Inspection·October 28, 2022

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to obtain a physician order for oxygen administration, failed to keep a resident's oxygen tubing off the floor, failed to change oxygen tubing, and failed to label portable oxygen cannula/tubing according to the plan of care. These failures affect one of three residents (R30) reviewed for respiratory care on the sample list of 19. Residents Affected - Few Findings include: R30's Physician Order Sheet (POS) dated October 2022 had an oxygen administration order added 10/27/22 as follows: Oxygen per nasal cannula at 3 (three) liters per nasal cannula (sic) continuous. Change oxygen equipment every Sunday. R30's Minimum Data Set (MDS) dated [DATE] documents R30's Brief Interview of Mental Status score of seven out of a possible 15, indicating severe cognitive impairment. The same MDS documents R30 was on oxygen while not a resident at the facility and while residing in the facility. R30's Care Plan dated 9/3/22 documents the following: Category Respiratory. I (R30) am receiving oxygen therapy due to diagnoses of History Respiratory Failure and anoxic brain injury. Care Plan Goal, Exhibits no shortness of breath per my (R30) report. Intervention (1.) Provide Humidification, label with date, change weekly. Intervention (6.) Change oxygen tubing weekly and as needed. Label with date. Keep tubing off floor. Store tubing in bag attached to concentrator or wheelchair. (7.) Administer oxygen therapy at three liters per nasal cannula or mask. On 10/25/22 at 11:03 AM, R30 had an oxygen bed-side concentrator with humidifier bottle dated as changed 10/21/22. R30 has nasal cannula and tubing dated as changed 10/08/22. R30's oxygen flow rate was set at a delivery rate of two liters (physician ordered at three liters and identified on the care plan) per nasal cannula. R30 also has oxygen tubing with additional eight foot extension oxygen tubing. The oxygen tubing laid on the floor partially coiled that extended from R30's nasal cannula down onto the floor and over five feet to the oxygen concentrator. R30 also had an E-cylinder portable oxygen tank with undated tubing/nasal cannula laid on a bedside table. The E-tank portable oxygen was in R30's wheelchair. R30 stated I am not sure if they change anything. I really don't know for sure. On 10/25/22 at 11:35 pm V4, Registered Nurse (RN) confirmed R30's oxygen tubing placement and tubing date. V4, RN stated (R30's) tubing should never be on the floor. Tubing should be changed and dated when changed every week. On 10/26/22 at 9:05 am V2, Director of Nursing (DON) confirmed R30 does not have a physician order (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145416 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)