Inspection·August 6, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to obtain a physician's order for oxygen and maintenance of supplemental oxygen for three residents (R1, R5, R6) of six residents reviewed for oxygen in a sample list of ten residents. Residents Affected - Few Findings Include: 1. R5's Care Plan updated 7/24/24 includes the diagnosis: Chronic Respiratory Failure. On 8/5/24 at 10:00AM R5 was observed sitting in his room with oxygen in place at three liters per minute flow per nasal cannula. On 8/5/24 at 10:30AM R5's physician's orders did not document a physician's order for supplemental oxygen. R5's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed. 2. R6's Care Plan updated 7/30/24 documents (R6) has an Activities of Daily Living Self Care Performance Deficit: Activity Intolerance, Confusion, Dementia, Shortness of Breath. This Care Plan also documents a diagnosis of Chronic Obstructive Pulmonary Disease. On 8/5/24 at 10:06AM R6 was observed sitting in his room with oxygen in place at three liters per minute flow per nasal cannula. On 8/5/24 at 10:30AM R6's physician's orders did not document a physician's order for supplemental oxygen. R6's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed. 3. R1's Care Plan updated 8/1/24 documents Risk for COPD Complication Chronic Obstructive Pulmonary Disease (COPD) Date Initiated: 08/01/2024. R1's Physician's Orders document an order dated 6/27/24 for Oxygen 2-5 Liters per Minute Per Nasal Cannula for comfort/Shortness of breath. R1's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed. (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 08/06/2024 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)