Heartland Senior Living

Inspectors wroteBased on interview and record review, the facility failed to promptly respond to a call light for a newly admitted resident who was identified as being at high risk for falls. This failure affects one (R1) of three residents reviewed for accidents. This failure resulted in R1 sustaining a fall resulting in R1 being transferred to the hospital where R1 was found to have acute swelling and bleeding on both sides of the brain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer R1 from the wheelchair to toilet resulting in R1 sustaining a broken arm requiring emergency evaluation and treatment at the hospital. This failure affects one resident (R1) of five reviewed for accidents in the sample of five. This past non-compliance occurred from 4/3/2025 to 4/4/2025.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse for one (R1) resident by another resident (R2) of three residents reviewed for abuse in a sample list of three residents.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders for one (R10) of three residents reviewed for medication administration from a total sample list of 11 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ordered interventions to prevent the development of deep tissue injuries and worsening of a pressure injury and failed to provide weekly measurements and assessments for pressure injuries for four of five residents (R10, R47, R39 and R53) reviewed for pressure injuries from a total sample list of 33. These failures resulted in R10 and R47 developing deep tissue injuries and R47's unstageable pressure injury worsening.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent injuries from multiple mechanical lift transfers (R10) and failed to supervise a dementia resident to prevent an elopement (R56) for two of two of residents reviewed for accidents from a total sample list of 33 residents. Failing to safely transfer R10 using the mechanical lift resulted in R10 suffering skin tears to bilateral legs.

Inspectors wroteBased on interview and record review the facility failed to obtain a consent to administer a psychotropic medication for one (R10) of five residents reviewed for psychotropic medications from a total sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse to the Abuse Coordinator for one (R22) resident out of one resident reviewed for abuse in a sample list of 33 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a urinary catheter in a safe, sanitary, and dignified manner for one resident (R38) of four residents reviewed for catheters in a sample list of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to properly administer intravenous medication to prevent infection for one (R316) of one residents reviewed for intravenous medication administration from a total sample list of 33 residents. Findings Include: The facility Medication Administration, Intravenous Administration of Fluids and Electrolytes documents that staff will be knowledgeable regarding the safe and aseptic administration of intravenous fluids and electrolytes for hydration. Prime tubing of administration set, disinfect needleless connection device with alcohol wipe, flush catheter using normal saline per facility protocol, connect primed administration set to needleless connection device, and then open roller clamp. R316's diagnosis list includes: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident had an order for the use of oxygen and failed to ensure oxygen/nebulizer tubing/equipment was changed according to facility policy for two of three residents (R265 and R266) reviewed for respiratory care in a sample list of 33 residents.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be informed of and participate in their treatment by failing to keep the resident's representative informed of a newly acquired infection and related treatment options for one of three residents (R1) reviewed for Resident Rights in the sample of three.

Inspectors wroteBased on observation, interview and record review the facility failed to test all staff that were in close contact with a COVID-19 positive resident and failed to post isolation signage immediately on an isolation room after the resident testing positive for COVID-19. This failure has the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe transfer and implement a pressure relieving intervention to prevent pressure wounds for two (R29 and R23) of seven residents reviewed for pressure sores from a total sample list of 39. These failures resulted in R29 developing an unstageable pressure sore and R23 developing a deep tissue injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall for one (R18) of five residents reviewed for accidents on the sample list of 39. This failure resulted in R18 sustaining a right hip fracture requiring surgical intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Controlled Substance Storage policy by failing to maintain possession of the keys to medication/narcotic storage areas. This failure has the potential to affect all 20 residents residing on the 300-hall including: R6, R10, R12, R13, R20, R21, R22, R23, R24, R25, R29, R30, R36, R38, R39, R46, R50, R52, R53, and R259 from a total sample list of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for physical cross-contamination of food. This failure has the potential to affect all 61 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to serve palatable food. This failure affects one resident (R11) of 24 reviewed for palatable food in the sample list of 39.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observations, interviews, and record review, the facility failed to follow their facility's infection control policy by failing to implement Enhanced Barrier Precautions for four (R29, R6, R49, and R55) of 24 residents reviewed for transmission-based precautions on the sample list of 39. B. Based on observation, interview, and record review, the facility failed to follow their infection control policy by failing to complete hand hygiene while passing resident medications for two (R53 and R21) of six residents reviewed for medication administration from a total sample list of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's rights to be free from physical abuse by another resident for two of two residents (R34 and R4) reviewed for Abuse in a sample list of 39 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a safe environment free of tripping and pooling water floor hazards in a resident room. This failure affects one of six residents (R162) reviewed falls/accident hazards on the sample list of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store controlled substance medication in a permanently affixed storage compartment, failed to discard expired Flu vaccination injection medication, failed to dispose of R208's unidentified medications stored in a 28-day personal supply multi-compartment pill box and failed to label R4's personal stock of Eliquis (blood thinner) medication. These failures had the potential to effect all 65 residents residing in the facility.

Inspectors wroteBased on record review, observation and interview the facility failed to hold and serve hot TCS (Time/Temperature Control for Safety) food at proper temperature and failed to prevent cross contamination of foods served during meal service. These failures have the potential to affect all 65 residents residing in facility.

Inspectors wroteBased on interview and record review the facility failed to conduct psychotropic medication assessments for R3 and failed to ensure the use of an as needed anxiolytic medication did not exceed the maximum permitted 14 days for R3. R3 is one of five residents reviewed for psychotropic medications in the sample of 30.

Inspectors wroteBased on interview and record review the facility failed to consult V8 (Medical Director) regarding dietary recommendations and failed to notify V8 of weight loss for two of three residents (R15, R37) reviewed for physician notification on the sample list of 30.

Inspectors wroteBased on record review and interview the facility failed to implement the facility Antibiotic Stewardship policy to prevent the use of unnecessary antibiotics as evidenced by antibiotics prescribed prophylactically and failed to obtain Physician ordered Culture and Sensitivity (C&S) tests after obtaining two separate Urinalysis (U/A) for one (R21) resident out of four residents reviewed for Urinary Tract Infections (UTI) in a sample list of 30 residents.