Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Square during CMS and state inspections, most recent first.
The facility failed to prevent cross-contamination during meal service. A cook was observed handling mechanically altered food without changing gloves after touching high-touch surfaces. The Dietary Supervisor acknowledged the risk of cross-contamination, and no policy for safe food handling was provided.
A resident was admitted with several wounds, including a necrotic heel, but the facility failed to obtain and implement treatment orders for these wounds in a timely manner. Despite initial assessments, specific wound care orders were delayed, and treatments were inconsistently documented. The situation worsened when the resident's wounds showed signs of deterioration, and the DON admitted the wounds were beyond her expertise.
A resident with depression, anxiety, and dementia experienced a significant weight loss of 9.4% over a month, but the facility failed to conduct weekly weight checks or implement necessary interventions. The Dietary Manager acknowledged the oversight and noted that the resident's intake levels had not decreased, indicating the weight loss was not due to reduced food intake.
A resident was not provided with the prescribed mechanically altered diet and thickened liquids, leading to coughing and difficulty swallowing. The CNA assisting the resident was unaware of the correct consistency for the drinks, and the Dietary Supervisor confirmed the meal was not prepared according to the physician's order. The facility's policy on therapeutic diets was not followed, despite the resident's medical history indicating a risk of aspiration.
A facility failed to properly implement enhanced barrier precautions for a resident with a feeding tube, leading to a deficiency in infection control. Staff did not follow procedures for doffing PPE within the resident's room, and there was no designated container for soiled gowns, resulting in improper disposal practices.
The facility inaccurately submitted PBJ hours, potentially affecting all 16 residents. The CMS report indicated a lack of 24-hour licensed nursing coverage on specific dates, attributed to data entry errors by a previous bookkeeper. Despite assertions from the DON and Administrator that coverage was maintained, a notice indicated non-compliance with staffing ratios. The facility has since contracted a third-party vendor for future PBJ submissions.
Cross-Contamination in Food Handling
Penalty
Summary
The facility failed to handle mechanically altered food properly, leading to potential cross-contamination. During the lunch service on 7/9/24, a cook, identified as V7, was observed plating meals, including mechanical soft diets, without changing gloves after touching high-touch surfaces such as oven handles, door handles, and the tray cart handle. V7 used the same gloved hand that contacted these surfaces to handle residents' mechanical soft chicken tenders, scooping the chicken with her gloved hand and placing it in the ladle. On 7/10/24, the Dietary Supervisor, V5, acknowledged that staff should not handle food after touching high-touch surfaces due to the risk of cross-contamination, noting that gloves can give a false sense of security. Additionally, when a policy for the safe handling of food was requested, it was not provided, indicating a lack of documented procedures to prevent such deficiencies.
Failure to Implement Timely Wound Care for Resident
Penalty
Summary
The facility failed to obtain orders and implement treatments for wounds on a resident's feet upon admission. The resident, identified as R13, was admitted with several skin integrity issues, including a necrotic area on the left heel and scabs on both feet. Despite these findings, no treatment orders were obtained or implemented for these wounds from the time of admission on June 17, 2024, until June 26, 2024. During this period, the facility's records showed no interventions or treatments for the resident's foot wounds, and the initial care plan only included general measures such as pressure reduction and monitoring. On June 26, 2024, the facility's staff noticed additional skin issues, including redness and excoriation, and a necrotic area on the heel. The Director of Nursing (DON) was notified, and orders for an air mattress and heel boots were created. However, it wasn't until June 27, 2024, that specific wound care orders were documented for the resident's foot ulcers. The treatment administration record indicated that these treatments were not consistently completed, as evidenced by missing documentation on several days. The situation escalated on July 9, 2024, when blood was noted on the resident's sock, and the wound on the left foot showed signs of deterioration, including odor and drainage. The DON acknowledged the lack of initial wound orders and the misidentification of the wounds as diabetic rather than pressure ulcers. The facility's wound care protocol was not effectively followed, and the DON admitted that the resident's wounds were beyond her expertise, highlighting a gap in the facility's wound care management.
Failure to Implement Weight Loss Interventions
Penalty
Summary
The facility failed to implement weight loss interventions for a resident who experienced significant weight loss. The resident, who had diagnoses including depression, anxiety, and dementia, showed a weight decrease from 127 pounds to 115.2 pounds over a month, which was a 9.4 percent loss. Despite this significant weight change, the facility did not conduct weekly weight checks as required by their policy. The Dietary Manager acknowledged the oversight and noted that a re-weigh was requested but not completed, and the resident's intake levels had not decreased, suggesting the weight loss was not due to reduced food intake. The facility's Weight Loss policy mandates monthly weight checks and weekly weights for residents with unintended weight loss, with immediate notification to the physician and dietitian. However, these procedures were not followed for the resident in question. The Dietary Manager admitted that if the weight was accurate, a nutritional assessment and creative interventions to increase calorie intake would have been initiated. The failure to re-weigh and implement interventions was recognized as a significant issue by the Dietary Manager, who communicated this to the Director of Nursing.
Failure to Provide Prescribed Diet and Thickened Liquids
Penalty
Summary
The facility failed to provide a resident with the prescribed mechanically altered diet and thickened liquids, as observed during a meal service. The resident, who was on a mechanical soft diet with nectar thick liquids, was served minced chicken, raw carrots, a whole brownie, soup, juice, and thickened water. The CNA assisting the resident was unaware of the correct consistency for the resident's drinks and did not properly thicken the juice, leading to the resident coughing and struggling to clear his throat. The Dietary Supervisor confirmed that the resident was on a moist minced diet for meat and mechanical soft for other foods, with nectar thick liquids. The supervisor noted that the carrots served were hard and should have been diced, and the juice was not thickened correctly as per the physician's order. The resident's diet card and care plan indicated the need for a mechanical soft diet and nectar thick liquids, but these were not adhered to during the meal. The facility's policy on therapeutic diets emphasizes the importance of staff training and monitoring residents' adherence to prescribed diets. However, the CNA's lack of knowledge about the resident's dietary requirements and the improper preparation of the meal components indicate a failure to follow these guidelines. The resident's medical history includes conditions such as aphasia, dementia, and risk of aspiration, underscoring the importance of adhering to the prescribed diet to ensure safe consumption of meals.
Improper PPE Disposal in Resident Room
Penalty
Summary
The facility failed to properly implement enhanced barrier precautions (EBP) for a resident with a feeding tube, leading to a deficiency in infection control practices. The resident, who had multiple diagnoses including aphasia, dementia, and diabetes, was on EBP due to the presence of an indwelling medical device. During an observation, it was noted that staff members, including CNAs and an RN, did not follow proper procedures for doffing personal protective equipment (PPE) within the resident's room. Specifically, the RN attempted to hang a used gown in the room instead of disposing of it, and one CNA exited the room wearing PPE, which was against the facility's policy. The facility's policy required that PPE be discarded in a bin inside the resident's room to prevent contamination outside the room. However, during the incident, there was no designated container for soiled gowns in the room, leading to improper disposal practices. Staff members acknowledged the absence of a proper disposal container and the need to discard PPE in the room to avoid spreading infection. The Director of Nursing confirmed that EBP should be in place for residents with feeding tubes or wounds, and that PPE should be discarded in the room to maintain infection control.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to accurately submit payroll-based journal (PBJ) hours, which has the potential to affect all 16 residents. The CMS PBJ report for the first quarter of 2024 indicated that the facility did not have licensed nursing coverage 24 hours per day on several specific dates. Despite the facility's assertion that there was always a nurse on duty, the PBJ report reflected data entry errors. Interviews with the Director of Nursing, the Administrator, and nursing staff confirmed that there was always licensed nurse coverage, and the issue was attributed to data submission errors by the previous bookkeeper. The facility's staffing policy, dated May 31, 2024, stated that they would meet or exceed the minimum requirements set by Illinois state regulations. However, a notice posted in the health center indicated that the facility did not meet the minimum staffing ratios required by law. The current bookkeeper, who took over from the previous one, acknowledged the importance of submitting accurate PBJ staffing data and confirmed that the information was not submitted correctly to CMS. The facility has since contracted a third-party vendor to handle PBJ data submissions going forward.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dixon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dixon Rehab & Hcc | 1.5 mi | — | 0 | 0 |
| Franklin Grove Living And Rehab | 9.4 mi | — | 1 | 0 |
| Polo Rehabilitation & Hcc | 10.1 mi | — | 0 | 0 |
| La Bella Of Sterling | 10.2 mi | — | 2 | 0 |
| Rock Falls Rehab & Hlth Care C | 10.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.