Heritage Care Center: Hospice Enrollment Failure - MO
The resident had arrived at Heritage Care Center, a nursing home at 4401 North Hanley Road in St. Louis, following a hospital discharge on July 14, 2025. The hospital discharge orders included a hospice assessment referral. The facility's physician reviewed those orders on July 18 and assumed, based on what he read, that hospice enrollment had been completed. It had not.
The reason it had not: the facility had been unable to obtain signatures from the next of kin. That administrative obstacle was never resolved. No one followed through. No one documented in the medical record that the resident remained unenrolled. And for the next twelve days, the resident, who was rarely understood when she spoke, had moderate cognitive impairment, and needed staff assistance to eat, move, and bathe, received care under the assumption that a hospice team was involved in managing her decline.
The physician said so himself when inspectors interviewed him on September 4. He had assessed the resident on July 18 and believed she was on hospice from that point forward. He did not recall being contacted about her deteriorating condition on July 30. He said he expected nursing assessments and vital signs to be documented in the medical record. They were not, at least not on that final day.
On July 24, a social worker noted that the hospice team had been contacted about the referral and learned it had been closed. A new referral would be sent to a different provider. No further progress notes in the record documented whether that new referral ever resulted in enrollment.
The next morning, July 25, a nurse found the resident lying on the floor next to her bed. The resident said she had rolled out. No injuries were noted. A message was left with the physician. That afternoon, a fall mat was ordered because of what the notes described as a decline in mental and physical status.
Five days later, on the morning of July 30, Licensed Practical Nurse G arrived for the 7:00 A.M. shift and received a report from the night nurse. The night nurse said the resident was not doing well, was believed to be on hospice, and that attempts to reach the next of kin had been unsuccessful.
LPN G assessed the resident. She appeared very ill. Her blood pressure was low. Her breathing was irregular. Her oxygen saturation was low. LPN G tried to reach the family and could not. She contacted the physician about the change in condition. She did not recall what the physician said, except that she should keep the resident comfortable.
Then, sometime around noon, LPN G reviewed the record to look up the hospice provider. What she found was that the resident had never been enrolled in hospice at all.
She did not call the physician back to tell him.
She wrote her assessment findings and the vital signs on a piece of paper. She later told inspectors she forgot to enter them into the medical record.
The resident died at 4:39 that afternoon. The physician was at the facility when it happened. He certified the cause of death as COPD. The family was called and could not be reached.
When inspectors interviewed the physician in September, he said that if staff had discovered the resident was not enrolled in hospice, he should have been notified. His response to that situation would have been direct: he would have sent the resident to the hospital for evaluation and treatment. He also noted that the resident had a history of refusing care, and that if she had refused hospice services, that refusal should have been documented in the medical record. It was not.
The facility's administrator and Assistant Director of Nursing confirmed to inspectors that the resident was not enrolled in hospice at the time of death. They said the enrollment had stalled because of the signature issue with the next of kin. They acknowledged that once staff became aware the resident was not enrolled, the nurse should have notified the physician. They acknowledged the physician might have elected to send the resident to the hospital. They acknowledged that all assessments and vital signs belong in the medical record.
What the inspection report does not contain is any explanation of why the signature problem, identified at least as early as the social work note on July 24, was never escalated to the physician or resolved in the six days before the resident died. The physician who believed she was on hospice was at the same facility on July 30 when she died. He certified her death. He did not know, until federal inspectors asked him about it more than a month later, that she had never received the services he thought were surrounding her.
The federally mandated assessment completed on July 19, one day after the physician's visit, documented the full weight of what this resident was carrying: lung cancer, dementia, heart disease, severe protein malnutrition, moderate cognitive impairment, and a need for staff help with every basic function. The same assessment checked "No" to the question of whether the resident had a life expectancy of six months or less, even as the physician's notes from the day before described her condition as end-stage COPD with exacerbation, and even as the facility was simultaneously attempting to arrange hospice care for her.
The inspection, prompted by a complaint, was completed September 9, 2025. CMS cited the deficiency at a level of minimal harm or potential for actual harm, affecting a few residents.
The physician was at the facility when she died. He signed the death certificate. He thought hospice had been there all along.
Nobody had told him otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Care Center from 2025-09-09 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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
HERITAGE CARE CENTER in SAINT LOUIS, MO was cited for violations during a health inspection on September 9, 2025.
The resident had arrived at Heritage Care Center, a nursing home at 4401 North Hanley Road in St.
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.