Heartland

Inspectors wroteBased on policy review, medial record review, observation, and interview, the facility failed to follow physicians orders for a percutaneous enteral gastrostomy (PEG) tube (a tube inserted through the skin and into the stomach to administer medications and supplements) when staff failed to administer the ordered enteral feeding at the correct rate for 1 of 2 residents (Resident #7) reviewed for tube feedings.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made for 4 of 5 (Resident #1, #24, #47, and #209) sampled residents reviewed for abuse.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments Section GG (Functional Abilities) were incomplete for 2 of 16 (Resident #20 and #21) MDS assessments reviewed.

Inspectors wroteBased on facility policy review, medical record review, observations, and interview, the facility failed to provide scheduled showers/baths for 1 of 28 (Resident #28) sampled residents reviewed for bathing.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to follow physician orders for 2 of 28 sampled residents (Resident #8 and Resident #207) reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services for a resident with a percutaneous endoscopic gastrostomy (PEG) tube (tube inserted into the stomach to administer medications, supplements and liquid food) when staff failed to notify physician and resident representative of a change in status resident weight loss, and refusal of peg tube feedings for 1 of 3 (Resident #6) sampled residents reviewed for enteral feedings.

Inspectors wroteBased on policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 8 of 13 CNAs (CNA F, G, H, I, J, K, L, and M) employed for a full year received at least 12 hours of in-service training.

Inspectors wroteBased on policy review, medication review, observation, and interview, revealed the facility failed to ensure medications were properly stored and secured for 2 of 16 (Resident #20 and #36) residents when medications were found unattended and unsecured in resident rooms.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 6 of 22 (Residents #23 and #26's room, Residents #9 and #20's room, Resident #13 and #37's room, Residents #1 and #41's room, Residents #7 and #24's room, and Resident #53's room) resident occupied rooms and bathrooms observed.

Inspectors wroteBased on policy review, review of the Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss User Manual, medical record review, facility document review, observation, and interview, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 (Resident #1) residents reviewed for falls. On 9/3/2023 Certified Nurse Assistant (CNA) #10 was providing incontinent care to Resident #1. Resident #1 diagnosed with Hemiplegia affecting the left non-dominant side. Resident #1 was turned by CNA #10 in the opposite direction facing away from the CNA on an alternating pressure mattress. CNA #10 then turned away from Resident #1 to obtain a care item. [...]

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to develop and implement a person-centered care plan for 4 of 7 (Resident #1, #2, #4, and #7) sampled residents reviewed. The facility failed to designate the number of staff required to provide physical assistance which resulted in inconsistent care and negative outcomes.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to assess, and document fall risk factors for 3 of 7 (Resident #1, #6, and #7) residents reviewed. The facility failed to provide seventy-two (72) hour post fall assessment and monitoring documentation for 4 of 7 (Resident #1, #2, #3, and #4) residents reviewed.

Inspectors wroteBased on facility policy review, document review, medical record review, observation, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 (Resident #5) residents reviewed.

Inspectors wroteBased on hospice agreement review, facility document review, medical record review, observation, and interview, the facility failed to notify hospice of a fall with injuries and hospital transfer for 1 of 2 (Resident #1) hospice residents reviewed.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to preserve the dignity of residents who required assistance with meals during the lunch meal observation on 6/20/2022, related to staff standing while assisting residents with meals and labeling residents as 'feeders.'

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to allow decision making for a prescribed diet for 1 of 28 sampled residents (Resident #24).

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure call lights were within reach for 5 of 59 sampled Residents (Resident #14, #18, #34, #45 and #48) reviewed.

Inspectors wroteBased on facility policy, medical record review and staff interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis for 2 of 28 sampled residents (Resident #34 and Resident #50) reviewed for PASARRs.

Inspectors wroteBased on facility policy review, medical record review, observations, and interview, the facility failed to implement approaches on the care plan for 1 of 28 sampled residents (Resident #34).

Inspectors wroteBased on facility documentation review, medical record review, observations, and interviews, the facility failed to ensure 1 of 59 sampled residents (Resident #45) had clean and groomed fingernails.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to store oxygen tubing properly for 1 of 2 sampled resident (Resident #42) observed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to serve food in a sanitary manner for residents being assisted with the lunch meal.

Inspectors wroteBased on observation and interview, the facility failed to prevent the spread of infection in 1 of 44 resident rooms.