A list of the most recent deficiencies for The 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-09 | 2024-03-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-02-09 | 2024-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-09 | 2024-03-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-09 | 2024-03-20 | 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 | 2024-02-09 | 2024-03-20 | 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 | 2024-02-09 | 2024-03-20 | 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 | 2024-02-09 | 2024-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-09 | 2024-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-09 | 2024-03-20 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-02-09 | 2024-03-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Meet other general requirements. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-02-06 | 2024-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-26 | 2023-01-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-26 | 2023-01-17 | 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 | 2022-10-31 | 2022-12-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-31 | 2022-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-31 | 2022-12-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-31 | 2022-12-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-31 | 2022-12-02 | 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 | 2022-10-31 | 2022-12-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-31 | 2022-12-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-10-26 | 2022-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-31 | 2022-11-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-10-31 | 2022-11-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-26 | 2022-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-26 | 2022-11-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-26 | 2022-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-26 | 2022-11-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-10-26 | 2022-11-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-10-26 | 2022-11-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-26 | 2022-11-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-26 | 2022-11-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-26 | 2022-11-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-26 | 2022-11-17 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-10-26 | 2022-11-17 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-31 | 2022-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-26 | 2022-11-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-08 | 2021-07-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-08-06 | 2019-09-13 | 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 | 2019-08-06 | 2019-09-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-06 | 2019-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-06 | 2019-09-13 | 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 | 2019-08-06 | 2019-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-06 | 2019-09-13 | N |
