Heartland Rehabilitation And Care Center

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands between dirty and clean tasks, and before handling clean equipment for one of two meals observed. The findings include: During a concurrent observation and interview on 07/30/2025 at 8:51 AM, this surveyor observed Dietary Aide (DA) #1 push a cart of pitchers without gloves on, which contaminated her hands. Without washing her hands, DA #1 picked up a coffee bag and placed it into the coffee basket to prepare coffee for the residents for lunch. This surveyor asked DA #1 what she should have done after touching dirty objects and before handling clean equipment. DA #1 stated she should have washed her hands. During a concurrent observation and interview on 07/30/2025 at 9:54 AM, this surveyor observed DA #2 lift the trash can lid and throw away tissue paper without gloves on, which contaminated her hands. Without washing her hands, DA #2 picked up a bag of tea and placed it into a brew basket to brew and serve to the residents for lunch. This surveyor asked DA #2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure foods stored in the freezer and dry storage area were covered, sealed, dated, and were stored in to prevent potential food borne illness for resident who received meals from 1 of 1 kitchen, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchens, and dietary staff washed their hands before handling clean equipment and food items to prevent potential food borne illness for residents. The failed practices had the potential to affect 66 residents who receive meals from the kitchen. The findings are: 1. On 04/24/2024 at 12:50 PM, the following items were noted on a shelf in the freezer, there were no dates of when the food items were received or when opened: a. An opened box of cheese omelets. The bag was not sealed or dated when opened. b. An opened box of egg patties. The box was not covered, sealed, or dated when opened. c. An opened box steak fingers. There was no open date on the box. d. An opened box of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure mechanical closets to the electrical and air conditioning rooms were locked to prevent residents from entering. The facility failed to lock a private bathroom on 400 Hall that did not have a call light or pull cord light to allow residents to call for assistance which had the potential to affect 9 400-Hall residents that can ambulate or self-propel and failed to transfer residents in an appropriate manner to prevent falls or injuries. The findings are: 1. On 04/22/2024 at 09:59 AM, the Surveyor observed a door labeled Mechanical Room slightly ajar on the front, right hand side of 400 Hall. The Surveyor opened the door and observed air conditioning equipment, boxes on the floor, and a rolling cart of tools. The Surveyor exited the room and walked across the hall to another unlocked door labeled Mechanical Room with air conditioning and light equipment. 2. On 04/24/2024 at 01:40 PM, the Surveyor asked to speak with the Maintenance Supervisor, and he identified 400 Hall Mechanical Rooms as the air…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance pureed food items and of hot food product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. This failed practice had the potential to affect 19 residents who receive meal trays in their rooms on the 100- Hall, 5 residents who receive meal trays on the 200- Hall, 4 residents who receive meal trays in their room on the 300- Hall, 14 residents who receive meal trays on 400- Hall. The findings are: 1. Resident #18 had diagnoses of End stage renal disease, Malnutrition, and Metabolic encephalopathy. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2024 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The care plan with a revision date of 03/18/2024 documented, .Problem: (Resident #18) has an ADL (Activities of Daily Living) self-care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received dental care to promote good hygiene and prevent nutritional and dental complications for 1 (Resident #14) sampled resident. This failed practice had the potential to affect 7 residents on 400-Hall that require complete dental assistance. The findings are: 1. Resident #14 had diagnoses of Cerebral infarction, Absence of right leg below the knee, and Type II diabetes mellitus with foot ulcer. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01/19/2024 indicated a Brief Interview for Mental Status [BIMS] score of 15 (13-15 suggest cognitively intact). Resident #14 required maximum assistance for eating, oral hygiene, dressing and personal hygiene. Resident #14 is dependent for toileting and bathing. a. On 04/22/2024 at 11:43 AM, the Surveyor observed an off white, and a blue and white, toothbrush resting on the bathroom sink behind the faucet, and the blue and white brush is above the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure ice packs were maintained in cooler bags at the bedside for residents on thickened liquids to ensure fluids were appetizing for the residents to help prevent dehydration and weight loss. This failed practice had the ability to affect two residents on 400-Hall on thickened liquids. The findings are: Resident #39 had diagnoses of Dysphagia, Chronic obstructive pulmonary disease, and Dementia. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 03/30/2024 documented a Brief Interview for Mental Status [BIMS] score of 6 (0-7 suggest severe cognitive impairment). Resident #39 required set up assistance with meals. A Physician Orders (Dated, 07/20/2023) documented, .Super calorie diet Pureed texture, Nectar consistency . A Care Plan (Revised, 10/10/2023) documented, .[Resident #39] has difficulty swallowing related to dysphagia and at risk for weight loss. Ensure that resident receives nectar thickened liquids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to date humidifier bottles to ensure nursing staff changed humidifier bottles weekly to prevent respiratory infections. This failed practice had the potential to affect 2 residents living on 400 Hall using oxygen with humidifier bottles. The findings are: 1. Resident #59 had diagnoses of Cerebrovascular disease, Pressure ulcer of the sacral region, and Schizophrenia. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 04/04/2024 indicated a Brief Interview for Mental Status score [BIMS] of 14 (13-15 indicates cognitively intact). a. A Care Plan (Revision, 03/27/2024) documented, .administer oxygen as ordered, change all disposable respiratory equipment clean/replace filter every Sunday night shift and bag and date . b. On 04/22/2024 at 11:32 AM, the Surveyor observed Resident #59 receiving 2 liters of oxygen via nasal cannula and an undated humidifier bottle. c. On 04/23/2024 at 10:20 AM, the Surveyor observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law, upon the death of 2 Residents (#125 and #126) who had personal funds deposited with the facility. The findings are: The Review of the Trust Account Documentation provided by the Business Office Manager (BOM) on 04/04/23 at 3:00 pm revealed that Resident #125 had a trust balance of $1723.61 and Resident #126 had a trust balance of $224.13. The Record Review completed on 04/04/23 at 3:30pm revealed that Resident #125 was admitted to the facility on [DATE]. She had a Durable Power of Attorney signed and notarized on 07/23/20 on file with the facility. A document titled Record of Death stated that her date of death was 10/02/22. The Record Review completed on 04/04/23 at 3:45pm revealed that Resident #126 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on Observation, Interview and Record Review the facility failed to place signage on a resident's entry way to identify the use of Oxygen by the resident, for 1 (#226) of 6 (#11, #15, #33, #57, #63 and #226) sampled residents who received Supplemental Oxygen. The findings are: 1.Resident #226 had diagnoses of Malignant Neoplasm of transverse Colon, Malignant Neoplasm of Right Lung, and Malignant Neoplasm of Left Lung. The admission Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/23 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 cognitively intact), required one person assist with bathing, personal hygiene, dressing, supervision with setup only for bed mobility, transfers, walk in room and corridors, locomotion on and off unit, eating and toilet use, and received supplemental oxygen. a. The Physician's Order dated 03/18/23 documented, .Oxygen at 2 Liters Per Milliliter [LPM] via nasal cannula as needed every shift b. The Physician's Order dated 03/19/23 documented, .Change all disposable respiratory equipment and clean/replace filters…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the Dialysis Facility for 1 (Resident #17) reviewed for End Stage Renal Disease/Dialysis services, according to a list provided by Director of Nursing (DON) on 04/06/23. The findings are: 1. Resident #17 was admitted on [DATE] with diagnoses of End Stage Renal Disease, Anxiety Disorder, Essential Hypertension, Anemia, And Dependence On Renal Dialysis. The Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/23 documented a score of 10 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). Resident needs extensive assist of one person with toileting and eating and is totally dependent on 2 persons for transfers. a. During a review of Resident #17's Electronic Health Record (EHR) on 04/06/23 at 3:11 PM, the Surveyor was unable to locate any lab results in the record that had been completed in the Dialysis Unit or communication of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.