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Deficiency Records for Hawthorne Inn of Danville
A list of the most recent deficiencies for Hawthorne Inn of Danville. 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 Hawthorne Inn of Danville. 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? |
|---|---|---|---|---|
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-04-17 | 2024-05-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-04-17 | 2024-05-08 | 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 | 2024-04-17 | 2024-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-17 | 2024-05-08 | 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 | 2024-04-17 | 2024-05-08 | 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 | 2024-04-17 | 2024-05-08 | 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 | 2024-04-17 | 2024-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-17 | 2024-05-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-17 | 2024-05-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-17 | 2024-05-08 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-04-17 | 2024-05-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-04-17 | 2024-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-17 | 2024-05-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-10 | 2023-07-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-10 | 2023-07-21 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-17 | 2023-06-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-17 | 2023-06-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-29 | 2023-05-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-29 | 2023-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-29 | 2023-04-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-23 | 2023-04-18 | 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 | 2023-03-23 | 2023-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-29 | 2023-04-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-11 | 2023-01-31 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-11 | 2023-01-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-06 | 2022-07-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-06 | 2022-07-07 | Y |
| 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 | 2022-07-06 | 2022-07-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-06 | 2022-07-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-06 | 2022-07-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-12 | 2022-04-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-12 | 2022-02-03 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-01-13 | 2022-02-01 | 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 | 2022-01-13 | 2022-02-01 | 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 | 2022-01-13 | 2022-02-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-13 | 2022-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-13 | 2022-02-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-13 | 2022-02-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-13 | 2022-02-01 | 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 | 2022-01-13 | 2022-02-01 | 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 | 2022-01-13 | 2022-02-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-13 | 2022-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-02-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-13 | 2022-02-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-13 | 2022-01-31 | N |
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