Heartwood Lodge Trinity Health

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 13, 2025

  Based on interview and record review, the facility failed to prevent a fall for 1 of 2 residents reviewed (R1) for falls, resulting in R1 sustaining multiple rib fractures and a hip fracture. Findings include: A review of R1's admission Record, dated 6/12/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed they had multiple diagnoses that included cerebral palsy, epilepsy, abnormal posture, torticollis (a rare condition in which the neck muscles contract causing the head to twist to one side), and scoliosis. […]

• Actual harm, isolatedF600May 21, 2021

  This citation pertains to intake # MI00- 1 Based on interview and record review, the facility neglected to follow the plan of care and use 2 staff persons to transfer one resident (Resident #5) from the bed to a wheelchair, resulting in a fractured right arm. Findings: Resident #5 (R5) Review of an Admission Record revealed R5 was a [AGE] year old female, originally admitted to the facility on [DATE], from a local emergency room , following a fall and subsequent displaced fracture of the left femur. Other pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Brief Interview for Mental Status assessment, dated 4/26/21, revealed R5 was cognitively intact. The discharge plan for R5 was to transfer to an assisted living facility following short term rehabilitation. […]

• No harm, potential for more than minimal, widespreadF865Jun 13, 2025

  Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify and address issues and develop/implement appropriate plans of action in regard to 1) call light response time and care, 2) Grievances 3) MDS (minimum data set) late submissions and incorrect coding 4) antibiotic stewardship and infection control, 5) complete and accurate medical records, 6) available/updated policies and procedures annually reviewed, 7) and monitor nursing staff for compliance with nursing standards of practice. This deficient practice has the potential to affect all 74 residents who reside at the facility. […]

• No harm, potential for more than minimal, widespreadF868Jun 13, 2025

  Based on interview and record review, the facility failed to have the required attendance of a Medical Director, or a designated physician at the facility's Quality Assessment/Improvement (QAPI) meetings at least quarterly resulting in the potential for lack of oversight of the quality assurance process and coordination of medical care that could impact 74 of 74 residents residing within the facility. Findings include: Review of the QAPI monthly sign in sheets from 6/2024 to 6/2025 revealed the Medical Director or designated physician was in attendance on 6/12/24, 8/5/24, and 4/9/25. This leaves 8 months with no physician representation for the QAPI meetings. […]

• No harm, potential for more than minimal, widespreadF880Jun 13, 2025

  This citation has two Deficient Practice Statements (DPS) DPS #1 Based on interview and record review, the facility failed to ensure an annual review was completed of the Infection Control policy and procedures to verify adherence to current national standards of care. Findings: Review of the Infection Control Policy and program provided by the facility did not reflect if or when a review had been conducted to ensure the policy and program met current standards of care. On 6/11/25 at 1:04 PM. during the Infection Control task, an interview was conducted with Infection Preventionist (IP) L. IP L was asked to provide documentation the facility Infection Prevention policy and program was reviewed annually. […]