housekeeping confirmed these lapses, with staff acknowledging the importance of cleaning high-touch surfaces but failing to do so during observed cleaning sessions. Additionally, the facility's staff did not adhere to proper hand hygiene protocols. A registered nurse was observed entering a resident's room and interacting with the environment without performing hand hygiene before or after the interaction. Similarly, a certified nurse aide did not offer hand hygiene to a resident after assisting with toileting and failed to perform hand hygiene before and after entering residents' rooms while distributing clean water cups. These actions were contrary to the facility's hand hygiene policy, which mandates hand hygiene before and after patient contact and after contact with inanimate objects in the patient's environment. Interviews with the infection preventionist and the director of nursing highlighted the importance of hand hygiene in preventing infection spread. They confirmed that staff should perform hand hygiene before entering and after leaving a resident's room and offer hand hygiene to residents after toileting. The failure to adhere to these practices indicates a significant gap in the facility's infection prevention and control measures, as observed by the surveyors.
Failure to Replace Lost Hearing Aid for Resident
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices for a resident with hearing and vision problems. The resident, over 65 years old, was admitted with diagnoses including hearing loss in both ears, macular degeneration, and anxiety disorder. Despite having no cognitive impairment, the resident experienced moderate difficulty hearing and required hearing aids. Observations over several days confirmed that the resident was only wearing a hearing aid in the left ear, with the right hearing aid missing. The resident reported that the facility lost the right hearing aid and promised to replace it, but had not done so, causing frustration and difficulty in interacting with others due to her low vision and hearing impairment. The facility's incident report documented that the resident's hearing aid was reported missing, and the facility committed to replacing it. However, more than two months passed without replacement. Interviews with staff revealed that the Social Service Director was not involved in the investigation, and the Nursing Home Administrator (NHA) acknowledged the delay, citing logistical issues with contacting the audiology clinic. The NHA admitted there was no documentation of attempts to replace the hearing aid until a staff member contacted the clinic during the survey. This inaction led to the deficiency in providing necessary assistive devices for the resident.
Failure to Conduct Timely PASRR for Two Residents
Penalty
Summary
The facility failed to conduct a preadmission screening resident review (PASRR) for two residents, resulting in a deficiency. Resident #20, who was over 65 years old, was admitted with a provisional PASRR and remained in the facility for more than 30 days without a new Level I PASRR being submitted. This resident had diagnoses including generalized anxiety disorder, depression, bipolar disorder, and cognitive-communication deficit. Despite being cognitively intact and receiving medications for depression and bipolar disorder, the facility delayed submitting a new Level I PASRR, which led to a nine-month delay in receiving recommended individual therapy and neurocognitive testing. Similarly, Resident #10, also over 65, was admitted with a provisional PASRR and stayed beyond the 30-day period without a new Level I PASRR being submitted. This resident had severe cognitive impairment and diagnoses including generalized anxiety disorder and dementia with anxiety. The resident's care plan included the use of antidepressant medication, but the facility did not submit a new PASRR Level I until the survey was conducted. The social services director (SSD) acknowledged the oversight, stating that the hospital had been completing only provisional PASRR screens and that she missed submitting new Level I PASRRs for both residents when they remained in the facility longer than 30 days. The SSD attributed the oversight to a lack of assistance and recent changes in hospital procedures, which led to the deficiency in timely PASRR submissions.
Failure to Reposition Resident Timely
Penalty
Summary
The facility failed to ensure that a resident, who required assistance with activities of daily living, was repositioned in a timely manner. The resident, over the age of 65, had diagnoses including Alzheimer's disease, dysphagia, prediabetes, and chronic kidney disease stage 3. The resident had severe cognitive impairments and required substantial to maximum assistance with mobility and transfers. Observations on a specific day revealed that the resident was not repositioned from 8:55 a.m. until 1:10 p.m., despite being in a tilt-back wheelchair that was not adjusted during this period. The resident's care plan indicated a need for repositioning every two hours to prevent skin breakdown due to impaired mobility and incontinence. Interviews with staff, including a registered nurse and the director of rehabilitation, confirmed that the resident was unable to move independently and required assistance from two staff members for transfers and repositioning. The resident's representative also noted that a special chair was made to aid in repositioning. However, during the observed period, the staff did not adhere to the care plan's directive to reposition the resident every two hours, leading to a deficiency in providing appropriate care and assistance for the resident's activities of daily living.
Deficiencies in Timely Physician Communication and Care
Penalty
Summary
The facility failed to ensure timely communication and appropriate care for two residents, leading to deficiencies in their treatment. Resident #37, who had multiple health issues including dementia and COPD, tested positive for COVID-19 and required medication that could not be crushed. Despite notifying the physician, there was no follow-up to address the resident's inability to take the prescribed medication. As the resident's condition declined, requiring oxygen and exhibiting a moist cough, there was no documentation of further communication with the physician. The facility also failed to obtain a physician's order to withhold or discontinue medications as the resident appeared to be actively passing away. Resident #1, who was cognitively intact and had a history of chronic UTIs, experienced symptoms indicative of a UTI, including burning and blood in the urine. Despite notifying the physician, there was no documented response or follow-up from the facility to address these symptoms. The resident continued to experience pain and burning with urination, and it was not until over a month later that a urinalysis confirmed a UTI, leading to the eventual prescription of antibiotics. The lack of timely physician follow-up and communication resulted in a delay in addressing the resident's UTI symptoms. Interviews with staff, including registered nurses and the director of nursing, revealed a lack of adherence to facility policies regarding physician notification and medication management. The facility's failure to ensure effective communication and timely medical intervention for changes in residents' conditions contributed to the deficiencies identified in the care of Residents #37 and #1.
Failure to Provide Restorative Care for Resident
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for Resident #24, who entered the facility without limited mobility. The facility's policy required a restorative program to be developed based on a comprehensive assessment, but Resident #24 was not on such a program. Despite the resident's representative requesting therapy and ROM exercises, the facility did not ensure these services were provided. Observations showed that Resident #24 was transferred using a mechanical lift, indicating a decline in mobility. Resident #24, who had severe cognitive impairments and required substantial assistance with mobility, was not receiving passive range of motion (PROM) exercises. The resident's care plan did not include ROM exercises, and the Kardex indicated extensive assistance was needed for transfers. Therapy notes documented that the resident refused therapy on several occasions, but there was no evidence of multiple attempts or involvement of the resident's representative, who claimed she was not invited to participate in therapy sessions. Interviews with staff revealed that the facility did not have an active restorative program, and there were no individualized plans for PROM. The Director of Nursing (DON) and the Director of Rehabilitation (DOR) confirmed the absence of a restorative program and the lack of baseline assessments for residents not on therapy services. Certified Nurse Aides (CNAs) also indicated that they did not perform ROM exercises with residents, and the facility lacked sufficient staff to implement restorative programs.
Failure to Conduct Annual Performance Review for CNA
Penalty
Summary
The facility failed to conduct an annual performance review and provide regular in-service education for a certified nurse aide (CNA) as required. Specifically, CNA #2, who was hired on June 22, 2022, did not have an annual performance review completed. Additionally, there was no in-service education plan developed based on the outcome of such a review. The nursing home administrator (NHA) acknowledged that CNA #2 had been out of the country from January 2024 to April 2024 and was currently working on a PRN (as needed) basis. Despite returning to work in April 2024, CNA #2 had not received a performance evaluation or in-service education based on the review outcome.
Failure to Document Rationale for Extended Use of PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of PRN psychotropic drugs. The resident, aged 79, with diagnoses including severe unspecified dementia and a history of falling, was observed calling out for help on multiple occasions. Despite these observations, the facility did not document a physician's rationale for extending the use of PRN lorazepam beyond the 14-day limit, as required by regulations. The resident's comprehensive care plan included the use of anti-anxiety medications, with interventions to monitor and document side effects and effectiveness. However, the electronic medical record lacked documentation for the physician's rationale for the extended use of lorazepam. The Director of Nursing acknowledged awareness of the requirement for a documented rationale but was unaware of the absence of such documentation for this resident.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of annual in-service training, which includes dementia management and resident abuse prevention training. This deficiency was identified during a review of training records for five randomly selected CNAs, where it was found that two CNAs, hired in 2022 and 2014 respectively, only completed 10 hours and 30 minutes of training in the annual training year. The nursing home administrator confirmed the shortfall in training hours for these CNAs, acknowledging the importance of completing the full training to maintain updated bedside skills and education.
Failure to Post Updated Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted daily in a prominent place, as required. Observations on August 26, 2024, at 8:38 a.m. and 11:07 a.m. revealed that the staffing information posted near the main nurse's station was outdated, with the last update dated July 18, 2024. This information was not readily accessible to residents and visitors, as it should have been updated daily. During an interview on August 26, 2024, at 11:10 a.m., the Director of Nursing (DON) confirmed that the staffing information had not been updated since July 18, 2024. The DON explained that the central supply staff member responsible for updating the staffing information was on vacation, which led to the oversight. The DON acknowledged the importance of having current staffing information available for visitors, residents, and staff members to know the number of staff working in the facility.
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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 Carbondale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenwood Springs Healthcare | 9.8 mi | — | 3 | 0 |
| Castle Peak Senior Life And Rehabilitation | 26.2 mi | — | 4 | 0 |
| Colorado State Veterans Nursing Home - Rifle | 30.5 mi | — | 2 | 0 |
| Grand River Health Care Center | 31.1 mi | — | 9 | 1 |
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