Heartwood Avenue Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF684Apr 14, 2026

  Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Facility staff failed to accurately document the use of BiPap ((Bilevel Positive Airway Pressure) machine is a non-invasive ventilator used to assist breathing by delivering pressurized air through a mask, improving oxygen levels) for Resident 1 as ordered by her physician,2. Facility staff administered an opioid medication (controlled drug highly effective for severe, acute, or chronic pain but carries significant risks of addiction, misuse, and overdose) on two occasions without adequate indication for use to Resident 1, and3. […]

• Actual harm, isolatedF689May 3, 2024

  Based on observations, interviews and records review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) were free from accidents, when: 1. The facility did not provide two-person assistance to Resident 1 during care, when Resident 1 was dependent (resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) from staff to maintain perineal hygiene (washing the genital and rectal areas of the body) and to turn in bed. […]

• Actual harm, isolatedF686Jan 9, 2024

  Based on observation, interview and record review, the facility failed to ensure a resident receive care consistent with professional standards of practice when one out of two sampled residents (Resident 1), who entered the facility without pressure ulcers, did not develop pressure ulcers when Resident 1 developed 4 pressure ulcers: one stage 4 pressure ulcer (PU, the most serious type of pressure ulcer, it extend below the muscle, tendons, and in severe cases, the bone) on his sacrum (the bottom of the spine) and three stage 2 pressure ulcers (PU that extend through deeper tissue and fat but do not reach muscle or bone) on his right inner foot, left inner proximal (near the center) foot and left inner distal (away from the center) foot. […]

• Actual harm, isolatedF689Jan 9, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure residents were provided an environment that is free from accident hazards over which the facility has control when staff failed to identify, evaluate, analyze hazards and risks and implement interventions to reduce hazards and risks for using a low air loss mattress (LAL, an air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) to prevent avoidable accidents for one out of three sampled residents (Resident 1). These failures resulted in Resident 1 fall incident on 11/4/23 and Resident 1 being sent to the hospital for further evaluation and treatment. […]

• No harm, potential for more than minimal, widespreadF814Feb 9, 2023

  Based on observation and interview the facility failed to keep the facility garbage dumpster closed and secured. This failure had the potential for insects and vermin to get into the garbage and spreading disease to the facility residents and the community. Findings: During an initial tour of the facility on 2/6/23 at 9:15 a.m., the dumpster was observed to be open, when the dumpster lid was was not securely in place. The dumpster was readily accessible to insects and vermin. In an interview with the Administrator (ADM) on 2/6/23 at 9:47 a.m. the ADM was shown the pictures of the facility dumpster being open. The ADM confirmed the images of the garbage dumpster should be closed at all times to prevent vermin or insects from having access to the contents of the dumpster. […]