Hearthstone Health and Rehabilitation

Inspectors wroteBased on record review, interview, and review of facility's policy, the facility failed to ensure 4 of 5 residents (Resident (R) 1, R35, R90 and R97) reviewed for hospitalization out of 31 sampled residents were given a bed hold notice prior to or within 24-hours of emergency transfer to the hospital and/or failed to ensure the Ombudsman was notified of the emergent transfers to the hospital. This failure creates the potential for residents, and responsible parties to not have the information needed to safeguard their return to the facility, and for the Ombudsman not to have the knowledge of their transfer.

Inspectors wroteBased on observations, interviews, record review, facility policy review, and review of the facility's investigations, the facility failed to ensure 2 residents (Resident (R) 9 and R120) of 4 residents reviewed for abuse out of 31 sampled residents were free from verbal abuse. R120 was verbally abused by her roommate (R119), and R9 was verbally abused by Certified Nursing Assistant (CNA) 9. The facility's failure to ensure residents were free from abuse had the potential to cause emotional and/or psychosocial harm to the residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to report substantiated verbal abuse to local law enforcement for 2 of 4 residents reviewed for abuse (Resident (R) 9 and R120) out of 31 sampled residents. Certified Nursing Assistant (CNA) 9 verbally abused R9 by making intimidating and threatening statements to the resident and R120 was verbally abused by another resident; however, the facility did not identify the abuse as a possible crime and report it to local law enforcement. This failure left the residents being victims of abuse without proper investigation from law enforcement.

Inspectors wroteBased on observations, interviews, record review, review of the facility's policy, and review of the facility incident reports and investigations, the facility failed to complete thorough investigations of allegations of abuse and neglect for 3 of 4 residents reviewed for abuse (Resident (R) 14, R68, and R120) out of 31 sampled residents. The facility's failure to complete thorough investigations placed residents at risk of being unprotected from abuse.

Inspectors wroteBased on record reviews, interviews, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were completed accurately for 3 of 31 sampled residents (Resident (R) 10, R48, and R97). Staff failed to accurately code hospice for R10; failed to accurately code a multidrug-resistant bacteria (MDRO) infection for R48; and failed to accurately code intravenous (IV) feeding for R97. Failure to code the MDS correctly can lead to inaccurate federal reimbursement and inaccurate assessment and care planning for the residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to develop person centered care plans based on residents' comprehensive assessments for 2 of 31 sampled residents (Resident (R) 14 and R27). This failure placed the residents at risk of unmet care needs.

Inspectors wroteBased on interviews, record review, and review of the medication manufacturer's instructions, the facility failed to ensure the nurse instructed 2 of 2 residents observed during medication administration (Resident (R) 70 and R123) to rinse their mouths after they were administered an inhaled steroid medication. The deficient practice could result in residents acquiring an oral infection.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide staff assistance with activities of daily living (ADLs) for 1 of 2 sampled residents reviewed for ADLs (Resident (R) 27) out of 31 sampled residents. This failure had the potential to lead to a decline in activities of daily living.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure that staff provided proper catheter care for 1 of 2 residents (Residents (R) 40) reviewed for catheter care out of 31 sampled residents. This failure placed the resident at risk for the transmission of an infection.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the exterior filter on the oxygen concentrator was clean for 1 of 3 residents reviewed for oxygen use (Resident (R) 9) out of 31 sampled residents. This failure created potential for the oxygen concentrator not to work efficiently, which could have reduced the purity of the oxygen delivered and placed R9 at risk of infection.

Inspectors wroteThe facility failed to implement Enhanced Barrier Precautions (EBP), Transmission Base-Precautions (TBP), and provide care in a manner to prevent cross contamination for 2 of 31 sampled residents (Resident (R) 40 and R15) reviewed for infection control. These failures placed all residents of the facility at risk for the transmission and spread of infections.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to: 1) perform nursing pre and post dialysis assessments and 2) access and maintain completed dialysis communication transfer forms in collaboration with the dialysis provider for 6 of 6 sampled residents on dialysis (Resident # 9, #20, #151, #51, #61, and #60). The deficient practice potentially placed the residents at risk for improper coordination of care between the facility and the dialysis provider.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) spoke about a resident in a respectful manner and treated a resident with dignity for 1 of 3 residents sampled related to facility reported incidents (FRI) (Resident #251). This deficient practice had the potential to cause a resident to experience psychosocial harm or mental anguish because of not being treated with respect.

Inspectors wroteBased on interview, clinical record review, and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 3 closed records sampled residents (Resident #99). This deficient practice had the potential to deprive the resident of necessary needs and services relative to their current health management needs upon discharge home.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure: 1) a resident's behaviors of threatening staff members with physical and sexual violence were care planned for 1 of 22 sampled residents (Resident #78). This deficient practice had the potential to result in staff working with the resident being unaware of the resident's behaviors and the resident's behaviors worsening or escalating with no interventions in place, 2) edema and the use of diuretic medications were care planned for 1 of 22 sampled residents (Resident #83). This deficient practice had the potential to result in staff working with the resident to be unaware of the need to monitor the resident for edema, provide medications (diuretic) as indicated, and monitor for adverse side effects of the medication.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure a medication ordered for edema was entered into a resident's order set and Medication Administration Record (MAR) for 1 of 22 sampled residents (Resident #83). This deficient practice resulted in the resident not receiving the medication and continuing to have edema and discomfort and the potential to result in an exacerbation of chronic illnesses.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure a resident's pain was managed, a physician was notified when pain medication was not effective and/or the resident's pain exceeded the parameters of the medication ordered for 1 of 22 sampled residents (Resident #83). This deficient practice could have the potential for unrelieved pain, discomfort, and inadequate pain management. Resident #83 Resident #83 was admitted to the facility on [DATE], with diagnoses including pain, unspecified, pain in left hip, cellulitis of left upper limb, restless leg syndrome, pain in left hip, and pain in right hip. A physician's order dated 04/19/2024, documented acetaminophen tablet 325 milligrams (mg). Give one tablet by mouth every four hours as needed for mild pain/headache not to exceed three grams per day. [...]

Inspectors wroteBased on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 2 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #7, and #8).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's behaviors of threatening staff members with physical and sexual violence were monitored per facility policy for 1 of 22 sampled residents (Resident #78). This deficient practice had the potential to result in a resident's behaviors worsening or escalating with no monitoring in place.

Inspectors wroteBased on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center were completed and correctly documented. This deficient practice resulted in a substandard quality of care. On 03/03/2025 at 1:13 PM, the Executive Director confirmed the facility lacked a process to ensure pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center was completed and correctly documented on the facility's Dialysis Communication Record. The Executive Director explained it was important the process was followed to ensure continuity of care between the facility and the dialysis center. [...]

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident's medical record was complete for 6 of 6 sampled residents (Resident #9, #20, #151, #61, #51, and #60), and to accurately document monitoring of a resident with significant weight loss for 1 of 22 sampled residents (Resident #1). The deficient practice had the potential for the resident to experience health risks associated with additional unknown weight loss.

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure 1) pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center were completed and correctly documented, and 2) medical records were completed and filed in a manner allowing the facility to easily locate the records and ensure the records were not misfiled and/or lost. This deficient practice resulted in a substandard quality of care related to the facility's dialysis process and keeping of medical records.

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff upon hire for 2 of 16 sampled employees (Employee #13 and #15).

Inspectors wroteBased on interview and document review, the facility failed to ensure facility staff received training on the facility's quality assurance and performance improvement (QAPI) program for 8 of 16 sampled employees (Employee #1, #3, #4, #7, #8, #9, #13, and #16).

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure facility staff received compliance and ethics training for 6 of 16 sampled employees (Employee #1, #3, #4, #6, #7, and #8).

Inspectors wroteBased on observation and interview, the facility failed to ensure current nursing hours was posted for the facility. This deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the number of nursing and direct care staff on duty.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to obtain to obtain an informed consent for a psychoactive medication prior to the administration of the medication for 2 of 5 residents reviewed for unnecessary medications (Resident #49 and #62).

Inspectors wroteResident #67 Resident #67 was admitted to the facility on [DATE], with a diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, anxiety, and depression. A physician's order dated 12/27/23, documented Resident #67 may not go out on pass. Resident #77 Resident #77 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with foot ulcer, localized edema and other acute osteomyelitis, right ankle and foot. A physician's order dated 12/29/23, documented Resident #77 may not go out on pass. Resident #42 Resident #42 was admitted to the facility on [DATE], with a diagnosis of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing. A physician's order dated 12/30/23, documented Resident #42 may not go out on pass. [...]

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 1) the Minimum Data Set (MDS) Coordinator, in charge of the facility's Restorative Nursing Program (RNP), had the knowledge and skills needed to manage the program and ensure all residents in need of RNP services were included in the program and 2) a nurse was trained to access resident care plans in the Electronic Medical Record (EMR) after the facility underwent a change of ownership with a new EMR program.

Inspectors wroteBased on observation and interview, the facility failed to ensure the outside receptacles were sealed (lid closed) and free of debris on the surrounding pavement.

Inspectors wroteBased on document review and interview, the facility failed to demonstrate effective and knowledgeable administration by not ensuring the facility's Minimum Data Set (MDS) Coordinator, in charge of the facility's Restorative Nursing Program (RNP) had the skills and knowledge necessary to manage RNP services and ensure residents identified to be in need of restorative services were included the facility's RNP. Findings Include: On 03/21/24, during the afternoon, the facility provided a list of 41 residents identified by the facility as requiring assistance from the RNP, 38 of 41 residents listed remained in the facility and 3 of 41 residents listed had been discharged from the facility. Review of the facility's list of residents receiving Restorative Nursing Assistant (RNA) services via the RNP lacked documented evidence 25 of the 38 residents identified received RNA services. [...]

Inspectors wroteBased on observation, clinical record review, interview and document review the facility failed to ensure 1) enhanced barrier precautions (EBP) were implemented for 24 of 24 residents reviewed with wounds and indwelling medical devices (Resident #110, #7, #55, #93, #516, #413, #161, #26, #19, #25, #18, #42, #76, #462, #74, #111, #22, #3, #84, #514, #260, #96, #45, and #39), 2) appropriate personal protective equipment (PPE) was worn by staff entering resident rooms with transmission-based precautions (TBP) signs in place, and 3) hand hygiene was performed between glove changes for 1 of 21 sampled residents (Resident #26) with the potential to effect the entire census.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure services provided met professional standards of quality of care by not ensuring 1) 25 of 38 residents identified by the facility as needing restorative aide assistance were included in the facility's Restorative Nursing Program (RNP) (Resident #61, #36, #49, #82, #1, #80, #63, #32, #67, #77, #42, #66, #90, #6, #53, #20, #60, #14, #43, #30, #54, #52, #58, #74, and #35) and 2) Residents with orders for Restorative Nursing Assistant (RNA) services were included in the RNP for 7 of 97 residents residing in the facility (Resident #50, #13, #44, #86, #23, #511, and #10). [...]

Inspectors wroteBased on observation, record review, interview, and document review the facility failed to protect privacy for 11 of 54 residents residing in the facility's A-Wing (Resident #110, #461, #76, #35, #260, #26, #57, #7, #45, #111 and #89), and failed to ensure resident rights to personal privacy was maintained by not covering a resident's urinary catheter collection bag containing urine for 1 of 21 sampled residents (Resident #76)

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1) a resident was kept safe from verbal abuse by a staff member for 1 of 21 sampled residents (Resident #412) and 2) a resident was kept safe from physical and verbal abuse by another resident for 1 of 21 sampled residents (Resident #62).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 1 of 21 sampled residents (Resident #72) and 1 of 3 closed record sampled residents (Resident #79) and the Residents' Representatives received written notification of transfer or discharge.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to provide a bed hold policy notification upon transfer to a hospital for 1 of 21 sampled residents (Resident #72) and 1 of 3 closed record sampled residents (Resident #79) and to the Residents' Representatives.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure a baseline care plan was developed to address pain management for 1 of 21 sampled residents (Resident #462).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure the Comprehensive Care Plan for 1 of 21 sampled residents (Resident #75) included care plans related to communication and Restorative Nursing Aide (RNA) services.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure staff performed hand hygiene and followed enhanced barrier precautions while providing wound care to 1 of 21 sampled residents (Resident #26).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure restorative nursing assistance (RNA) was provided to a resident in accordance with therapy recommendations for 1 of 21 sampled residents (Resident #75). The failure to provide RNA services had the potential for the resident to have a decline in muscle tone and development of contractures.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure a resident's pain was managed and a physician was notified when pain medication was not effective for 1 of 21 sampled residents (Resident #462).

Inspectors wroteBased on clinical record review, interview and document review the facility failed to maintain completed dialysis communication transfer forms for 1 of 21 sampled residents (Resident #23).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure controlled substance logs were correctly completed to provide accurate reconciliation of controlled medications for 3 of 21 sampled residents (Resident #161, #60, and #73).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was not administered a pain medication without the physician specified pain level reached per physician's order resulting in a resident receiving oxycodone hydrochloride (HCL) unnecessarily for 1 of 5 sample residents reviewed for unnecessary medications (Resident #49).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure 1) temperatures were monitored and documented for 1 of 2 medication storage rooms including the medication refrigerator and freezer, 2) a cup of medication was not pre-poured and stored in a medication cart for 1 of 21 sampled residents (Resident #410), 3) a medication cart was not left unsecured and unattended and 4) a treatment cart containing medications was not left unsecured and unattended.

Inspectors wroteBased on interview, observation, clinical record review, and document review, the facility failed to ensure a resident was interviewed for food preferences within 71-hours of admission per facility policy for 1 of 21 sampled residents (Resident #514).

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to complete the Treatment Administration Record (TAR) for the treatment of a wound for 1 of 21 sampled residents (Resident #7), and the Medication Administration Records (MAR) for the administration of insulin for 1 of 21 sampled residents (Resident #84).

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #75) was screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the vaccine was offered and either administered or declined.

Inspectors wroteBased on observation, interview, and document review, the facility failed to document training needed for all staff.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was treated with respect and dignity by facility staff during discharge planning conversations for 1 of 9 sampled residents (Resident #4).

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure staff followed a resident's chosen code status prior to initiating emergency lifesaving measures (Resident #2) and residents' code status was accurate and complete for staff to access for 7 of 33 residents reviewed (Resident #25, #35, #40, #49, #56, #9 an #57). The failure to honor a resident's choice to not have life sustaining measures provided put the resident at imminent risk for psychosocial harm when a resident's life was extended by two days. During the survey, Immediate Jeopardy (IJ) was identified as a result of a resident receiving Cardiopulmonary Resuscitation (CPR) following a documented choice to be Do Not Resuscitate (DNR) on a Provider Order for Life-Sustaining Treatment (POLST). The IJ was called on [DATE] at 4:38 PM, in the presence of the Director of Nursing (DON). [...]

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to protect a resident's quality of life when the facility-initiated life saving measures during a Code Blue (medical emergency), to include chest compressions, for a resident with a Do Not Resuscitate (DNR) order for 1 of 20 sampled residents (Resident #2). This was a result of not honoring a resident's choice regarding the resident's plan of care resulting in psychosocial harm when the resident's life was prolonged by two days. Cross reference with Immediate Jeopardy tag F 684. [...]

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a resident was free from misappropriation of property when a Certified Nursing Assistant (CNA) asked for money from a resident and failed to pay the money back to the resident for 1 of 20 sampled residents (Resident #4).

Inspectors wroteBased on observation, clinical record review, document review, and interview, the facility failed to update a resident's care plan to address hearing loss and use of a hearing device for 1 of 20 sampled residents (Resident #3), resident exhibiting resistance to care for 1 of 20 sampled residents (Resident #8) and resident's pathological left femur fracture following surgery for 1 of 20 sampled residents (Resident #9). Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnosis including presence of other specified devices. A Nursing Progress Note dated 08/30/23, documented the resident was able to make needs known and was hard of hearing. Resident #3's care plan initiated on 08/09/23, lacked documented evidence the resident had a hearing deficit and used a hearing device. [...]

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure the facility staff properly operated a resident lift with two persons to prevent an injury to a resident for 1 of 20 sampled residents (Resident #5).

Inspectors wroteBased on observation, and interview, the facility failed to ensure food delivered to residents in a dining area were properly covered and not exposed prior to the residents' consumption, potentially affecting 111 of 111 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident information was not visible on an unattended computer screen facing a public area for 17 of 17 residents residing in a unit.

Inspectors wroteBased on clinical record review and interview, the facility failed to complete physician visits within the required timeframe for 12 of 22 sampled residents (Resident #3, #13, #16, #18, #19, #23, #25, #30, #34, #40, #49, and #56).