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Deficiency Records for Embassy of Hearthside
A list of the most recent deficiencies for Embassy of Hearthside. 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 Embassy of Hearthside. 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 a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-04-26 | 2024-06-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-26 | 2024-06-18 | 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 | 2024-04-26 | 2024-06-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-26 | 2024-06-18 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-04-26 | 2024-06-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-26 | 2024-06-18 | Y |
| 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 | 2024-04-26 | 2024-06-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-26 | 2024-06-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-26 | 2024-06-18 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-04-26 | 2024-06-18 | Y |
| 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 | 2024-04-26 | 2024-06-18 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-04-26 | 2024-06-18 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-04-26 | 2024-06-18 | Y |
| 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 | 2024-04-26 | 2024-06-18 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-26 | 2024-06-18 | Y |
| 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 | 2024-04-26 | 2024-06-18 | Y |
| Provide or obtain dental services for each resident. | Health | 2024-04-26 | 2024-06-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-26 | 2024-06-18 | Y |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-04-26 | 2024-06-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-26 | 2024-06-18 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-04-10 | 2024-05-14 | N |
| Use approved construction type or materials. | Fire Safety | 2024-04-10 | 2024-05-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-10 | 2024-05-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-04-10 | 2024-05-14 | 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 | 2024-04-10 | 2024-05-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-10 | 2024-05-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-10 | 2024-05-14 | 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 | 2024-02-15 | 2024-03-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-02-15 | 2024-03-11 | Y |
| Meet other general requirements. | Fire Safety | 2023-09-14 | 2023-09-22 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Establish methods for sharing information. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-07-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-05 | 2023-06-14 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-05 | 2023-06-14 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-05 | 2023-06-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-05 | 2023-06-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide appropriate foot care. | Health | 2023-05-05 | 2023-06-14 | Y |
| 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 | 2023-05-05 | 2023-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-05 | 2023-06-14 | Y |
| 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 | 2023-05-05 | 2023-06-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-05 | 2023-06-14 | Y |
| 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 | 2023-05-05 | 2023-06-14 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-05-05 | 2023-06-14 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-05-05 | 2023-06-14 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-05 | 2023-06-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-05 | 2023-06-14 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-05-05 | 2023-06-14 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-05 | 2023-06-14 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-12 | 2022-08-16 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-25 | 2022-08-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-25 | 2022-06-28 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-25 | 2022-06-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-25 | 2022-06-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-25 | 2022-06-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-25 | 2022-06-28 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-25 | 2022-06-28 | Y |
| 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 | 2022-05-25 | 2022-06-28 | Y |
| 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 | 2022-05-25 | 2022-06-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-25 | 2022-06-28 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-25 | 2022-06-28 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-05-25 | 2022-06-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-25 | 2022-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-25 | 2022-06-28 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-25 | 2022-06-28 | Y |
| 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 | 2022-05-25 | 2022-06-28 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-05-17 | 2022-05-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-17 | 2022-05-27 | 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 | 2022-05-17 | 2022-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-17 | 2022-05-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-17 | 2022-05-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-17 | 2022-05-27 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-11 | 2022-03-01 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-12-01 | 2022-01-13 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-21 | 2021-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-21 | 2021-11-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-21 | 2021-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-06 | 2021-11-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-22 | Not Fixed | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-19 | Not Fixed | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-08-15 | Not Fixed | Y |
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