Heartland Senior Living

In the surveyor’s words

From the most serious findings on record at Heartland Senior Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 7, 2022

  Based on interview and record review the facility failed to provide supervision for a severely cognitively impaired resident, who was assessed as being at risk for elopement (leaving the facility unnoticed), wandered from the facility unnoticed and undetected by staff. This failure affects one of three residents (R1) reviewed for elopement risk in a sample list of three. This failure resulted in R1 leaving the building unattended and without staff knowledge, R1 was found when a community member called the facility to notify them that R1 was outside, standing in slipper socks on the busy road in front of the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 6/3/22, the facility remained out of compliance at a severity level two. […]

• Actual harm, isolatedF689Mar 6, 2026

  Based on interview and record review, the facility failed to promptly respond to a call light for a newly admitted resident who was identified as being at high risk for falls. This failure affects one (R1) of three residents reviewed for accidents. This failure resulted in R1 sustaining a fall resulting in R1 being transferred to the hospital where R1 was found to have acute swelling and bleeding on both sides of the brain. Findings include:The facility's policy titled Policy and Procedure: Call Light System, which is undated, documents that it is the policy of the facility to provide a means of communication to meet the needs of each resident. […]

• Actual harm, isolatedF689Apr 16, 2025

  Based on observation, interview, and record review, the facility failed to safely transfer R1 from the wheelchair to toilet resulting in R1 sustaining a broken arm requiring emergency evaluation and treatment at the hospital. This failure affects one resident (R1) of five reviewed for accidents in the sample of five. This past non-compliance occurred from 4/3/2025 to 4/4/2025. Findings include: R1's medical diagnosis list (4/16/2025) documents R1's diagnoses include: Unsteadiness on Feet, Muscle Weakness, Pain in Right Knee, Pain in Left Knee, Osteoarthritis, and Polyneuropathy. R1's quarterly assessment (2/25/2025) documents R1 does not reject care from staff, utilizes a wheelchair for mobility, and is dependent on staff or requires maximal staff assistance for mobility. […]

• Actual harm, isolatedF686Jun 12, 2024

  Based on observation, interview and record review the facility failed to provide ordered interventions to prevent the development of deep tissue injuries and worsening of a pressure injury and failed to provide weekly measurements and assessments for pressure injuries for four of five residents (R10, R47, R39 and R53) reviewed for pressure injuries from a total sample list of 33. These failures resulted in R10 and R47 developing deep tissue injuries and R47's unstageable pressure injury worsening. Findings include: The facility provided Prevention of Pressure Ulcers Policy dated August 2008 documents that the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and intervention for specific risk factors. […]

• Actual harm, isolatedF689Jun 12, 2024

  Based on observation, interview and record review the facility failed to prevent injuries from multiple mechanical lift transfers (R10) and failed to supervise a dementia resident to prevent an elopement (R56) for two of two of residents reviewed for accidents from a total sample list of 33 residents. Failing to safely transfer R10 using the mechanical lift resulted in R10 suffering skin tears to bilateral legs. Findings include: 1.) On 6/11/24 at 1:15PM, R10's bilateral shins have open areas, with dried, blood soaked dressings approximately the size of a knee cap covering the tears. The facility skin and wound evaluation dated 4/24/24 documents a new skin tear on R10's right front shin. […]