Heartland Living & Rehab at the Moses H Cone Memor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and Responsible Party and staff interviews, the facility failed to dispose of a urinary catheter drainage bag left on the resident's sink for 1 of 3 residents (Resident #94) on 1 of 3 halls reviewed for clean, comfortable, and homelike environment. The findings included:Review of Residents #94's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and was coded for use of an indwelling urinary catheter.Interview and observation with Residents #94's Responsible Party (RP) on 04/27/26 at 11:40 AM revealed concerns of cleanliness of Resident #94's bathroom. An observation conducted at the same time revealed a leg bag (a small, wearable urine collection bag used to collect urine from an indwelling catheter) laying on the resident's bathroom counter next to the sink. There was observation of approximately 50 milliliters (ml) in the catheter leg bag, but no signs of urine on the sink. The RP indicated the leg bag had…

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 observations, record review, and resident, staff, and Nurse Practitioner interviews, the facility failed to administer oxygen as specified in the physician order for 2 of 2 residents reviewed for oxygen therapy (Resident #53 and Resident #35).Findings included: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (low levels of oxygen in body tissue which are common with chronic heart and lung conditions and causes symptoms like confusion, restlessness, difficulty breathing rapid heart rate and bluish skin), chronic obstructive pulmonary disease, and hypertension. Review of Resident #53's care plan dated 03/12/26 revealed the resident required oxygen at times or continuously. The resident was at risk for signs and symptoms of respiratory distress, dry or bloody nose, irritated skin around the ears from tubing or if mask is work, possible irritation round the mouth, increased fatigue, headaches. The goal was for Resident #53 to…

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 record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 91 days reviewed for sufficient nurse staffing (September 2024, October 2024, November 2024). Findings included: Review of the facility's Posted Nurse Staffing for September of 2024 revealed there was not a Registered Nurse scheduled for at least 8 hours a day on September 6, 2024, September 7, 2024, September 21, 2024, and September 22, 2024. The Posted Nurse Staffing for October 2024 was reviewed and there was not a Registered Nurse scheduled for at least 8 hours a day on October 6, 2024 and October 20, 2024. The November Posted Nurse Staffing was also reviewed and there was not a Registered Nurse scheduled for at least 8 hours daily for November 3, 2024, November 16, 2024, and November 17, 2024. During an interview with the Director of Nursing on 2/25/2025 at 1:19 pm she stated she was responsible for the nurse staffing schedule in September 2024, October 2024, and November 2024. The Director of Nursing stated…

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 observations, record review, and resident and staff interviews, the facility failed to ensure walls in a resident's room did not have stains (room [ROOM NUMBER]A) and failed to ensure a call light panel was securely attached to the wall behind a resident's bed (room [ROOM NUMBER]B) for 2 of 4 rooms on 1 of 3 halls (100 hall) reviewed for a safe, clean and homelike environment. Findings included: 1. On 2/23/2025 at 10:39 am the wall beside the bed in room [ROOM NUMBER]A had two 4-centimeters by 3-centimeters dried, dark brown stains. During observations on 2/24/2025 at 9:59 am and on 2/25/25 at 8:57 am the two 4-centimeters by 3-centimeters dried, dark brown stains remained on the wall beside the bed in room [ROOM NUMBER]A. On 2/25/2025 at 9:18 am Nurse Aide #2 was interviewed, and she stated she was assigned to room [ROOM NUMBER]A and housekeeping was responsible for cleaning the walls. Nurse #1 was interviewed on 2/25/2025 at 9:00 am and she stated room [ROOM NUMBER]A was on her assignment but had not…

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 observations, staff interviews, and record review, the facility failed to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 3 residents (Resident #55) reviewed with a urinary catheter. The findings included: Resident #55 was admitted to the facility on [DATE]. Her cumulative diagnoses included obstructive uropathy (a condition where the flow of urine is blocked, leading to a buildup of urine in the urinary tract). Resident #55's care plan included an area of focus related to the resident having an indwelling urinary catheter in place (Initiated on 2/6/25). An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderately impaired cognition. No behaviors nor rejection of care were reported. The assessment indicated Resident #55 required supervision or touching assistance for eating and personal hygiene; partial to moderate assistance for sit to stand and chair/bed to chair transfers; and substantial to maximum…

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 observations, interviews with the staff and consultant pharmacist, and record reviews, the facility failed to acquire a medication (a combination calcium and vitamin D supplement) ordered for administration resulting in multiple doses of the prescribed medication being missed for 1 of 5 residents (Resident #61) observed for medication administration. The findings included: Resident #61 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes and heart failure. On 9/27/23 at 8:15 AM, Medication (Med) Aide #2 was observed as she prepared and administered 11 oral medications to Resident #61. At that time, the med aide reported this resident's calcium and vitamin D combination tablet was not available on the med cart for administration because it had not been delivered by the pharmacy. A follow-up interview was conducted on 9/27/23 at 11:28 AM with Med Aide #2. During the interview, the med aide confirmed Resident #61's calcium / vitamin D tablets had been previously supplied by…

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 observations, interviews with staff and the consultant pharmacist, and record reviews, the facility failed to: 1) Label medications with the minimum information required, including the first and last name of the resident on 3 of 3 medication (med) carts observed (the 300 Hall Nurse's Med Cart, the 100 Hall Nurse's Med Cart, and the 300 Hall Med Aide's Med Cart); 2) Store medications in accordance with the manufacturer's storage instructions on 2 of 3 med carts (300 Hall Nurse's Med Cart and the 300 Hall Med Aide Med Cart); and 3) Discard an expired medication on 1 of 3 med carts observed (the 300 Hall Med Aide's Med Cart). The findings included: 1-a. An observation was conducted on [DATE] at 3:58 PM of the 300 Hall Nurse's medication (med) cart in the presence of Nurse #3. The observation revealed the following medications stored on the med cart failed to be labeled with the minimum information required: --An opened, manufacturer's bottle of 0.4 milligrams (mg) nitroglycerin tablets (a medication used…

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, resident interviews, staff interviews and observations, the facility failed to provide a room free of a strong smell of urine. This was evident in 1 of 5 rooms reviewed for clean, homelike environment (room [ROOM NUMBER]). Findings included: Resident #10 was admitted in the facility on 12/13/13 with the most recent readmission on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 was independent with toilet use and required oversight, encouragement or cueing with personal hygiene with one-person physical assist. Resident #10 required one-person physical assist with bathing with physical help limited to transfer only. A review of Resident #10's care plan dated 4/20/23 revealed Resident #10 Resident sometimes resisted/refused care which may compromise health/ safety/ well-being. Often refused baths and personal hygiene care. Also sometimes refused to allow laundry to wash dirty clothes or allow staff to move dirty…

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 staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Hospice/End of life care (Resident #74) and discharge location (Resident #85). This occurred for 2 of 23 residents reviewed for accuracy of assessments. The findings included: 1. Resident #74 was admitted to the facility on [DATE] with a cumulative diagnosis which included heart failure and a history of a cerebrovascular accident (stroke). The resident's admission Minimum Data Set (MDS) was dated 5/3/23. A review of the resident's electronic medical record (EMR) revealed her physician orders included a Hospice consult on 5/9/23. A significant change MDS assessment dated [DATE] was completed for resident #74. However, review of this MDS revealed the section on Health Conditions did not indicate the resident had a life expectancy of less than 6 months. Also, the MDS section on Special Treatments, Procedures and Programs did not indicate Resident #74 was receiving Hospice…

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 observations, staff interviews, and record review, the facility failed to implement a comprehensive fall prevention care plan for a resident (Resident #67) with a history of falling. This occurred for 1 of 2 residents reviewed for falls. The findings included: Resident #67 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, cerebral infarction, and convulsions. A review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 6/27/2023, revealed Resident #67 had severe cognitive impairment, required extensive assistance of one staff member for bed mobility, and total assistance of two staff members for transferring. She had no documented falls since the prior assessment. A review of the comprehensive care plan, dated 6/27/2023, identified a focus area that read; Resident #67 was at risk for falls related to multiple factors including her cerebral vascular accident, hemiplegia, increased weakness, decreased endurance, decreased safety awareness, lack 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff and the consultant pharmacist, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 5 residents (Resident #72 and Resident #61) observed during the medication administration observation. The findings included: 1. Resident #72 was admitted to the facility on [DATE]. His cumulative diagnoses included diabetes. On 9/27/23 at 11:30 AM, Nurse #1 was observed as she checked Resident #72's blood glucose (sugar) with the result noted to be 337 milligram (mg) / deciliter (dl). The nurse was then observed as she returned to the medication cart and prepared to administer Novolog insulin in accordance with his sliding scale insulin orders (where the dose of insulin administered would be dependent on the resident's current blood glucose level). Based on Resident #72's blood glucose result, Nurse #1 reported she needed to administer 9…

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 observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 7/14/22. This was for 1 deficiency that was cited in the area of Free of Medication Error Rate of 5 Percent or More (F759). The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QA). The findings included: This citation is cross referred to: F759: During the facility's recertification survey on 9/28/23, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 5 residents (Resident #72 and Resident #61) observed during the medication administration observation. During the facility's recertification survey of 7/14/22, the facility's medication error rate was greater…

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 observations, staff interviews, and record review, the facility staff failed to clean and disinfect a blood glucose meter (glucometer) dedicated for individual-resident use in a manner that would protect against the cross-contamination from contact with other meters or equipment. This was observed for 2 out of 8 sample residents (Residents #64 and #17) who were observed to have a blood glucose (sugar) check. The findings included: A review of the facility policy entitled Glucometer Disinfection (Date Implemented: January 2018; Date Reviewed / Revised: December 2019) included the following Policy Explanation and Compliance Guidelines related to the disinfection of glucometers, in part: Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned, disinfected, and air-dried after each use and according to manufacturer's instructions for multi-resident use 2. The glucometers should be disinfected with a wipe pre-saturated with an EPA [Environmental Protection Agency] registered healthcare disinfectant that is effective against…

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.