Deficiency Records for Hawthorn Glen Nursing Center
Updated as of April 01, 2020
This is not the most recent data for Hawthorn Glen Nursing Center. For the most recent information, click here.
A list of the most recent deficiencies for Hawthorn Glen Nursing Center. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Be properly staffed | Fire Safety | 2019-11-04 | 2019-12-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-06 | 2019-12-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-11-06 | 2019-12-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-06 | 2019-12-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-06 | 2019-12-09 | 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 | 2019-11-06 | 2019-12-09 | 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 ne | Health | 2019-11-06 | 2019-12-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-06 | 2019-12-09 | 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 | 2019-11-06 | 2019-12-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-06 | 2019-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-06 | 2019-12-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-06 | 2019-12-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Develop a communication plan. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-10-01 | 2018-11-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-04 | 2018-11-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2018-10-04 | 2018-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-04 | 2018-11-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-06-25 | 2018-07-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-25 | 2018-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-25 | 2018-07-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-25 | 2018-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-06-06 | 2018-07-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-19 | 2018-07-19 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-04-19 | 2018-07-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-07 | 2018-03-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-02-07 | 2018-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-07 | 2018-03-29 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-02-07 | 2018-03-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-08-03 | 2017-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-01 | 2017-10-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-01 | 2017-10-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-08-01 | 2017-10-02 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-08-03 | 2017-10-02 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-03 | 2017-10-02 | N |
