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 Senior Living during CMS and state inspections, most recent first.
A newly admitted high fall-risk resident, identified as needing supervision for unsteady gait and unsafe transfers, activated a bathroom call light that was not promptly answered. Facility policy requires prompt response to call lights, but one CNA at the nurses’ station did not monitor the call light panel, assuming most residents were in the dining room, while another CNA saw the call light while passing meal trays and assumed it would be answered, delaying response for about seven minutes. When the second CNA finally entered the room, the resident was found prone on the bathroom floor and unresponsive, with a bleeding skin tear; an LPN was notified and EMS was called. The DON stated that all new admissions are treated as fall risks and that staff are expected to respond immediately to call lights or within a few minutes if occupied, and to communicate to ensure call lights are answered. A subsequent brain scan showed acute swelling and bleeding on both sides of the brain related to the fall.
A resident with significant mobility deficits and a need for two-person assist was transferred by a single CNA without a gait belt, resulting in a fractured arm. The CNA was unaware of the resident's transfer requirements and did not follow facility policy, leading to the resident experiencing severe pain and requiring hospital treatment.
A resident was struck by another resident in the sunroom, violating their right to be free from abuse. The resident who was struck is cognitively intact, while the aggressor has dementia with agitation. An LPN witnessed the incident, and the facility's abuse prevention policy was not upheld.
A facility failed to follow physician orders for insulin administration for a resident with Type II Diabetes Mellitus. The resident's insulin was administered without checking blood sugar levels as required, despite specific instructions to hold insulin if levels were below 90. The DON acknowledged the oversight, noting the resident was a brittle diabetic with changing insulin orders.
The facility failed to provide necessary interventions to prevent and manage pressure injuries for several residents. A resident developed a new deep tissue injury due to the absence of heel protectors, while another resident's existing pressure injury worsened. Inconsistent and missing wound assessments were noted for two other residents, highlighting gaps in wound care management.
The facility failed to prevent injuries during mechanical lift transfers for a resident, resulting in skin tears on both shins. Additionally, a dementia resident was able to elope from the facility due to inadequate supervision when a visitor propped open a door, allowing the resident to exit unnoticed.
A facility failed to obtain the necessary consent for administering Sertraline, a psychotropic medication, to a resident. The facility's policy requires written consent before administering such medications. However, the resident's medical record lacked signed consents for the prescribed 75mg and 100mg doses, as confirmed by the DON, who only had consents for 25mg and 50mg doses.
A resident with cognitive intactness and significant medical needs reported being roughly handled by a CNA, resulting in bruises. Despite the resident's complaints and visible bruises, staff failed to report the allegations to the facility's Administrator, violating the facility's abuse reporting policy.
A resident with chronic kidney disease and benign prostatic hypertrophy experienced unsafe catheter care, with tubing dragging on the floor and improper handling during transfer, leading to urine backflow. The catheter was not anchored, causing pain and redness around the urinary meatus. The resident was on antibiotics for recurrent UTIs, and the DON acknowledged the catheter bag should be kept below bladder level.
A resident with multiple health conditions was at risk of infection due to improper IV medication administration by an LPN. The LPN opened the catheter system, contrary to protocol, and allowed blood to drip while priming Vancomycin, leading to a deficiency in safe and aseptic IV administration.
The facility failed to ensure proper respiratory care for two residents by not having orders for oxygen use and not changing oxygen/nebulizer equipment as per policy. One resident had an oxygen concentrator without a documented order or dated tubing, while another used a nebulizer with undated equipment, contrary to facility policy.
Failure to Promptly Respond to Call Light for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly respond to a call light for a newly admitted resident who had been identified as a high fall risk and required staff supervision due to unsteady gait and safety concerns with transfers and ambulation. The facility’s undated Call Light System policy requires staff to respond promptly when a call light is activated, address the resident’s need or request, and, if unable, locate another staff member who can meet the need. The resident was admitted and within approximately five hours sustained an unwitnessed fall with suspected injury and loss of consciousness, with nursing notes documenting a bleeding skin tear on the left arm and an emergency transfer to the hospital. The incident report shows that at approximately 4:25 p.m., a CNA going to respond to the resident’s bathroom call light found the resident on the bathroom floor, unresponsive and lying prone. Interviews revealed that one CNA was at the nurses’ station at the time of the fall and was not paying attention to the call light panel, assuming most residents were in the dining room. Another CNA observed the resident’s call light blinking and sounding while passing meal trays and assumed the CNA at the nurses’ station would answer it, continuing to pass trays. When this CNA later returned to the hall, the call light was still flashing and sounding; she then entered the room and found the resident on the floor, estimating about seven minutes had passed from when she first noticed the call light. The LPN reported arriving to find the resident unresponsive with a bleeding skin tear and contacting EMS. A brain scan documented acute swelling and bleeding on both sides of the brain as a result of the fall. The DON stated that newly admitted residents are treated as fall risks and that his expectation is that any staff member aware of a call light should respond immediately, or within five to eight minutes if actively assisting another resident, and that communication between CNAs should have ensured the call light was answered.
Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments and a documented need for maximum assistance of two staff for transfers was transferred by a single certified nurse aide (CNA) without the use of a gait belt. The resident, who had diagnoses including unsteadiness on feet, muscle weakness, osteoarthritis, and polyneuropathy, was dependent on staff for mobility and required hands-on assistance for all transfers, as documented in the care plan and quarterly assessment. On the day of the incident, the resident activated the call light for assistance to use the bathroom, and the CNA responded alone, transferring the resident from the wheelchair to the toilet using a 'bear hug' technique without a gait belt. During the transfer, the resident became weak and complained of left arm pain immediately after being seated on the toilet. The CNA later stated that they believed the resident required only one-person assistance, despite documentation indicating a two-person assist was necessary. The CNA also confirmed that a gait belt was not used during the transfer, contrary to facility policy, which requires gait belts for all hands-on transfers unless contraindicated. The Director of Nursing confirmed that multiple communication methods were in place to inform staff of residents' transfer status, and there were no staffing shortages at the time of the incident. Following the transfer, the resident exhibited severe pain and was sent to the hospital, where an acute fracture of the left upper arm was diagnosed. Medical records and staff interviews confirmed that the injury was consistent with improper transfer technique and lack of appropriate assistance. The resident, who previously experienced minimal pain, reported daily pain following the incident and was placed on a non-weight bearing order for the affected arm.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident where one resident struck another on the cheek in the sunroom. The incident report dated 1/19/25 documents that the resident who was struck is cognitively intact, while the resident who committed the act has unspecified dementia with agitation and cognitive communication deficit. The care plan for the resident who was struck indicates a risk for inappropriate altercations with other residents, while the care plan for the resident who struck indicates a history of verbal abuse towards roommates and new residents. On 1/28/25, the resident who was struck reported being backhanded in the mouth by the other resident, possibly after bumping into them with a wheelchair. The resident who struck claimed that the other resident was trying to block their path. A Licensed Practical Nurse (LPN) witnessed the aftermath, hearing the struck resident yell and the other resident express that the action was deserved. The facility's Abuse Prevention Program, dated October 2022, affirms the residents' right to be free from abuse, which was not upheld in this incident.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for the administration of insulin to a resident diagnosed with multiple conditions, including Type II Diabetes Mellitus. The resident had a physician order for Insulin Lispro to be administered subcutaneously at 10:00 AM within ten minutes of eating a meal, with specific instructions to hold the insulin if blood sugar levels were below 90 and to notify the endocrinologist if levels were below 70 on three consecutive occasions. However, the medication administration record for June 2024 indicated that the insulin was administered daily from June 6 to June 23 without checking the resident's blood sugar levels prior to the 10:00 AM administration, as required by the physician's order. Interviews with the Director of Nursing revealed that the resident was considered a brittle diabetic, and the insulin orders had been changed multiple times during the resident's stay. Despite this, the facility did not document the resident's blood sugar levels before administering the insulin, which was a clear deviation from the physician's orders. This oversight in following the prescribed protocol for insulin administration represents a failure in the facility's medication management practices.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary interventions to prevent the development and worsening of pressure injuries for several residents. Resident R10, who was at risk for pressure ulcer development due to decreased strength and mobility, was observed without heel protectors, which were part of her care plan to prevent pressure injuries. This lack of intervention led to the development of a new deep tissue injury on R10's right heel. Staff members, including the Director of Nursing and a Licensed Practical Nurse, acknowledged that the absence of heel protectors likely contributed to the injury. Resident R47 also experienced a failure in care, as she was observed without heel protectors despite physician orders requiring them. This oversight resulted in a new deep tissue injury on R47's right heel and the worsening of an existing unstageable pressure injury on her left heel. The facility's weekly wound reports documented the progression of R47's injury, but there were gaps in the measurements and assessments, indicating a lack of consistent monitoring and intervention. Additionally, residents R53 and R39 experienced deficiencies in wound care management. R53's medical records showed inconsistent and missing measurements for a pressure wound on the sacrum, with unexplained discrepancies in assessments. Similarly, R39's records lacked documentation of wound assessments and measurements for a pressure ulcer on the coccyx, with only one recorded measurement. The Director of Nursing confirmed the missing assessments and attributed them to the absence of a wound nurse, highlighting a gap in the facility's ability to provide adequate wound care management.
Failure to Prevent Injuries and Supervise Residents
Penalty
Summary
The facility failed to prevent injuries during mechanical lift transfers for a resident, identified as R10, who suffered skin tears on both shins. Observations revealed open areas with dried, blood-soaked dressings on R10's shins. The facility's documentation noted a new skin tear on R10's right shin on 4/24/24, but no new interventions were recorded. A subsequent risk evaluation on 5/3/24 identified a skin tear on R10's left shin caused by the mechanical lift. Despite these incidents, the facility's weekly wound report on 5/27/24 only documented the left shin tear, omitting the right shin injury. The Director of Nursing confirmed that the mechanical lift was the cause of the injuries. Additionally, the facility failed to supervise a dementia resident, R56, to prevent an elopement. R56, who is severely cognitively impaired and requires maximum assistance for daily activities, was found outside the facility in a wheelchair, having followed a visitor who had propped open a door. The visitor had paused the alarm on the back sliding doors, allowing R56 to exit unnoticed. The facility's administrator acknowledged that staff should have been more vigilant and noted that the facility's elopement policy only addresses actions after a resident is found missing, lacking guidance on monitoring residents when doors are left open.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for administering a psychotropic medication to one of the residents reviewed. According to the facility's Psychotropic Medication Use-Management Policy dated 10/1/2019, consent must be obtained from the resident or their representative before administering any psychotropic medication, and this consent should be documented in writing. However, for a resident with a physician's order dated 4/26/24 for Sertraline 75mg to be administered daily, the medical record lacked a signed consent for both the 75mg and 100mg doses. The Director of Nursing confirmed the absence of consents for these doses, noting that only consents for 25mg and 50mg doses were available.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident, identified as R22, to the Abuse Coordinator. R22, who has medical diagnoses including Non Traumatic Intracerebral Hemorrhage and Diastolic Heart Failure, reported being pushed and handled roughly by a Certified Nurse Aide (CNA), identified as V3. R22, who is cognitively intact and requires maximum assistance for transfers, stated that V3 pushed her around and left bruises on her right arm. Despite R22's complaints to another CNA, V4, and the presence of bruises, the allegations were not reported to the facility's Administrator or Director of Nurses. Interviews with staff revealed a lack of understanding and adherence to the facility's abuse reporting policy. V6, a Registered Nurse, and V4, a CNA, both observed bruises on R22 but did not report them, believing they were not indicative of abuse. V3, the CNA accused of rough handling, acknowledged that R22 had complained about being hurt but did not report the incident, assuming it was typical behavior for R22. The facility's policy requires immediate reporting of any abuse allegations to the Administrator, which was not followed in this case.
Failure to Maintain Safe and Sanitary Catheter Care
Penalty
Summary
The facility failed to maintain a urinary catheter in a safe, sanitary, and dignified manner for a resident with chronic kidney disease and benign prostatic hypertrophy. The facility's policy on catheter care, revised in September 2005, outlines procedures to prevent urinary tract infections, including keeping catheter tubing and drainage bags off the floor, ensuring the drainage bag is positioned lower than the bladder, and securing the catheter with a leg strap to reduce friction and movement. However, during an observation, the resident was seen with catheter tubing dragging on the floor, and the catheter bag was not contained in a dignity bag. During catheter care, a CNA lifted the catheter bag to the level of the resident's chest, causing urine to backflow into the catheter tubing. The CNA was unaware that the drainage bag should be kept below the bladder level. Additionally, the catheter was not anchored, leading to torsion on the tubing, and the resident reported pain when the tube was pulled. Redness was observed around the urinary meatus, and the resident's medication administration record included an order for an antibiotic for recurrent urinary tract infections. The Director of Nursing acknowledged that the catheter bag should not be above the bladder level and that an anchor device is usually used.
Improper IV Medication Administration
Penalty
Summary
The facility failed to properly administer intravenous medication to a resident, leading to a potential risk of infection. The resident, who had a diagnosis list including cellulitis, diabetes mellitus type two, rhabdomyolysis, insomnia, depression, hypertension, and joint pain, was ordered to receive Vancomycin intravenously. On the specified date, an LPN unscrewed the needleless cap from the end of the intravenous catheter, exposing the catheter line to air, which is against the facility's protocol for maintaining a closed system. The LPN then used an alcohol swab on the open end of the catheter and flushed it with normal saline, allowing blood to drip on the floor while priming the Vancomycin through the tubing. The Director of Nursing later confirmed that the LPN had been instructed to keep the system intact and not to open it, indicating a lack of adherence to proper intravenous administration procedures. The actions taken by the LPN, such as opening the catheter system and wiping the open catheter with alcohol, were not in line with the facility's protocol and could potentially lead to an infection for the resident. This incident highlights a deficiency in the safe and aseptic administration of intravenous fluids and electrolytes as per the facility's documented procedures.
Failure to Ensure Proper Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R265 and R266, by not ensuring proper orders and equipment management. For R265, there was an oxygen concentrator in the room, but the hydration bottle and oxygen tubing were not dated, indicating when they were last changed. Additionally, there was no documented order for oxygen administration or tubing changes in R265's Medication Administration Record, Treatment Administration Record, or Order Summary Report. Despite this, a nurse's note indicated that R265 was using oxygen via nasal cannula, and the Director of Nursing confirmed the absence of an active order for oxygen administration. For R266, the nebulizer machine was observed with tubing and a mask that were not dated to indicate when they were last changed, despite the resident using the nebulizer multiple times that day. The facility's policy requires nebulizer tubing and masks to be changed every 24 hours, but R266's records did not document any orders for such changes. The Director of Nursing stated that all tubing is changed on Saturday nights, but this task was not documented in the resident's Treatment Administration Record. R266 had orders for nebulizer treatments due to pneumonia, but there was no documentation of orders for changing the nebulizer equipment.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Neoga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mattoon Rehab & Hcc | 11 mi | ★★★★★ | 28 | 0 |
| Palm Garden Of Mattoon | 11.3 mi | ★★★★★ | 36 | 1 |
| Odd Fellow-rebekah Home | 12.4 mi | ★★★★★ | 20 | 0 |
| Evergreen Nursing & Rehab Center | 13.8 mi | ★★★★★ | 4 | 0 |
| Lakeland Rehab & Healthcare Center | 14.3 mi | ★★★★★ | 10 | 0 |
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