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Deficiency Records for Heartwood Extended Healthcare
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.
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 services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-12 | 2024-07-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-12 | 2024-07-27 | 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 | 2024-04-12 | 2024-05-24 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-04-12 | 2024-05-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-12 | 2024-05-24 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-04-12 | 2024-05-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-12 | 2024-05-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-12 | 2024-05-24 | 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 | 2024-04-12 | 2024-05-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-12 | 2024-05-24 | N |
| Provide activities to meet all resident's needs. | Health | 2024-04-12 | 2024-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-12 | 2024-05-24 | N |
| 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 | 2024-04-12 | 2024-05-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-12 | 2024-05-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-12 | 2024-05-24 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-04-12 | 2024-05-24 | 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 | 2024-04-12 | 2024-05-24 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-04-12 | 2024-05-24 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-04-12 | 2024-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-12 | 2024-05-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-12 | 2024-05-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-12 | 2024-05-24 | 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 | 2024-04-12 | 2024-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-12 | 2024-05-24 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-09 | 2024-05-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-09 | 2024-05-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-04-09 | 2024-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-09 | 2024-05-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-09 | 2024-05-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-04-09 | 2024-05-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-09 | 2024-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-09 | 2024-05-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-09 | 2024-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-27 | 2024-04-17 | Y |
| 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 |
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