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Deficiency Records for Hazel Hawkins Memorial Hospital D/p Snf
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.
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? |
|---|---|---|---|---|
| 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 | 2024-03-19 | 2024-06-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-19 | 2024-05-10 | N |
| Use approved construction type or materials. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-20 | 2024-05-03 | 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 | 2024-03-20 | 2024-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-03-20 | 2024-05-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-19 | 2024-04-26 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-19 | 2024-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-19 | 2024-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-19 | 2024-04-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-19 | 2024-04-14 | 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 | 2024-03-19 | 2024-04-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-19 | 2024-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-19 | 2024-04-14 | N |
| 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 |
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