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Deficiency Records for Hearthstone Place
A list of the most recent deficiencies for Hearthstone Place. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Hearthstone Place. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-12 | 2024-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-09-12 | 2024-10-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-12 | 2024-10-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-12 | 2024-10-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-09-12 | 2024-10-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-09-12 | 2024-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-12 | 2024-10-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Develop a communication plan. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-09-11 | 2024-10-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-22 | 2022-11-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-22 | 2022-11-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-22 | 2022-11-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-22 | 2022-11-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-06 | 2020-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-06 | 2020-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-03 | 2020-01-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-03 | 2020-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-03 | 2020-01-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-03 | 2019-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-03 | 2019-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-13 | 2018-10-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-13 | 2018-10-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-09-13 | 2018-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-13 | 2018-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-13 | 2018-10-09 | N |
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