A list of the most recent deficiencies for The Home at 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-16 | 2023-05-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-28 | 2022-06-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-28 | 2022-06-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-22 | 2022-06-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-22 | 2022-06-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-02-03 | 2022-03-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-03 | 2022-03-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-03 | 2022-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-04 | 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 | 2022-02-03 | 2022-03-04 | 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 | 2022-02-03 | 2022-03-04 | N |
| 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 | 2022-02-03 | 2022-03-04 | Y |
| Develop a communication plan. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-25 | 2021-04-13 | 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 | 2021-03-25 | 2021-04-13 | 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 | 2021-03-25 | 2021-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-25 | 2021-04-13 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-28 | 2019-05-01 | 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 | 2019-03-28 | 2019-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-28 | 2019-05-01 | 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 | 2019-03-28 | 2019-05-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-28 | 2019-05-01 | 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 | 2019-03-28 | 2019-05-01 | 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 | 2019-03-26 | 2019-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-26 | 2019-05-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-26 | 2019-05-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-26 | 2019-05-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-03-26 | 2019-05-01 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-02-01 | 2018-02-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-01 | 2018-02-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-02-01 | 2018-02-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-01 | 2018-02-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-01 | 2018-02-28 | N |
| Respond appropriately to all alleged violations. | Health | 2018-02-01 | 2018-02-28 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-02-01 | 2018-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-01 | 2018-02-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-01 | 2018-02-28 | 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 | 2018-02-01 | 2018-02-28 | 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 | 2018-02-01 | 2018-02-28 | N |
| Post nurse staffing information every day. | Health | 2018-02-01 | 2018-02-28 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-02-01 | 2018-02-28 | 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 | 2018-02-01 | 2018-02-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-02-01 | 2018-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-01 | 2018-02-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-02-01 | 2018-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-01 | 2018-02-28 | N |
