A list of the most recent deficiencies for Heartwood Avenue 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-09 | 2024-01-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-09 | 2024-01-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-09 | 2024-01-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-09 | 2024-01-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-09 | 2024-01-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-09 | 2023-03-13 | 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 | 2023-02-09 | 2023-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-09 | 2023-03-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-09 | 2023-03-13 | 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 | 2023-02-09 | 2023-03-13 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-09 | 2023-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-03-13 | N |
| Dispose of garbage and refuse properly. | Health | 2023-02-09 | 2023-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-09 | 2023-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-09 | 2023-03-13 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-22 | 2023-03-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-05 | 2019-11-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-05 | 2019-11-14 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-09-05 | 2019-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-05 | 2019-11-14 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-05 | 2019-11-14 | N |
| 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 | 2019-09-05 | 2019-11-14 | 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 | 2019-09-05 | 2019-11-14 | 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 | 2019-09-05 | 2019-11-14 | 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 | 2019-09-05 | 2019-11-14 | 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 | 2019-09-05 | 2019-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-05 | 2019-11-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-05 | 2019-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-05 | 2019-11-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-05 | 2019-11-14 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-01 | 2019-10-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-24 | 2018-11-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-10-24 | 2018-11-09 | N |
| Use approved construction type or materials. | Fire Safety | 2018-10-24 | 2018-11-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-24 | 2018-11-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-24 | 2018-11-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-10-24 | 2018-11-09 | 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 | 2018-09-21 | 2018-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-21 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-21 | 2018-10-31 | N |
