Hearthstone Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hearthstone Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 16, 2023

  Based 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). […]

• Actual harm, isolatedF600May 4, 2023

  Based on clinical record review, interview, and document review the facility failed to protect 1 of 24 sampled residents (Resident #26) from physical abuse and ensure a resident was free from neglect when a resident with aspiration precautions and dysphagia was left in a room with no staff present, causing actual harm when the resident choked on a hot dog, had to be resuscitated, admitted to a hospital Intensive Care Unit and expired for 1 of 3 closed records (Resident #370). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus type two, and bipolar disorder, unspecified. […]

• Actual harm, isolatedF689May 4, 2023

  Based on observation, clinical record review, interview, and document review the facility failed to ensure supervision was provided during meals for a resident with aspiration precautions resulting in the resident choking on a hot dog, requiring cardiopulmonary resuscitation (CPR), and hospitalization for 1 of 3 closed records reviewed (Resident #370). Findings include: Resident #370 Resident #370 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery, cough, unspecified, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and dysphagia, oropharyngeal phase. […]

• No harm, potential for more than minimal, widespreadF698Mar 3, 2025

  Based 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. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, and heart failure. […]

• No harm, potential for more than minimal, widespreadF552Mar 25, 2024

  Based 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). Findings include: Resident #49 Resident #49 was admitted to the facility on [DATE], with a diagnosis of anxiety disorder, unspecified and urticaria, unspecified. Resident #49's physician's orders documented the following: -Start date 07/27/23, Hydroxyzine hydrochloride (HCL) tablet 25 milligrams (mg), oral, as needed for itching, diagnosis anxiety disorder unspecified, three times a day as needed. […]