Heartland Living & Rehab: Oxygen Flow Rate Failure - NC
The finding came from a complaint inspection completed April 30, 2026.
The resident, identified in inspection records as Resident #35, had a physician order for oxygen at 3 liters per minute. When inspectors reviewed that order with her assigned nurse on April 27, then walked with the nurse to the resident's room, the oxygen concentrator was running at 2 liters per minute. The nurse, identified as Nurse #4, changed the setting on the spot. She told inspectors she did not know why the rate was at 2 liters and did not recall when she had last checked it during her shift.
The facility's own nurse practitioner told inspectors the lower setting could cause respiratory distress for this resident. She said if Resident #35 needed a different oxygen level, she would expect staff to notify her and for there to be a new order. There was no new order. There was no notification. The concentrator had simply been running at the wrong rate.
Nobody could say for how long.
A medical assistant, identified as MA #1, had checked Resident #35's pulse oxygen saturation that morning and recorded it at 98 percent. But when inspectors asked her about the flow rate, she said she wasn't sure what it was and would need to check with the nurse. She initially thought it might be 2 liters per minute, then said the nurse was responsible for setting and monitoring the rate, not her.
That responsibility fell squarely on the nurses, and multiple staff members said so explicitly. Nurse #7, who was the assigned nurse on April 30, told inspectors that monitoring oxygen flow rates was the nurse's job, that nurses should confirm the rate matched the physician order at the start of every shift, and that only nurses should change the setting. The Director of Nursing said the same. So did the Administrator.
Everyone agreed on who was responsible. The concentrator had still been set wrong.
Resident #35 could not have adjusted it herself. A nurse aide who was regularly assigned to her, identified as NA #6, told inspectors the resident was physically unable to reach the concentrator without falling out of bed and could not sit up without staff assistance. NA #6 said she had never changed the oxygen flow rate herself.
That left one explanation: the rate had been set incorrectly at some point before the April 27 inspection visit, and no nurse had caught it. The shift checks that Nurse #7 described as standard practice, confirming the rate at the start of each shift, had either not happened or had not been done carefully enough to detect a one-liter discrepancy on a dial.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the outcome inspectors could document, not necessarily what the resident experienced during whatever period the concentrator ran low.
The nurse practitioner's assessment was direct: 2 liters per minute, for this resident, could cause respiratory distress. The physician had ordered 3. The concentrator was on 2. The nurse responsible for monitoring it could not say when she had last looked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heartland Living & Rehab At the Moses H Cone Memor from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
Heartland Living & Rehab at the Moses H Cone Memor in Greensboro, NC was cited for violations during a health inspection on April 30, 2026.
The finding came from a complaint inspection completed April 30, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.