Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Health Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke sequelae, depression, and dependence on staff for ADLs experienced an unwitnessed fall while attempting to self-toilet and was found sitting on the floor by the bed. Instead of assisting the resident up, an RN/LPN changed the resident’s socks and instructed the resident to turn, get onto hands and knees in a “prayer position,” and pull up from the floor into bed without staff assistance, reportedly stating this was to “teach a lesson” about falls. The resident later reported feeling angry and very embarrassed by the interaction, while other staff stated they would have assisted a resident from the floor and followed fall protocol.
The facility failed to ensure proper reconciliation and regular counting of controlled substances, including overflow narcotics, which led to the discovery that 12 hydrocodone tablets were missing for a resident. A CMA and an LN found only 18 tablets in an overflow bottle that was documented as containing 30, and the LN altered the count on the narcotic sheet without promptly notifying administration, while the CMA delayed reporting the discrepancy until the next day. The hydrocodone had been received from a third-party pharmacy and locked in overflow storage without an initial pill count at the time the narcotic sheet was created, and no further counts were performed for several days until staff attempted to refill the med cart and identified the shortage.
Surveyors identified unsanitary conditions in food preparation and storage areas, including soiled equipment, undated and unlabeled food items, improper thawing of meat at room temperature, and food debris on surfaces and carts. These actions did not comply with facility policies for sanitation and food safety.
Surveyors observed that all dumpsters outside the kitchen were left open with trash scattered around them, and this condition persisted over multiple observations. Dietary staff confirmed that dumpsters were supposed to remain closed, and facility policy required covered dumpsters and clean surrounding areas to prevent insect or rodent attraction.
The facility did not ensure that controlled substances on a medication cart were properly reconciled by two staff members at shift changes, as required by policy. Documentation showed missing signatures and incomplete verification, with staff confirming that both outgoing and incoming personnel should sign off on the narcotic count.
Surveyors found that a medication cart was left unlocked and unattended, containing various medications including narcotics, and that insulin vials and pens in a treatment cart were either expired or not dated when opened. Staff interviews confirmed that carts should be locked and insulin pens dated, but these practices were not consistently followed, contrary to facility policy.
A resident with panic disorder and depression was prescribed multiple psychotropic and antipsychotic medications without documented informed consent. Facility policy required that residents or their representatives be informed of the benefits, risks, and alternatives before starting such medications, but this was not done in this case.
Two residents were discharged or transferred from the facility without the required notification to the state Ombudsman, as confirmed by record review and staff interview. One resident had severe cognitive impairment and was discharged to the community, while another with CHF and moderate cognitive impairment was transferred to a hospital. Documentation of Ombudsman notification was missing in both cases.
A resident with multiple complex medical conditions, including a pressure ulcer and dependence on staff for ADLs, did not receive scheduled bathing assistance as required. Documentation showed only one shower was provided in a month, with no refusals recorded, despite the resident's requests for showers and facility policy requiring regular bathing and documentation. Staff interviews confirmed the expectation for regular bathing and proper documentation, but these were not met for this resident.
Two residents with pressure ulcers did not receive wound care and assessments in accordance with professional standards, as weekly nurse skin assessments were either missing or lacked required measurements and descriptions. Nursing staff confirmed that wound assessments should include measurements and detailed descriptions, but these were not documented, and the facility did not provide a policy for pressure ulcer monitoring.
Staff did not consistently clean, date, or properly store nebulizer equipment for several residents receiving breathing treatments. Equipment was observed left open to air on furniture, not dated, and not stored in bags as required by facility policy. Residents and staff confirmed that proper cleaning and storage procedures were not followed.
Resident Required to Self-Lift After Fall, Causing Anger and Embarrassment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when a licensed nurse required the resident to get up from the floor without assistance after an unwitnessed fall. The resident had a history of cerebral infarction with sequelae and depression, used a wheelchair and walker, and required staff assistance with all ADLs, including transfers and toileting. His care plan identified him as at risk for falls related to weakness and high‑risk medications and directed staff to carry out all interventions to prevent falls and to provide partial to moderate assistance with toilet use, transfers, and bed mobility. Despite these documented needs, after the resident experienced an unwitnessed fall while attempting to self‑toilet and was found sitting on the floor leaning against his bed, staff did not physically assist him up. Nursing documentation showed that staff replaced the resident’s slick socks with gripper socks and slippers, then encouraged him to turn around, get on his knees, and pull himself up from the floor into bed. Official statements recorded that a CMA heard the nurse state she made the resident remain on the floor “to teach him a lesson” while she completed tasks and then made him get off the floor without assistance. Another statement documented that the resident reported the nurse told him to get into a “prayer position” and pick himself up, and that she was upset and argued with him about how many falls he had. During interview, the resident confirmed that the nurse instructed him to get into a praying position and get himself off the floor without her assistance, which made him feel angry and very embarrassed. Other staff interviewed indicated that they would have assisted a resident up from the floor and notified the nurse, and administrative staff characterized the nurse’s actions as inappropriate.
Failure to Reconcile Overflow Narcotics Resulting in Missing Hydrocodone
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper narcotic reconciliation, including regular counts of all controlled substances and those stored as overflow, which resulted in missing hydrocodone tablets for a resident. The facility reported that staff discovered 12 hydrocodone tablets were missing after a discrepancy was identified between the documented count and the actual number of pills in the bottle. The narcotic dispensing record for the resident’s hydrocodone showed that a count of 30 tablets had been crossed out and changed to 18, with the change initialed by two individuals and dated and timed, followed by documentation that one tablet was administered, leaving a remaining count of 17. According to witness statements, a CMA requested assistance from an LN to obtain hydrocodone from the overflow cabinet to refill the medication cart. When they counted the pills in the overflow bottle, they found only 18 tablets, while the narcotic count sheet indicated 30. The LN then corrected the count on the sheet from 30 to 18 without immediately notifying administration of the discrepancy, and the CMA also delayed reporting the error until the following day. The facility’s investigation determined that when the hydrocodone was originally picked up from a third-party pharmacy and placed in the overflow cabinet, the LN who secured the medication created a narcotic count sheet but did not count the contents of the bottle at that time. The investigation further documented that the hydrocodone bottle was not recounted between the initial correct count performed later that same day by two LNs and the subsequent count several days later when the 12 missing tablets were discovered. During this period, no additional counts of the overflow narcotics were performed, and the discrepancy was only identified when staff attempted to move the medication from overflow storage to the medication cart. The facility’s failure to consistently perform and reconcile narcotic counts, including for overflow medications, and the delay in reporting the discrepancy by involved staff, led to the identification of missing hydrocodone tablets for the resident.
Failure to Maintain Sanitary Food Preparation and Storage Conditions
Penalty
Summary
Surveyors observed multiple failures in food preparation and storage practices that did not meet sanitary standards. During a kitchen tour, they found a heavily soiled microwave, window areas with dried-on food and liquid, and a stationary can opener with moist food residue. The preparation table and a three-tiered cart used for breakfast had food debris, and several plastic containers for condiments and baking ingredients were grimy and sticky. A large roast was found thawing at room temperature, contrary to facility policy. In the reach-in refrigerator, several opened food items, including sour cream and liquid eggs, were undated, and containers of peaches, mayonnaise, and mustard had dried-on food substances. Spilled salsa contaminated other items and surfaces in the refrigerator. In the dining room snack area, the counter and snack cart were sticky and dirty, with food debris and grime on the cart wheels. The resident refrigerator/freezer contained multiple opened and undated or unlabeled food items, including mixed fruit, sodas, shakes, and ice cream, with some items having exploded in the freezer. Dietary staff confirmed improper thawing practices and acknowledged the need for correction. Facility policies required regular cleaning and proper labeling and dating of foods, as well as approved thawing methods, which were not followed in these instances.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During an environmental tour of the kitchen, surveyors observed that the lids to all three dumpsters located outside the kitchen were left open, with trash present on the ground around the dumpsters. These observations were made at two separate times on the same day, confirming that the issue persisted. Further interview with dietary staff confirmed that staff were expected to keep dumpster lids closed at all times. Review of the facility's policy indicated that dumpsters should be kept covered when not being loaded and that the surrounding area should remain clean to minimize debris and the attraction of insects or rodents.
Failure to Reconcile Controlled Substances on Medication Cart
Penalty
Summary
The facility failed to properly reconcile controlled substances on the medication cart, as required by policy. Specifically, review of the controlled substance reconciliation log for the east hallway cart showed that on one occasion, only the day shift nurse signed off, with no evidence of a second staff member verifying the count. Additionally, there was no documentation or signatures indicating that a reconciliation was completed for a subsequent shift. Interviews with a Certified Medication Aide and an administrative nurse confirmed that the expectation is for two staff members to count and verify controlled substances at each shift change, in accordance with facility policy. The lack of dual verification and missing signatures on the reconciliation log demonstrated a failure to follow established procedures for controlled substance accountability.
Failure to Secure and Label Medications and Insulin in Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, storage, and security of drugs and biologicals. An unlocked and unattended medication cart was found in the east hall, containing various medications including Talzenna, Gabapentin, and narcotics stored in a lock box. Additionally, the east treatment cart contained an opened Novolog insulin vial that had expired, as well as Tresiba and Lantus insulin pens that were not dated when opened, making it impossible for staff to determine their expiration. Interviews with staff confirmed that medication carts should be locked when unattended and that insulin pens are expected to be dated upon opening, in accordance with facility policy. The facility's policy also requires all medications and biologics to be kept in locked compartments, with scheduled two medications under double lock, but these procedures were not consistently followed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments, specifically regarding the use of psychotropic and antipsychotic medications. Record review revealed that a resident with diagnoses of panic disorder and depression was prescribed multiple psychotropic medications, including duloxetine, risperidone, and trazodone, for depression, resistant depression, and insomnia. However, the electronic medical record did not contain documentation of informed consent for these medications. An administrative nurse confirmed that it was the facility's expectation for staff to obtain psychotropic drug consents prior to medication initiation. The facility's policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives before starting or increasing psychotropic medications. Despite this policy, there was no evidence that informed consent was obtained for the resident's psychotropic and antipsychotic medications.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the state Ombudsman of the discharge or transfer of two residents, as required by facility policy. One resident with severe cognitive impairment was admitted with the goal of discharging to the community and was later discharged accompanied by family, but there was no documentation in the electronic medical record (EMR) that the Ombudsman was notified of this discharge. Social Services staff confirmed that the Ombudsman had not been notified as required. The facility's policy states that the Ombudsman, along with the resident and their representative, must be notified of emergency transfers or discharges. Another resident with a diagnosis of congestive heart failure and moderately impaired cognition was discharged to a critical access hospital. The EMR for this resident also lacked documentation of Ombudsman notification regarding the discharge. Upon request, the facility was unable to provide evidence that the Ombudsman had been notified for either resident. The deficiency was identified through interviews and record reviews, which confirmed the lack of required notifications.
Failure to Provide Required Bathing Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs), including bathing, did not receive the necessary assistance with bathing. The resident had multiple diagnoses, including a cutaneous abscess, COPD, end stage renal disease, a periprosthetic fracture, a Stage 2 pressure ulcer, and anxiety disorder. Documentation in the electronic health record and shower sheets showed that the resident received only one shower during the month of July, with no documented refusals for bathing. The care plan and assessments indicated the resident required staff assistance for bathing and other ADLs, and the facility policy required staff to provide and document bathing or refusals. Observations confirmed that the resident was dependent on staff for mobility and hygiene, and interviews with the resident and staff revealed that the resident had requested showers but did not receive them as scheduled, resulting in the resident having to perform bed baths independently. Staff interviews confirmed that bathing was to be offered at least twice weekly, and refusals were to be documented, but there was no evidence of refusals or consistent bathing provided. This failure to provide necessary ADL care was based on direct observation, record review, and interviews.
Failure to Provide Proper Pressure Ulcer Assessment and Documentation
Penalty
Summary
The facility failed to provide necessary wound care and services in accordance with professional standards of practice for two residents with pressure ulcers. For one resident with multiple diagnoses including COPD, hypothyroidism, and a Stage 3 pressure ulcer, the care plan directed weekly skin assessments and wound care per facility guidelines. However, electronic health records showed that weekly nurse skin assessments were either not performed or lacked required wound measurements and descriptions. There was also a delay in initiating the weekly assessments, and some assessments were missing entirely. The facility did not provide a policy related to pressure ulcer monitoring. Another resident, diagnosed with mild protein-calorie malnutrition and cachexia, was admitted with two Stage 2 and one Stage 3 pressure ulcers. The care plan directed weekly skin assessments but did not specify preventative measures for pressure sores. Physician orders were in place for wound care, but documentation in the electronic medical record lacked evidence of wound measurements, wound bed evaluation, and effectiveness of treatments. Weekly skin assessments and skilled evaluations failed to include measurements or descriptions of the wounds. Interviews with nursing staff and administrative nurses confirmed that wound assessments were supposed to include measurements and detailed descriptions, but these were not documented. Staff were unable to determine the healing status of the wounds due to incomplete documentation. The facility did not provide a policy related to pressure ulcer monitoring, and the lack of proper documentation and assessment placed the residents at risk for complications and delayed healing.
Failure to Maintain Sanitary Storage and Cleaning of Nebulizer Equipment
Penalty
Summary
Facility staff failed to implement sanitary storage and maintenance of nebulizer breathing treatment devices for multiple residents. Observations revealed that nebulizer equipment, including tubing and masks, was left open to the air on chairs and bedside tables, not dated, and sometimes placed on paper towels to dry but not stored in a sanitary manner. In several instances, the equipment was attached to machines sitting on the floor or chair, and there was no evidence of proper cleaning or dating. Residents reported that their nebulizer equipment was regularly left out in this manner, and one resident stated that his nebulizer had not been rinsed out since his admission. Interviews with staff confirmed that nebulizers and oxygen tubing should have been dated, cleaned after each use, and stored in a bag once dry, in accordance with facility policy. However, observations and resident reports indicated that these procedures were not consistently followed. The facility's own policy required cleaning, disassembly, rinsing with sterile or distilled water, air drying, and storage in a zip lock bag, but these steps were not observed in practice for the residents sampled.
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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 Chanute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Chanute | 1.1 mi | ★★★★★ | 19 | 0 |
| Medicalodges Iola | 18.1 mi | ★★★★★ | 7 | 0 |
| Yates Operator, Llc | 19.7 mi | — | 0 | 0 |
| Prairie Mission Retirement Village | 20.4 mi | ★★★★★ | 0 | 0 |
| Neodesha Care And Rehab | 20.5 mi | ★★★★★ | 21 | 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.