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Deficiency Records for Hearthstone
A list of the most recent deficiencies for Hearthstone. 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. 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-25 | 2024-04-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-25 | 2024-04-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-25 | 2024-04-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-25 | 2024-04-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-03-25 | 2024-04-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-25 | 2024-04-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-25 | 2024-04-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-25 | 2024-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-25 | 2024-04-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-25 | 2024-04-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-25 | 2024-04-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-25 | 2024-04-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-03-25 | 2024-04-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-25 | 2024-04-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-25 | 2024-04-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-03-25 | 2024-04-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-25 | 2024-04-30 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-25 | 2024-04-30 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-03-25 | 2024-04-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-25 | 2024-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-25 | 2024-04-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-25 | 2024-04-30 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-03-25 | 2024-04-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-25 | 2024-04-30 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-28 | 2024-04-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-24 | 2024-02-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-16 | 2024-01-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-16 | 2023-12-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-16 | 2023-12-22 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-11-16 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | 2023-12-22 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-11-16 | 2023-12-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-16 | 2023-12-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-04 | 2023-06-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-06-09 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-04 | 2023-06-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-04 | 2023-06-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-06-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-04 | 2023-06-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-04 | 2023-06-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-04 | 2023-06-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-05-04 | 2023-06-09 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-04 | 2023-06-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-04 | 2023-06-09 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-05-04 | 2023-06-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-04 | 2023-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-06-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-04 | 2023-06-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-05-04 | 2023-06-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-04 | 2023-06-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-04 | 2023-06-09 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-05-04 | 2023-06-09 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-05-04 | 2023-06-09 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-05-04 | 2023-06-09 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-04 | 2023-06-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-14 | 2023-03-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-14 | 2023-03-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-03-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-21 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-21 | 2022-08-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-07-21 | 2022-08-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-21 | 2022-08-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-21 | 2022-08-22 | 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 | 2022-07-21 | 2022-08-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-21 | 2022-08-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-07-21 | 2022-08-22 | 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 | 2022-07-21 | 2022-08-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-21 | 2022-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-21 | 2022-08-22 | N |
| Dispose of garbage and refuse properly. | Health | 2022-07-21 | 2022-08-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-07-21 | 2022-08-22 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-21 | 2022-08-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-21 | 2022-08-22 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-21 | 2022-08-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-21 | 2022-08-22 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-21 | 2022-08-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-02 | 2022-04-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-02 | 2022-04-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-21 | 2022-01-21 | Y |
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