Heartwood

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Aug 7, 2024

  Based on observation, interview and document review, the facility failed to ensure a unit refrigerator maintained a safe temperature for storage of food. This had the potential to affect all residents who received food from unit refrigerator. Findings include: During observation on 8/7/24 at 11:06 a.m., the unit refrigerator contained milk, cheese, and yogurt. A regular thermometer was not in the unit refrigerator and a request was made to the culinary director log of temperatures for the month of August 2024. During an interview on 8/7/24 at 2:12 p.m., the culinary director stated she did not know the range the unit refrigerator should be set at. […]

• No harm, potential for more than minimal, patternF883Jul 19, 2023

  Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 5 of 5 residents (R11, R28, R36, R37, R42) reviewed for immunizations. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of congestive heart failure. R11's immunization record dated 7/19/23, identified R11 received the pneumococcal 23 (PPSV23) on 10/23/14 and the pneumococcal conjugate vaccine 13 variant (PCV13) on 1/04/16. R11's medical record failed to provide evidence the PCV20 (pneumonia immunization) was offered and/or education was provided in conjunction with the provider to R11/R11's representative. […]

• No harm, potential for more than minimal, isolatedF880Aug 19, 2026

  Based on observation, interview, and document review, the facility failed to ensure staff followed Enhanced Barrier Precautions during high-contact resident care activities for 1 of 1 resident (R6) reviewed for catheter care. Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and diagnoses that included Alzheimer's disease and urinary retention. R6 required partial/moderate assistance with eating, was dependent on staff for all other care areas and R6 used an indwelling catheter. R6's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 5/24/26, identified R6 had a indwelling catheter. A trial reduction was attempted, however R6 was unable to void without the catheter placement. […]

• No harm, potential for more than minimal, isolatedF641Jul 23, 2025

  Based on observation, interview and document review, the facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for 1 of 5 resident (R6) reviewed for unnecessary medications.Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and included a diagnosis of type 2 diabetes. R12 received an injection of insulin one day per week.R6's Order Summary Report dated 6/30/25, identified semaglutide (a GLP-1 receptor agonist used primarily for managing type 2 diabetes and aiding in weight loss, with significant effects on appetite regulation and blood sugar control.) subcutaneous solution pen-injector 2 milligram (MG)/3 milliliter (ML) inject 0.5 mg subcutaneously one time a day every Monday for type 2… […]

• No harm, potential for more than minimal, isolatedF699Jul 23, 2025

  Based on interview and document review, the facility failed to comprehensively assess for trauma informed care and identify potential triggers, to avoid potential re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care.Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and included a diagnosis of post traumatic stress disorder (PTSD).R6's medical record failed to identify a Trauma-Informed Care Assessment was completed.R6's care plan revised 5/9/25, did not include R6's PTSD triggers and/or interventions specific to his PTSD.During an interview on 7/21/25 at 2:22 p.m., R6 was lying in bed in her room. R6 spoke with a flat affect and stated she liked to keep to herself in her room. […]