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? |
|---|---|---|---|---|
| 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 |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-07-13 | 2018-08-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-13 | 2018-08-20 | N |
| Respond appropriately to all alleged violations. | Health | 2018-07-13 | 2018-08-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-07-13 | 2018-08-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-13 | 2018-08-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-13 | 2018-08-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-13 | 2018-08-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-13 | 2018-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-13 | 2018-08-20 | 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 | 2018-07-13 | 2018-08-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-07-13 | 2018-08-20 | N |
| 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 | 2018-07-13 | 2018-08-20 | N |
| Post nurse staffing information every day. | Health | 2018-07-13 | 2018-08-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-13 | 2018-08-20 | 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 | 2018-07-13 | 2018-08-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-07-13 | 2018-08-20 | N |
| 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 | 2018-07-13 | 2018-08-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-07-13 | 2018-08-20 | 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 | 2018-07-26 | 2018-08-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-26 | 2018-08-17 | N |
