Heartland

In the surveyor’s words

From the most serious findings on record at Heartland, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 28, 2023

  Based on policy review, review of the Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss User Manual, medical record review, facility document review, observation, and interview, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 (Resident #1) residents reviewed for falls. On 9/3/2023 Certified Nurse Assistant (CNA) #10 was providing incontinent care to Resident #1. Resident #1 diagnosed with Hemiplegia affecting the left non-dominant side. Resident #1 was turned by CNA #10 in the opposite direction facing away from the CNA on an alternating pressure mattress. CNA #10 then turned away from Resident #1 to obtain a care item. […]

• No harm, potential for more than minimal, patternF580May 22, 2023

  Based on facility policy review, medical record review, and interview, the facility failed to notify the resident's physician and/or the resident representative with changes in status for 4 of 6 (Resident #1, #2, #3, and #4) sampled residents reviewed for skin integrity/wounds. The findings include: Review of the facility policy titled, Patient Care Policies, reviewed/revised ,d+[DATE], revealed, .The charge nurse on duty is notified immediately of any change in a patient's condition .The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's representative . […]

• No harm, potential for more than minimal, patternF686May 22, 2023

  Based on facility policy review, medical record review, personnel file review, and interview, the facility failed to ensure care and treatment consistent with professional standards of practice to promote healing and prevent new ulcers from developing for 3 of 3 (Resident #1, #2, and #3) sampled residents reviewed for pressure ulcers. The findings include: Review of the facility policy titled, Communication, Skin Integrity Manual, reviewed ,d+[DATE], revealed, .Physician .Notify on admission if new pressure ulcer is present and notify promptly of in-house development .Notify for lack of progress in wound healing .Weekly Skin And Wound Assessments-Weekly assessments include type, stage or depth of tissue injury, location, and measurement of site (length, width, and depth) .Daily Pressure… […]

• No harm, potential for more than minimal, patternF726May 22, 2023

  Based on facilty policy review, employee job description review, medical record review, and interview, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing care including but not limited to assessing, evaluating, and implementing resident care plans and responding to resident's needs for 7 of 7 (Resident #1, #2, #3, #4, #5, #6 and #7) sampled residents reviewed for skin integrity/wounds. The findings include: Review of the facility policy titled, Communication, Skin Integrity Manual, reviewed ,d+[DATE], revealed, .Physician .Notify on admission if new pressure ulcer is present and notify promptly of in-house development .Notify for lack of progress in wound healing .Weekly Skin And Wound Assessments-Weekly assessments include type,… […]

• No harm, potential for more than minimal, patternF835May 22, 2023

  Based on facility policy review, employee job description review, medical record review, and interview, the Administration failed to administer the facility in a manner to ensure resources were used effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Administration's failure to adequately administer the facility resulted in the failure to notify the provider and/or family representative in changes to resident condition for 4 of 6 (Resident #1, #2, #3 and #4) sampled residents, failure to ensure Comprehensive Care Plans were revised with interventions implemented for an actual skin impairment for 1 of 7 (Resident #1) sampled residents, failure of nursing staff to provide care and treatment consistent with professional standards of… […]