Heartwood Avenue Healthcare

Inspectors wroteBased on interviews and record review, the facility failed to ensure required 1:1 supervision was provided for one of three sampled residents (Resident 2) when the assigned staff member was not closely supervising Resident 2 and did not intervene when a verbal altercation between Resident 1 and Resident 2 escalated into a physical altercation. This failure resulted in Resident 1 and Resident 2 physically kicking each other placed both residents at risk for physical harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for three of 19 sampled residents (Resident 7, Resident 22 and Resident 60) when:1. Resident 7's blood pressure was not accurately assessed;2. Resident 22 was administered a blood pressure medication outside of the ordered parameters;3. Resident 60 was administered a lower than prescribed dose of medication; and4. Resident 60's oxygen was not accurately documented and monitored. These failures increased the risk for an inaccurate blood pressure for Resident 7, low blood pressure for Resident 20, subtherapeutic dose of medication, breathing problems, and hallucinations for Resident 60.1. Resident 7 was admitted to the facility in early 2026 with diagnoses that included high blood pressure and heart failure. During an observation and interview on 5/4/26 at 1:30 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate reconciliation and accountability of controlled medications for three of 19 sampled residents (Resident 22, Resident 56 and Resident 57) when discrepancies were found during the random controlled medication audits. These failures resulted in the facility lacking accurate accountability of controlled substances and increased the potential for diversion in a 60-certified-bed facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of 19 sampled residents (Resident 4 and Resident 9) were free from significant medication errors when nursing staff did not administer prescribed as needed antihypertensive medications during repeated, documented episodes of elevated systolic blood pressure. This failure compromised the residents' safety and placed both Resident 4 and Resident 9 at increased risk for serious and potentially life threatening outcomes, including hypertensive crisis, stroke, and cardiac arrest.1. Resident 9 was admitted to the facility in late 2022 with diagnoses that included a stroke, an irregular heartbeat, and heart disease. During a review of Resident 9's Order Summary Report [OSR], order dated 4/2/26, the OSR indicated, cloNIDine HCl Oral Tablet 0.1 MG [milligram, unit of measurement]. [...]

Inspectors wroteBased on observation, interview and documentation review, the facility failed to implement their medication storage policy when: Multiple medications were unlabeled, and Expired medications were stored and available for use. These failures had the potential for residents to receive unsafe, ineffective, or inappropriate medications for a census of 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 54 residents who received food prepared from the kitchen, when: 1. Food debris and dried watermarks was observed on several kitchen utensils stored inside the plastic container. The bottom of the container, which was designated for storing clean utensils, contained visible dirt and food debris; 2. Several kitchen utensils, stock pot, plastic trays, metal pans were found stacked wet and stored at the clean and ready-to-use storage areas; 3. A plastic coffee carafe on the countertop contained a white substance adhered to the interior walls and debris collected at the bottom; 4. A staff used wiping cloth from the red bucket to wipe the countertop during cooking and food preparation without wearing gloves. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for one of three sampled residents (Resident 9) when:Resident 9 did not receive diclofenac sodium gel 1% (a gel used treat joint pain and inflammation from osteoarthritis) to his leg or as needed clonidine (fast acting medication to lower blood pressure). These failures resulted in two medication errors out of 35 opportunities, yielding a medication error rate of 5.71%.

Inspectors wroteBased 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. Facility failed to order Narcan (naloxone: [...]

Inspectors wroteBased on interview and record review the facility failed to provide quality care to one of two sampled residents (Resident 1) when:The facility failed to create specific and measurable care plan interventions for Resident 1's risk for elopement. The facility staff failed to follow physician orders for monitoring elopement attempts. These failures had the potential for Resident 1 to have an increased risk for elopement, had the potential for staff caring for Resident 1 to be unaware of his elopement attempt on 2/19/26 and had the potential to contribute to Resident 1's elopement attempt on 2/19/26.1. During a review of Resident 1's Facesheet dated 2/25/26, facesheet indicated, Resident 1 was admitted to the facility 29 days ago. Resident 1 had diagnoses including Respiratory failure, Falls, and Alzheimer's Disease (disease characterized by memory loss and cognition decline). [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect Resident 1's right to be free from physical abuse when Resident 2 hit Resident 1, a deficient practice identified for one of four sampled residents. This failure resulted in an injury to Resident 1's lip.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of four sampled residents (Resident 1) when an allegation of abuse was not reported to the State Agency. This failure resulted in delays in the abuse investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and their privacy was protected when curtains did not reach around the resident personal space and vertical blinds were broken or missing for five residents (Resident 19, 31, 7, 14, and 16) in a census of 55. These failures resulted in Resident 19 and Resident 7 feeling a lack of privacy and had the potential for shame or embarrassment for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy when medications were not labeled with an opened date and an expired medication was available for use in the medication cart. These failures placed the residents at risk for receiving contaminated medications, medications with reduced potency or unpredictable results that could lead to complications over time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. Staff did not wear a gown when providing high contact care to one resident (Resident 206) on Enhanced Barrier Precautions [EBP-set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)], 2. Staff didn't wash hands after providing care for a resident who had C Diff [Clostridium Difficile, bacteria that cause inflammation of the colon]; and 3. Tube feeding bottle was not labeled. These failures had the potential to contribute to the spread of infections for a facility census of 55 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to accommodate resident needs when one of 15 sampled residents (Resident 27) call light was not within reach. This failure increased the risk that Resident 27's needs would go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards for two of 15 sampled residents (Resident 206 and Resident 19), when: 1. Resident 206's peripherally inserted central catheter's dressing (PICC, a long, thin tube that's inserted into a vein in the arm and ends in a large vein near the heart used to deliver antibiotics) was not changed per physician orders, 2. Resident 19 recieved metformin (a diabetes medication for blood sugar control) without food as ordered by the provider. These failures had the potential to result in a serious bloodstream infection for Resident 206 and upset stomach for Resident 19.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure proper infection control was practiced when: 1. Dietary Staff (DS) was observed to touch the part of a fork that goes into the mouth with bare hands, and 2. DS did not perform hand hygiene (HH, hand washing) prior to putting on new gloves. These failures had the potential to increase the transmission of illness and infection among the 56 vulnerable residents of the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents were provided a clean and safe environment when: 1. A.the floor were sticky in rooms [ROOM NUMBERS]. B.the tissue was touching the floor in room [ROOM NUMBER]'s bathroom. C.there was a brownish colored material on the floor in room [ROOM NUMBER]'s bathroom. D.there were multiple clothes hanging in the towel rack in room [ROOM NUMBER]'s bathroom and a purple colored sweat pants was seen on the floor in room [ROOM NUMBER]. E.there was a stack of basin on top of the paper towel dispenser in room [ROOM NUMBER]. F. there was a brownish material smeared on the toilet bowl seat which staff identified as feces. 2. there was a hole in room [ROOM NUMBER]'s bathroom door. These failures resulted in an unclean, unsanitary and unsafe environment for the residents in rooms [ROOM NUMBERS]. [...]

Inspectors wroteBased 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. This failure resulted in Resident 1 rolling over while receiving perineal care and falling on the other side of the bed sustaining a left tibia (the inner and usually larger of the two bones of the leg between the knee and ankle) fracture (a break on the bone). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate infection control guidelines for Resident 1 ' s Permacath central line catheter (intravenous tube that is inserted into a main blood vessel in the chest). This failure resulted in Resident 1 ' s central line catheter tip becoming infected and needed to be replaced in the hospital. During a review of Resident 1 ' s medical record, History and Physical dated 1/25/24, authored by MD G, indicated Resident 1, was a [AGE] year-old man hospitalized for acute decompensated heart failure, end stage kidney failure, Diabetes, history of TIA (injury from lack of oxygen to the brain), deconditioning, (muscle weakness and wasting) and history of methamphetamine use. Fair rehab potential. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents receive care in accordance with professional standards of practice when three out of three sampled residents (Residents 4, 5 and 6) complained the facility lacked the supplies such as briefs, incontinent wipes, towels, and linens readily available for residents use. This failure led to residents being left on soiled incontinent briefs for prolonged period and residents feeling annoyed, frustrated and undignified. This also put residents at risk for the development of pressure sore (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) and infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure they were adequately staffed for 18 out of 31 days in 10/2023 and 12 out of 28 days from 11/1/23 up to 11/28/2023 which resulted in complaints of assistance not being provided by staff in a timely manner and call light not being answered timely for two out of two sampled residents (Residents 2 and 3) which led to Resident 1 feeling upset and frustrated and Resident 3 feeling worried staff would not come on time if there ' s an emergency. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the 1. kitchenette area was clean, free from dusts and cobwebs and was regularly cleaned 2. there were no personal staff items in the kitchenette area when a gray colored jacket was on top of a tray used to serve residents ' meals. 3. towels used for cleaning the kitchenette counter were discarded properly in a receptacle and not placed on food tray cart after use 4. the baseboard in the kitchenette area was well maintained and was properly sealed. These failures could result in cross contamination, infection from food borne illnesses (an illness that comes from eating contaminated food) and pest infestation. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents personal and nutritional information when the residents' dietary meal tickets were thrown in together with the regular garbage. These failures had the potential for residents personal health information being seen by non-facility persons involved in the care of the residents for a facility census of 31.

Inspectors wroteBased on observations, interview and record review the facility failed to store, and prepare, and serve food in accordance with professional standards food service safety. This failure had the potential for increased risk for food borne illness for 27 residents who received facility cooked and prepared meals and snacks for a facility census of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to to ensure and maintain a sanitary, orderly, and comfortable interior for 1 of 31 sampled residents (Resident 1) when there was a linear crack in the wall observed located near the head of the bed approximately 6 inches by 3 inches. This failure resulted in the residents living in an uncomfortable room and the possibility for insects and vermin to have access into the room and building.

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of MDS (minimum data set, an assessment tool) assessments when one of three residents sampled for closed records (Resident 36) had the incorrect discharge location coded on their discharge MDS. This resulted in inaccurate information in Resident 36's record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered activities care plan for one of six residents sampled for activities (Resident 23). This failure potentially resulted in Resident 23 feeling isolated, bored, or depressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the activities care plan for one of six residents sampled for activities (Resident 23). This failure resulted in the responsible party's preferences to not be included in Resident 23's care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities per care plan or family preference for one of six residents sampled for activities (Resident 23). This failure potentially resulted in an unmet need for stimulation, socialization, and physical activity for Resident 23.

Inspectors wroteBased on interview and record review, the facility failed to assess risk for falls per policy for one of three residents sampled for falls (Resident 7). This failure potentially resulted in Resident 7 falling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow enhanced precautions protocol for one of four residents with a gastrostomy tube (also called a g-tube, a tube that is surgically inserted through the abdomen to bring nutrition directly to the stomach) (Resident 18). This failure had the potential to spread infectious microorganisms in a vulnerable population.