Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hawthorne Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to submit its PBJ staffing data for the first fiscal year quarter. The Admin stated the consulting group was responsible for timely submission and confirmed that the CMS validation report showed the wrong fiscal year was submitted instead of the quarter covering October through December. Surveyors also reviewed the SOM, which states the facility is responsible for submitting staffing data through the CMS PBJ system.
A resident table with four dependent residents had only one staff member assisting one resident while the other residents waited with covered meal trays. The affected residents had diagnoses including DM, paraplegia, dysphagia/dysphasia, and TBI history, and their MDSs showed dependence on staff for eating. Staff stated residents waiting for help could feel neglected or jealous, and the Dining Program policy said residents at a table should generally be served at the same time.
Unlabeled and Undated Food Item in Freezer: Surveyors observed a clear bag of sweet potato fries in Freezer 2 that was not labeled or dated. The DSS stated all food items should be labeled and dated, and the facility P&P for Food Storage indicated that all food items are to be labeled and dated.
Soiled resident clothing was observed inside the clean linen cart during a hallway observation with the IPN. The IPN identified the gray sweater as a resident's personal item and stated it should have been bagged separately rather than mixed with clean linen because soiled items can contaminate clean linen. The facility's infection control P&P states it is intended to help maintain a safe, sanitary environment and prevent transmission of infections.
A resident with COPD, inflammatory polyneuropathy, major depressive disorder, and PTSD had an MDS active diagnosis assessment that incorrectly indicated the resident was not on hospice, even though the resident had been placed on hospice and was receiving hospice services. The resident was documented as lacking decision-making capacity, with severely impaired cognition and dependence on staff for ADLs. The MDSN stated the hospice status was marked incorrectly and that the assessment was inaccurate.
PASARR screenings were not resubmitted for two residents after new mental illness diagnoses and psychotropic medications were documented. One resident had paranoid schizophrenia, MDD, and impaired decision-making, with Quetiapine and Mirtazapine ordered; another had schizophrenia, MDD, psychosis, fluctuating capacity, and Haloperidol ordered. The DON stated the original PASARR Level 1 screenings were completed when the residents had no serious mental illness diagnoses and that new Resident Review screenings should have been completed.
Missing Care Plans for Psychotropic Medication and Schizophrenia: The facility failed to develop a comprehensive care plan for a resident receiving Lorazepam for anxiety and failed to create a care plan for another resident with paranoid schizophrenia. Records showed both residents had significant cognitive impairment and lacked decision-making capacity, and staff confirmed the required care plans were not in place.
Failure to Provide Communication Board for a Nonverbal Resident: A resident with aphasia, stroke history, and dependence with ADLs was care planned for alternative communication support, including use of a communication board. However, staff observed no communication board at the bedside, and the resident was nonverbal and relied on gestures. An MDSN confirmed the resident was not provided a communication board and that staff were translating the resident’s needs instead.
Failure to Assist Resident With Community Wheelchair Transportation: A resident with CVA with hemiplegia, COPD, and DM reported that the SSD did not help him complete an Access transportation application or schedule transportation, despite the resident needing it for family visits, church, and medical appointments. The SSD said the facility provides help with community wheelchair transportation and claimed to have assisted with the application, but could not provide documentation, while the resident stated he only received a blank application and had to request it himself.
A resident with anxiety disorder, epilepsy, and psychosis had severely impaired cognitive skills and lacked decision-making capacity. The Consultant Pharmacist’s MRR recommended lab work including CMP, CBC, carbamazepine level, lipid, folate, and vitamin B12 levels, but the ADON stated the facility did not act on the recommendation or notify the physician, and there was no documentation that the MRR recommendation was completed.
Failure to monitor behaviors for psychotropic medications: A resident with paranoid schizophrenia and MDD was prescribed quetiapine and mirtazapine for increased agitation, verbal aggression, and depression, but the MAR had no documented behavior monitoring. The ADON stated behavior monitoring should be recorded as Yes or No to track medication effectiveness and determine whether a GDR could be attempted.
A resident with hypothyroidism, UTI, and DM had a physician order for T3, FT4, and TSH labs, but the tests were not completed and results were unavailable. The ADON stated there was no documentation of follow-up with the lab provider, and the DON noted the labs were needed to evaluate levothyroxine effectiveness and guide further interventions.
Failure to follow up on recommended denture services for a resident with dysphagia, cerebral ischemia, epilepsy, and severely impaired cognitive skills. Dental notes showed the dentist recommended dentures, but the SSD did not follow up on the recommendation and the DON was not aware of it. The resident reported broken dentures and difficulty eating without them, while facility policy called for oral healthcare and dental services to be provided.
The facility failed to ensure two CNAs had mandatory effective communication training on file. During record review, one CNA hired in 2025 and another hired in 2026 had no evidence of the required training. The DSD stated she was responsible for providing this training for all direct care staff and that it was important for staff to interact adequately with residents and other staff.
Facility Assessment Not Updated to Reflect Actual Census: The facility failed to maintain an updated average daily census on the Facility Assessment Tool. The ADM stated she was responsible for updating the tool and that it should be updated yearly or as needed when the census changes or when special treatments or services are provided. The assessment listed an average daily census of 80 residents, while the facility census showed 83 residents, and the ADM stated three residents were not accounted for on the tool.
A dietary aide was observed working in the kitchen without a hairnet, in violation of the facility's infection control policy requiring hair restraints in food preparation areas. The dietary manager acknowledged that this practice increases the risk of hair falling and cross contamination to food and utensils.
The facility failed to properly monitor orthostatic blood pressure for three residents, leading to incomplete assessments. A resident with hypotension had blood pressure readings not taken in the correct sequence, while another with schizophrenia had similar issues. A third resident on anti-psychotic medication had only systolic readings recorded, omitting necessary diastolic measurements. Staff confirmed these deficiencies, which are crucial for identifying changes and alerting physicians.
The facility failed to use the correct scoop size for serving mechanical soft diets, potentially affecting 29 residents' nutritional intake. The cook used a smaller scoop than specified in the menu, confirmed by the Dietary Supervisor and Registered Dietician, which could lead to decreased intake and weight loss.
A facility failed to update the care plan for a resident who self-removed his indwelling catheter twice. Despite the resident's ability to express ideas and understand others, and being independent with self-care, the care plan was not revised to address the self-removal incidents. The facility's policy required care plan updates for new problems or changes in condition, but no revisions were made to include monitoring for complications after the catheter was re-inserted.
A facility failed to document a change of condition after a resident self-removed his catheter for the second time. Despite the resident's ability to communicate and being independent, the facility did not complete the required Change in Condition form, as per their policy. The resident's medical history includes benign prostatic hyperplasia, bipolar disorder, and anxiety disorder. The RN confirmed that the form should have been completed, highlighting a lapse in protocol adherence.
A resident with a care plan requiring the use of a smoking apron was observed smoking without it, despite its availability. The Smoking Aide was unaware of the specific requirement for this resident, and the Director of Nursing confirmed the oversight. The facility's policy mandates individualized care plans for smoking residents, but this was not effectively communicated or implemented.
The facility failed to label a bottle of ClearLax with the date it was opened, as observed during a medication administration by an LVN. The LVN admitted the bottle should have been labeled to ensure timely removal after 30 days, in accordance with the facility's medication storage policy.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to ensure its Payroll Based Journal (PBJ) staffing data was submitted for the first fiscal year quarter. During review of the PBJ Staffing Data Report for Fiscal Year Quarter 1, the report showed the facility did not submit data for that quarter. In interviews, the Administrator stated the consulting group was responsible for submitting the PBJ information timely and acknowledged that PBJ was required to be submitted quarterly. The Administrator also confirmed that the CMS submission validation report showed fiscal year 2 was submitted instead of fiscal year 1, which covered October 2025 through December 2025. The State Operations Manual reviewed by surveyors stated the facility is responsible for submitting staffing data through the CMS PBJ system and that failure to submit PBJ data as required would be reflected on the CASPER report and result in a deficiency citation.
Delayed Eating Assistance at Dining Table
Penalty
Summary
The facility failed to provide adequate eating assistance for three residents who were dependent on staff for eating. During the dining room observation, Resident 1, Resident 7, and Resident 18 were seated at the same table with covered food plates in front of them while only one staff member was seated at the table assisting a fourth resident with eating. At a later observation, the same three residents were still seated at the table with covered food plates while one staff member continued assisting the same resident, and the three residents did not yet have eating assistance. Three staff members were not present at the table until a later observation. Resident 1’s records showed diagnoses including type 2 DM, long-term insulin use, and muscle weakness, and the MDS indicated dependence on staff for eating and several other ADLs. Resident 7’s records showed diagnoses including complete paraplegia, type 2 DM, and dysphagia, and the MDS indicated dependence on staff for eating and other ADLs. Resident 18’s records showed diagnoses including paraplegia, dysphasia, and a personal history of traumatic brain injury, and the MDS indicated dependence on staff for eating and other ADLs. Staff interviews stated that residents waiting for assistance could feel neglected or jealous because they should eat at the same time, and the facility’s Dining Program policy stated residents at a given table should generally be served at the same time.
Unlabeled and Undated Food Item in Freezer
Penalty
Summary
The facility failed to ensure that sweet potato fries stored in Freezer 2 in the kitchen were labeled and dated. During an initial observation tour of the kitchen on 3/24/2026 at 8:54 a.m., surveyors observed a clear bag of sweet potato fries in Freezer 2 that was undated and unlabeled. During a concurrent observation and interview at 8:56 a.m., the Dietary Services Supervisor stated that all food items should be labeled and dated and that failure to do so could result in staff being unable to identify the food item and possible expiration. Review of the facility policy and procedures titled Food Storage, dated 11/1/2014, indicated that all food items are to be labeled and dated.
Soiled Resident Clothing Found in Clean Linen Cart
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a resident's soiled personal clothing was found inside the facility's clean linen cart during a concurrent observation and interview with the Infection Preventionist Nurse in the resident's hallway. The Infection Preventionist Nurse identified the gray sweater as belonging to a resident, but she did not know which resident it belonged to. She stated that residents' personal clothing, whether clean or dirty, should be bagged in a plastic bag and should not be mixed with the facility's clean linen cart, and that soiled items could contaminate clean linen by transferring bacteria. Review of the facility's Infection Control Policies and Procedures, dated 1/2012, stated that the facility's infection control policies and procedures are intended to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections.
Inaccurate Hospice Status Documented in MDS
Penalty
Summary
Resident 60’s MDS active diagnosis assessment dated 11/28/2025 indicated the resident was not on hospice care, even though the resident had been placed on hospice on 11/21/2025 and was receiving hospice services at that time. The resident’s face sheet listed diagnoses including inflammatory polyneuropathy, COPD, major depressive disorder, and PTSD. The resident’s H&P dated 2/12/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated [DATE] indicated severely impaired cognitive skills and dependence on staff for ADLs. During a concurrent interview and record review on 03/25/2026 at 3:43 p.m., the MDSN 2 stated the hospice status was marked incorrectly on 11/28/2026 and that the assessment was inaccurate. The MDSN 2 stated the resident was receiving hospice services on 11/28/2025 and that documenting an inaccurate resident diagnosis could result in the possibility of a resident’s needs not being met according to inaccurate assessment coding. The facility’s RAI Process policy stated the purpose of the RAI process was to provide resident assessments that accurately depict and identify resident-specific issues and objectives while meeting state and federal guidelines and data submission requirements.
PASARR screenings not resubmitted for residents with new mental illness diagnoses
Penalty
Summary
The facility failed to ensure PASARR Level 1 screenings were completed and resubmitted for two residents with mental illness diagnoses and psychotropic medication use. For Resident 10, the record showed diagnoses of paranoid schizophrenia, major depressive disorder, and COPD. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS showed severely impaired cognitive skills for daily decision making. The order summary showed Quetiapine Fumarate and Mirtazapine were started for psychotic disorder with agitation and verbal aggression, and for major depressive disorder. During interview and record review, the DON reviewed Resident 10’s PASARR Level 1 screening and stated it had been completed when the resident had no serious mental illness diagnoses. The DON stated the resident later developed paranoid schizophrenia and that the facility should have completed and resubmitted a new PASARR Level 1 screening under Resident Review because of the new mental illness diagnosis. The DON stated that by not resubmitting the screening, there was a possibility the resident would not be able to avail treatment services for the mental illness diagnosis. For Resident 12, the record showed diagnoses of schizophrenia, major depressive disorder, and psychosis. The MDS indicated the resident was independent in cognitive skills for daily decision making, while the H&P stated the resident had fluctuating capacity to understand and make decisions. The order summary showed Haloperidol was started for schizophrenia manifested by aggressive behavior. The DON reviewed Resident 12’s PASARR Level 1 screening and stated it had been completed when the resident had no serious mental illness diagnoses and was not on psychotropic medications, that the case was closed, and that a PASARR level II mental health evaluation was not required. The DON stated the facility should have completed and resubmitted a new PASARR Level 1 screening under Resident Review because of the resident’s mental illness diagnoses and Haloperidol use, and stated the facility did not follow the PASARR procedure for resubmitting the screening.
Missing Care Plans for Psychotropic Medication and Schizophrenia
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 9 related to the use of Lorazepam for anxiety disorder. Resident 9 was initially admitted and later readmitted to the facility, and the record showed diagnoses that included anxiety disorder, epilepsy, and psychosis. The MDS dated 1/29/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired, and the H&P dated 2/23/2026 stated the resident did not have the capacity to understand and make decisions. An order summary dated 3/26/2026 showed a telephone order on 3/1/2026 for Lorazepam 1 mg by mouth three times daily for anxiety disorder manifested by inability to relax. During interview and record review on 3/26/2026, MDSN 1 stated there was no comprehensive care plan to address Resident 9’s use of Lorazepam. The facility also failed to create a care plan for Resident 77’s schizophrenia diagnosis. Resident 77’s face sheet listed diagnoses including metabolic encephalopathy, paranoid schizophrenia, type 2 DM, dementia, and epilepsy. The H&P dated 2/26/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 3/4/2026 indicated cognitive skills were severely impaired and the resident was dependent on staff with ADLs. On 3/26/2026, review of the care plan showed no schizophrenia care plan. During interview and record review, MDSN 2 stated psychiatric diagnoses were required to have a care plan and confirmed that Resident 77 required a care plan for schizophrenia.
Failure to Provide Communication Board for Nonverbal Resident
Penalty
Summary
The facility failed to ensure a communication board was provided to Resident 58, who required assistance with communication. Resident 58 was originally admitted and later readmitted with diagnoses including aphasia, type 2 DM, cerebral infarction, and osteoporosis. The H&P dated 6/24/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 1/12/2026 indicated the resident was cognitively intact and dependent on staff with ADLs. The care plan dated 5/2/2022 directed staff to allow adequate time to respond, repeat as necessary, request clarification, face the resident when speaking, make eye contact, turn off the TV/radio, ask yes/no questions if appropriate, use simple brief words/cues, use alternative communication tools as needed, and evaluate the resident's dexterity/ability to use a communication board. During observation on 3/25/2026, there was no communication board at the bedside, and Resident 58 was nonverbal but attempted to use gestures to communicate. During interview on 3/26/2026, MDSN 2 stated non-verbal residents are provided a communication board with pictures or a marker to write needs, that Resident 58 was not provided a communication board, and that staff were using gestures to translate the resident's needs instead. The facility policy on accommodation of residents' communication needs listed writing pads, pens, and communication boards/charts as examples of adaptive devices or accommodations.
Failure to Assist Resident With Community Wheelchair Transportation
Penalty
Summary
The facility failed to ensure that one sampled resident was provided assistance in obtaining community wheelchair transportation. Resident 70 was admitted and readmitted to the facility with diagnoses including CVA with hemiplegia, COPD, and DM. The resident’s H&P indicated he had the capacity to understand and make decisions, and the MDS indicated he was independent in cognitive skills for daily decision making, while requiring supervision with toileting hygiene, upper body dressing, and personal hygiene. The care plan for the resident’s CVA included monitoring and documenting abilities for ADLs and assisting as needed. During interview, Resident 70 stated he asked the SSD about a month earlier for help completing the Access transportation application and scheduling an appointment, but said the SSD did not help him. He stated he needed Access transportation to visit family, church friends, and schedule his own medical appointments. The SSD stated the facility provides assistance with community wheelchair transportation and said he helped the resident complete the Access application and mailed it, but he could not provide documentation showing he assisted with completing the application. Resident 70 later stated he had received only a blank Access application form by mail and had to call to request it because no facility staff were willing to help him. The SSD also stated he received and gave the approval notice for the Access application, and the Social Service Coordinator job description and social service policy described responsibilities that included ensuring psychosocial and care needs were met and making referrals and obtaining outside services.
Failure to Act on Consultant Pharmacist Recommendation
Penalty
Summary
The facility failed to ensure that a Consultant Pharmacist recommendation from the monthly medication regimen review was acted upon for one sampled resident. Resident 9 was admitted and later readmitted to the facility with diagnoses including anxiety disorder, epilepsy, and psychosis. The resident’s MDS dated 1/29/2026 indicated severely impaired cognitive skills for daily decision making, and the H&P dated 2/23/2026 stated the resident did not have the capacity to understand and make decisions. During a concurrent interview and record review on 3/26/2026, the ADON reviewed the Consultant Pharmacist’s MRR dated 12/11/2025, which recommended obtaining a CMP, CBC, carbamazepine level, lipid, folate level, and vitamin B12 level. The ADON stated the facility failed to take any action on the recommendation by not informing the resident’s physician, and there was no documentation that the Consultant Pharmacist’s MRR recommendation was completed. The DON stated the pharmacy consultant reviews residents’ drug regimens monthly and that recommendations should be addressed in a timely manner, and the facility policy stated recommendations are acted upon and documented by facility staff and/or the prescriber.
Failure to Monitor Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to monitor one of eight sampled residents, Resident 10, for behaviors while the resident was prescribed psychotropic medications. Resident 10 was admitted and later readmitted to the facility with diagnoses including paranoid schizophrenia, major depressive disorder, and COPD. The admission H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated severely impaired cognitive skills for daily decision making and the need for set-up assistance with oral hygiene, lower body dressing, and personal hygiene. The physician ordered quetiapine fumarate 50 mg at bedtime for other psychotic disorder manifested by increased agitation and verbal aggression, and mirtazapine 7.5 mg at bedtime for major depressive disorder. During interview and record review, the ADON stated the MAR from 3/3/2026 to 3/25/2026 contained no documented evidence of behavior monitoring for the resident's increased agitation, verbal aggression, and depression. The ADON stated behavior monitoring should be documented as Yes or No on the MAR and was important to determine whether the psychotropic medications were effective and whether a GDR could be attempted. The facility policy stated psychoactive medication orders must include a specific behavior manifestation, and another policy stated the facility would provide comprehensive, interdisciplinary care, but it did not disclose the frequency and importance of behavior monitoring.
Failure to Complete Ordered Thyroid Laboratory Tests
Penalty
Summary
The facility failed to implement a physician's order for laboratory testing for one resident with hypothyroidism, UTI, and DM. The resident was admitted and later readmitted to the facility, and the record showed the resident had fluctuating capacity to understand and make decisions in the H&P, while the MDS indicated the resident was independent in cognitive skills for daily decision making and needed set-up assistance with some ADLs. The physician placed a telephone order for T3, FT4, and TSH testing to evaluate thyroid function and medication management, but the laboratory results were not completed and were not available. During interview and record review, the ADON stated there was no documentation that staff followed up with the laboratory provider to determine what happened with the tests, and that licensed nursing staff must document and notify the physician if laboratory orders are not completed. The DON stated the thyroid labs were important to evaluate the effectiveness of levothyroxine and to guide further interventions if needed.
Failure to Follow Up on Recommended Denture Services
Penalty
Summary
The facility failed to follow up on dental services for new dentures for Resident 30. Resident 30 was admitted and later readmitted to the facility and had diagnoses including dysphagia, cerebral ischemia, and epilepsy. The record also showed that Resident 30 did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decision making. Dental progress notes dated 9/3/2025 and 2/5/2026 both documented that the dentist recommended a denture for Resident 30. During interview, Resident 30 stated she broke her dentures about 3 to 4 months earlier and had a hard time eating without them. The SSD stated he was aware Resident 30 had been seen by the dentist but was not aware of the recommendation for a denture and did not follow up with the dentist regarding the status of the denture. The DON stated he was not aware of the dentist treatment recommendations for a denture. The facility policy and the Social Service Coordinator job description indicated that oral healthcare and dental services were to be provided and that ancillary services necessary to maintain the resident's needs were to be arranged.
Missing Effective Communication Training for CNAs
Penalty
Summary
The facility failed to ensure that two randomly selected CNAs received mandatory effective communications training. During a concurrent interview and record review with the Director of Staff Development, CNA 1’s personnel record showed a hire date of 7/7/2025 with no evidence of effective communication training on file, and CNA 2’s personnel record showed a hire date of 3/5/2026 with no evidence of effective communication training on file. The DSD stated she was responsible for providing effective communication training for all direct care staff and stated that such training was important so staff could adequately interact with residents and other staff to ensure a good working environment and residents’ safety. The Facility Assessment Tool, updated on 3/23/2026, indicated the facility’s current CNA training program sufficiently addresses the resident population, and the DSD job description stated she was responsible for planning, implementing, directing, and evaluating the facility’s educational programs for all employees and coordinating and conducting an effective ongoing in-service plan for all employees.
Facility Assessment Not Updated to Reflect Actual Census
Penalty
Summary
The facility failed to revise and maintain an updated average daily census on the Facility Assessment Tool. During review of the facility census, the census showed 83 residents in the facility on 3/23/2026 and 83 residents on 3/24/2026. During a concurrent interview and record review on 3/25/2026, the Administrator stated she was responsible for updating the Facility Assessment Tool and that it should be updated yearly or as needed if there is a change in the facility census or if there are special treatments or services provided to residents. The Administrator reviewed the Facility Assessment Tool, which had been updated on 3/23/2026, and stated the assessment listed an average daily census of 80 residents. She stated the assessment was not accurate because the average daily census was below the actual census of residents residing in the facility, and that three residents were not accounted for on the Facility Assessment Tool. The facility policy titled Facility Assessment, dated 4/15/2021, stated the Administrator should review and update the Facility Assessment annually and as necessary whenever there is, or the facility plans, for any change that would require a substantial modification to any part of the assessment.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
During an observation in the facility's kitchen, a dietary aide was seen working without a hairnet, contrary to the facility's policy and procedure on infection control for the dietary department. The aide stated she had removed her hairnet as she was coming to the kitchen door, but no hairnet was observed in her hand at the time. The dietary manager confirmed that not wearing a hairnet in the kitchen increases the risk of hair falling and cross contamination to foods and utensils. A review of the facility's infection control policy indicated that all staff are required to wear effective hair restraints, such as hats or hairnets, while in any kitchen and food storage areas.
Failure to Properly Monitor Orthostatic Blood Pressure
Penalty
Summary
The facility failed to obtain proper orthostatic blood pressure readings for three residents, which is necessary to determine if they have orthostatic hypotension. Resident 36, who was readmitted with diagnoses including failure to thrive and hypotension, had orders for orthostatic blood pressure monitoring every Saturday. However, the blood pressure readings recorded did not follow the correct procedure of taking measurements in the lying, sitting, and standing positions, as confirmed by a Licensed Vocational Nurse (LVN) during an interview. Resident 65, admitted with conditions such as muscle weakness and schizophrenia, also had orders for orthostatic blood pressure monitoring. The blood pressure readings for this resident similarly did not adhere to the required procedure, as they were not taken in the correct sequence of positions. The LVN acknowledged that the readings were not true orthostatic measurements, which are crucial for identifying changes in blood pressure and alerting physicians for necessary interventions. Resident 75, with diagnoses including anxiety disorder and Alzheimer's disease, had orders to monitor orthostatic blood pressure weekly due to anti-psychotic medication use. The Medication Administration Record showed that only systolic blood pressure was recorded, omitting the diastolic measurements necessary for a complete assessment. The Director of Nursing confirmed that this was not the correct documentation method, which hindered the ability to identify trends and notify the doctor as required by the orders.
Incorrect Scoop Size Used for Mechanical Soft Diets
Penalty
Summary
The facility failed to ensure the correct sized serving scoop was used for residents on mechanical soft diets, which could potentially lead to decreased nutritional intake and weight loss. During an observation in the kitchen, it was noted that the cook used a scoop size number 12, which is one-third of a cup, instead of the required scoop size number 10, which is three-eighths of a cup, for serving mechanical soft roast beef. This discrepancy was confirmed through a review of the Cooks Spreadsheet - Winter Menus and the facility's list of residents on mechanical soft diets, which indicated that 29 residents were affected by this practice. Interviews with the cook, the Dietary Supervisor, and the Registered Dietician confirmed the use of the incorrect scoop size. The cook acknowledged using the smaller scoop and recognized the importance of using the correct size to prevent residents from receiving less food, which could lead to weight loss. The Dietary Supervisor and Registered Dietician both emphasized that the menu's specified scoop size should be followed to ensure residents receive adequate nutrition. The facility's policy and procedure on menus, dated April 2014, also indicated that food served should adhere to the written menu.
Failure to Update Care Plan After Resident Self-Removes Catheter
Penalty
Summary
The facility failed to update the care plan for a resident who self-removed his indwelling catheter on two separate occasions. The resident, who was admitted with diagnoses including benign prostatic hyperplasia, bipolar disorder, and anxiety disorder, had the ability to express ideas and understand others, and was independent with self-care and mobility. Despite these incidents of self-removal of the catheter, the care plan, which was initially focused on keeping the resident free from catheter-related trauma, was not revised to address the new issue of self-removal. The facility's policy required care plans to be reviewed and revised upon the onset of new problems or changes in condition. However, after the resident self-removed the catheter on two occasions, the care plan was not updated to include monitoring for potential complications such as bleeding and low urine output. The physician was notified after each incident, and the catheter was re-inserted, but no changes were made to the care plan to prevent recurrence or address the resident's behavior.
Failure to Document Change of Condition After Catheter Removal
Penalty
Summary
The facility failed to complete a change of condition report after a resident, identified as Resident 79, self-removed his indwelling catheter for the second time. This incident was not documented in the Change in Condition form as required by the facility's policy. The resident's medical history includes benign prostatic hyperplasia, bipolar disorder, and anxiety disorder. Despite the resident's ability to express ideas and understand others, and being independent with self-care and mobility, the facility did not provide a detailed explanation of the incident or confirm if the physician and responsible party were notified. During a review of the resident's progress notes, it was found that the physician and responsible party were notified according to the notes, but the Change in Condition form was not completed. The facility's policy, revised in April 2015, mandates that documentation of a change in the resident's condition be maintained in the medical record and on the Twenty-Four-Hour report. The registered nurse acknowledged that the form should have been completed per facility protocol, indicating a lapse in following established procedures.
Failure to Provide Smoking Apron to Resident
Penalty
Summary
The facility failed to provide a smoking apron to a resident, as indicated in his care plan, which had the potential for the resident to burn himself. The resident, who has been at the facility for five years, was observed smoking a cigarette in the designated smoking area without wearing a smoking apron, despite one being available nearby. The resident expressed that he had never worn the apron and questioned the need to start now. The Smoking Aide (SA) responsible for overseeing the smoking area stated that she offers the apron to older, frail individuals whom she believes need it for safety, but she was not informed of specific residents who should wear it. The Director of Nursing (DON) confirmed that the resident's care plan, initiated in February 2022, required him to wear a smoking apron while smoking. The DON stated that the SA is responsible for offering the apron and should inform the staff if a resident refuses to wear it. The facility's policy and procedure on smoking residents, revised in July 2023, indicated that the interdisciplinary team (IDT) should develop an individualized plan of care for residents who smoke, including the use of smoking materials and required supervision. However, there was a lack of communication and implementation of the care plan, leading to the deficiency.
Failure to Label Medication Bottle
Penalty
Summary
The facility failed to label a bottle of ClearLax, a medication used to treat occasional constipation, with the date it was opened. This oversight was observed during a medication administration by an LVN, who used the unlabeled bottle. During an interview, the LVN acknowledged that the bottle should have been labeled upon opening to ensure it was removed from use after 30 days. The facility's policy and procedure for medication storage require that containers be dated when their original seal is broken, which was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hawthorne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Imperial Crest Health Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Osage Healthcare & Wellness Centre | 1.5 mi | ★★★★★ | 27 | 0 |
| Centinela Skilled Nursing & Wellness Centre West | 1.5 mi | ★★★★★ | 18 | 0 |
| Camino Healthcare | 2 mi | ★★★★★ | 21 | 0 |
| Inglewood Health Care Center | 2.3 mi | ★★★★★ | 28 | 0 |
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