Deficiency Records for Hearthstone Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Hearthstone Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-08 | 2024-01-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-08 | 2024-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2024-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-08 | 2024-01-23 | 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 | 2023-11-08 | 2024-01-23 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-01 | 2024-01-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-08 | 2023-12-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-08 | 2023-12-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-08 | 2023-12-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-08 | 2023-12-28 | 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 | 2023-11-08 | 2023-12-28 | 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 | 2023-11-08 | 2023-12-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-08 | 2023-12-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-08 | 2023-12-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-11-08 | 2023-12-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-08 | 2023-12-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-08 | 2023-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-08 | 2023-12-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-08 | 2023-12-28 | 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 | 2023-11-08 | 2023-12-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-12-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-08 | 2023-12-28 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-11-08 | 2023-12-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-08 | 2023-12-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-11-08 | 2023-12-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-08 | 2023-12-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-08 | 2023-12-28 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-08 | 2023-12-28 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-11-08 | 2023-12-28 | N |
| 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 | 2023-11-08 | 2023-12-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-08 | 2023-12-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-08 | 2023-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-08 | 2023-12-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-08 | 2023-12-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-08 | 2023-12-28 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-08 | 2023-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-08 | 2023-12-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-12-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-08 | 2023-12-28 | 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 | 2023-11-08 | 2023-12-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-08 | 2023-12-28 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-08 | 2023-12-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-08 | 2023-12-28 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-11-01 | 2023-12-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-11-01 | 2023-12-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-01 | 2023-12-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-01 | 2023-12-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-01 | 2023-12-27 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-23 | 2023-12-11 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-23 | 2023-12-11 | 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 | 2023-10-23 | 2023-12-11 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-06-20 | 2023-08-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-20 | 2023-08-09 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-09-23 | 2022-11-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-23 | 2022-11-02 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-23 | 2022-11-02 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-23 | 2022-11-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-23 | 2022-11-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-23 | 2022-11-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-23 | 2022-11-02 | Y |
| Provide appropriate foot care. | Health | 2022-09-23 | 2022-11-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-23 | 2022-11-02 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-09-23 | 2022-11-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-23 | 2022-11-02 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-23 | 2022-11-02 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-27 | 2022-11-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-27 | 2022-11-02 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-02-23 | 2022-06-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-23 | 2022-06-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-06-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-23 | 2022-04-24 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-23 | 2022-04-24 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-02-23 | 2022-04-24 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-23 | 2022-04-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-23 | 2022-04-24 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-23 | 2022-04-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-23 | 2022-04-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-23 | 2022-04-24 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-23 | 2022-04-24 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-02-23 | 2022-04-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-23 | 2022-04-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-23 | 2022-04-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-23 | 2022-04-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-23 | 2022-04-24 | 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 | 2022-02-23 | 2022-04-24 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-23 | 2022-04-24 | 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 | 2022-02-23 | 2022-04-24 | 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 | 2022-02-23 | 2022-04-24 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-02-23 | 2022-04-24 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-23 | 2022-04-24 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-02-23 | 2022-04-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-23 | 2022-04-24 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-23 | 2022-04-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-06 | 2021-05-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-06 | 2021-05-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-15 | 2021-05-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-15 | 2021-04-26 | 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 | 2021-03-15 | 2021-04-26 | 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 | 2021-03-15 | 2021-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-15 | 2021-04-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-15 | 2021-04-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-10 | 2019-10-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-09-10 | 2019-10-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-10 | 2019-10-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-10 | 2019-10-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-10 | 2019-10-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-10 | 2019-10-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-10 | 2019-10-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-10 | 2019-10-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-09-10 | 2019-10-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-10 | 2019-10-14 | N |
| Post nurse staffing information every day. | Health | 2019-09-10 | 2019-10-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-10 | 2019-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-10 | 2019-10-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-10 | 2019-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-10 | 2019-10-14 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-10 | 2019-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-10 | 2019-10-14 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-09-10 | 2019-10-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-06 | 2019-10-14 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-08-06 | 2019-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-06 | 2019-10-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-06 | 2019-10-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-06 | 2019-10-14 | N |
