Inspection Report
Follow-Up
Census: 42
Deficiencies: 0
Jul 2, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to medication administration documentation were corrected.
Report Facts
Sampled residents for review: 7
Sampled residents with medication documentation issues: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sunny Kent | Licensor | Department staff who did the on-site verification. |
| Scottie Sindora | ALF Licensor | Department staff who did the on-site verification. |
Inspection Report
Follow-Up
Census: 28
Deficiencies: 4
Dec 6, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to tuberculosis testing, background checks, negotiated service agreements, and full assessment topics were corrected.
Deficiencies (4)
| Description |
|---|
| Failure to ensure 2 of 6 staff completed required tuberculosis skin test within three days of employment, placing 28 residents at risk of exposure to communicable disease. |
| Failure to ensure a national fingerprint background check was completed for 1 of 6 sampled staff, placing 28 residents at risk due to unknown staff criminal background history. |
| Failure to develop and document a Negotiated Service Agreement (NSA) supporting the care needs of 1 sampled resident, placing the resident at risk of not receiving needed care and services. |
| Failure to perform a 14-day full assessment addressing capabilities, needs, and preferences for 1 of 2 sampled residents, placing residents at risk for unmet needs and improper use of equipment. |
Report Facts
Residents at risk: 28
Sampled residents: 7
Sampled staff: 6
Deficiencies previously cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Faith Le | NCI | Department staff who did the on-site verification. |
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who did the on-site verification. |
| Staff B | Wellness Nurse | Named in findings related to tuberculosis testing and negotiated service agreements. |
| Staff F | Dietary Server | Named in findings related to tuberculosis testing. |
| Staff E | Nursing Assistant Certified | Named in findings related to fingerprint background check. |
| Staff G | Director of Human Resources | Confirmed incomplete tuberculosis testing and fingerprint background checks. |
Inspection Report
Life Safety
Deficiencies: 8
Feb 14, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the Hearthstone residential care facility to assess compliance with fire-resistance construction, door operation, sprinkler system maintenance, and illumination requirements.
Findings
The inspection identified multiple violations including lack of documentation for annual firewall inspection, damaged ceiling tile near a sprinkler head, holes in fire barriers, fire doors not closing properly, corroded and improperly installed sprinkler heads, and an exit light that did not stay on during testing.
Deficiencies (8)
| Description |
|---|
| Facility is unable to provide documentation that the annual firewall inspection has been completed. |
| Ceiling tile around a sprinkler head in the accounting office records room needs repair. |
| Hole in the fire barrier above the poker tables in the basement level. |
| Fire doors to laundry room area in basement hallway did not close properly. |
| Sprinkler heads in the kitchen on the second floor are corroded and should be assessed for replacement. |
| Row of sidewall sprinkler heads installed backward in the chapel, pointed at the wall. |
| Sprinkler heads in basement hallway storage and maintenance area appear due for replacement or sample testing due to age. |
| Exit light by room 401 did not stay on with pushbutton test. |
Report Facts
Next inspection scheduled: Mar 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arthur Jesse Ward | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Tim Alton | Facilities Director | Signed as Owner or Authorized Representative |
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