Heritage Living Center: Suicide History Ignored - AR
A resident at Heritage Living Center died, and in the aftermath, the facility's own director of nursing told inspectors she thought she had known about the resident's prior suicide attempt but had let it slip from memory. "The resident did not have any signs or symptoms while here to remind us of the attempt," the director of nursing said during an interview on August 13, 2025.
Nobody had scheduled a psychiatrist.
The resident, identified in inspection records only as Resident 1, was admitted to the facility in February. According to the administrator in training, who had previously served as the facility's social director for five and a half years, she had worked directly with Resident 1 from February until June. The resident had a documented history of suicidal behavior. That history existed in the paperwork. The director of nursing acknowledged she had re-read it only after the incident.
When the resident died, a family member told the coroner that the resident had finally done it.
The director of nursing, recounting that detail to inspectors, said: "You would think if they felt that way, they would have said something to us or that the resident was capable of doing this and would have shared that with us at the facility. I do not know if it would have changed the outcome but at least we would have known it."
She already knew. She had simply stopped knowing.
The director of nursing told inspectors that staff at Heritage Living Center would not know whether a resident had a history of suicidal thoughts or prior attempts. They would only know of active diagnoses. A prior attempt, documented and sitting in the chart, did not function as a flag. It functioned as background noise, the kind of thing that could be read once and set aside, the kind of thing that required active symptoms to stay visible.
Resident 1 had no follow-up scheduled with a psychiatrist. The director of nursing explained the arrangement this way: the general doctors at the facility would handle care, and if they saw any issues, they would refer to a specialist. The trigger for a referral was a visible problem. A history was not a visible problem.
The administrator in training, who began that position in mid-June after more than five years as the facility's social director, had spent months working directly with this resident. What she knew about the resident's history, what she carried from that relationship into the transition of roles, is not detailed in the portion of the inspection report available. Her interview was still underway when the document was cut off.
Federal inspectors cited the facility under F0741, which covers mental health needs and behavioral health services. The level of harm was classified as minimal harm or potential for actual harm. A small number of residents were identified as affected.
That classification, minimal harm, applies to a situation in which a person is now dead.
The inspection was conducted as a complaint investigation. Someone prompted it. Someone outside the facility, or inside it, believed that what happened to Resident 1 warranted outside scrutiny. The report does not say who filed the complaint or when.
What the report does say is this: the director of nursing of a licensed nursing facility, responsible for the clinical oversight of every resident in her care, forgot that a person living under her roof had tried to die before. She remembered it after. She told inspectors she did not know whether remembering sooner would have changed anything.
The family already had their answer. They gave it to the coroner.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Living Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 20, 2026 · Our methodology
Heritage Living Center in Conway, AR was cited for violations during a health inspection on August 14, 2025.
"The resident did not have any signs or symptoms while here to remind us of the attempt," the director of nursing said during an interview on August 13, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.