Deficiency Records for Hawthorne Healthcare and Wellness Centre, LP
Updated as of March 01, 2024
A list of the most recent deficiencies for Hawthorne Healthcare and Wellness Centre, LP. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-02-16 | 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 | 2024-01-26 | 2024-02-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-01-26 | 2024-02-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-26 | 2024-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-02-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-01-26 | 2024-02-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-01-26 | 2024-02-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-26 | 2024-02-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-26 | 2024-02-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-02-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-31 | 2024-02-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-10 | 2023-11-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-10 | 2023-11-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-14 | 2023-01-11 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-10-21 | 2022-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-01 | 2022-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-09 | 2022-06-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-04 | 2022-05-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-04 | 2022-05-16 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-28 | 2021-07-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-28 | 2021-07-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-21 | 2021-07-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-21 | 2021-07-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-06-21 | 2021-07-12 | N |
| Provide activities to meet all resident's needs. | Health | 2021-06-21 | 2021-07-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-21 | 2021-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-21 | 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 | 2021-06-21 | 2021-07-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-21 | 2021-07-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-21 | 2021-07-12 | 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 | 2021-06-21 | 2021-07-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-21 | 2021-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-21 | 2021-07-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-06-21 | 2021-07-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-21 | 2021-07-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-21 | 2021-07-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-16 | 2020-02-07 | 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 | 2020-01-16 | 2020-02-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-16 | 2020-02-07 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-01-12 | 2020-02-06 | 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 | 2020-01-12 | 2020-02-06 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-12 | 2020-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-12 | 2020-02-06 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-01-12 | 2020-02-06 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-01-12 | 2020-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-12 | 2020-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-12 | 2020-02-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-12 | 2020-02-06 | N |
| Post nurse staffing information every day. | Health | 2020-01-12 | 2020-02-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-12 | 2020-02-06 | 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 | 2020-01-12 | 2020-02-06 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-01-12 | 2020-02-06 | N |
| Help the resident with transportation to and from laboratory services outside of the facility. | Health | 2020-01-12 | 2020-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-12 | 2020-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-12 | 2020-02-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-12 | 2020-02-06 | N |
