Home at Hearthstone, The

In the surveyor’s words

From the most serious findings on record at Home at Hearthstone, The, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Dec 17, 2025

  Based on observations, staff interview, review of the admission agreement, and record review, the facility failed to ensure residents were treated with dignity and respect during dining and incontinence care. This affected four (#6, #27, #38, and #55) of four residents reviewed for dignity. The facility census was 87. Findings include:1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction.The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderately impaired cognition and required substantial assistance with toileting.Observation in the 100-hallway on 12/17/25 from 9:03 A.M. to 9:05 A.M. […]

• No harm, potential for more than minimal, isolatedF609Jul 25, 2024

  Based on interview, record review, and policy review, the facility failed to report an alleged incident of resident to resident abuse. This affected two (Residents #25 and #65) of two residents reviewed for mood/behavior needs. Findings include: 1. Review of the admission record revealed the facility admitted Resident #65 on 11/23/19. The resident had diagnoses including dementia of unspecified severity with other behavioral disturbance, need for assistance with personal care, restlessness and agitation, delusional disorders, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/22/24, revealed Resident #65 had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. […]

• No harm, potential for more than minimal, isolatedF695Jul 25, 2024

  Based on observation, interview, record review, and policy review, the facility failed to have physician orders for the use of supplemental oxygen. This affected one (Resident #57) of one resident reviewed for respiratory care. Findings included: Review of the admission record revealed Resident #57 was admitted on [DATE]. The resident had diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Review of the physician orders revealed no order for oxygen. Review of the admission Minimum Data Set (MDS) assessment, dated 07/12/24, revealed Resident #57 had moderate cognitive impairment. Resident #57 did not have oxygen therapy on admission or while a resident during the assessments 14-day lookback period. […]

• No harm, potential for more than minimal, isolatedF880Jul 25, 2024

  Based on observation, interview, record review, and policy review, the facility failed to ensure a urinary catheter bag was not left on the floor and failed to ensure contaminated incontinence care supplies were disposed of appropriately. This affected two (Residents #54 and #21). Findings include: 1. Review of the admission record revealed the facility admitted Resident #54 on 07/14/23. Diagnoses included obstructive and reflux uropathy. Review of the annual Minimum Data Set (MDS) assessment, dated 06/08/24, revealed Resident #54 had intact cognition. The resident had an indwelling catheter. During an observation on 07/22/24 at 10:37 AM, Resident #54 was sitting up on the side of their bed with the urinary catheter bag lying on the floor. […]

• No harm, potential for more than minimal, isolatedF686May 16, 2023

  Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure interventions to prevent skin breakdown were in place as ordered by the physician and per the resident plan of care. This affected two (#18 and #60) of three residents reviewed for pressure ulcers. The facility census was 86. Finding include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD), osteoporosis, and mitral valve insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #18 dated 03/13/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). […]