A list of the most recent deficiencies for Hearthstone Manor. 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? |
|---|---|---|---|---|
| Establish policies and procedures for sheltering. | Fire Safety | 2023-09-28 | 2023-11-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-09-28 | 2023-11-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-28 | 2023-11-12 | 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 | 2023-09-28 | 2023-11-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-28 | 2023-11-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-09-28 | 2023-11-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-28 | 2023-11-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-28 | 2023-11-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-13 | 2023-10-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-13 | 2023-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-28 | 2023-10-20 | 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 | 2023-09-28 | 2023-10-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-09-28 | 2023-10-20 | 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 | 2023-09-28 | 2023-10-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Have an externally vented heating system. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-28 | 2023-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-18 | 2023-06-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-28 | 2023-04-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-03 | 2023-01-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-03 | 2023-01-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-29 | 2023-01-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-29 | 2023-01-27 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-28 | 2023-01-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-28 | 2022-12-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Develop a communication plan. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-28 | 2022-12-12 | 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 | 2022-10-28 | 2022-12-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-28 | 2022-12-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-10-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-13 | 2022-10-29 | 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 | 2022-10-13 | 2022-10-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-13 | 2022-10-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-13 | 2022-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-13 | 2022-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-13 | 2022-10-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-11 | 2022-02-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-07 | 2022-02-09 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Establish methods for sharing information. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-11 | 2022-02-09 | N |
| Use approved construction type or materials. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-11 | 2022-02-08 | 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 | 2022-01-11 | 2022-02-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-01-11 | 2022-02-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-05 | 2022-02-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-05 | 2022-02-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-05 | 2022-02-07 | 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 | 2022-01-05 | 2022-02-07 | 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 | 2022-01-05 | 2022-02-07 | 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 | 2022-01-05 | 2022-02-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-05 | 2022-02-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-05 | 2022-02-07 | 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 | 2022-01-05 | 2022-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-05 | 2022-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-05 | 2022-02-07 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-05 | 2022-02-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-09 | 2021-11-30 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-12 | 2021-10-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-12 | 2021-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-03 | 2021-10-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-12 | 2021-08-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-12 | 2021-08-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-12 | 2021-08-25 | Y |
