Above 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 Grove Estates during CMS and state inspections, most recent first.
A cognitively impaired resident at risk for elopement left a facility unsupervised due to a door not being properly latched and staff failing to check an alarm. The resident was outside in cold weather for over an hour before being found in an Assisted Living building. The incident revealed lapses in supervision and alarm response procedures.
The facility failed to ensure agency staff received required communication training, relying on a contracted agency for education. A CNA and an LN lacked documented communication training, despite having other training. The facility had no policy for required education, risking impaired care and decreased quality of life for residents.
The facility failed to ensure agency staff received required training on resident rights, impacting care quality. Training records for an agency CNA and LN lacked documentation of resident rights training, though they had training in other areas like ANE and dementia. The facility relied on the agency for staff education and lacked a policy for required direct care staff training.
A resident with dementia and other conditions was transferred to a shower room in a manner that compromised their dignity. The resident, unable to sit upright, was pulled backward in a shower chair down the hallway, partially uncovered, contrary to the facility's dignity policy. Staff interviews confirmed this practice was inappropriate and against established guidelines.
A resident with dementia and COPD was at increased risk for respiratory infection due to improper storage of oxygen tubing. Observations showed the tubing was wrapped around a chair and draped over a concentrator instead of being stored in a provided bag. Staff interviews confirmed the expectation for sanitary storage, but the facility lacked a policy to ensure compliance.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring hemodialysis. Despite a care plan for monitoring the resident's arteriovenous access, records showed no consistent communication with the dialysis provider. Staff interviews revealed that communication sheets were not sent with the resident, and the dialysis provider did not always return them, contrary to the facility's policy.
Failure to Supervise Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident, who was at risk for elopement and falls, resulting in the resident leaving the facility unsupervised. The resident, who had severe cognitive impairment due to Alzheimer's disease and vascular dementia, was able to self-propel in a wheelchair through a hallway to a locked door with a keypad. The door was not properly latched, allowing the resident to exit the building through a set of double doors, which triggered an alarm at the nurse's station. However, the staff turned off the alarm without checking the door, allowing the resident to remain outside in cold weather for over an hour. The resident was eventually found in the dining room of the Assisted Living building, having traveled across a parking lot and through snow in temperatures ranging from 22 to 23 degrees Fahrenheit. The resident was dressed inadequately for the weather, wearing only a short-sleeved T-shirt, sweatpants, socks, and shoes, and was reported to be cold to the touch upon return to the facility. The resident's vital signs indicated a low body temperature, but no signs of hypothermia were observed. The incident highlighted a failure in the facility's response to door alarms and supervision of residents at risk for elopement. Interviews and investigations revealed that the door the resident exited through had not latched properly, and the nurse on duty deactivated the alarm without verifying the source. The facility's policy required staff to immediately check the source of any door alarm before deactivating it, which was not followed in this case. The facility's failure to adhere to its elopement prevention procedures and ensure the security of exit doors placed the resident in immediate jeopardy.
Removal Plan
- A new elopement risk assessment was completed for the resident.
- The nurse involved received corrective actions for not following elopement procedures and received education.
- Maintenance assessed and adjusted the door and checked door alarms.
- Staff education on policy, elopements, and door alarm response was completed.
- A QAPI meeting related to elopements was completed.
- Signs posted on door alarm mechanism at each nursing station to ensure all alarms are on and reminder that under no circumstances will an alarm be turned off until the source of the activation has been determined completed.
- An all-staff in-service completed.
- Reviewed elopement risk posters to ensure all were up to date and completed.
- The resident's care plan was updated to include interventions and monitoring of wandering completed.
Failure to Ensure Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required communication training, which is essential for providing quality care to residents. The facility had a census of 57 residents and relied on a contracted agency to provide necessary education for agency nursing staff. However, upon review, it was found that the credentialing files for an agency Certified Nurses Aid (CNA) and an agency Licensed Nurse (LN) lacked documentation of completed communication training. While the CNA had training in abuse, neglect, and exploitation (ANE), dementia, and infection control, and the LN had training in ANE and dementia, neither had documented communication training. An interview with the Administrative Nurse revealed that the facility did not ensure that the agency staff had the required education and training for direct care staff. Additionally, the facility was unable to provide a policy related to the required education for direct care staff, which contributed to the deficiency. This oversight placed residents at risk for impaired care and decreased quality of life.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 57 residents, failed to ensure that agency staff received the required training on resident rights, which is essential for providing proper care and maintaining the quality of life for residents. During a review of training records, it was found that the credentialing files for an agency CNA and an agency LN lacked documentation of completed training on resident rights. Although the CNA had received training in abuse, neglect, and exploitation (ANE), dementia, and infection control, and the LN had received training in ANE and dementia, neither had documented training on resident rights. An administrative nurse at the facility stated that the facility relied on the contracted agency to provide the necessary education for agency nursing staff, and admitted that the facility had not ensured that the agency staff had the required education and training for direct care. Additionally, the facility was unable to provide a policy related to the required education for direct care staff, leading to a deficiency in ensuring the completion of necessary resident rights training for staff providing care.
Failure to Maintain Resident Dignity During Transfer
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R41, during a transfer to the shower room. R41, who had diagnoses of dementia, COPD, and anxiety, was dependent on staff for activities of daily living and had severely impaired cognition. The resident's care plan specified a preference for evening showers twice weekly and required staff to break down tasks into manageable segments, maintain a routine, and provide reassurance. On the day of the incident, R41 was transferred from bed to a shower chair using a Hoyer lift by two CNAs. The resident was dressed in a gown open at the back and was unable to sit upright on the shower chair. Due to the unavailability of a bath bed, the CNAs attempted to reposition R41 on the shower chair and pulled him backward down the hallway to the shower room, with one CNA trying to prevent the resident's feet from dragging on the floor. Interviews with staff revealed that pulling a resident backward in a shower chair and transporting them uncovered in the hallway were against the facility's dignity policy. The policy emphasized maintaining residents' dignity by ensuring privacy and covering them during transport outside their rooms. Despite this, the staff did not adhere to the care plan or the dignity policy, resulting in a failure to treat R41 with respect and dignity. This incident placed the resident at risk for negative psychosocial outcomes and decreased dignity.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of oxygen tubing for a resident, identified as R41, which increased the risk of respiratory infection and complications. R41's medical history included dementia, chronic obstructive pulmonary disease (COPD), and anxiety, with severely impaired cognition and dependence on staff for activities of daily living. Observations revealed that the oxygen tubing and nasal cannula were improperly stored, being wrapped around a Broda chair and draped over an oxygen concentrator, rather than being placed in a provided black bag for sanitary storage. Interviews with facility staff, including a Certified Nurse Aide (CNA), a Licensed Nurse (LN), and an Administrative Nurse, confirmed that the expectation was for oxygen equipment to be stored in a sanitary manner, using bags or containers provided for this purpose. Despite this, the facility was unable to provide a policy related to the sanitary storage of oxygen equipment when not in use, highlighting a gap in ensuring proper procedures were followed to prevent contamination and potential health risks for the resident.
Failure to Ensure Communication with Dialysis Center
Penalty
Summary
The facility failed to establish a consistent form of communication between the facility and the dialysis center for a resident, identified as R3, who required hemodialysis. R3 had diagnoses of dependence on renal dialysis and end-stage renal disease, necessitating dialysis on Monday, Wednesday, and Friday. Despite having a care plan that required staff to monitor and assess R3's arteriovenous access for signs of infection or impairment, the facility's records from late May to early August lacked evidence of consistent communication with the dialysis provider. This deficiency was highlighted during interviews with facility staff, who acknowledged that communication sheets were not sent with R3 to the dialysis center, and the dialysis provider did not always return them. The facility's undated Hemodialysis Policy required coordination of care, including the transmission of information to and from the dialysis unit. However, the facility had stopped sending communication sheets due to the dialysis provider not returning them. This lack of communication placed R3 at risk of potential adverse outcomes and physical complications related to dialysis, as there was no consistent exchange of information regarding R3's condition before and after dialysis sessions.
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Illustrative
What surveyors actually found near you
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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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Illustrative
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Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brewster Health Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Tanglewood Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Providence Living Center | 3.7 mi | ★★★★★ | 52 | 1 |
| Lexington Park Nursing & Post Acute Center | 3.7 mi | ★★★★★ | 10 | 0 |
| Excel Healthcare And Rehab Topeka | 3.8 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.