Inspection Reports for
Heritage Square Healthcare Center
710 N. Ruddle Road, Blytheville, AR, 72316-2137
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to monitor and supervise a severely cognitively impaired resident (Resident #46) who eloped from the facility using an exit door code without staff knowledge.
Complaint Details
The complaint investigation found that Resident #46 eloped from the facility on 6/29/2024 using an exit door code without staff knowledge. The Immediate Jeopardy began on 6/29/2024 and was removed on 7/4/2024 after corrective actions were implemented. The incident was substantiated with witness statements and facility records.
Findings
The facility failed to prevent elopement of Resident #46, who exited the facility unsupervised and traveled approximately 250 feet away. Immediate Jeopardy was identified due to the risk of serious harm. Corrective actions including in-service training, secured unit placement, elopement risk assessments, and monthly exit code changes were implemented and verified by the survey team.
Deficiencies (1)
Failure to monitor and supervise severely cognitively impaired residents and ensure exit door codes were secured to prevent elopement for Resident #46.
Report Facts
Date of elopement incident: Jun 29, 2024
Distance resident traveled: 250
BIMS score at time of elopement: 6
BIMS score at time of survey: 15
In-service completion date: Jul 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Former Director of Nursing | Former DON | Notified of incident, completed assessment on Resident #46, initiated staff in-service |
| Restorative Certified Nursing Assistant #1 | RCNA #1 | Witnessed Resident #46 elopement, notified facility, confirmed in-service completion |
| Certified Nursing Assistant #4 | CNA #4 | Assisted Resident #46 back to facility after elopement |
| Nurse Manager | Nurse Manager | Confirmed Resident #46's improvement and lack of exit seeking behaviors |
| Administrator | Administrator | Informed of Immediate Jeopardy, stated facility changes exit codes monthly and supervises Resident #46 |
Inspection Report
Deficiencies: 1
Date: May 8, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a person-centered care plan for a resident using restraints.
Findings
The facility failed to develop and implement a comprehensive care plan for Resident #72 that included the use of a wheelchair seat belt restraint, despite the resident's documented need and request for it due to muscle spasms causing falls. The care plan did not reference the seat belt as an intervention to prevent falls.
Deficiencies (1)
Failure to develop a comprehensive care plan that was correct for Resident #72 for restraints.
Report Facts
Residents Affected: 1
Brief Interview for Mental Status (BIMS) score: 15
Date of Nursing Restraint Evaluation: Apr 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding care planning and restraint use |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 14, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, environment, and facility operations at Heritage Square Healthcare Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, including issues with scraped and blotchy paint on walls and presence of dead insects. Deficiencies were also noted in care planning for oxygen use, failure to maintain oxygen flow rates per physician orders, inadequate personal hygiene care including shaving and nail care for some residents.
Deficiencies (6)
Walls in multiple resident rooms had scraped paint, blotchy and missing paint, and exposed sheetrock.
Floors were not clean and had dead roaches beside medical equipment.
Resident #21's care plan did not include oxygen use despite documented oxygen therapy.
Resident #21 received oxygen at incorrect flow rates, not consistent with physician orders.
Resident #1 was not shaved as needed; razors were available but not used timely.
Residents #39 and #61 had long, jagged, and dirty fingernails and toenails, indicating inadequate nail care.
Report Facts
Residents sampled: 8
Residents sampled: 28
Residents sampled: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #2 | CNA | Named in shaving deficiency for Resident #1 |
| Licensed Practical Nurse #1 | LPN | Named in oxygen flow rate monitoring and nail care deficiencies |
| Director of Nursing | DON | Interviewed regarding razors availability and shaving care |
| Assistant Director of Nursing | ADON | Interviewed regarding nail care responsibilities |
| Housekeeper #1 | Housekeeper | Interviewed regarding cleaning and presence of dead roaches |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding paint condition and maintenance activities |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental issues and maintenance process |
Inspection Report
Routine
Deficiencies: 10
Date: Dec 21, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication administration, infection control, and staff vaccination status.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy with unsecured electronic health records, incomplete and untimely care plans for residents, inadequate personal hygiene care, improper medication administration with errors, unsecured medications, failure to monitor and prevent pressure ulcers, lack of physician orders for tracheostomy care, unsafe smoking practices, and incomplete COVID-19 vaccination among staff.
Deficiencies (10)
Failed to ensure privacy and confidentiality of residents' medical records; computers with resident EHRs were left unlocked and visible to unauthorized persons.
Failed to develop comprehensive person-centered care plans addressing all resident needs, including pressure ulcer prevention and hospice services.
Failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene for dependent residents.
Failed to ensure PICC line dressing was changed weekly to prevent infection; dressing was last changed in hospital and was overdue.
Failed to provide appropriate pressure ulcer care and prevent new ulcers; resident developed a stage 3 pressure ulcer that was not monitored or documented timely.
Failed to ensure safe smoking practices and proper storage of tobacco products; resident smoked unsupervised without required apron and kept tobacco on person.
Medication error rate exceeded 5%; three medication errors observed including wrong aspirin form, incorrect vitamin D dosage for two residents.
Failed to ensure medications were locked and secured properly; medication cart left unattended with medication accessible.
Failed to ensure medical records were accurate; no physician orders for tracheostomy care despite resident having a tracheostomy.
Failed to ensure all staff completed COVID-19 primary vaccination series within 60 days; three staff members remained partially vaccinated and continued working.
Report Facts
Medication errors observed: 3
Partially vaccinated staff: 4
Staff vaccination compliance days: 60
PICC line dressing change interval: 7
Pressure ulcer size: 2.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error for administering wrong aspirin form and leaving medication cart unlocked. |
| LPN #9 | Licensed Practical Nurse | Logged into EHR without locking screen; partially vaccinated staff member. |
| LPN #12 | Licensed Practical Nurse | Identified stage 3 pressure ulcer; partially vaccinated staff member. |
| LPN #14 | Licensed Practical Nurse | Prepared medications with errors; failed to document pressure ulcer assessment. |
| CNA #15 | Certified Nursing Assistant | Partially vaccinated staff member; involved in nail care deficiency. |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies and expectations. |
| Administrator | Facility Administrator | Provided interviews regarding deficiencies and expectations. |
| APRN #18 | Advanced Practice Registered Nurse | Interviewed regarding pressure ulcer and tracheostomy care orders. |
| ADON | Assistant Director of Nursing | Interviewed regarding smoking policies and resident supervision. |
| Consultant CST #11 | Consultant | Provided facility policies and vaccination status data. |
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