Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heartwood during CMS and state inspections, most recent first.
MDS Medication Coding Error: The facility failed to accurately code the MDS medication section for a resident with intact cognition and type 2 DM. The resident was ordered semaglutide for diabetes, but the coding department director stated it was coded as insulin in error. The DON stated MDS assessments should be coded correctly to ensure correct payment and that residents received the care they required.
A resident with intact cognition and PTSD had no documented Trauma-Informed Care Assessment, and the care plan did not include PTSD triggers or related interventions. Staff were unaware of the diagnosis and could not identify triggers or anything to avoid, while the DON stated the resident was missed during ownership and EMR changes. The facility policy required assessment of residents with trauma history or PTSD and care to minimize triggers and re-traumatization.
The facility failed to maintain a safe temperature in a unit refrigerator, affecting food storage for residents. The refrigerator, containing milk, cheese, and yogurt, lacked a thermometer, and staff were unaware of the correct temperature range. The automated monitoring system recorded temperatures above 41°F for over six days, contrary to the facility's policy requiring temperatures between 35-39°F.
A facility failed to perform ongoing monitoring and wound care for a resident with a chronic wound. The resident, with a history of peripheral vascular disease, had an unhealed ulcer on the left ankle. The care plan required daily wound care, but the dressing was not changed as scheduled. An LPN found the wound open with slough, contrary to previous reports. Staff interviews revealed a lack of awareness and communication about the wound's status, and the facility did not adhere to its policy for weekly wound documentation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic vascular wound. The resident had a history of peripheral vascular disease and an unhealed ulcer, but the care plan and physician orders did not include EBP. During an observation, no signage or PPE was available, and an LPN did not use EBP while providing wound care. Staff interviews revealed a lack of awareness and communication about the resident's wound status and EBP requirements. The facility's policy on EBP was not followed, leading to the deficiency.
The facility failed to document CDC education on pneumococcal vaccine risks and benefits for three residents who refused the vaccine. Documentation did not specify which vaccine was offered or what education was provided. Interviews with family members and staff revealed a lack of completed documentation forms, and the facility's pneumococcal policy was not provided.
MDS Medication Coding Error
Penalty
Summary
The facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for one resident, R6, who was reviewed for unnecessary medications. R6’s admission MDS identified intact cognition and a diagnosis of type 2 diabetes. The resident’s Order Summary Report dated 6/30/25 identified semaglutide, a subcutaneous solution pen-injector ordered at 0.5 mg subcutaneously one time a day every Monday for type 2 diabetes. An email from the coding department director dated 7/23/25 stated that R6’s semaglutide was coded as insulin in error. During an interview, the DON stated MDS assessments should be coded correctly to ensure correct payment was received and to ensure residents received the care they required. The facility policy required the RAI process to be completed in accordance with the current MDS 3.0 RAI User’s Manual, which directs staff to review the medication administration record for the look-back period, determine whether the resident received insulin injections, determine whether insulin orders changed, and count the number of days insulin injections were received and/or insulin orders changed.
Failure to Assess PTSD Triggers and Trauma-Informed Care Needs
Penalty
Summary
The facility failed to comprehensively assess for trauma-informed care and identify potential triggers for a resident with intact cognition and a diagnosis of post-traumatic stress disorder (PTSD). The resident’s admission MDS identified PTSD, but the medical record did not show that a Trauma-Informed Care Assessment was completed, and the revised care plan did not include the resident’s PTSD triggers or interventions specific to PTSD. During interview, the resident was observed lying in bed with a flat affect, stated she liked to keep to herself in her room, and said she was unaware of any traumatic events in her life or anything that would make her upset specifically. Staff interviews showed they were unaware of the resident’s PTSD diagnosis and could not identify any triggers or anything that should be avoided. An RN stated social services was responsible for completing the Trauma-Informed Care Assessment and revising the care plan if problems were identified, while the DON stated the resident was missed during a period of ownership and electronic medical record changes, and therefore the assessment was not completed. The facility’s Trauma Informed Care Policy stated residents with mental disorder, psychological adjustment difficulty, trauma history, or PTSD should be assessed and provided appropriate treatment and services to manage the assessed problem and support psychological well-being.
Refrigerator Temperature Control Deficiency
Penalty
Summary
The facility failed to maintain a safe temperature for food storage in a unit refrigerator, which had the potential to affect all residents receiving food from it. During an observation, it was noted that the refrigerator contained milk, cheese, and yogurt, but lacked a regular thermometer. The culinary director was unable to provide a log of temperatures for the month of August 2024 and did not know the appropriate temperature range for the refrigerator. The automated monitoring system was supposed to alert the culinary director, bio-med technician, and executive director if the temperature was out of range, but the culinary director could not identify the temperature range or the alert threshold. The History Detail Report for the Skyview unit refrigerator showed that from August 1 to August 7, 2024, the refrigerator's temperature was at or above 41 degrees Fahrenheit for extended periods, totaling 6 days, 6 hours, and 30 minutes. The bio-med technician was also unaware of the correct temperature range or alert settings. An email later revealed that the automated system was set to a range of 33.8 to 48.2 degrees Fahrenheit. The director of nursing stated that the refrigerator should be kept below 41 degrees Fahrenheit to prevent food spoilage, as per the facility's Food Storage policy, which requires temperatures between 35-39 degrees Fahrenheit for TCS foods.
Failure to Perform Ordered Wound Care
Penalty
Summary
The facility failed to perform ongoing monitoring and wound care as ordered for a resident with a chronic reoccurring wound. The resident, who had a history of peripheral vascular disease, high blood pressure, and coronary artery disease, had an unhealed venous or arterial ulcer on the left lateral ankle. The care plan required weekly skin assessments and specific wound care interventions, including daily application of betadine and a foam border dressing. However, the facility did not consistently follow these orders, as evidenced by the failure to change the dressing on 8/6/24, which was last changed on 8/5/24. During an observation, an LPN noted that the wound was open with slough present, contradicting previous reports that the wound was scabbed over. The LPN admitted that the dressing should have been changed the previous day. Interviews with staff revealed a lack of awareness and communication regarding the resident's wound status, with one RN unaware of the open wound and another RN signing off on wound care without ensuring it was completed. The facility's policy required weekly documentation of wounds, which was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic vascular wound. The resident, identified as R34, had a history of peripheral vascular disease, hypertension, and coronary artery disease, and had an unhealed venous or arterial ulcer. The care plan for R34, revised on 7/3/24, included interventions for skin integrity and wound care but did not direct staff to implement EBP during wound care. Physician orders and skin observation notes also failed to mention EBP for the resident's chronic wound. During an observation on 8/7/24, it was noted that there was no signage or personal protective equipment available for EBP at the resident's door, and the licensed practical nurse (LPN) did not implement EBP while providing wound care. Interviews with staff revealed a lack of awareness and communication regarding the resident's wound status and the need for EBP. The LPN and registered nurse (RN) were unaware of the requirement for EBP, and the RN stated that she was not informed of the resident's open wound. The director of nursing (DON) confirmed that staff were expected to implement EBP for chronic wounds until healed. The facility's policy on Enhanced Barrier Precautions emphasized the use of personal protective equipment to prevent the transmission of multidrug-resistant organisms, particularly during high-contact activities such as wound care. However, this policy was not followed in the case of R34, leading to the deficiency noted in the report.
Failure to Document Pneumococcal Vaccine Education
Penalty
Summary
The facility failed to provide and document the most recent CDC education regarding the potential risks and benefits of the pneumococcal vaccine for three residents reviewed for immunizations. Resident 20, who had diagnoses including diabetes mellitus and hypertension, refused a pneumococcal conjugate (PCV20) vaccination, but there was no documentation of the education provided regarding the vaccine. Similarly, Resident 39, with diagnoses such as coronary artery disease and dementia, and Resident 42, with conditions including hypertension and dementia, also refused the pneumococcal vaccination. However, the documentation for both residents failed to specify which vaccine was offered and what education was provided. Interviews with family members of the residents revealed that they could not recall any specific education being provided about the pneumococcal vaccination. A registered nurse acknowledged creating a form for documenting the offering, education, and acceptance/refusal of pneumococcal immunizations, but admitted that the nursing staff did not complete the forms as directed. The Director of Nursing confirmed that efforts were being made to update vaccination documentation forms to ensure accurate documentation, but the facility's pneumococcal policy was not provided upon request.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Crosby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aicota Health Care Center | 10.6 mi | ★★★★★ | 11 | 0 |
| Aitkin Health Services | 11.3 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Bethany | 16.2 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Woodland | 16.8 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Pine River | 27.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.