Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heartland Care Center during CMS and state inspections, most recent first.
Missed Nutritional Assessments for Residents With Admission Needs and Changes in Condition: The facility failed to complete required nutritional assessments for multiple residents with complex medical histories, including DM, CHF, dysphagia, stroke, and cognitive impairment. Several residents had no admission nutritional assessment, while others had choking episodes, pressure ulcers, or significant weight loss without timely RD assessment or documentation of notification. The RD reported poor communication with the facility and stated she was playing catch up on assessments.
Food service safety standards were not followed when the kitchen hood vent was observed dirty with grease and debris buildup, with no in-between cleaning schedule in place. During meal service, staff reheated soup and puree pouches on the steam table, used the same contaminated gloves while handling menus, utensils, bread, buns, and hamburger patties, allowed a housekeeper without a hair net near the steam table, and sent room trays with uncovered cake.
The facility failed to notify the physician and/or family when residents had significant changes of condition for 3 residents reviewed. One resident with severe cognitive impairment and multiple diagnoses had a significant weight loss, but the record lacked documentation that the family was notified. Two residents had choking episodes during meals; staff documented assessment findings and symptom resolution, but the records lacked documentation that the physician was notified. The DON stated family notification was expected for the weight loss and physician notification was expected for choking episodes.
Delayed Call Light Response and Insufficient Staffing A resident with intact cognition reported a call light was left on for about 30 minutes, and the resident’s daughter said the light was often used when the resident’s wife needed help to the bathroom. Call light records for the resident’s room showed multiple response times over 15 minutes, including several over 20 and 30 minutes, with the longest lasting 34 minutes and 50 seconds. The DON stated the standard response time was 15 minutes and that the facility did not have a call light policy.
Improper glove use during peri care: A CNA wore the same contaminated gloves while assisting a resident with a mechanical stand transfer, handling clothing, preparing wipes, and then performing peri care. The resident had intact cognition, was dependent on staff for toileting hygiene, was occasionally incontinent, and was on enhanced barrier precautions for ESBL with treatment for a UTI. The DON agreed the gloves should have been changed before peri care, and the facility PPE policy required glove changes and hand hygiene between clean and dirty tasks.
A resident with a history of respiratory failure and other serious conditions experienced inadequate respiratory care when staff changed oxygen therapy from scheduled to PRN without proper monitoring or consultation with the resident and family. The resident's oxygen levels repeatedly dropped below safe thresholds, monitoring frequency decreased, and documentation was lacking. The resident became lethargic and cyanotic, ultimately requiring hospitalization for respiratory distress.
The facility failed to follow the menu as written for one meal and did not ensure that menus were reviewed and approved by a dietician. Incorrect portions were served, and changes to the menu were made without dietician approval, leading to a deficiency.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed greasy stove hoods, improper glove use by a cook, and food temperatures below the required levels, violating facility policies and FDA guidelines.
A resident diagnosed with c-diff was discharged without a required discharge summary that included a recapitulation of their stay. The DON confirmed that the recap was not completed as mandated by the facility's policy.
The facility failed to ensure that restorative care was completed as planned for a resident with Alzheimer's and a seizure disorder. The care plan required passive ROM exercises for both upper and lower extremities 5-7 days per week, but the facility did not consistently perform these exercises. The DON acknowledged insufficient staffing on weekends and lack of documentation for missed sessions, while the MDS Coordinator had not conducted recent follow-ups.
The facility failed to provide proper care and services to prevent infection for a resident with a urinary catheter. The resident's catheter bag was improperly placed on multiple occasions, and staff did not follow correct procedures for catheter care, as outlined in the facility's competency assessment.
The facility failed to educate and offer the pneumonia vaccine to a resident with COPD, lacking documentation of vaccine receipt, education, and consent or refusal, despite the facility's policy requiring it upon admission.
The facility failed to ensure that a resident had access to the most recent COVID-19 vaccine. The clinical records lacked documentation that the resident or their responsible party had been educated on, offered, or received the 2023-2024 COVID-19 vaccine. The DON had not yet asked the resident about the updated vaccine, despite CDC guidelines recommending vaccination to protect against serious illness.
Missed Nutritional Assessments for Residents With Admission Needs and Changes in Condition
Penalty
Summary
The facility failed to complete nutritional assessments for multiple residents, including residents with new admissions, significant clinical conditions, and changes in condition. The facility record review, staff interviews, and policy review showed that a qualified dietitian was expected to complete a comprehensive nutritional assessment within 72 hours of admission, annually, and upon significant change in condition, but this did not occur for several residents. Resident #4 had diagnoses including GERD, type 2 DM, and CHF, was on a regular diet, needed supervision or touching assistance with eating, and had Stage 2 and Stage 3 pressure ulcers on admission. The clinical record showed no nutritional admission assessment was completed. Resident #14 had stroke, anxiety disorder, DM, and hypertension, was on a regular diet, needed supervision or touching assistance with eating, and also had no nutritional admission assessment documented. Resident #20 had dysphagia, CAD, hypertension, and DM, was on a regular diet, was independent with eating, and likewise had no nutritional admission assessment in the record. Resident #17 had severe cognitive impairment, CVA, anxiety disorder, and hypertension, was on a general diet, and was independent with eating, but had a choking episode and lacked nutritional assessments between prior assessments and after the choking incident. Resident #32 had stroke, hemiplegia, hemiparesis, anxiety, and depression, was on a mechanically altered diet, needed supervision or touching assistance with eating, and had choking episodes documented, yet the nutritional assessments in the record were dated months apart. Resident #26 had severe cognitive impairment, Alzheimer’s disease, seizure disorder, anxiety, and depression, was dependent on staff for eating, was on a mechanically altered diet, and had a 5% weight loss in 30 days; the record lacked documentation that the RD was notified and lacked a nutritional assessment. The RD stated she came monthly, sometimes care conferences were cancelled, communication with the facility was not good, she was not notified of the weight loss, pressure area, or choking episodes, and she was playing catch up on assessments.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. During kitchen observations, the oven hood was dirty with buildup of debris, dust, and grease, and the sticker on the hood showed the last professional cleaning was in January 2026. The Dietary Manager acknowledged the hood vent had a lot of buildup and stated the facility did not have a schedule to clean the hood vent between professional cleanings. She also said the last outside cleaning did not do a very good job and that the facility might purchase new vent inserts/filters and possibly start a regular cleaning schedule. During meal service, staff heated tomato soup in the can on the steam table, and the Dietary Manager later stated the steam table was intended to hold food temperatures, not reheat food. Staff C wore gloves throughout meal service but touched multiple surfaces, including menus, plates, utensils, foil, a serving cart, ketchup bottle, and scissors, while continuing to use the same gloves to handle bread, buns, and hamburger patties without a utensil. Puree pouches of carrots, green beans, and chicken were also observed on the steam table and reported to have been reheated there. Additional observations showed a housekeeper entered the kitchen near the steam table without a hair net, and three room trays were sent to residents with uncovered cake. The facility policy required reheating to 165 degrees Fahrenheit, covering food when traveling down the hallway, wearing hair restraints, and maintaining clean nails and gloves in good condition; the 2022 Food Code also states gloves can be a source of cross contamination if misused.
Failure to Notify Physician and Family of Significant Changes
Penalty
Summary
The facility failed to notify the physician and/or family when residents had significant changes of condition for 3 of 3 residents reviewed. Resident #26, who had severely impaired cognition, Alzheimer’s disease, non-Alzheimer’s disease, seizure disorder, anxiety, depression, and dependence on staff for eating, had a 5.62% weight loss between 3/9/26 and 4/2/26. A weight change note dated 4/7/26 documented the loss, but the clinical record lacked documentation that the family was notified. The DON stated on 5/5/26 that she could not locate documentation that the family had been notified and said it was an expectation for the family to be notified. Facility policies defined significant weight loss and directed notification of the responsible party when there was a significant change in condition or when a physician was required to be contacted. Resident #17, who had severely impaired cognition, CVA, anxiety disorder, and GERD, was reported choking on a piece of meat in the dining room on 4/30/26. Staff removed the resident from the dining room, assessed her, and documented that she was talking and coughing, with later findings of a temperature of 98.2 and slight expiratory wheezes; food was cleaned from her teeth and her mouth was rinsed. The clinical record lacked documentation that the physician was notified. Resident #32, who had intact cognition, CVA, hemiplegia, hemiparesis, depression, and anxiety disorder, had a choking episode at breakfast on 4/11/26 while eating scrambled eggs and had a small emesis, but later reported feeling fine with clear lung sounds and oxygen saturation of 97%. The clinical record lacked documentation that the physician was notified, and the DON stated the expectation was to notify the physician if a resident had a choking episode.
Delayed Call Light Response and Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staff to care for residents in a timely manner and did not have a licensed nurse in charge on each shift as described in the deficiency statement. Facility records, resident interviews, and staff interviews showed the facility had a census of 27 residents. Resident #24’s MDS dated 3/11/26 identified a BIMS score of 15, indicating intact cognition. On 5/04/2026 at 1:10 PM, Resident #24 reported that a call light had been on for 30 minutes the previous afternoon and said he checked the clock when he activated it and again when it was answered. Resident #24’s daughter, who was present, stated the call light was usually used when Resident #24’s wife, who also lived in the room, needed to go to the bathroom. Review of the call light reports for Resident #24’s room from 4/29/26 to 5/6/26 showed the longest elapsed time was 34 minutes and 50 seconds, with multiple call light activations lasting 15 minutes or more, including several instances lasting over 20 and 30 minutes. On 5/6/26 at 11:23 AM, the DON stated the standard response time for call lights was 15 minutes and reported the facility did not have a call light policy.
Improper glove use during peri care
Penalty
Summary
The facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for one resident reviewed for peri care. Resident #23 had a BIMS score of 15, indicating intact cognition, and was dependent on staff for toileting hygiene and occasionally incontinent of urine. The resident’s MDS listed Parkinson’s disease and TIA, and the care plan directed staff to clean the peri area and change the disposable brief after each incontinent episode. The May 2026 MAR showed the resident was receiving Macrodantin 100 mg twice daily for a UTI, with the last dose scheduled the morning of 5/4/26. A progress note dated 4/28/26 documented enhanced barrier precautions due to a positive urine culture for ESBL. During observation on 5/5/26, Staff A, a CNA, entered the resident’s room wearing a gown and gloves and assisted with a mechanical stand transfer. Staff A used the same pair of gloves while touching the mechanical stand, assisting with clothing removal, handling incontinent wipes, and then performing peri care. Staff A acknowledged she had touched multiple surfaces with her gloves before performing peri care and agreed she probably should have changed her gloves before completing the peri care. The DON stated she expected staff to have equipment prepared ahead of time and agreed the gloves should have been changed prior to completing the peri care. The facility policy on PPE directed staff to change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn.
Failure to Provide Adequate Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required supplemental oxygen therapy. The resident, who had a history of respiratory failure, coronary artery disease, renal insufficiency, pneumonia, and sarcoidosis of the lungs, was admitted with a care plan specifying continuous oxygen at 2L, to be increased to 3.5L with ambulation. Despite this, staff changed the oxygen order from scheduled to as-needed (PRN) without increased monitoring or proper consultation with the resident and family. Documentation shows that the resident's oxygen saturation levels were repeatedly below 90% on room air following the order change, and there was a significant decrease in the frequency of oxygen monitoring. Therapy and nursing notes indicated that the resident experienced significant drops in oxygen saturation during therapy sessions, sometimes falling into the low 80s and requiring time to recover. After the order was changed to PRN, the resident's oxygen levels were not checked as frequently, and there was a lack of documentation regarding the rationale for the order change or communication with the family. Staff interviews revealed confusion about who authorized the order change, and the primary care physician was not familiar with the resident or the change. Family members reported that the resident was taken off oxygen abruptly without discussion, and observed him to be lethargic, shaking, and cyanotic prior to hospitalization. Ultimately, the resident was found with oxygen saturations in the low 70s, was placed back on continuous oxygen, and was subsequently hospitalized for shortness of breath, weakness, and pulmonary congestion. Facility policy required that residents and families be informed of new orders, especially those related to changes in condition, and that nurses observe and document signs of respiratory distress. These procedures were not followed, leading to inadequate respiratory care and a negative outcome for the resident.
Failure to Follow Menu and Obtain Dietician Approval
Penalty
Summary
The facility failed to follow the menu as written for one meal and did not ensure that menus were reviewed and approved by a dietician. On 4/3/24, the noon menu included specific portions of creamed chipped beef, mashed potatoes, green beans, and bread. However, Staff A, the cook, served incorrect portions using different scoop sizes. Staff A and the Dietary Manager (DM) were unable to identify the correct scoop sizes, leading to discrepancies in the meal portions served to residents. The DM acknowledged that Staff A gave extra chipped beef gravy but did not adjust the other portions accordingly. Additionally, the facility's menus from Sunday through Saturday had changes made in writing, but none were signed by a dietician. The Administrator and DM confirmed that the facility had been without a dietician for some time, relying on a dietician from an affiliated hospital who visited once a month. The DM admitted to making changes to the menu based on residents' preferences without dietician approval. This lack of oversight and adherence to the menu planning policy resulted in the deficiency noted by the surveyors.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation, the stove hood appeared greasy and grimy, and the sprinklers above the oven had a greasy feel with fuzz hanging intermittently. The Dietary Supervisor was unaware of the last cleaning date for the hood, and the Administrator confirmed that the oven hood was not on the cleaning schedule. The facility policy required stove hoods and filters to be cleaned at least monthly, but there was no record of the last cleaning before the recent one on Monday. Additionally, during the noon meal service, a cook wore the same gloves throughout various tasks, including touching multiple surfaces and handling food, which violated the facility's policy and the FDA Food Code 2017. Furthermore, food temperatures were not maintained at the required levels. After serving the main dining room, the temperature of the mashed potatoes and chipped beef gravy was recorded at 120 degrees, below the required 135 degrees. This failure to maintain proper food temperatures was against the facility's policy, which mandated that all food be cooked, held, and served at appropriate internal temperatures.
Failure to Provide Required Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary that included a recapitulation of the resident's stay for a resident who was discharged. The resident, who had no cognitive impairment and was diagnosed with enterocolitis due to clostridium difficile (c-diff), was admitted to the facility because he was unable to care for himself at home and experienced severe diarrhea. The resident's baseline care plan indicated that he was receiving physical therapy to regain strength and had good family support. On the day of discharge, the resident packed his belongings, received discharge paperwork, and left the facility with his family. However, the clinical record lacked a discharge summary that included a recap of the resident's stay, which was confirmed by the Director of Nursing (DON) who acknowledged that the recap was not done as required by the facility's policy. The facility's undated Discharge Summary/Recapitulation Policy mandates that a discharge summary, including a recapitulation of the resident's stay, be completed for every resident at the time of discharge. This summary should include diagnoses, treatments, therapies provided, and a final summary of the resident's status. The failure to provide this required documentation was identified during a review of the resident's clinical record and confirmed through staff interviews, highlighting a lapse in adherence to the facility's discharge procedures.
Failure to Complete Restorative Care as Planned
Penalty
Summary
The facility failed to ensure that restorative care was completed as planned for a resident with Alzheimer's disease and a seizure disorder. The resident, who had long and short-term memory problems and severely impaired skills for daily decision-making, depended on staff for activities of daily living. The care plan required passive range of motion (ROM) exercises for both upper and lower extremities to be performed 5-7 days per week as tolerated by the resident. However, the facility did not consistently perform these exercises as scheduled, with numerous weeks showing incomplete or missing sessions for both upper and lower extremities. The Director of Nursing (DON) acknowledged that the days marked as 'not applicable' could mean the resident refused the exercises, but there was no documentation to support this. Additionally, the DON admitted that the facility lacked sufficient staff to perform the exercises on weekends. The MDS Coordinator, who oversaw the restorative program, had not conducted any recent follow-ups to ensure compliance with the care plan. This lack of adherence to the prescribed restorative care regimen was identified through record reviews and staff interviews, highlighting a significant deficiency in the facility's care practices.
Failure to Provide Proper Catheter Care and Prevent Infection
Penalty
Summary
The facility failed to provide appropriate care and services to prevent infection for a resident with a urinary catheter. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was observed with the catheter bag improperly placed on multiple occasions. On one instance, the catheter bag was hung from a garbage can, and on another, it was found lying on the floor. The resident's care plan included specific interventions to monitor for signs and symptoms of urinary tract infections (UTIs) and to provide catheter care, but these were not adequately followed as evidenced by the improper handling of the catheter bag. During pericare, staff were observed using improper techniques, such as placing an incontinent pad before removing gloves and not following the correct procedure for cleansing the catheter. The Director of Nursing (DON) acknowledged that the catheter bag should not be hung on the trash can. The facility's competency assessment for catheter care outlined specific steps for cleansing the catheter and genital area, which were not adhered to by the staff, leading to a failure in preventing potential infections for the resident.
Failure to Educate and Offer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were educated on the options for the pneumonia vaccination and given the opportunity to accept or decline it. Specifically, for one resident, who had no cognitive impairment and was diagnosed with chronic obstructive pulmonary disease (COPD), the clinical record lacked documentation of receiving a pneumococcal vaccine, education on the vaccine, and a signed consent or refusal. The Director of Nursing (DON) confirmed that the resident had not been offered the pneumonia vaccine, despite the facility's policy stating that all residents would be offered the vaccine upon admission, with risks and benefits provided to them or their representatives.
Failure to Ensure Access to Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that residents had access to the most recent COVID-19 vaccine for one of the five residents reviewed. Specifically, the clinical records for Resident #6 lacked documentation that they, or their responsible party, had been educated on the 2023-2024 COVID-19 vaccination, been offered, or received a dose of the vaccine. This deficiency was identified during a review of the facility's records and staff interviews, which revealed that the Director of Nursing (DON) had not yet asked Resident #6 about the updated COVID-19 vaccine. The DON stated that some residents received the COVID-19 vaccine at the clinic, and she administered some at the facility. Initially, she had to obtain 10 doses at a time, which required enough residents to express interest. However, she mentioned that it was now possible to get fewer doses at a time. Despite this, Resident #6 had not been approached regarding the updated vaccine. The CDC's updated guidelines recommended the 2023-2024 COVID-19 vaccines to protect against serious illness, emphasizing the importance of vaccination for individuals aged 5 years and older, and particularly for those who are moderately or severely immunocompromised.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marcus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Happy Siesta Health Care Center | 8.3 mi | ★★★★★ | 0 | 0 |
| Careage Hills Rehabilitation And Healthcare | 13.5 mi | ★★★★★ | 9 | 0 |
| Cherokee Specialty Care | 13.7 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Cherokee, Llc | 14.3 mi | ★★★★★ | 6 | 0 |
| Good Samaritan - Lemars | 17.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.