Deficiency Records for Hazel Hawkins Memorial Hospital D/p Snf
Updated as of April 01, 2024
A list of the most recent deficiencies for Hazel Hawkins Memorial Hospital D/p Snf. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-25 | 2023-12-19 | Y |
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-12-21 | 2023-01-09 | Y |
Address subsistence needs for staff and patients. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Provide family notifications of emergency plan. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Use approved construction type or materials. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-07 | 2022-07-26 | N |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-24 | 2022-07-21 | N |
Ensure each resident receives an accurate assessment. | Health | 2022-06-24 | 2022-07-21 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-24 | 2022-07-21 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-24 | 2022-07-21 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-24 | 2022-07-21 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-24 | 2022-07-21 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-10 | 2022-05-25 | Y |
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2022-02-25 | 2022-04-28 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-04-28 | Y |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-13 | 2019-07-24 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-18 | 2019-05-28 | N |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-18 | 2019-05-28 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-18 | 2019-05-28 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-18 | 2019-05-28 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-18 | 2019-05-28 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-18 | 2019-05-28 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-18 | 2019-05-28 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-18 | 2019-05-28 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-18 | 2019-05-28 | N |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-04-25 | 2018-05-15 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2018-04-25 | 2018-05-15 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-25 | 2018-05-15 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-25 | 2018-05-15 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-15 | 2018-04-06 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-15 | 2018-04-06 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-03-15 | 2018-04-06 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-15 | 2018-04-06 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-03-15 | 2018-04-06 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-15 | 2018-04-06 | N |