Heritage Springs Memory Care.

“No staff person certified in First Aid and CPR was present in the home from 3:00 p.m. to 11:00 p.m. on 3/08/2026 when 28 residents were present, violating the requirement that at least one certified staff member be present for every 50 residents.”

“Staff Person A did not receive training in infection control and general principles of cleanliness and hygiene and areas associated with immobility during the 2025 training year.”

“Staff Person A did not receive training in resident rights or The Older Adult Protective Services Act during the 2025 training year.”

“The training record for Personal Care Services of the Resident and Falls and Accident Prevention completed on 11/20/2025 did not include the training source or the length of time of the course.”

“Narcotic count logs for two residents' LORAZEPAM prescriptions were not updated when medications were administered, creating discrepancies between the narcotic count log and medication cards. Resident #1's log showed 27 tablets but the card showed 26 tablets; Resident #2's log showed 6 tablets on 3/16/2026 but the card showed 5 tablets.”

“Resident #3 resides in the facility's Secure Dementia Care Unit, but the resident's record does not contain a "no objection" statement documenting that the resident and the resident's designated person have not objected to the admission or transfer.”

“Staff failed to immediately report suspected abuse to the Area Agency on Aging when a resident reported that a staff member forcibly removed their sweater, causing their hearing aids to fall off, after the resident asked the staff member to remove the hearing aids first.”

“The facility failed to immediately develop and implement a plan of supervision or suspend a staff member involved in an alleged abuse incident when a resident reported the staff member forcibly removed their sweater.”

“A resident was physically abused and mistreated when a staff member angrily commanded the resident to put their hand down multiple times and then forcibly removed the resident's sweater over their head, causing their hearing aids to fall off, despite the resident's request to remove the hearing aids first.”

“A resident's medical evaluation did not list a diagnosis of Alzheimer's disease or other dementia as required within 60 days prior to admission for placement in a secured dementia care unit.”

“Hot water temperature in resident accessible areas exceeded the maximum of 120°F, measuring 130.6°F in Room 125 and 131.5°F in Room 127.”

“Resident #1's Preadmission screening form did not indicate whether the facility could meet the needs of the resident.”

“Correction tape was observed on the Memory Care Controlled Substance Log for Resident #2's Haloperidol count sheet, violating the requirement that record entries be permanent and legible.”

“The posted Licensing Inspection Summary dated 4-15-24 included a resident privacy coding sheet, allowing resident confidential information to be accessible to anyone.”

“A resident tripped and fell in a common area, suffering a hematoma to the forehead and bruising on the chin and nose. Despite documented symptoms including extensive swelling, ecchymosis, eye swelling, breathing difficulty, and pain, the resident was not evaluated by a physician until several days after the fall, despite the home's obligation to assist residents in securing medical care when health status declines.”

“Staff members (dietary staff A and B) were overheard yelling and cursing in the kitchen on multiple occasions within earshot of residents in the dining room, violating the requirement that residents be treated with dignity and respect.”

“Two resident-home contracts did not contain verification that residents were educated on their right to question or refuse medications. The facility failed to document resident education regarding medication error concerns as required.”

“The home failed to report a resident's fall and hospital transport for a diagnosis within 24 hours to the Department's regional office as required.”

“A resident admitted to the home did not receive prescribed medications on the day of admission and medication administration was delayed until a later date, failing to follow the prescriber's orders.”

“A medication error occurred when a resident did not receive prescribed medications on the day of admission; this error was not immediately reported to the resident, the resident's designated person, and the prescriber.”

“The home did not maintain adequate staffing to meet resident needs during an emergency. On the night in question, only one staff person was present to supervise 30 residents in a secured setting, including residents requiring assistance with transfers and all residents needing cueing to evacuate during emergencies.”