Hearthstone Nursing and Rehabilitation

Inspectors wroteBased on interview, observation and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #22, Resident #34, and Resident #61) reviewed for accuracy of assessments. The facility failed to ensure Resident #22's annual MDS, dated [DATE], accurately reflected her smoking status. The facility failed to ensure Resident #34's admission MDS, dated [DATE], accurately reflected her smoking status. The facility failed to ensure Resident #61's annual MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure the food Processor used for puree' was sanitized prior to use on 04/01/2026.2. The facility failed to ensure CK H used proper hand hygiene when preparing puree' foods on 04/01/2026.3. The facility failed to ensure CK H hair restraint was on properly and covered her hair completely to prevent hair from contacting food. These deficient practices could place residents at risk for food borne illness. Observation of CK H preparing puree food on 04/01/26 at 10:45 a.m., revealed CK H did not wash her hands before starting the puree process for the chicken. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for 19 of 103 residents reviewed for infection control: The facility failed to ensure staff used proper hand sanitation while serving meals to the residents. These deficient practices could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 2residents (Resident #23 and ) reviewed for environmental concerns. The facility failed to ensure Resident #23's room was roach-free. This failure could place residents at risk of pests in their rooms that spread bacteria. Findings Include: A review of Resident #23's records reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Annual MDS Assessment, dated 12/19/25, her BIM was 15, and she was cognitively intact. The resident has a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #23 was dependent on staff for Activities of daily living. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 6 residents (Resident #1) reviewed for care plan revisions. The facility failed to update Resident #1's care plan to reflect ongoing aggressive behaviors toward staff and interventions to meet her physical, psychosocial, and functional needs. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6(Resident #1) residents reviewed for PASARR. The facility failed to ensure that Resident #1 was referred for a level II PASARR after an evident diagnosis of Major Depressive Disorder diagnosed on [DATE]. These failures could place residents at risk for decline and the inability to receive services. Findings Included:RR of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. The face sheet revealed that Resident #1 had a diagnosis of Major Depressive Disorder as of 10/06/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for 1 of 6 (Resident #2) residents reviewed for PASARR. The facility failed to ensure that Resident #2 was referred to PASARR services after a positive level II PASARR screening. These failures could place residents at risk for not receiving services intended for the residents mental, intellectual or developmental disabilityFindings Included: RR of Resident #2's undated face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE]. The face sheet revealed that Resident #2 had a diagnosis of Major Depressive Disorder as of 03/14/2013. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #10) reviewed for care plans. The facility failed to include Resident #10 was receiving hospice services in the comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 2 of 2 residents (Resident #17 and #44) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene and sanitized equipment between residents when passing medications to Residents #17 and #44. This failure could place residents at risk for development of communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #1) out of seven residents reviewed for abuse and neglect in that: CNA A slapped Resident #1 on his head in the front lobby in the presence of the facility's Receptionist and the Van Driver from another facility. This noncompliance was identified as PNC. The deficient practice occurred on 11/30/2024 and in-service was completed on 12/03/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, injury, and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records. The facility failed to ensure LVN C documented any follow-up observations or assessments of Resident #2 after she initiated treatments for his uncontrolled coughing. This failure could result in errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure LVN A confirmed Resident #1 consumed her morning medication on 04/03/24 as she was witnessed spitting her medication into the trashcan. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #1) of 5 residents reviewed for informed consent for treatment options. The facility failed to: 1. obtain a signed informed consent for the use of Seroquel for Resident #1 by her MPOA 2. obtain a signed informed consent for the use of ABH gel for Resident #1 by her MPOA This failure could affect all residents by placing them at risk of receiving psychotropic medications without informed consent which could cause decrease quality of life and increase the risk of injury and violate the rights of residents to make informed decisions related to care.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for one of one (Resident #1) of two residents reviewed for Comprehensive Care Plans, in that: The facility failed to schedule a care plan meeting with FAM and Resident #1 that involved a multidisciplinary team and instead documented a phone call between FAM and the Social Worker as the care plan meeting. This failure could place residents at risk of not receiving the highest practicable interventions, treatments and care by not involving the resident and FAM (MPOA) of a care plan meeting.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #1) of 5 residents reviewed for psychotropic drug use. The facility failed to: 1. ensure Resident #1 was prescribed Seroquel and ABH gel for a specific diagnosis and instead prescribed it for behavioral disturbance at bedtime This failure could affect all residents by placing them at risk of receiving psychotropic medications without a specific diagnosis and rather being prescribed psychotropic medication for behavior; this could cause decrease quality of life and increase the risk of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 2 Common Baths (Pod A (SB) and Pod B (JH)) and 9 of 25 resident rooms (room [ROOM NUMBER]SB, 110SB, 111SB, 217SB, 218SB, 220SB, 108JH, 218JH and 326JH) reviewed. The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 113 to 118.8 F, and The facility failed to ensure bathing and restroom area grab bars were securely attached to the walls. This failure could place residents at risk for injuries related to non-secure grab bars and could place residents at risk for sustaining scalding injuries when using resident-use/resident accessible hot water.

Inspectors wroteBased on observation, interview, and record review the facility failed to offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 4 of 4 residents (Residents #2, 7, 22, and 39). The facility failed to provide Residents #2, 7, 22, and 39 with their physician ordered therapeutic diets that included fortified foods, Cardiac diet, and 2GM Sodium for the noon and evening meals on 12/12/23 and the noon meal on 12/13/23. This failure could place residents at risk for hunger, weight loss, and chemical imbalances.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and puree) for 4 residents (Residents #2, 7, 22 and 25) reviewed during mealtime. The facility failed to ensure Residents #2, 7, 22, and 25 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (12/14/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 4 of 5 residents (Residents #13, #14, #21, and #66) and 3 of 3 staff (LVN D, CNA B, and CNA C) reviewed for infection control. 1. LVN D failed to perform hand hygiene between glove changes during wound care for Resident #14 and Resident #66. 2. CNA B failed to perform hand hygiene between glove changes when providing incontinent care for Resident #13. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #21. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of three residents reviewed for notification of changes, in that: The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) out of three residents reviewed for neglect. The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #2) of three residents reviewed for medications. The facility failed to ensure Resident #2 was administered her scheduled morphine every six hours as prescribed by the physician. This failure could place residents at risk for not receiving therapeutic effect of their medications as ordered by the physician.