Inspection Reports for
Heartland Care and Rehabilitation Center
2525 BOUTIN DR, CAPE GIRARDEAU, MO, 63701-8551
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
63 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 2
Date: Nov 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to the facility's environment, maintenance, and infection prevention and control practices during the annual survey.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to maintenance issues such as broken tiles, holes in walls, and doors that could not be opened. Additionally, infection control practices were inadequate during catheter care and blood sugar checks, with staff failing to use gowns and gloves appropriately, potentially exposing residents to infection risks.
Deficiencies (2)
Failed to provide a clean, comfortable, and homelike environment including broken tiles, holes in walls, and a bathroom door that could not be opened.
Failed to maintain proper infection control practices during catheter care and blood sugar checks, including failure to wear gowns and gloves as required.
Report Facts
Facility census: 63
Broken tiles: 8
Cracked tiles: 15
Tiles missing: 2
Holes in wall: 4
Residents sampled for infection control: 5
Residents with catheter care observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding maintenance repair processes and logs | |
| Certified Medication Technician (CMT) D | Interviewed about maintenance repair request process | |
| Licensed Practical Nurse (LPN) E | Interviewed about maintenance repair reporting | |
| Certified Nursing Assistant (CNA) F | Interviewed about maintenance repair reporting | |
| Licensed Practical Nurse (LPN) G | Interviewed about maintenance repair reporting | |
| Administrator | Interviewed about expectations for building maintenance and repair | |
| RN A | Registered Nurse | Observed and interviewed regarding improper catheter care and infection control practices |
| RN B | Registered Nurse | Observed and interviewed regarding improper blood sugar check procedures and infection control practices |
| CNA C | Certified Nurse Assistant | Observed performing catheter care without proper gown use |
| Director of Nursing (DON) | Interviewed about infection control expectations |
Inspection Report
Routine
Census: 74
Deficiencies: 5
Date: Oct 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident personal funds management, following physician's orders, respiratory care, medication administration, and medication labeling and storage at Heartland Care and Rehabilitation Center.
Findings
The facility was found deficient in managing resident trust fund accounts accurately, following physician's orders for weights, insulin administration, and oxygen therapy, maintaining medication error rates below 5%, and ensuring proper labeling and storage of medications. Several residents were affected by these deficiencies, with potential for minimal to actual harm.
Deficiencies (5)
Failed to maintain accurate accounting of resident trust fund petty cash, with a discrepancy of $5.90.
Failed to follow physician's orders for weights and insulin administration for four residents.
Failed to ensure physician's orders for oxygen with bilevel positive airway pressure (BIPAP) were followed for two residents.
Failed to maintain medication error rates below 5%, with an 11% error rate in insulin administration for one resident.
Failed to ensure drugs and biologicals were labeled and stored properly; one resident had medications at bedside without physician's order.
Report Facts
Discrepancy amount: 5.9
Facility census: 74
Medication administration opportunities: 28
Medication errors: 3
Medication error rate: 11
Missed insulin administrations and blood sugar checks: 48
Missed daily weights: 10
Missed weekly weights: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Named in medication error finding for failing to prime insulin pens prior to administration |
| Assistant Director of Nursing | ADON | Interviewed regarding insulin pen priming and bipap oxygen orders |
| Human Resources Manager/Business Office Manager | HR Manager/BOM | Counted resident petty cash and acknowledged discrepancy |
| Administrator | Administrator | Interviewed about petty cash reconciliation |
| Director of Nursing | DON | Interviewed regarding expectations for following physician orders and medication administration |
| Licensed Practical Nurse G | LPN | Interviewed about resident refusal of blood sugar checks and insulin administration |
| Certified Nurse Assistant E | CNA | Interviewed about weighing residents and charting weights |
| CNA F | Certified Nurse Assistant | Responsible for getting and charting weights |
| Assistant Director of Nursing | ADON | Interviewed about bipap supplies and oxygen orders |
Inspection Report
Routine
Census: 76
Deficiencies: 4
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, environment, discharge planning, and pest control at Heartland Care and Rehabilitation Center.
Findings
The facility was found deficient in accurately documenting residents' code status, maintaining a safe and clean environment, ensuring proper discharge planning, and controlling pest infestations, specifically flies in the secure unit. These deficiencies had the potential to affect multiple residents but were generally rated as minimal harm or potential for harm.
Deficiencies (4)
Failed to ensure a code status was accurately and consistently documented throughout the medical record for one resident.
Failed to provide a safe, clean, and comfortable homelike environment, including issues with ceiling tiles, floor tiles, vents, and strong urine odors in resident rooms.
Failed to ensure a discharge planning process was in place addressing goals and needs involving the resident and interdisciplinary team for one discharged resident.
Failed to maintain an effective pest control program to control the fly population in the facility, especially in the secure unit.
Report Facts
Residents affected: 1
Residents affected: 76
Residents affected: 1
Residents affected: 76
Residents affected: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Interviewed regarding code status documentation |
| Registered Nurse B | Registered Nurse | Interviewed regarding code status documentation and environmental concerns |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding code status documentation and environmental concerns |
| Director of Nursing | Director of Nursing | Interviewed regarding code status documentation |
| Administrator | Administrator | Interviewed regarding code status documentation, environmental concerns, discharge planning, and pest control |
| Medical Records designee | Interviewed regarding discharge planning documentation | |
| Social Service Director | Social Service Director | Interviewed regarding discharge planning process |
| Licensed Practical Nurse F | Licensed Practical Nurse | Observed and interviewed regarding pest control and fly swatting |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding maintenance and pest control reporting |
| Housekeeper E | Housekeeper | Interviewed regarding environmental issue reporting |
| Nurse Assistant C | Nurse Assistant | Interviewed regarding environmental and pest control reporting |
| Certified Nurse Assistant D | Certified Nurse Assistant | Interviewed regarding environmental and pest control reporting |
| Certified Medication Technician H | Certified Medication Technician | Interviewed regarding pest control and fly issues |
| Certified Nurse Assistant G | Certified Nurse Assistant | Interviewed regarding pest control and fly issues |
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