Heartland Nursing & Rehab

Inspectors wroteBased on observation, interview and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 53 residents residing at the facility. The Long-Term Care Facility Application for Medicare and Medicaid form dated 1/26/26 documents 53 residents reside in the facility. On 01/27/2026 at 11:51 AM the facility's walk-in cooler was observed with a dark brown substance puddled onto the floor beneath a rack of raw meat. A large portion of meat wrapped in plastic was sitting on a cardboard box on the bottom shelf of the cooler with accumulating fluids on top of the box that were dripping down the side of the box. The walk-in freezer was observed with loose carrots and unknown debris on the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to have quarterly Quality Assessment Performance Improvement (QAPI) meetings and failed to ensure required staff members attended meetings. These failures have the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to implement a Legionella surveillance program. This failure has the potential to affect all 53 residents who reside in the facility. Findings Include:The facility's Long-Term Care Application for Medicare and Medicaid Services form dated 1/26/26 documents 53 residents residing at the facility. The facility's Safe Water Policy dated 2/1/24 states Maintenance Supervisor must be able to demonstrate sound knowledge and specific skills in service being provided. This may include the maintenance of water systems equipment/services such as: Water storage tanks, vessels, and connecting pipework above and below ground. Sanitary appliances and associated taps, thermostatic mixing valves, and other fittings. Fire Fighting Services. On 1/29/26 at 2:51PM V17, Maintenance Supervisor stated All I check is the water temperature in rooms. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure interventions for safe smoking were followed for three of 27 residents (R2, R43, R39) reviewed for accident hazards in a sample list of 27. Findings Include: R2's Care Plan documents an admission date of 07/08/2025 with the following diagnoses: Constipation, Tobacco Use, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Asthma, Gastric Ulcer, Presence of Right Artificial Shoulder Joint, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, Dependence on Renal Dialysis, Depression, and Heart Failure. R2's Care Plan documents a focus area dated 7/09/2025 documenting the resident is a smoker with a goal of maintaining safety while following smoking protocol. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications timely and according to physician orders for three (R2, R40, R43) of fifteen residents reviewed for medication administration on the sample list of 27. These failures resulted in three medication errors out of twenty-five opportunities resulting in a 12% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label nasal spray dispensers with the opened date for three (R1, R7, R48) of fifteen residents reviewed for medication administration on a sample list of 27.

Inspectors wroteBased on interview and record review the facility failed to monitor/ manage a gastrostomy feeding tube and report changes to the dietitian/physician for one (R52) of one resident reviewed for feeding tube in a sample of 27 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain full mechanical lifts in safe/operable condition. This failure has the potential to affect eight of eight residents (R3-R10) reviewed for full mechanical lifts in the sample list of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to properly transfer a resident (R3), for one of three residents (R3) reviewed for falls in a sample list of ten.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects one resident (R3) out of three reviewed for abuse on a sample list of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall and accident prevention interventions according to a resident's care plan and physician orders. This failure affects one resident (R3) out of three reviewed for falls on the sample list of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 42 residents residing in the facility. Findings Include: On 12/10/24 at 9:55 AM, V5, Dietary Manager, was actively supervising and directing the food preparation and wares sanitation processes in the facility kitchen. At 11:50 AM and 12:08 PM, V5 was actively supervising and directing the meal service for lunch. On 12/10/24 at 9:55 AM, V5 stated she was the Dietary Manager. V5 further stated she had a (national company) cooking sanitation certificate. V5 continued to state she did not have a Certified Dietary Manager certificate (CDM, 6 to 9 month clinical nutrition curriculum), nor a Certified Food Protection Professional certificate (CFPP, CDM equivalent). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen utensils to prevent potential contamination of food, and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: On 12/10/24 at 10:15 AM, there was a metal, long handle measuring scoop located inside the bulk sugar bin. The handle of the scoop was in direct contact with, and partially buried by, the sugar. On 12/10/24 at 10:15 AM, V5, Dietary Manager, and V6, Regional Dietary Representative, both stated the scoop should not be left in the sugar. On 12/10/24 at 10:20 AM, there was a silicone blade spatula in a kitchen utensil drawer with a broken corner approximately three-quarters of an inch diagonal, exposing the granulated and rough internal material of the spatula. [...]

Inspectors wroteBased on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: The facility did not provide an Infection Control Surveillance and Monitoring Policy and no documents were provided for how the facility trends monthly infections to prevent further infection throughout the facility. The facility has no documentation for the identified infections pattern/trend and interventions. On 12/10/24 at 02:10 PM, V2 Director of Nursing (DON) Infection Preventionist (IP) stated V2 has not kept up with a log for infections for residents, and only has October and November 2024, for infection logs and only for residents and not for employees. V2 stated V2 and does not complete any Quality Assurance (QA) on infections that reoccur. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an infection prevention and control program that includes an antibiotic stewardship program and failed to review this policy annually. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: On 12/11/24 at 10:40 AM, V2 Director of Nursing (DON) stated V2 has not completed an Antibiotic Stewardship Program for the facility. V2 stated there are no antibiotic protocols or a system to monitor antibiotics in place. The facility's Antibiotic Stewardship Program stated the purpose of the policy is to monitor antibiotic use of the residents. This policy has a date of 2/7/23, which has not been updated annually. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to act on grievances from residents/family promptly, explain to residents how to file a grievance, inform residents where the survey book is located, and address lack of meal substitutes offered at mealtimes and not offering snacks at bedtime. This failure affects four of four residents (R3, R13, R21 and R25) reviewed for grievances in the sample list of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to change, date and store oxygen tubing, humidifier bottles, nebulizer masks, and suctioning equipment in a sanitary manner for four of five residents (R4, R14, R34, R350) reviewed for oxygen in the sample list of 26. Findings Include: The facility policy Departmental Respiratory Therapy Prevention of Infection dated reviewed 4/27/24 documents the oxygen administration supplies consist of oxygen tubing and humidifier bottle. This policy documents to change the oxygen tubing cannula every seven days, and to discard the entire administration set up every seven days. 1. R34's Medical Diagnoses list dated December 2024 documents R34 is diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. [...]

Inspectors wroteBased on Interview and record review, the facility failed to follow through with contacting Physicians for unaddressed Pharmacist recommendations, and failed to maintain documented evidence of Physician responses to Pharmacist recommendations. This failure affects four residents (R12, R16, R22, R26) out of six reviewed for unnecessary medications on the sample list of 26. Findings Include: 1. R16's Registered Pharmacist Consultant recommendation recorded in R16's Nursing Progress Notes dated 11/25/24 documents a Pharmacist recommendation to conduct an abnormal involuntary movement scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R16's electronic medical record (EMR). [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct psychotropic medication assessments, failed to maintain accurate documentation in psychotropic medication assessments, failed to conduct abnormal involuntary movement assessments for Antipsychotic medications, failed to obtain a time period duration for PRN (as needed) psychotropic medications, and failed to attempt gradual dose reductions for residents receiving anti-psychotic medications. These failures affect five residents (R12, R16, R22, R26, and R29) out of six reviewed for unnecessary medications on the sample list of 26. Findings Include: 1. R16's Medical Diagnoses list dated 12/13/24 documents R16 experiences medical conditions including Alzheimer's Disease and Dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident's dignity by failing to place a urinary catheter collection bag inside a covering or pouch. This failure affects two residents (R22 and R33) out of two reviewed for urinary catheters on the sample list of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to request a Preadmission Screening and Resident Review PASARR II Screening for (R26) who has a diagnosis of Schizoaffective Disorder and is receiving Antipsychotic medication. R26 is one of one resident reviewed for PASARR screening on a sample list of 26. Findings Include: R26's Medical Diagnosis sheet dated 12/13/24 lists (R26's) Primary Medical Diagnosis for admission on [DATE] as Interstitial Pulmonary Disease. Included with the list of diagnoses is Schizoaffective Disorder with date of 9/2/2022. The Medical Diagnosis Sheet states under the column Classification for the Schizoaffective Disorder as During Stay. [...]

Inspectors wroteBased on interview and record review the facility failed to document a discharge summary that includes a recapitulation of stay, a final summary of the resident's status, and a post discharge plan of care. This failure has the potential to affect one of one resident (R49) reviewed for discharge on the sample list of 26. Findings Include: The facility's Discharge Summary and Plan Policy Statement dated 2/17/24 documents when a resident's discharge is anticipated, a discharge summary and medication plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide complete antibiotic doses for a urinary tract infection for one resident (R42) of one resident reviewed for infections on the sample list of 26. Findings Include: R42's Nursing Notes dated 11/9/24 at 2:13 PM, document per urology orders replaced indwelling catheter, also dip-tested urine to reveal abnormal urine sample, sending to lab for urine analysis (UA) and culture and sensitivity. R42's Nursing Notes dated 11/12/24 at 2:10 PM, document V22 Medical Director aware of UA results, new order received for Bactrim DS everyday for five days. R42's Medication Administration Record (MAR) dated November 2024, documents Bactrim DS tablet 800-160 milligrams (Sulfamethoxazole-Trimethoprim) one tablet by mouth twice a day for urinary tract infection for five days, with a start date of 11/12/24 at 8:00 AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess for smoking safety and failed to provide supervision for a potential smoking accident for one of one resident (R6) assessed for smoking safety on the sample list of 26. Findings Include: R6's Care Plan dated 1/31/2023 documents the following diagnoses: Presence of Right Artificial Shoulder Joint, Dependence on Renal Dialysis and Tobacco use. The same care plan for R6 documents a goal of (R6) will maintain safety while following smoking protocol. This was dated 7/9/24. An intervention for the goal was R6 is supervised while smoking. Date initiated 07/09/24. Another intervention for the goal was smoking materials are kept secured by staff. Date initiated 07/09/24. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the resident's physician of significant weight loss and failed to develop a plan of care to adequately address a resident's significant risk for weight loss. These failures affected one of one resident (R350) reviewed for nutrition on the sample list of 26. Findings Include: The facility's Weight Assessment and Intervention policy dated September 2008 documents the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Any change of 5% or more nursing will notify the Dietician and Primary Care Physician. Greater than 5% loss within one month will be considered severe weight loss. R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor and obtain a physician order regarding Gastrostomy site monitoring, dressing changes and self administration of medication via Gastrostomy tube. These failures have the potential to affect one of one resident (R350) reviewed for Gastrostomy Tube on the sample list of 26. Findings Include: R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status. R350's Physician Order Sheet (POS) dated December 2024 documents orders for R350 to be NPO (Nothing by Mouth) and for Enteral Feed, four times a day related to Severe Protein-Calorie Malnutrition. On 12/10/24 at 11:32 AM R350 stated she administers her own feedings and medications through her gastrostomy tube. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medication in a timely manner for one resident (R10) of four residents reviewed for timely medication in a sample list of ten residents. Findings Include: R10's Medication Administration Record (MAR) documents R10 is scheduled to receive the following medications at 8:00AM: Ascorbic Acid 500Mg (Milligrams), Cholecalciferol 50Mcg (Micrograms), Famotidine 40Mg, Fluoxetine 20 Mg, Furosemide 40Mg, Gabapentin 100Mg, Phentermine 15Mg, Potassium Chloride 20Meq (Milliequivalents), Spiriva one puff, Symbicort 160/4.5Mcg one puff, Bupropion 100Mg, Cranberry Tab 900Mg, and MiraLAX 17Gm (Grams). On 8/6/24 at 10:17AM V5, Licensed Practical Nurse (LPN) was observed preparing the above medications for R10 in the hall at the medication cart outside R10's room. V5 verified the medications were R10's 8:00AM doses. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a physician's order for oxygen and maintenance of supplemental oxygen for three residents (R1, R5, R6) of six residents reviewed for oxygen in a sample list of ten residents. Findings Include: 1. R5's Care Plan updated 7/24/24 includes the diagnosis: Chronic Respiratory Failure. On 8/5/24 at 10:00AM R5 was observed sitting in his room with oxygen in place at three liters per minute flow per nasal cannula. On 8/5/24 at 10:30AM R5's physician's orders did not document a physician's order for supplemental oxygen. R5's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of food. This failure has the potential to affect all 49 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential to affect five residents (R48, R102, R202, R204, R208) of five reviewed for arbitration agreements on the sample list of 31.

Inspectors wroteBased on interview and record review the facility failed to honor the choice to refuse the influenza vaccine for one (R22) of five residents reviewed for immunizations on the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to evaluate and obtain orders for self administration of medications for two (R6, R26) of two residents reviewed for self administration of medications from a total sample list of 31 residents.

Inspectors wroteBased on interview and record review the facility failed to accurately code Minimum Data Set assessments for two (R50, R27) of 17 residents reviewed for assessments on the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a pressure relieving intervention (cushion) for one of three residents (R22) reviewed for pressure ulcers in the sample list of 31. Findings Include: The facility's Prevention of Pressure Ulcers/Injuries policy with a revised date of July 2017 documents, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. This policy also documents, Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. R22's Face Sheet documents diagnoses including Pseudobulbar Affect, Vascular Dementia and Hypothyroidism. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide safe transport for one of three residents (R42) reviewed for accidents on the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oxygen per physician's orders for one of one resident (R42) reviewed for oxygen administration in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to relieve pain by failing to provide pain medication as ordered for three (R9, R32, R47) of three residents reviewed for pain on the sample list of 31 residents.

Inspectors wroteBased on interview and record review the facility failed to provide pain medication as ordered by the physician for two (R9 and R32) of two residents reviewed for pain on the sample list of 31 residents.

Inspectors wroteBased on interview and record review the facility failed to assess the need for psychotropic medications and reassess the need for as needed antianxiety medication for three of five residents (R6, R22, R29) reviewed for unnecessary medications on the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a bed rail for areas of entrapment for one of one (R29) resident reviewed for bed rails on the sample list of 31.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive person centered care plan for one resident (R1) of three residents reviewed for care plans in the sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for a resident (R1) at risk for eloping from the facility. This failure affects one of three (R1) residents reviewed for elopement in the sample list of three.