A list of the most recent deficiencies for Heartwood Extended Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-13 | 2024-01-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-13 | 2024-01-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-13 | 2024-01-12 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-12-13 | 2024-01-12 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-12-13 | 2024-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-13 | 2024-01-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-13 | 2024-01-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-25 | 2023-11-13 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-10-25 | 2023-11-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-10-25 | 2023-11-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-09-20 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-12 | 2023-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-12 | 2023-06-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-12 | 2023-06-08 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-12 | 2023-06-08 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-05-12 | 2023-06-08 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-05-12 | 2023-06-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-12 | 2023-06-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-12 | 2023-06-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-12 | 2023-06-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-12 | 2023-06-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-12 | 2023-06-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-12 | 2023-06-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-12 | 2023-06-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-12 | 2023-06-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-12 | 2023-06-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-12 | 2023-06-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-12 | 2023-06-08 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-05-12 | 2023-06-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-06-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-12 | 2023-06-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-12 | 2023-06-08 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-05-12 | 2023-06-08 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-08 | 2023-06-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-06 | 2023-04-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-31 | 2023-02-17 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-01-31 | 2023-02-17 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-12-15 | 2022-11-23 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-07-13 | 2022-08-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-13 | 2022-08-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-13 | 2022-08-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-07-13 | 2022-08-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-13 | 2022-08-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-13 | 2022-08-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-07-13 | 2022-08-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-07-13 | 2022-08-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-13 | 2022-08-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-13 | 2022-08-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-13 | 2022-08-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-13 | 2022-08-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-13 | 2022-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-13 | 2022-08-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-13 | 2022-08-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-13 | 2022-08-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-07-13 | 2022-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-13 | 2022-08-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-13 | 2022-08-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-07-13 | 2022-08-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-13 | 2022-08-12 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-07-13 | 2022-08-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-13 | 2022-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-08-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-13 | 2022-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-13 | 2022-08-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-08-12 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-07 | 2022-08-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-07 | 2022-08-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-07 | 2022-08-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-07 | 2022-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-07 | 2022-08-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-07 | 2022-08-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-07 | 2022-08-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-07 | 2022-08-11 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-03 | 2021-09-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-06-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-01 | 2021-06-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-01 | 2021-06-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-01 | 2021-06-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-01 | 2021-05-28 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-01 | 2021-05-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-12-23 | 2020-02-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-12-23 | 2020-02-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-12-23 | 2020-02-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-12-23 | 2020-02-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-12-23 | 2020-02-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-23 | 2020-02-06 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-23 | 2020-02-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-23 | 2020-02-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-23 | 2020-02-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-23 | 2020-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-23 | 2020-02-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-23 | 2020-02-06 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-12-23 | 2020-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-23 | 2020-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-23 | 2020-02-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-23 | 2020-02-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-12-23 | 2020-02-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-12-23 | 2020-02-06 | N |
| Post nurse staffing information every day. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-12-23 | 2020-02-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-12-23 | 2020-02-06 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-12-23 | 2020-02-06 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-12-23 | 2020-02-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-12-23 | 2020-02-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-23 | 2020-02-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-23 | 2020-02-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-12-23 | 2020-02-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-23 | 2020-02-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-23 | 2020-02-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-23 | 2020-02-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-12-23 | 2020-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-23 | 2020-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-23 | 2020-02-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-12 | 2020-01-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-23 | 2020-01-17 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2019-12-23 | 2020-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-12 | 2020-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-12 | 2020-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-12 | 2020-01-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-12 | 2020-01-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-12 | 2020-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-12 | 2020-01-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-12 | 2020-01-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-12 | 2019-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-12 | 2019-12-23 | N |
