Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Nursing Center - Skilled Nursing By Ameri during CMS and state inspections, most recent first.
A facility failed to ensure the resident call light system worked correctly and that call lights were kept within reach. Multiple residents were observed in bed with call lights lying on the floor, and call light panels on two halls showed activated lights without any audible alert. Staff and the DON were aware that the system did not always sound, and Resident Council minutes reflected complaints about unanswered call lights and delays in getting residents to the restroom.
The facility failed to maintain a safe, clean, and homelike environment when strong foul and stale odors persisted in common areas, hallways, and near the main entrance over multiple days. Staff acknowledged that odors lingered and were sometimes very strong, and one CNA did not report the issue, assuming others were aware. The Administrator attributed odors on one hall to male residents urinating on the floors when using the bathroom. This unresolved odor problem had the potential to affect all residents in the facility.
The facility failed to provide scheduled showers and bathing assistance to multiple residents who required substantial, maximal, or dependent help with ADLs, resulting in numerous missed showers over several weeks despite a policy requiring routine bathing. Several residents with conditions such as CVA with hemiplegia/hemiparesis, COPD, dementia, schizophrenia, heart failure, muscle wasting, fractures, depression, and anxiety were scheduled for showers one to two times per week but frequently did not receive them, with some missing nearly all scheduled opportunities. Hospice involvement in bathing for at least one resident was not clearly addressed in facility policy, and a CNA reported never bathing that resident because hospice was expected to do so. Residents reported not receiving showers twice weekly and sometimes not remembering their last shower, while leadership (the DON and Administrator) stated they expected residents to receive at least two showers per week and for any refusals to be documented.
The facility failed to complete a CBC for an employee before hire, despite its policy requiring CBCs on all new hires prior to starting work. Employee C's file showed a hire date with no documentation that the CBC was completed beforehand. The DON said she was responsible for CBCs and did not know how it was missed, and the Administrator said the pre-hire paperwork did not get to her.
Failure to follow physician orders for external catheter use. A resident with overactive bladder had orders for a PureWick only at bedtime, but observations showed it in place during the day while the resident sat in a recliner or lay in bed. CNAs said they applied it whenever the resident asked, and the DON stated staff did not notify the physician that the device was being used more often than ordered.
Failure to reconcile overflow narcotics on a medication cart affected a resident. An observation found hydrocodone/acetaminophen and gabapentin cards for the resident on the Northwest Hall cart, but the overflow narcotic count log had no documentation for either medication. An LPN and a CMT stated they did not reconcile overflow narcotic medications at each shift change, although the DON and Administrator expected all narcotics on the cart, including overflow medications, to be reconciled each shift.
The facility failed to maintain a safe and homelike environment, with observations revealing spider webs, dirt buildup, and maintenance issues like chipped tiles and non-functioning lights. Staff interviews indicated a lack of clear communication and documentation regarding maintenance responsibilities, contributing to unresolved issues.
A facility failed to complete a significant change MDS assessment for a resident admitted to hospice care. The facility's policy required care plans to be updated with significant change MDS assessments, but it did not specifically address the 14-day requirement following a change in health condition. As a result, the resident's care plan was not updated after their admission to hospice, contrary to the expectations of the MDS Coordinator, DON, and Administrator.
The facility failed to maintain a medication error rate below five percent due to improper insulin pen administration. LPNs did not prime insulin pens as required, affecting five residents. Observations and interviews revealed a misunderstanding of the priming procedure, leading to a medication error rate of 17.86%.
A facility failed to implement Enhanced Barrier Precautions and proper infection control during wound care and CVAD medication administration for a resident. An LPN did not wear a gown or perform necessary hand hygiene, and failed to use an antiseptic agent on the CVAD hub, contrary to facility policies. Interviews confirmed these lapses in protocol.
Call Light System Not Functioning Properly and Call Lights Left Out of Reach
Penalty
Summary
The facility failed to ensure the resident call light system was functioning correctly and that call lights were kept within reach of residents. The facility policy stated that call lights were to be available at each resident bedside, toilet, and bathing area, and that staff were to ensure the call light was within reach and accessible to residents in bed, at the toilet, and in bath or shower areas. The census was 48 residents. During observation, multiple residents were found in bed with their call lights lying on the floor and out of reach, including residents in several rooms on the North Hall. The call light indicator panel at the main nurses’ station showed activated lights for rooms on the North Hall, but no audible sound came from the panel. On the Homeward Bound Hall, the call light panel also showed activated lights without any audible sound, while staff were observed walking past the panel or sitting with their backs to it. The Administrator later activated a bathroom emergency call light in one room and observed the panel light activate without an audible sound. Resident Council meeting minutes reflected complaints about unanswered call lights, staff taking too long to get residents to the restroom, and call lights being on too long. Residents also stated that call lights and delays in answering them had been discussed at several recent Resident Council meetings. Staff interviews confirmed that the call light system did not always make an audible sound, that the issue had been present for some time, and that administration was aware of concerns about the lack of audible alerts and the need for visual monitoring outside resident rooms.
Failure to Maintain Odor-Free, Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not identifying and resolving the source of persistent, strong foul odors throughout multiple areas of the building. Surveyor observations over several days documented strong foul odors near the front entrance, in the commons area, and along the south and northwest halls at various times of day. These odors were repeatedly present despite the facility’s policy stating that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Staff interviews confirmed that odors lingered in the facility and were sometimes very strong. One CNA reported that there were odors at times and described a stale smell but did not report it to anyone, assuming all staff could smell it. The Administrator acknowledged being informed that day about strong odors in the facility and stated that the northwest hall smelled because some male residents urinated on the floors when using the bathroom. The ongoing presence of foul odors and the lack of effective action to locate and eliminate their source led to the deficiency, which had the potential to affect all 48 residents in the facility.
Failure to Provide Scheduled Showers and Bathing Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers and bathing assistance for multiple dependent residents in accordance with its own shower policy and schedules. The facility’s policy stated that residents would be assisted with bathing to maintain hygiene and would receive showers per request or facility schedule, with partial baths between regular showers. However, the policy did not address how showers or baths provided by hospice staff would be managed or monitored. Record review showed repeated missed showers and bed baths for six residents who required substantial, maximal, or dependent assistance with bathing and showers. One resident with a cerebrovascular event and hemiplegia/hemiparesis was dependent on staff for bathing and was scheduled to receive bed baths/showers from hospice staff twice weekly, but hospice shower sheets showed five missed baths/showers out of 13 opportunities. A CNA reported never having provided this resident with a shower or bath, stating that hospice performed the showers. Another resident with a right femur fracture, history of falls, depression, and anxiety, who required substantial/maximal assistance, was scheduled for showers twice weekly but missed 12 of 13 scheduled showers; the resident reported sometimes receiving assistance with bathing in bed or at the bedside table. A resident with COPD, depression, anxiety, Alzheimer’s disease, dementia, schizophrenia, and UTI, who required substantial/maximal assistance and had severely impaired vision, was scheduled for showers twice weekly but missed 11 of 14 scheduled showers. Additional residents with cerebrovascular events and hemiplegia/hemiparesis or with heart failure, muscle wasting, and stroke with hemiplegia/hemiparesis, who required partial to moderate or substantial/maximal assistance, also did not receive their scheduled showers. One resident scheduled for twice-weekly showers missed 12 of 14 opportunities and stated they did not receive showers twice a week. Another resident scheduled for twice-weekly morning showers missed all 14 scheduled showers and could not remember the last time they had a shower or bed bath. A further resident scheduled for twice-weekly showers missed 10 of 14 opportunities and reported being lucky to get one shower a week, stating staff told them it was not their shower day. The DON stated he expected residents to receive at least two showers a week, acknowledged that hospice residents did not receive regular showers except when there was an accident or need, and said missed documentation likely meant refusals, while the Administrator stated she expected at least two showers a week and for refusals to be documented.
Missed Pre-Hire Criminal Background Check
Penalty
Summary
The facility failed to follow its policy for criminal background checks by not completing a CBC for one employee before hire. The facility policy titled, Criminal Background Checks, stated that the facility representative was responsible for processing a criminal background check on each employee prior to the employee starting work, and that an applicant could begin work only after the information was received and no pertinent criminal history was indicated. Review of Employee C's personnel file showed a hire date of 11/06/25 with no documentation that the CBC was completed before the hire date. During interview, the DON stated she was responsible for doing the CBCs on employees and did not know how this one was missed. The Administrator stated the CBC should be checked on all new hires before they began work, that the DON was responsible for pre-hire paperwork, and that the paperwork did not get to her, but she did not know what happened in this case.
Failure to Follow Physician Orders for External Catheter Use
Penalty
Summary
The facility failed to follow physician's orders for one resident with a PureWick external catheter. The resident had a diagnosis of overactive bladder and orders dated 04/18/25 for a PureWick external catheter at bedtime, to be placed in the evening and removed in the morning. The facility's policy stated the interdisciplinary team would determine appropriate residents for external catheter use and the nurse would obtain and verify the physician's order for use of the external catheter. Observations showed the resident had the PureWick in place during the day on multiple occasions while sitting in a recliner and once while lying in bed. On 02/18/26, a CNA placed the PureWick in the morning while the resident was in a recliner. During interviews, the CNA said the catheter was placed every morning because that was what the resident wanted, and the resident stated the PureWick was worn anytime he/she was in the recliner or bed. The DON said the PureWick was only ordered for nighttime use, but the family and resident insisted it be in place at all times, and staff had not notified the physician that it was being used more often than ordered. Other CNAs stated they applied it during the day because the resident asked for it, and the Administrator stated the PureWick should be applied as ordered by the physician.
Failure to Reconcile Overflow Narcotics
Penalty
Summary
The facility failed to reconcile overflow narcotics for one observed medication cart, affecting Resident #16. During observation of the Northwest Hall medication cart, one card of hydrocodone/acetaminophen 10/325 mg with 30 tablets and one card of gabapentin 100 mg with 16 tablets were present for Resident #16. Review of the Northwest Hall Overflow Narcotic Count Log showed no documentation for either the 30 tablets of hydrocodone/acetaminophen or the 16 tablets of gabapentin. The facility policy titled Controlled Substance Administration and Accountability stated that two licensed nurses or a licensed nurse and a CMT account for all controlled substances and access keys at the end of each shift. During interviews, an LPN and a CMT stated they did not reconcile the overflow narcotic medications at each shift change. The DON and the Administrator stated they expected staff to reconcile all narcotic medications on the medication cart, including overflow narcotic medications, at each shift change.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as observed through multiple instances of neglect in various areas. Observations over several days revealed a buildup of spider webs and dirt on the vinyl ceilings and sides of the outside front entrance, exit doors near the therapy and laundry rooms, and other exit doors. Additionally, there were issues with the physical condition of the facility, such as deep-scraped exposed sheetrock, peeled paint, exposed wood, and scuff marks in various halls and common areas. Further observations highlighted maintenance issues in the assisted bathing rooms near Suites 113 and 114, where broken and chipped ceramic tiles, a buildup of dirt and debris, and non-functioning light fixtures were noted. The maintenance request forms from September to November 2024 showed no documentation of these concerns being addressed. Interviews with housekeeping staff and the Maintenance Supervisor (MS) revealed a lack of clarity and communication regarding responsibilities for cleaning and maintenance tasks, with staff often verbally reporting issues rather than using formal maintenance request forms. The Administrator acknowledged the expectation for staff to document environmental concerns on maintenance request forms to ensure timely resolution. However, the current practice of verbal communication led to unaddressed maintenance issues, contributing to the facility's failure to provide a safe and homelike environment for its residents.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who was admitted to hospice care. According to the facility's policy, care plans should be updated with significant change MDS assessments as per the Resident Assessment Instrument (RAI) manual. However, the policy did not specifically address the requirement to complete a significant change MDS within 14 days of a resident's change in health condition. This oversight led to the failure in updating the care plan for the resident who was admitted to hospice. Resident #4 was admitted to the facility on June 6, 2024, and later admitted to hospice on October 11, 2024. A review of the resident's MDS assessments revealed that no significant change MDS was completed on or after the resident's admission to hospice. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed that they expected a significant change MDS to be completed within 14 days of the resident's admission to hospice, which was not done in this case.
Failure to Prime Insulin Pens Leads to High Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 17.86% due to improper insulin pen administration. Observations revealed that Licensed Practical Nurses (LPNs) did not prime insulin pens as per the manufacturer's instructions before administering insulin to residents. This error was noted in the administration of Novolog, Humalog, and Fiasp insulin pens for five residents. The failure to prime the pens was consistent across multiple residents, indicating a systemic issue in following the correct procedure for insulin administration. The report highlights specific instances where LPNs administered insulin without priming the pens, as required by both the facility's policy and the manufacturer's instructions. Interviews with staff, including LPNs and the Director of Nursing (DON), confirmed a misunderstanding or lack of adherence to the priming procedure. The DON acknowledged that insulin pens should be primed with two units before each administration, contradicting the practice observed during the survey. This deficiency affected five residents out of the eleven sampled, contributing to the high medication error rate.
Failure to Implement Enhanced Barrier Precautions and Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper infection control practices during wound care and medication administration through a central venous access device (CVAD) for a resident. The facility's policy required the use of gowns and gloves for residents with wounds or indwelling medical devices, but this was not followed. During an observation, a Licensed Practical Nurse (LPN) did not wear a gown while accessing the CVAD line, despite signage indicating the need for gown and gloves. Additionally, the LPN did not adhere to proper hand hygiene protocols during wound care. The LPN prepared wound dressings without gloves and failed to perform hand hygiene at several critical points, such as after removing soiled dressings and before applying new ones. The LPN also did not use an antiseptic agent before attaching a syringe to the CVAD hub, which is against the facility's policy for intravenous therapy. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the expected procedures were not followed. The DON stated that gowns and gloves should always be worn for residents with EBP, and the RN outlined the correct process for wound care and CVAD access, which includes scrubbing the hub of the PICC line and performing hand hygiene after removing soiled dressings.
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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 Kennett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Kennett | 0.9 mi | ★★★★★ | 0 | 0 |
| Senath South Health Care Center | 8.2 mi | — | 0 | 0 |
| Rector Nursing And Rehab | 11.5 mi | ★★★★★ | 0 | 0 |
| Piggott Healthcare & Senior Living, Llc | 12.1 mi | ★★★★★ | 18 | 0 |
| Campbell Healthcare & Senior Living | 17.3 mi | ★★★★★ | 15 | 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.