Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Living Center during CMS and state inspections, most recent first.
Weekend staffing did not match the Facility Assessment staffing grid, with repeated CNA and charge nurse shortages across multiple weekend days. The Staffing Coordinator said she did not use the Facility Assessment to guide staffing and instead followed an older staffing guide, while the Administrator said the facility used the assessment and noted fewer CNAs on weekends because there was no van driver or shower aides.
Ice Machine Not Kept Clean and Sanitary: The facility failed to maintain the only ice machine in a clean and sanitary condition. During observation, the DM found black residue inside the machine where ice traveled to the collector. The DM said the ice was used for resident water pitchers and beverages, and a DA stated he had only been cleaning the lower area and had not been told to clean the upper area. The cleaning log was incomplete, with missing entries and no staff initials on a recent sheet.
An RN failed to sanitize hands between removing gloves after applying a topical patch and putting on clean gloves before administering eye drops to a resident. Staff also failed to follow EBP during Foley catheter and perineal care for another resident, as an LPN provided care without a gown despite the resident having an indwelling urinary catheter. Interviews showed the RN was unsure about hand hygiene at that point, and the LPN did not know the EBP requirements.
A resident with moderate cognitive impairment and diagnoses including anxiety, depression, and a language disorder had about 11 inches of long hair cut off by a shower aide to remove a knot, without the resident’s permission. Staff stated CNAs are not allowed to cut hair, and one aide reported another aide helped cut the hair during a shower; afterward, the resident said the haircut was unwanted and remained upset, while the resident’s representative said the facility did not communicate with her about it.
A resident with a history of major depressive disorder, anxiety, and prior suicide attempt was admitted for rehabilitation, but their suicide history was not included in the Care Plan, and staff were not trained or informed to monitor for suicide risk. The resident was found deceased by suicide, and interviews revealed that staff were unaware of the resident's behavioral health history and did not receive guidance on suicide prevention or intervention.
The facility failed to ensure proper hand hygiene and food safety practices, affecting 127 residents. Dietary staff did not wash hands or change gloves after handling contaminated items before handling food. Hot food items were not maintained at the required temperature, and food storage practices were inadequate, with uncovered and undated items. These actions violated the facility's cleanliness and handwashing policy.
The facility failed to securely store razors and nail trimmers, posing a safety risk to two residents with cognitive impairments. One resident, with moderate cognitive impairment, had razors left unsecured in their bathroom, while another resident, with severe cognitive impairment and a history of self-harm, had nail trimmers on their bedside table. Staff interviews confirmed these items should not be stored in resident rooms.
A surveyor observed a treatment cart left unlocked and unattended in a hallway, contrary to facility policy. The cart contained various medications and supplies, including silver sulfadiazine and nystatin powder. An LPN and RN confirmed the cart should be locked to prevent unauthorized access. The DON acknowledged the requirement for carts to be locked when unattended.
The facility did not adhere to the planned menu for residents on pureed diets, leading to insufficient servings during lunch and incorrect meal preparation during breakfast. A dietary aide used incorrect portion sizes, resulting in a shortage of servings for 23 residents. Additionally, residents were served regular cereal instead of pureed cereal, as confirmed by the dietary manager.
The facility failed to serve meals at appropriate temperatures, affecting residents' nutritional intake and satisfaction. Observations showed food items were served cold, and dietary practices were inadequate, with improper handling of food items like melted ice cream. The meal delivery process using unheated carts contributed to the issue, as confirmed by temperature checks and resident complaints.
The facility failed to provide pureed food items with a smooth, lump-free consistency for residents on pureed diets. Observations revealed that scalloped potatoes, pork roast, zucchini, grits, sausage, and oatmeal were not properly pureed, posing a potential risk to 21 residents. Dietary staff confirmed the presence of lumps in these meals.
The facility failed to serve meals at scheduled times, affecting all 127 residents. Observations showed lunch and breakfast trays were served late, and grievance logs documented resident complaints about meal delays. During a Resident Council meeting, residents reported issues with food quality, such as melted ice cream and overcooked or burnt food, indicating a failure to maintain appropriate food temperatures and quality.
A resident's EMR was left visible on a tablet in a public hallway, exposing sensitive information without staff supervision. An LPN attempted to hide the screen after being observed, and an RN acknowledged the need to turn off the EMR for privacy. The DON could not specify how quickly screens should blank, leading to a deficiency in protecting resident confidentiality.
The facility failed to securely store portable oxygen cylinders, as observed in the 600 Hall therapy gym where one cylinder was left free-standing. Staff, including a Speech Pathologist and an LPN, confirmed the improper storage and acknowledged that oxygen should be stored in a bag on a resident's wheelchair, in a rolling carrier, or in a storage room. The DON reiterated the facility's policy against free-standing storage to prevent accidents.
The facility failed to ensure bathroom call lights had pull strings, affecting residents' ability to call for help. Observations showed missing pull cords in several bathrooms, including one used by a resident with cognitive impairment and mobility issues. Staff interviews revealed the issue was not reported to maintenance, and the facility lacked a call light policy. The DON acknowledged the importance of call light strings, but the Maintenance Director was unaware of the problem until the survey.
Weekend Staffing Did Not Match Facility Assessment Requirements
Penalty
Summary
The facility failed to use its Facility Assessment to ensure minimum weekend staffing needs were met on 8 of 26 weekend days during April, May, and June 2025. The Facility Assessment, last updated 10/31/2024, listed an average daily census of 125-130 residents and identified direct-care staffing needs of 8-11 licensed nurses and 35-50 nurse aides, along with shift-based staffing ratios for weekdays and weekends. A review of the Payroll-Based Journal report and the weekend Direct Care Daily Staffing Log showed repeated weekend staffing shortages compared with those assessment requirements. The staffing log documented shortages on multiple weekend dates, including deficits in CNA coverage and, on some dates, charge nurse coverage. Examples included shortages on 04/05/2025, 04/06/2025, 04/12/2025, 04/13/2025, 04/19/2025, 04/20/2025, 04/26/2025, 04/27/2025, 05/03/2025, and 05/04/2025, with census ranging from 126 to 133 residents. The report stated the facility was short 11.5 CNAs over the course of 26 weekend days based on the 35-50 CNA range, and short 223.4 CNAs and 22.5 licensed staff over the same period based on the individual staff assignment section. During interview, the Staffing Coordinator stated she did not use the Facility Assessment to inform staffing decisions and instead used a guide from when she started the job about 2 years earlier; the Administrator stated the Facility Assessment was utilized and that the facility met the minimum of 35 per day, while also noting there were usually four fewer CNAs on weekends because there was no van driver or shower aides on those days.
Ice Machine Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to ensure the ice machine was maintained in a clean and sanitary condition. During an observation with the Dietary Manager, the ice machine located by the kitchen door was wiped on the inside and had an accumulation of black residue where ice traveled down to the ice collector. The Dietary Manager stated the ice machine had been cleaned two days earlier and that it was cleaned two times a week by a Dietary Aide, and she confirmed it was the only ice machine for the facility and that the ice was used to fill resident water pitchers and beverages at mealtimes. During an interview, a Dietary Aide stated he had started cleaning the ice machine two weeks earlier and had been educated by the Dietary Manager to wipe the walls on the bottom that holds the ice. He stated he saw the surveyor have the Dietary Manager wipe the upper area where the ice drops down and said he had never cleaned that upper part before and was not told he had to clean it. Review of the Ice Machine Cleaning Monitoring Sheet showed no monitoring sheet for the prior week and a sheet dated the day before the observation that did not have staff initials for cleaning. Facility policy required the ice machine and ice storage container to be drained, cleaned, and sanitized per manufacturer instructions, and the manufacturer guidelines stated to clean and sanitize per the instruction manual or maintenance label, but no manual was provided.
Infection Control Lapses During Medication Administration and Foley Care
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during medication administration for one resident. During an observation of the 8:00 AM medication pass, an RN applied a topical patch to the resident’s right arm, removed and discarded her gloves, and then put on a clean pair of gloves without sanitizing her hands before handling and administering eye drops. The RN used the same gloved hands to open the eye drop tube, hold the resident’s eyelid, and instill drops into both eyes before discarding the tube and gloves and then using hand sanitizer. The resident involved was receiving a [brand name] 4% patch and [brand name] eye drops. In interview, the RN stated she did not know whether she sanitized or washed her hands after removing the gloves used to place the patch or before putting on a clean pair of gloves. She stated she should sanitize her hands to avoid getting what was on the resident’s skin in the resident’s eyes and to avoid cross-contaminating the two medications. The DON stated it would be good practice to sanitize or wash hands between administering a topical medication and an eye drop. The facility also failed to ensure staff followed Enhanced Barrier Precautions during care of a resident with an indwelling urinary catheter. During observed Foley catheter care and perineal care, an LPN washed her hands and put on gloves, but did not wear a gown while providing care. The LPN leaned over the bed while performing care, and her clothes and legs touched the bed. In interview, the LPN stated she thought EBP was used only for dialysis residents and did not know what to do when a resident had EBP in place. A CNA stated residents with Foley catheters, wounds, and isolation were on EBP and that a gown had to be worn before touching them. The DON stated a gown and gloves were to be worn when providing care to residents with wounds, Foley catheters, dialysis, or intravenous access.
Unwanted Haircut Without Resident Permission
Penalty
Summary
The facility failed to protect resident rights that promote individuality and dignity for one resident who had moderate cognitive impairment, along with diagnoses including a language disorder, loss of blood supply to the brain, anxiety, depression, and decreased brain function due to a chemical imbalance in the body. The resident reported that several months earlier, a shower aide cut about 11 inches of the resident’s long hair to remove a knot in the middle back of the hair without the resident’s permission. The resident stated the haircut was unwanted and later described feeling devastated by the incident, noting that the resident had always worn long hair pulled back in a low ponytail. During interviews, CNAs and a shower aide stated that CNAs are not allowed to cut residents’ hair and should only brush, comb, or make hair presentable, with haircuts to be addressed through the nurse or DON. One shower aide stated that during the shower, another aide received permission to cut the knot out of the resident’s hair, but could not recall who gave that permission; the aide then helped cut the resident’s hair with scissors, and the resident stated afterward that the resident did not want a haircut. The resident’s representative stated the facility did not communicate with her before or after the haircut, and the resident continued to mention the incident frequently.
Failure to Address Behavioral Health Needs for Resident with Suicide History
Penalty
Summary
The facility failed to ensure that behavioral health services were provided to meet the needs of a resident with a history of suicide and a family history of suicide. Upon admission, the nurse did not include the resident’s suicide history in the Care Plan, and staff were not trained to identify or respond to behavioral health needs for this resident. The resident had been admitted for rehabilitative services with diagnoses including major depressive disorder, anxiety disorder, and a personal history of suicidal behavior, as well as a recent intentional self-harm drug overdose. Despite this, the Care Plan and assessments did not adequately address the resident’s suicide risk, and staff were unaware of the resident’s prior suicide attempt. Observations and interviews revealed that the resident was independent, participated in activities, and did not display overt behavioral changes that would have alerted staff to an increased suicide risk. Staff, including nurses and CNAs, reported that they were not informed of the resident’s suicide history and did not receive specific instructions to monitor for suicidal ideation or behaviors. The resident’s medical records and progress notes documented ongoing pain, depression, and medication changes, including medications with known side effects of suicidal ideation, but these factors were not integrated into a comprehensive behavioral health plan. On the morning of the incident, the resident was found deceased in their room, having used a shoestring to hang themselves in the closet. Staff interviews confirmed that the resident’s history of suicide was not communicated or documented in a way that would have prompted increased monitoring or intervention. The facility’s assessment and care planning processes did not ensure that staff had the necessary information or training to address the behavioral health needs of residents with a history of suicide, resulting in a failure to provide appropriate care.
Deficiencies in Hand Hygiene and Food Safety Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and food safety practices in the kitchen, which had the potential to affect 127 residents. Dietary staff were observed not washing their hands or changing gloves after handling potentially contaminated items before handling food. For instance, a dietary aide used bare hands to turn off a faucet, contaminating her hands, and then handled plates and bowls. Another aide used gloves to handle a spray bottle and then, without changing gloves, handled food items. Additionally, food items were not stored properly, with some containers left uncovered, exposing them to potential contamination. Furthermore, the facility did not maintain hot food items at the required temperature of 135 degrees Fahrenheit, with fried chicken recorded at 110 degrees Fahrenheit on the steam table. The facility also had issues with storage, such as rusty drawers, uncovered food items in the refrigerator, and undated food items in the walk-in freezer. These practices were contrary to the facility's policy on employee cleanliness and handwashing techniques, which required handwashing before handling food and after touching dirty objects.
Failure to Secure Hazardous Items in Resident Rooms
Penalty
Summary
The facility failed to ensure that hazards, specifically razors and nail trimmers, were securely stored to promote resident safety. This deficiency was identified for two residents who were reviewed for accidents and hazards. The facility's policy on safety and supervision of residents emphasizes making the environment as free from accident hazards as possible, yet observations revealed that razors and nail trimmers were left unsecured in residents' rooms. Resident #7, who has a history of cognitive impairment and dementia, was observed to have three razors on top of the soap dispenser in their bathroom on multiple occasions. Despite the resident's moderate cognitive impairment, as indicated by a BIMS score of 9, the facility did not ensure that these potentially dangerous items were stored securely, contrary to their policy. Similarly, Resident #82, who has severe cognitive impairment and a history of self-harm, was found with nail trimmers on their bedside table. This resident is dependent on staff for personal hygiene and has a history of skin picking, which resulted in a skin tear that required medical treatment. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that razors and nail trimmers should not be stored in residents' rooms due to the risk of harm, yet these items were found unsecured in the residents' living areas.
Unattended and Unlocked Treatment Cart in Hallway
Penalty
Summary
The facility failed to ensure that a nurse's wound treatment cart remained locked when left unattended in the hallway, as observed by a surveyor. The facility's policy, dated April 2007, mandates that compartments containing drugs and biologicals must be locked when not in use, and carts should not be left unattended if open or accessible. During an observation, a surveyor noted a 4-drawer cart parked in the hallway with the bottom drawer slightly open and no staff present. Over a period of time, staff, residents, and visitors passed by the unlocked cart, which contained various medications and supplies. When questioned, an LPN admitted to locking the cart only after being approached by the surveyor. Another staff member, an RN, confirmed that the cart should be locked to prevent unauthorized access to the medications and supplies. The cart contained items such as silver sulfadiazine, zinc oxide formula, medihoney gel, triple antibiotic ointment, povidone-iodine swabsticks, iodine cleaner, wound cleanser, and prescription nystatin powder, among others. The Director of Nursing also acknowledged that treatment carts should be locked to prevent access by unauthorized individuals or residents.
Failure to Follow Planned Menu for Pureed Diets
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which compromised the nutritional needs of residents on pureed diets. During lunch, the dietary aide used incorrect portion sizes and was short by two servings for 23 residents requiring pureed diets. Specifically, the aide used a 4-ounce spoon instead of the prescribed #10 scoop for scalloped potatoes, pork roast, and zucchini, resulting in insufficient servings. Additionally, during breakfast, residents on pureed diets were served regular oatmeal or grits instead of the required pureed hot cereal. The dietary manager confirmed that the residents should have received pureed cereal, indicating a deviation from the planned menu.
Inadequate Meal Temperature and Handling in LTC Facility
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures, which compromised the palatability and nutritional intake for residents. Observations and interviews revealed that meals were often served cold or at inadequate temperatures, affecting residents across multiple halls. For instance, residents complained about receiving cold food, and grievances were documented regarding the issue. During meal observations, food temperatures were recorded significantly below acceptable levels, with items such as pork chops, fried chicken, and scrambled eggs being served at temperatures ranging from 86.1 to 114 degrees Fahrenheit. Additionally, the facility's dietary practices were found lacking, as evidenced by the improper handling of food items. Melted ice cream was observed being placed back in the freezer, which was acknowledged as inappropriate by the Dietary Manager. Furthermore, the consistency of food items did not meet dietary requirements, as regular oatmeal was served to residents on pureed diets, indicating a failure to adhere to prescribed dietary modifications. The facility's meal delivery process was also scrutinized, with the Dietary Manager indicating that meal tray distribution should take approximately one hour. However, the unheated food carts used for meal delivery contributed to the cooling of food before it reached residents. This was corroborated by temperature checks conducted immediately after meal service, which consistently showed food items at suboptimal temperatures. Residents expressed dissatisfaction with the quality and temperature of their meals during a Resident Council meeting, further highlighting the widespread nature of the issue.
Improper Puree Consistency in Resident Meals
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. During observations, it was noted that scalloped potatoes, pork roast, and zucchini were not properly pureed, resulting in lumpy textures. The Dietary Aide used a blender to puree these items, but the resulting consistency was not smooth, posing a potential risk to residents who required pureed diets. The Dietary Manager confirmed the presence of lumps in the pureed food items, including pork roast, scalloped potatoes, zucchini, and bread. Further observations revealed that other pureed food items, such as grits, sausage, and oatmeal, were also not prepared to the required consistency. Certified Nursing Assistants reported that the grits were not pureed, and the oatmeal was described as regular rather than creamy and smooth. The Dietary Manager acknowledged that the pureed sausage and bread were not smooth and contained lumps. These deficiencies in food preparation had the potential to affect 21 residents who were on pureed diets.
Inconsistent Meal Service Times and Food Quality Issues
Penalty
Summary
The facility failed to ensure that resident meals were consistently served at regularly scheduled times, affecting the dependability of the eating schedule for all 127 residents receiving meals from the kitchen. Observations and records indicated that meal services were delayed, with lunch trays served 45 minutes late and breakfast trays 33 minutes late. Grievance logs documented resident complaints about late meal services, specifically noting late lunch and breakfast trays. During a Resident Council meeting, residents reported issues with food quality, including melted ice cream and overcooked or burnt food, indicating a failure to maintain appropriate food temperatures and quality.
Failure to Secure Resident's EMR in Public Hallway
Penalty
Summary
The facility failed to secure a resident's private health information on a facility tablet, leading to unauthorized exposure of the electronic medical record (EMR) in a public hallway. The incident involved Resident #330, who was cognitively intact and had a Brief Interview of Mental Status (BIMS) score of 12. The resident's EMR, which included sensitive information such as name, date of birth, medical conditions, and current vital signs, was left visible on a tablet screen atop a treatment cart outside the resident's room. This occurred without any staff present to monitor or secure the information, allowing staff, residents, and visitors to pass by and potentially view the private data. During the survey, it was observed that a Licensed Practical Nurse (LPN) attempted to hide the information by tapping the screen to make it go white, but this action was taken only after the surveyor's observation. A Registered Nurse (RN) acknowledged that the EMR should be turned off to protect resident privacy, citing HIPAA regulations. The Director of Nursing (DON) was unable to specify how quickly the tablet screens should go blank, despite the surveyor noting that the screen remained active for 19 minutes. This lack of proper security measures and staff awareness led to the deficiency in protecting resident confidentiality.
Improper Storage of Portable Oxygen Cylinders
Penalty
Summary
The facility failed to ensure the secure storage of portable oxygen cylinders, as observed by surveyors. During multiple observations in the 600 Hall therapy gym, a surveyor noted that three oxygen cylinders were present, with two stored in a portable rolling stand and one left free-standing with a regulator in place. This was confirmed by both a Speech Pathologist and an LPN, who acknowledged the improper storage of the free-standing cylinder. The staff members indicated that oxygen cylinders should be stored in a bag on the back of a resident's wheelchair, in a rolling oxygen cylinder carrier, or in a designated oxygen storage room to prevent them from falling over and potentially exploding. The Director of Nursing (DON) confirmed the facility's policy on oxygen storage, which aligns with the observations made by the surveyor. The DON stated that oxygen cylinders should be stored in a bag holder on the back of a resident's wheelchair, in a rolling cart stand with wheels, or in a rack in the storage rooms on various halls. The DON emphasized that oxygen cylinders are not stored free-standing to prevent them from falling over and to ensure resident safety. Despite these policies, the surveyor's observations revealed a lapse in adherence to these safety protocols, resulting in the deficiency noted in the report.
Deficiency in Bathroom Call Light System
Penalty
Summary
The facility failed to ensure that bathroom call lights had pull strings in place for residents to call for help while in the bathroom. During an initial tour, it was observed that four out of fifteen shared bathrooms in the 400-hall did not have a call light string attached to the call light system. This deficiency was noted in the bathrooms of several residents, including Resident #7, who had a cognitive communication deficit, repeated falls, muscle wasting, and dementia. The resident required maximal assistance for toilet transfer and moderate assistance for toilet hygiene, yet the bathroom lacked a pull cord, preventing the resident from calling for help if needed. Observations over several days confirmed the absence of pull cords in the bathrooms, and interviews with staff revealed that the issue had not been reported to maintenance. Certified Nursing Assistant (CNA) #18 and Licensed Practical Nurse (LPN) #19 both acknowledged the missing pull strings and stated that such issues should be logged in the maintenance log at each nurse's station. However, a review of the facility's Maintenance Request log showed no entries related to call light strings for the 400 hall, indicating a lapse in communication and reporting. The Director of Nursing (DON) confirmed the importance of having call light strings in place for residents to activate when assistance is needed. Despite this, the facility did not have a policy for call lights, which contributed to the oversight. The Maintenance Director was unaware of the missing pull strings until the survey and was in the process of addressing the issue. This lack of a systematic approach to ensuring the functionality of call light systems in resident bathrooms led to the deficiency identified by the surveyors.
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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.
Illustrative
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Nursing homes near Conway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Conway Rehab & Nursing Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Conway Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 8 | 0 |
| Salem Place Nursing And Rehabilitation Center, Inc | 1.7 mi | ★★★★★ | 5 | 0 |
| Superior Health & Rehab, Llc | 3.4 mi | ★★★★★ | 6 | 0 |
| Greenbrier Nursing And Rehabilitation Center | 10.1 mi | ★★★★★ | 0 | 0 |
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