Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Nursing & Rehab during CMS and state inspections, most recent first.
The facility did not maintain full mechanical lifts in safe working order, as several lifts were found to be nonfunctional, with broken emergency releases and makeshift repairs such as adhesive tape. Staff and residents reported frequent problems, and maintenance did not perform routine checks or receive work orders for these issues, resulting in continued use of unsafe equipment for multiple residents requiring lift assistance.
A resident who required a full mechanical lift for transfers, as documented in the care plan due to a right femur fracture, was transferred using a sit-to-stand lift by a CNA when the appropriate lift was not working. The resident expressed concern during the transfer, and staff confirmed that no updated therapy recommendations had been made to change the transfer method. The facility's policy for assessing and documenting transfer needs was not followed.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient safeguards and oversight by the facility.
A resident with dementia and multiple comorbidities, identified as a fall risk, did not have required fall prevention interventions in place, including non-skid strips, non-slip wheelchair material, and protective leggings and sleeves. The nurse call device was also out of reach. This lack of adherence to the care plan and physician orders resulted in an unwitnessed fall with multiple injuries.
The facility failed to employ a qualified director of food and nutrition services, impacting all 42 residents. The Dietary Manager lacked necessary certifications, holding only a cooking sanitation certificate. The facility used a Registered Dietician one day per month, and the previous Certified Dietary Manager was on leave and not returning. Issues with palatability, sanitation, and meal service were noted.
The facility failed to prevent potential food contamination by improperly storing a measuring scoop in a bulk sugar bin and keeping a broken spatula in a utensil drawer. These deficiencies could affect all 42 residents.
The facility failed to maintain an effective infection prevention and control program, lacking a comprehensive policy and documentation for trending monthly infections. The DON, also the Infection Preventionist, did not maintain a complete infection log, with records only for October and November 2024, and none for employees. No Quality Assurance process was in place for recurring infections, and no infection trending was completed, potentially affecting all 42 residents.
The facility failed to implement an effective infection prevention and control program, specifically lacking an antibiotic stewardship program. The DON admitted that there were no antibiotic protocols or monitoring systems in place. The existing policy, dated 2/7/23, had not been updated annually, potentially affecting all 42 residents.
The facility failed to address grievances from residents and inform them about the grievance process. Residents reported dissatisfaction with meal options and lack of snacks at bedtime. The Dietary Manager acknowledged issues with meal service, and the survey book was found hidden and outdated. The grievance policy was not effectively communicated or implemented.
The facility failed to maintain sanitary conditions for respiratory care equipment for four residents, leading to deficiencies in infection control practices. A resident with COPD had undated oxygen tubing improperly stored, while another with pneumonia used a dirty suction catheter. A third resident's request for less frequent tubing changes was not documented or communicated regarding infection risks, and a fourth resident's oxygen equipment was not changed as required. These issues indicate a failure to adhere to the facility's policy on respiratory equipment sanitation.
The facility failed to contact physicians for unaddressed pharmacist recommendations and did not document physician responses, affecting several residents. For example, a resident on long-term antipsychotic medication lacked an AIMS assessment, and another was prescribed Seroquel without an approved diagnosis. Additionally, a resident's medication review suggested dose reductions due to falls, but the physician's response was delayed and undocumented. The facility did not adhere to its policy requiring regular AIMS assessments.
The facility failed to conduct necessary assessments and maintain accurate documentation for residents on psychotropic medications. Residents with conditions such as Alzheimer's, Dementia, and Major Depression were prescribed medications like Olanzapine, Sertraline, and Quetiapine without required quarterly assessments or attempts at gradual dose reductions. PRN orders lacked specified durations, and AIMS assessments were not completed as per policy, highlighting significant lapses in medication management.
The facility failed to maintain resident dignity by not covering urinary catheter bags for two residents. A resident's catheter bag was observed uncovered, exposing urine, and a caregiver reported inconsistent coverage of another resident's bag. The DON expressed disapproval of the practice, and the facility's policy requires catheter bags to be covered.
A facility failed to request a PASARR Level II Screening for a resident with Schizoaffective Disorder who was receiving antipsychotic medication. The resident's medical records indicated the disorder as a diagnosis during the stay, and observations showed symptoms consistent with the disorder. The facility's President of Clinical Operations confirmed the absence of a PASARR II request and acknowledged the lack of a policy for admissions regarding PASARR screenings.
A facility failed to document a discharge summary for a resident with multiple medical conditions, including Acute Kidney Failure and Heart Failure. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care. The Director of Nurses confirmed the absence of this documentation, which is crucial for ensuring continuity of care.
A resident with a urinary tract infection did not receive complete doses of prescribed antibiotics due to a failure in medication administration. The resident's MAR showed missing doses, leading to a subsequent infection confirmed by urinalysis. The DON acknowledged the error, noting the potential impact on treatment efficacy.
A resident with a history of tobacco use and other medical conditions was observed smoking unsupervised, despite the care plan indicating supervision was required. The resident kept smoking materials in her room and smoked alone, contrary to documented interventions. Facility staff confirmed the care plan did not match the resident's actual smoking practices, leading to a deficiency in ensuring a safe environment.
A resident experienced a 7.24% weight loss within two weeks of admission, but the facility failed to notify the physician or develop a care plan. The resident, with severe protein-calorie malnutrition and NPO status, was at high risk for weight loss due to multiple health issues. Despite the facility's policy requiring notification for significant weight changes, no new interventions were implemented.
A facility failed to monitor and obtain physician orders for a resident with a gastrostomy tube. The resident, diagnosed with dysphagia and severe protein-calorie malnutrition, was on NPO status and required enteral feeding. Despite this, the resident self-administered feedings and medications without orders for self-administration or staff monitoring. The DON confirmed the lack of orders and documentation for site maintenance or monitoring.
A facility failed to administer medications on time for a resident, with medications scheduled for 8:00 AM not prepared until 10:17 AM. An LPN cited being occupied with another resident's surgery as the reason for the delay. Other LPNs confirmed that late medication administration was common due to staffing challenges. The DON acknowledged that medications should be on time, and the facility's policy requires timely administration, but the MAR did not reflect actual administration times.
The facility failed to obtain physician's orders for supplemental oxygen for three residents, including those with chronic respiratory conditions. Observations revealed that two residents were using oxygen without documented orders, and all three lacked orders specifying when to change oxygen equipment, contrary to facility policy. The DON acknowledged the oversight due to a recent computer program change.
Failure to Maintain Safe and Operable Mechanical Lifts
Penalty
Summary
The facility failed to maintain full mechanical lifts in safe and operable condition, affecting all eight residents reviewed who required the use of these lifts. Multiple residents reported that the full mechanical lifts were not functioning properly, with issues such as the lifts only lowering and not raising, and the emergency release mechanisms being broken. Staff confirmed that one lift had gray adhesive tape around the gear box housing, which had been present for at least three years, and that the emergency release had also been nonfunctional for a significant period. Staff had to use alternative equipment or borrow lifts from other areas due to these malfunctions. The maintenance director stated that no work orders had been received for the lifts and that there were no routine checks performed on the equipment. Upon inspection, the maintenance director confirmed that one lift would not raise and both lifts had nonfunctional emergency releases. Facility policy required that lifts be tested for proper function, including the emergency release, and that non-working lifts be removed from service until repaired. However, these procedures were not followed, and the lifts remained in use despite ongoing mechanical issues.
Improper Transfer Method Used Due to Equipment Failure
Penalty
Summary
A deficiency occurred when a resident, who is cognitively intact and dependent on staff for transfers due to a right femur fracture, was transferred using a sit-to-stand mechanical lift instead of the care plan-specified full mechanical lift. On the day in question, the full mechanical lift on the resident's hallway was not functioning, and maintenance staff were unavailable. The Certified Nursing Assistant (CNA) used the sit-to-stand lift to transfer the resident from the wheelchair to the bed, despite the resident expressing concern about falling. The resident's care plan and Minimum Data Set (MDS) indicated that a full mechanical lift was required for transfers, and there had been no documented change in transfer status from therapy staff. Interviews with facility staff confirmed that the resident's transfer status remained unchanged and that the use of the sit-to-stand lift was not approved for this resident. The CNA acknowledged submitting a work order for the broken lift but proceeded with the alternative transfer method without updated recommendations from therapy or changes to the care plan. The facility's policy requires ongoing assessment and documentation of transfer needs, which was not followed in this instance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall and accident prevention interventions as outlined in a resident's care plan and physician orders. The resident, who had diagnoses including dementia, major depression, hypertension, and osteoarthritis, was identified as a fall risk and required staff supervision and assistance for all activities of daily living. Despite physician orders and care plan interventions for non-skid strips in front of the recliner, non-slip material in the wheelchair seat, and the use of protective leggings and sleeves, these measures were not in place at the time of observation. The resident's nurse call device was also found out of reach, hanging from a light fixture several feet away from where the resident was seated. The resident experienced an unwitnessed fall from bed, resulting in multiple bruises, abrasions, and a head injury that required emergency department evaluation and treatment. Upon return to the facility, further injuries were noted, including additional bruising and surgical glue applied to wounds. Staff interviews confirmed that required fall prevention interventions were not consistently implemented, and the resident was not wearing the prescribed protective equipment. The lack of adherence to the care plan and physician orders directly contributed to the resident's fall and subsequent injuries.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a qualified director of food and nutrition services, affecting all 42 residents. The Dietary Manager, identified as V5, was observed supervising and directing food preparation and meal services without holding the necessary qualifications. V5 only possessed a cooking sanitation certificate from a national company and did not have a Certified Dietary Manager (CDM) certificate or a Certified Food Protection Professional (CFPP) certificate. Additionally, V5 did not meet the state requirements for a Director of Food Services or the definition of a Dietetic Service Supervisor, lacking a national dietetic school program graduation, relevant experience prior to 1990, or qualifying military experience. The facility utilized the services of a Registered Dietician on a consultant basis for only one day per month. The Regional Dietary Representative, V6, also lacked the necessary certifications but was enrolled in a Certified Dietary Manager course, with plans to enroll V5 after 30 days of employment. The facility's administrator, V1, acknowledged that the previous Certified Dietary Manager was on family medical leave and would not return, leading to V5's hiring. The report also noted issues with palatability, sanitation, lack of alternative menu items, lack of bedtime snacks, and potential contamination in the kitchen and meal services.
Kitchen Utensil Contamination Risk
Penalty
Summary
The facility failed to maintain kitchen utensils in a manner that prevents potential food contamination. During an observation, a metal, long handle measuring scoop was found inside a bulk sugar bin, with the handle in direct contact with and partially buried by the sugar. This was acknowledged by the Dietary Manager and the Regional Dietary Representative, who confirmed that the scoop should not be left in the sugar. Additionally, a silicone blade spatula with a broken corner was found in a kitchen utensil drawer. The broken spatula exposed granulated and rough internal material, which could potentially crumble off and contaminate food during preparation, and was not easily cleanable. These deficiencies have the potential to affect all 42 residents residing in the facility.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of a comprehensive Infection Control Surveillance and Monitoring Policy. The facility did not provide documentation on how it trends monthly infections to prevent further spread throughout the facility. The Director of Nursing, who also serves as the Infection Preventionist, admitted to not maintaining a log for infections for residents, with records only available for October and November 2024, and none for employees. Additionally, there was no Quality Assurance process in place for recurring infections, and no trending of the facility's infections was completed. This deficiency has the potential to affect all 42 residents residing in the facility.
Lack of Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program. This deficiency was identified during an interview and record review, where the Director of Nursing (DON) admitted that the facility had not completed an Antibiotic Stewardship Program. There were no antibiotic protocols or systems in place to monitor antibiotic use among the residents. The existing policy, intended to monitor antibiotic use, was dated 2/7/23 and had not been updated annually. This oversight has the potential to impact all 42 residents residing in the facility.
Failure to Address Resident Grievances and Meal Service Issues
Penalty
Summary
The facility failed to adequately address grievances from residents and their families, as well as inform them about the grievance process and the location of the survey book. Four residents expressed that while they could voice complaints, no actions seemed to follow. They were unaware of how to file a grievance form, and the Activity Director, who took their complaints, did not document or follow up on these concerns. Additionally, the residents reported dissatisfaction with meal options and the lack of snacks at bedtime, noting that meals were often late and cold, and that they were not informed about an 'always available' menu. The Dietary Manager acknowledged issues with meal service, including cold and late meals, and stated that the 'always available' menu was not being utilized properly. The survey book, which should be accessible to residents, was found hidden behind decor and was not up to date, containing only surveys from 2022. The facility's grievance policy states that grievances should be directed to the Administrator, who is responsible for addressing them promptly, but this process was not being effectively communicated or implemented.
Deficiencies in Respiratory Equipment Sanitation
Penalty
Summary
The facility failed to maintain sanitary conditions for respiratory care equipment for four residents, leading to deficiencies in infection control practices. Resident R34, diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, had undated oxygen tubing and nebulizer equipment improperly stored, confirmed by both the resident's daughter and the Director of Nurses. Resident R350, diagnosed with Pneumonia and Sepsis, was using a dirty oral suction catheter that was not covered, and the Director of Nurses confirmed it should have been cleaned and stored properly. Resident R4, who was using continuous oxygen therapy, had requested less frequent changes of his oxygen tubing, which was not documented or communicated to him regarding the infection control risks. The tubing and humidifier bottle were not changed weekly as per the physician's order. Resident R14, with diagnoses including Obstructive Sleep Apnea, had oxygen tubing and a water bottle that were not changed since the previous month, despite using oxygen nightly. These observations indicate a failure to adhere to the facility's policy on changing and storing respiratory equipment, leading to potential infection risks.
Failure to Address Pharmacist Recommendations and Document Physician Responses
Penalty
Summary
The facility failed to ensure that physicians were contacted for unaddressed pharmacist recommendations and did not maintain documented evidence of physician responses to these recommendations. This deficiency affected four residents who were reviewed for unnecessary medications. For instance, a pharmacist recommended an AIMS assessment for a resident on long-term antipsychotic medication, but there was no documented physician response or evidence of the assessment being conducted. Another resident was prescribed Seroquel without an approved diagnosis, and there was no physician response to the pharmacist's request for justification. Additionally, a resident's medication regimen review suggested dose reductions due to self-reported falls, but the physician did not respond timely and provided no documented reason for declining the recommendation. Another resident had multiple pharmacist recommendations for AIMS assessments, yet there was no evidence of these assessments being conducted or any physician response. The facility's policy required AIMS assessments before starting neuroleptic therapy and every six months thereafter, but this was not adhered to, and there was no policy provided regarding following pharmacy recommendations.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to conduct necessary assessments and maintain accurate documentation for residents receiving psychotropic medications. Specifically, the facility did not perform required quarterly psychotropic medication assessments or abnormal involuntary movement scale (AIMS) assessments for residents on antipsychotic medications. For instance, a resident with Alzheimer's Disease and Dementia was receiving Olanzapine and Sertraline without any documented attempts at gradual dose reduction or clinical contraindications for such reductions. Additionally, the resident's electronic medical record lacked any quarterly psychotropic medication assessments or AIMS assessments. Another resident with Major Depression was prescribed Bupropion, yet their electronic medical record did not include any required quarterly psychotropic medication assessments. The Director of Nursing acknowledged that these assessments should be completed quarterly, and AIMS assessments every six months, but they were not found in the records. Furthermore, a resident with Dementia and Irritability was prescribed Quetiapine and Lorazepam on a PRN basis without a specified stop date or duration, contrary to the facility's policy requiring PRN psychotropic medications to be limited to 14 days unless justified by a physician. The facility's failure to adhere to its own policies and regulatory requirements was further evidenced by another resident with Schizoaffective Disorder who did not have any AIMS assessments documented until prompted by the surveyors. Similarly, a resident with Dementia and Major Depression was prescribed Risperidone and Sertraline without any documented AIMS assessments or attempts at gradual dose reductions over the past year. The facility's policies clearly state that psychotropic medications should be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and review, which was not followed in these cases.
Failure to Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to protect the dignity of residents by not ensuring that urinary catheter collection bags were covered. This deficiency was observed in two residents, R22 and R33, who were part of a sample list of 26. On December 10, 2024, at 10:50 AM, R33's urinary catheter collection bag was seen under his wheelchair without any covering, exposing approximately 400 cc's of yellow urine. The Director of Nursing, V2, expressed disapproval of the exposed catheter bags, indicating a preference for them to be covered. Additionally, V7, a private caregiver for R22, reported that the staff inconsistently covered R22's catheter bag, leading to situations where R22's family had to search for a covering bag when taking R22 out of the facility. The facility's policy on Quality of Life - Dignity, dated 2001, mandates that residents be cared for in a manner that promotes dignity, explicitly stating that urinary catheter bags should be covered.
Failure to Request PASARR Level II Screening for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) Level II Screening for a resident diagnosed with Schizoaffective Disorder who was receiving antipsychotic medication. The resident's medical diagnosis sheet, dated December 13, 2024, indicated that the primary medical diagnosis for admission was Interstitial Pulmonary Disease, with Schizoaffective Disorder listed as a diagnosis during the stay. The initial PASARR screening, completed on August 8, 2021, at a different facility, documented that the resident did not need a Level II screening at that time. Observations on December 12, 2024, showed the resident engaging in conversation with an imaginary person, indicating symptoms of Schizoaffective Disorder. The resident's physician's order sheet from December 2024 confirmed the use of Quetiapine Sulfate (Seroquel) for treating Schizoaffective Disorder, with the medication starting on July 1, 2024. The President of Clinical Operations confirmed the absence of a PASARR II request and acknowledged that the facility lacked a policy for admissions regarding PASARR screenings.
Failure to Document Discharge Summary
Penalty
Summary
The facility failed to document a comprehensive discharge summary for a resident, identified as R49, who was reviewed for discharge. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care. This documentation is crucial for ensuring that necessary information is communicated to the resident and the receiving healthcare provider at the time of a planned discharge. The absence of this documentation was confirmed by the Director of Nurses, who acknowledged that there was no discharge summary available for R49. R49 had multiple medical diagnoses, including Acute Kidney Failure, Unsteadiness on feet, Reduced Mobility, Cognitive Communication Deficit, Depression, and Heart Failure. Despite these complex medical conditions, the electronic medical record for R49 did not contain the required discharge documentation. This oversight has the potential to affect the quality of care and continuity of care for the resident after leaving the facility, as critical information regarding the resident's course of illness, treatment, and current status was not communicated to the next care provider.
Incomplete Antibiotic Administration for UTI
Penalty
Summary
The facility failed to provide complete antibiotic doses for a urinary tract infection for a resident, identified as R42. On November 9, 2024, R42's nursing notes indicated an abnormal urine sample was sent for analysis. By November 12, 2024, a new order for Bactrim DS was received to be administered twice daily for five days. However, the Medication Administration Record (MAR) for November 2024 showed that the doses scheduled for November 16, 2024, were not documented as given, indicating a failure to complete the prescribed antibiotic course. Subsequently, on December 8, 2024, R42's family reported symptoms of abdominal pain and bladder pressure, prompting a new urinalysis. The results on December 11, 2024, confirmed a positive infection, leading to a new prescription for Augmentin due to ESBL resistance. The Director of Nursing acknowledged the error in transcription and administration, noting that the incomplete antibiotic course could have contributed to the untreated infection, which R42 was now being treated for.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to accurately assess and supervise a resident for smoking safety, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who has a right artificial shoulder joint, is dependent on renal dialysis, and uses tobacco, was documented in the care plan to be supervised while smoking, with smoking materials kept secured by staff. However, observations and interviews revealed that the resident kept smoking materials in her room and smoked unsupervised, contrary to the care plan interventions. On multiple occasions, the resident was observed smoking alone in the designated smoking area and stated that she was never accompanied by staff while smoking. The facility's staff, including the MDS/Care Plan Coordinator and the Director of Nurses, confirmed that the resident was capable of smoking independently and that the care plan did not reflect the actual practice. This discrepancy between the care plan and the resident's actions indicates a failure to provide adequate supervision and ensure the resident's safety while smoking.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to notify a resident's physician of significant weight loss and did not develop a care plan to address the resident's risk for weight loss. The facility's policy requires notification of the dietician and primary care physician for any weight change of 5% or more, with a loss greater than 5% within one month considered severe. Despite this policy, the facility did not notify the physician or implement new interventions for a resident who experienced a 7.24% weight loss within two weeks of admission. The resident, diagnosed with dysphagia and gastrostomy status, was admitted with severe protein-calorie malnutrition and was NPO with orders for enteral feeding four times a day. The resident's weight decreased from 174 pounds to 161.4 pounds over a short period, indicating severe weight loss. The Director of Nurses confirmed the significant weight loss and acknowledged the lack of notification to the physician and absence of new interventions, despite the resident's high risk for weight loss due to multiple health issues, including recent cancer treatment and severe malnutrition.
Failure to Monitor and Obtain Orders for Gastrostomy Tube Care
Penalty
Summary
The facility failed to monitor and obtain a physician order for a resident with a gastrostomy tube, which is necessary for proper care and management. The resident, diagnosed with dysphagia and gastrostomy status, was on a physician-ordered NPO (Nothing by Mouth) status and required enteral feeding four times a day due to severe protein-calorie malnutrition. Despite this, the resident self-administered her feedings and medications through the gastrostomy tube without any physician orders for self-administration or staff monitoring of the gastrostomy site. The Director of Nurses confirmed the absence of orders for self-administration, site maintenance, or monitoring by staff, and there was no documentation of staff monitoring the gastrostomy site for abnormal signs or symptoms.
Medication Administration Delays
Penalty
Summary
The facility failed to administer medications in a timely manner for one resident, identified as R10, out of a sample of ten residents. R10's Medication Administration Record (MAR) indicated that several medications were scheduled for administration at 8:00 AM, including Ascorbic Acid, Cholecalciferol, Famotidine, Fluoxetine, Furosemide, Gabapentin, Phentermine, Potassium Chloride, Spiriva, Symbicort, Bupropion, Cranberry Tab, and MiraLAX. However, on the day of observation, these medications were not prepared until 10:17 AM by an LPN, who acknowledged that the medications were late due to being occupied with another resident's cataract surgery. The LPN admitted that the MAR was filled in prior to administration, which did not reflect the actual time the medications were given. Further interviews with other LPNs revealed that administering medications late was a regular occurrence, attributed to the size of the building and staffing challenges, such as being the only nurse on duty. The Director of Nursing (DON) confirmed that the facility had only 45 residents and that medications should be administered on time. The facility's policy, revised in December 2012, mandates that medications be administered safely, timely, and within one hour of the prescribed time. However, the MAR did not accurately document the actual administration times, indicating a systemic issue in medication administration practices.
Failure to Obtain Physician's Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen for three residents, leading to a deficiency in providing safe and appropriate respiratory care. Resident 5, diagnosed with Chronic Respiratory Failure, was observed using oxygen at three liters per minute without a documented physician's order. Similarly, Resident 6, who has Chronic Obstructive Pulmonary Disease (COPD) and other health issues, was also using oxygen at the same flow rate without a physician's order. Additionally, Resident 1, who has a documented order for oxygen use, did not have a specified order for when the oxygen tubing or humidification bottle should be changed. The Treatment Administration Records (TAR) for all three residents lacked documentation specifying when the oxygen tubing and humidification bottles should be changed, which is a requirement according to the facility's policy. The Director of Nursing confirmed the absence of these orders and attributed the oversight to a recent change in computer programs. The facility's policy on respiratory therapy and infection prevention, revised in November 2011, outlines specific procedures for maintaining oxygen equipment, which were not followed in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 184 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Casey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casey Rehab And Nursing | 0.5 mi | ★★★★★ | 3 | 0 |
| Greenup Rehab And Nursing | 9.2 mi | ★★★★★ | 6 | 0 |
| Charleston Rehab And Nursing | 15.9 mi | ★★★★★ | 21 | 0 |
| Marshall Rehab & Nursing | 16.9 mi | ★★★★★ | 6 | 0 |
| Hilltop Skilled Nsg & Rehab | 21.4 mi | ★★★★★ | 4 | 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.