Heritage Care Center
HERITAGE CARE CENTER in SAINT LOUIS, MO — inspection on September 9, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the facility's Resident Trust policy, dated 6/12/25, showed Resident Trust clerk must reconcile the cash left in the box with the receipts in the box by completing the Resident Trust Petty Cash Reconciliation Form.
Attach all receipts in the petty cash box to the Resident Trust Petty Cash Reconciliation form.
The administrator signs reconciliation form for approval.
Review of the facility-maintained bank statements for the months 4/25 through 7/25, showed no documentation of reconciliations.Review of the facility-maintained attempted reconciliation forms, dated 4/25 through 7/25, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of the attempted reconciliation.Observation and interview on 9/5/25 at 11:40 A.M., showed the Business Office Manager (BOM) counted the resident petty cash that was in the safe.
The cash totaled $163.00.
The BOM said he/she had been at the facility since July, 2016 and he/she did not know if the petty cash was accounted for on the reconciliation on the bank statement.
The corporate office determines the set amount of petty cash that is withdrawn at the beginning of each month which is added to the existing petty cash.
The BOM counts the resident petty cash every time he/she replenishes the cash.
The BOM said the petty cash comes from the resident trust.
There is running total on the petty cash sheet for tracking.
The BOM said he/she has never had over $4,000.00 cash on hand and does not know why the bank reconciliation reports showed cash on hand in the amount of $6,626.00 in May 2025, $16,971.00 in June and $16,941.00 in July 2025.
During an interview on 9/8/25 at 11:53 A.M., the Activity Director (AD) said every morning, he/she counts the petty cash envelope with the BOM, verifying the cash balances with the receipt book.
The AD said each individual withdrawal with the resident signature is recorded in the receipt book. At the end of the day, the petty cash envelope cash is reconciled with the BOM and AD.
During an interview on 9/5/25 at 11:45 A.M., the Corporate Business Office Manager (CBOM) said he/she expected the petty cash to be accounted for on the monthly reconciliation sheet and the actual cash itself is counted and documented to ensure accuracy.
The petty cash is residents' money.
During an interview on 9/9/25 at 9:45 A.M., the Administrator said she expected the facility to ensure the resident trust fund account is reconciled each month.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
265534 09/09/2025
Heritage Care Center 4401 North Hanley Road Saint Louis, MO 63134
Observation on 9/3/25 at 1:24 P.M., and on 9/5/25 at 2:47 P.M., of bedroom and bathroom A-10, showed the floor was dirty and sticky upon walking. In addition, in the bathroom, the baseboard was pulled out from the wall on the bottom left-hand side and the plaster was peeled away from the wall on the top right-side corner above the sink. 3.
Observation on 9/3/25 at 1:46 P.M., and on 9/5/25 at 2:50 P.M., of room A-7, showed the floor was dirty and sticky upon walking. In the bathroom, the paint was peeled away from the wall behind the commode.
- Observations on 9/3/25 at 2:17 P.M., and on 9/5/25 at 2:56 P.M., of room B-4, showed the floor
was dirty and sticky upon walking. In in addition, the baseboard was pulled away from the wall behind the bedroom door. 5.
Observation on 9/3/25 at 10:41 A.M., showed the floors of room D-3 were sticky upon walking and what appeared to be an opaque, dirty film on the tiles near the doorway. 6.
Observation on 9/3/25 at 11:09 A.M., near the D-hall entrance, showed a broken ceiling tile above the doorway to the beautician's office, leaving an approximate 5 inch by 7 inch gap, exposing the electrical wires and space above the ceiling tiles. 7.
During an interview on 9/8/25 at 9:30 A.M., the Maintenance Assistance (MA) said the staff fills out the facility's work order sheet when repairs are needed.
Once the staff completes the form, the form is placed in the wall mounted box that is located at the entrance of each hall.
The MA said every morning he gathers all the completed forms so the issues can be address.
The MA said due to budget cuts, the supplies needed to make the repairs are slow.
265534 09/09/2025
Heritage Care Center 4401 North Hanley Road Saint Louis, MO 63134
12:50 P.M., the Administrator said the resident had a resident to resident earlier that day. He/She was
smoke with the other residents.
His/her 1:1 staff, Floor Tech N, was behind him/her.
The resident
in his/her head and pulling his/her hair.
Floor Tech N pulled the resident off CNA O. By that time, she heard some noise, maybe a code green call, so she went to the hall and staff were there.
Floor Tech N was walking down the hall.
She told staff to get residents into their rooms.
Normally, they would have had a de-escalator.
Floor Tech N was supposed to have deescalated the situation, which was include making sure everyone was safe, de-escalate, making sure the resident was safe, and making sure nothing was in the way.
Floor Tech N was more focused on the resident getting off the unit and wasn't following her directive (to de-escalate).
She told Floor Tech N to get his/her family member off the hall but deescalate and make sure all the residents were in their rooms.
Floor Tech N finally followed the directive. By that time, she had told the staff to let the resident have the hall.
She told one of the nurses to call the Physician to get an IM for the resident. At that point, Floor Tech N said he/she would do what was asked and that what was to escalate.
The Administrator was the closet one to the resident.
The resident started hitting her in the head.
Mostly, the right side of her head and then when she leaned over to try to protect her face, he/she started hitting her on both sides of her head and other parts of her body.
The Administrator was yelling out to get the residents to their rooms.
Floor Tech N made sure his/her family member was off the unit and out the door.
Then he/she grabbed the resident's arms (wrist area) to stop the resident from hitting her.
After that, Floor Tech N tried to deescalate the resident, so he/she had the resident in a CPI hold by his/her wrists and walked him/her off the unit to the dining room area.
Floor Tech N never had the resident in a head lock.
She didn't think Floor Tech N did the CPI hold correctly.
The hold was correct although it would have normally been two people to do the hold.
Floor Tech N was terminated because he/she did not follow her directives regarding the de-escalation. It was her expectation for all the residents to be free from abuse and neglect. It is everyone's responsibility to ensure residents are free from abuse and neglect.
This would include leaders, managers, supervisors, directors as well as front line staff.2606143
265534 09/09/2025
Heritage Care Center 4401 North Hanley Road Saint Louis, MO 63134
Review of the facility's policy titled, Abuse and Neglect, dated 6/12/24, showed:-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent;-Theft of money from bank accounts;-Unauthorized or coerced purchases from resident's funds;-The Administrator will conduct all investigations. A formal investigation shall begin immediately and include interviews with all staff, interview facility residents and document that interviews were completed.
Review of Resident #20's Mental Status Exam, dated 8/18/25, showed:-No cognitive impairment;-Diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder, depression and dementia.
Review of the resident's Trust Statement, dated 6/30/25, showed: -On 4/10/25, a $500.00 cash withdrawal with description, money for shopping with family;-On 4/17/25, a $5,756.16 (invoice #81466) and $1,620.85 (invoice #82089) withdrawal with description, Resident Essentials Clothing.
Review of the Resident Essentials Clothing invoice #81466, dated 4/17/25, showed:-Various sweatpants, shirts and other clothing items;-[NAME] two drawer nightstand for $550.00;-[NAME] five drawer chest for $1,260.00;-Home music system for $135.00;-Two twin bed sets for a total of $270.00;-Pep talk recliner for $945.00.
Review of the Resident Essentials Clothing invoice #82089, dated 4/30/25, showed:-Various t-shirts, socks and other clothing items;-Two comforters for a total of $170.00.
Observation on 9/8/25 at 3:30 P.M showed the resident sat on the edge of his/her bed with a large unopened box (24x18x24) marked Resident Essentials on the floor, in front of the closet and a blue roller walker.
There were black tote boxes filled with various t-shirts, sweatpants and tops.
There were numerous baseball hats laying around the room.
The style and color of the resident's bedding, dresser and nightstand were seen throughout the facility.
The Pep talk recliner, [NAME] nightstand, [NAME] dresser, twin bed sets, and comforters were not present.
Observation on 9/9/25 at 9:04 A.M., showed the home music system in the unopened box in the resident's room and the Pep talk recliner were located in room A15.
During an interview on 9/8/25 at 2:30 P.M., the resident said he/she did not give the facility permission to use his/her funds to make any purchases on his/her behalf.
The resident said he/she received some clothes and a recliner but requested those items be returned because he/she only wears Adidas clothing and the recliner was a waste of money.
The resident said he/she never received a new dresser, nightstand, twin bed sets and comforters.
During an interview on 9/8/25 at 3:30 P.M., the Business Office Manager (BOM) said when the corporate office reports a resident is over resources (Medicaid eligibility maximum resource is $5,909.25), he/she will ask the Certified Nurse Aides (CNA) what the resident needs, then will make those purchases on the resident's behalf.
The BOM said he/she remembers giving the resident $500 to go shopping with his/her family but forgot to have the resident sign the ledger receipt book.
The BOM said she did not speak to the resident prior to making purchases and was unaware the resident did not want the items or requested for the items to be returned.
During an interview on 9/9/25 at 9:30 A.M., the Administrator said she expected staff to follow the facility's patient withdrawal policy.
The resident must sign the receipt for all withdrawals.
The facility should not make purchases for a resident without first obtaining their permission and signature.
265534 09/09/2025
Heritage Care Center 4401 North Hanley Road Saint Louis, MO 63134
During an interview on 9/4/25 at 12:43 P.M., Licensed Practical Nurse (LPN) G said on 7/30/25 he/she started work at 7:00 A.M., and he/she received report from the night shift nurse.
The night shift nurse said the resident was not doing well, was on hospice and he/she attempted to reach the next of kin. LPN G said he/she assessed the resident, and he/she appeared very ill.
The resident had low blood pressure, irregular breathing and a low oxygen saturation. LPN G attempted to call the next of kin and was unable to speak to family. He/She contacted the physician regarding the change in condition, and did not recall what the physician said, except to keep the resident comfortable. LPN G reviewed the record for the hospice provider and when researched, LPN G discovered the resident had not been enrolled in hospice care. LPN G made the discovery around noon and he/she expired several hours later. LPN G did not call the physician back and notify him the resident was not on hospice services. LPN G wrote down the assessment and vital signs on a piece of paper and forgot to document the findings in the medical record.
During an interview on 9/4/25 at 12:23 P.M., the resident's physician said he assessed the resident on 7/18/25 and assumed the resident had been admitted into hospice services per review of the hospital discharge orders on 7/14/25. He did not recall if he had been contacted regarding the resident's change in condition on 7/30/25 and expected the nursing assessment and vital signs to be documented in the medical record. If the staff discovered the resident had not received hospice services, he should have been notified. He would have sent the resident to the hospital for evaluation and treatment.
The resident had a history of refusal of care, if he/she refused hospice services, it should have been documented in the medical record.
During an interview on 9/4/25 at 1:23 P.M., the Administrator and Assistant Director of Nursing (ADON) B said the resident's hospital discharge orders included hospice assessment orders.
The resident had not been admitted to hospice services related to obtaining signatures from the next of kin.
The resident was not enrolled in hospice services at the time of his/her death.
When staff became aware the resident was not enrolled in hospice, the nurse should have notified the physician.
The physician may have elected to send the resident to the hospital.
All assessments and vital signs should be in the medical records. 2591480
265534 09/09/2025
Heritage Care Center 4401 North Hanley Road Saint Louis, MO 63134
Review of the facility's census, showed 105 residents.
Review of the facility's staffing roster, showed the facility had a DON.
Review of the facility's handwritten RN coverage, received on 9/9/25, showed the RN Supervisor provided RN coverage on 9/3/25, 9/4/25, 9/5/25, 9/8/25, and 9/9/25.
During an interview on 9/3/25 at 10:52 A.M., the Administrator confirmed the facility had a full time DON.
During an interview on 9/9/25 at 12:25 P.M., Assistant Director of Nursing (ADON) B said the DON is on medical leave. He/She was unsure of when the DON would return.
The RN Supervisor was the interim DON to his/her knowledge, but he/she was not sure if the RN provided RN coverage or the interim DON.
During an interview on 9/9/25 at 12:41 P.M., the Administrator said the current DON was supposed to notify her of when he/she would return.
The RN Supervisor is the interim DON and he/she started last week. On 9/8/25 and 9/9/25, he/she provided RN coverage.
They did not have an interim DON on 9/8/25 and 9/9/25. RN staff from corporate also provide eight hours of coverage.
Some provide coverage every other weekend. It was discussed during their Quality Assurance and Quality Improvement (QAPI) meeting. It was discussed if the DON would be able to complete some tasks from home.
During an interview on 9/9/25 at 1:40 P.M., the RN supervisor confirmed he/she was the RN supervisor.
265534 09/09/2025
Heritage Care Center 4401 North Hanley Road Saint Louis, MO 63134
Review of the facility's Matrix (form used to track resident conditions and care needs), received on 9/3/25, showed:-Residents with diagnoses of Alzheimer's/Dementia: 20;-Hospice: 3;-Dialysis: 1;-Intravenous therapy: 1;-Indwelling catheter;-Post Traumatic Stress Disorder (PTSD)/Trauma: 7;-Insulin: 13;-Anticoagulant: 4;-Antianxiety: 24;-Antipsychotic: 85;-Antidepressant: 46;-Hypnotic: 5.
During the course of the survey process, problems were identified which included:-No full time Director of Nursing (DON);-No full time Social Worker or social service designee.
During an interview on 9/9/25 at 12:31 P.M., the Administrator said she is responsible for ensuring the facility assessment is completed.
She was supposed to do it but did not have maintenance or nursing information to add to the assessment.
The only thing that was documented in the facility assessment was who they were supposed to call or when to use another facility, and contact information.
She did not want to give a partial facility assessment. It was not a complete assessment.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.