Inspection Reports for
Heartland Care Center

The complaint investigation found that the oxygen order for Resident #3 was changed on 5/10/25 from continuous to PRN without proper approval from the on-call physician and without consulting the resident or family. This led to decreased oxygen monitoring, oxygen levels dropping into the 70s, increased lethargy, and hospitalization on 5/13/25. The family reported the resident was taken off oxygen 'cold turkey' without discussion. The facility acknowledged documentation and communication lapses.

The facility failed to provide adequate respiratory care for Resident #3 by changing his oxygen order from continuous to PRN without proper physician on-call authorization or family consultation, resulting in decreased oxygen monitoring, low oxygen saturations, increased lethargy, and hospitalization. Documentation and communication deficiencies were noted, and the oxygen order was later changed back to continuous after the resident's condition worsened.

The investigation was triggered by complaints #1801716-C and #1801706-C, which resulted in a deficiency related to respiratory care for Resident #3. The complaints were substantiated as evidenced by the findings.

The facility failed to provide adequate respiratory care for one of three residents reviewed, specifically Resident #3, who required supplemental oxygen. The staff failed to increase monitoring and consult with the resident and family before changing oxygen orders, resulting in low oxygen saturations, increased lethargy, and hospitalization. Documentation and communication regarding oxygen orders and monitoring were inconsistent and incomplete.

The facility was found deficient in multiple areas including failure to ensure bed hold notices were signed for residents transferred out, inadequate coordination of PASARR assessments, incomplete comprehensive care plans especially regarding psychotropic and opioid medications, improper use and documentation of psychotropic medications, and deficiencies in infection prevention and control practices including Enhanced Barrier Precautions (EBP).

The facility was found deficient in multiple areas including failure to obtain signed bed hold notices for residents transferred or on therapeutic leave, failure to refer a resident for Level II PASRR evaluation, incomplete care plans lacking non-pharmacological interventions and side effect monitoring for high risk medications, failure to implement enhanced barrier precautions during wound care for a resident with MDRO, and failure to identify targeted behaviors related to psychotropic medications.

The facility was found deficient in multiple areas including failure to provide a discharge summary for a discharged resident, incomplete restorative care as planned, improper urinary catheter care, failure to follow menu plans and obtain dietician approval, food safety violations including improper glove use and inadequate food temperature control, failure to educate and offer pneumonia vaccination to a resident, and failure to assure access to the updated COVID-19 vaccine for a resident.

The facility was found deficient in several areas including discharge summaries, restorative programs, urinary catheter care, menu and nutritional adequacy, food safety, immunizations including influenza, pneumococcal, and COVID-19 vaccinations. Deficiencies were based on record reviews, staff interviews, observations, and policy reviews.

The facility failed to document an accurate code status for one resident, with discrepancies between the electronic health record and paper documentation. Additionally, the facility failed to ensure food items were properly labeled with dates after opening, labeled with product information, and discarded after expiration, with multiple expired or unlabeled food items found in the kitchen.

The facility failed to document an accurate code status for one resident and did not ensure food safety requirements were met, including labeling and dating of stored food items. Several expired or unlabeled food items were found in the kitchen and storage areas.

Complaint #92698-C was substantiated following the investigation conducted June 7-10, 2021.

The complaint #92698-C was substantiated. The facility was found deficient in notifying the Power of Attorney (POA) of significant weight loss for residents, maintaining resident personal property inventories, establishing and following grievance procedures, and developing comprehensive care plans. The facility failed to provide reasonable care for protection of resident property and failed to hold care plan meetings including residents or their representatives.