A list of the most recent deficiencies for Hathaway Manor Extended Care. 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 safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-28 | 2024-02-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-28 | 2024-02-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-29 | 2024-01-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-29 | 2024-01-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-29 | 2024-01-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-29 | 2024-01-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-28 | 2023-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-28 | 2023-12-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-12 | 2023-11-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-12 | 2023-11-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-12 | 2023-11-20 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-12 | 2023-11-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-12 | 2023-11-20 | 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 | 2023-10-12 | 2023-11-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-12 | 2023-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-11-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-23 | 2022-11-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-23 | 2022-11-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-23 | 2022-11-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-08-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-13 | 2021-07-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-13 | 2021-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-07-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-13 | 2021-07-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-13 | 2021-07-12 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-13 | 2021-07-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-13 | 2021-07-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-13 | 2021-07-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-13 | 2021-07-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-13 | 2021-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-13 | 2021-07-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-13 | 2021-07-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-13 | 2021-07-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-13 | 2021-07-12 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-13 | 2021-07-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-13 | 2021-07-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-13 | 2021-07-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-13 | 2021-07-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-13 | 2021-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-13 | 2021-07-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-05-13 | 2021-07-12 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-13 | 2021-07-12 | N |
| Keep all essential equipment working safely. | Health | 2021-05-13 | 2021-07-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-05-13 | 2021-07-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-19 | 2021-07-03 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-05-19 | 2021-06-18 | 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 | 2021-05-19 | 2021-05-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-16 | 2021-04-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-16 | 2021-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-16 | 2021-04-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-22 | 2021-04-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-03-22 | 2021-04-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-03-03 | 2021-03-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-10-19 | 2020-11-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-06 | 2020-04-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-06 | 2020-04-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-03-06 | 2020-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-06 | 2020-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-06 | 2020-04-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-06 | 2020-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-06 | 2020-04-20 | N |
