Hawthorne Healthcare & Wellness Centre, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure its Payroll Based Journal (a mandated reporting system used by the Centers for Medicare & Medicaid Services (CMS) to collect auditable, employee-level staffing data from long-term care facilities) was submitted for the first fiscal year quarter. This deficient practice resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations.

Inspectors wroteBased on observation and interview, the facility failed to provide adequate eating assistance for three of four residents (Resident 1, Resident 7, and Resident 18) by assigning only one staff member to a table where all four residents required assistance. This resulted in Residents 1, 7, and 18 experiencing delays while the staff member assisted another resident. This deficient practice violated the residents' right to be treated with respect and dignity and had the potential to negatively impact their self-esteem, cause emotional distress, and adversely affect their psychosocial well-being. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that sweet potatoes fries stored in Freezer 2 in the kitchen were labeled and dated to ensure proper food safety and storage practices. This deficient practice had the potential to place residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's soiled personal clothing was not placed inside the clean linen cart. This failure had the potential to result in cross contamination (a transfer of harmful bacteria from one place to another or one object to another) and place residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate hospice documentation was accurate in the Minimum Data Set (MDS- a federally mandated resident assessment tool) for Resident 60. This deficient practice had the potential to negatively affect Resident 60's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level 1 screenings (a federally required preliminary screening for individuals seeking admission to a Medicaid-certified nursing facility) were completed and resubmitted for two of seven sampled residents (Residents 10 and 12) with diagnoses of mental illness and who were receiving psychotropic medications. This deficient practice had the potential to result in Residents 10 and 12 not being appropriately evaluated and, therefore, not receiving necessary specialized services for mental illness.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for two of 20 sampled residents (Residents 9 and 77) by failing to:Ensure a care plan was developed for Resident 9's use of Lorazepam (drug to relieve anxiety). Ensure a care plan was created for Resident 77's diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). This failure had the potential to result in a lack of meeting necessary care and addressing medical needs for Residents 9 and 77.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a communication board was provided to Resident 58, who required assistance with communication. This deficient practice had the potential to result in ineffective communication, which could lead to unmet needs and decreased quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 70) was provided with assistance in obtaining community wheelchair transportation. This deficient practice placed Resident 70 at risk for missed medical appointments and social isolation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a recommendation from the Consultant Pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) was acted upon for one of eight sampled residents (Resident 9). This failure had the potential to result in Resident 9 experiencing a delay in treatment.

Inspectors wroteBased on interview and record review, the facility failed to monitor one of eight sampled residents (Resident 10) behaviors while prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). This deficient practice had the potential to result in the use of unnecessary psychotropic medication that could cause harm to Resident 10.

Inspectors wroteBased on interview and record review, the facility failed to implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident, (Resident 12). This deficient practice had the potential to result in the delay of the identification of medical concerns, delaying the care and services necessary for Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to follow-up on dental service for new dentures for one of one sampled resident (Resident 30). This deficient practice had the potential to result in inability to chew food and weight loss for Resident 30.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of two randomly selected Certified Nurse Assistant's (CNA] 1 and CNA 2) received mandatory effective communications training. This deficient practice had the potential to result in inadequate staff communication skills, which may negatively impact residents' quality of care.

Inspectors wroteBased on interview and record review, the facility failed to revise and maintain an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient failure had the potential to place residents at risk for not receiving care and services necessary to maintain their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Dietary Department-Infection Control. Dietary Aide 1 did not wear a hairnet while working in the kitchen. This failure had the potential for cross contamination and increase the risk of infections among residents.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain blood pressure readings to determine if three of three sampled residents (Resident 36, Resident 65 and Resident 75) have orthostatic hypotension (a form of low blood pressure that happens when standing after lying down or sitting). This deficient practice had the potential for Resident, 36, 65, and 75 to experience a delay in interventions if they were positive for orthostatic hypotension.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the correct sized serving scoop was used for 29 of 29 residents on mechanical soft diets. This deficient practice had the potential for resident to receive the wrong caloric intake when not following the menu, resulting in decreased nutritional intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Update the careplan for one of four sampled residents (Resident 79) after the resident self-removed his indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine into a drainage bag) on two occasions. This failure had the potential to cause complications such as urinary tract infections (UTI - an infection in the bladder/urinary tract), bleeding, and/or pain with urination.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Complete a change of condition after Resident 79 self-removed his indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine into a drainage bag), for the second time. This failure resulted in Resident 79 not having a detailed explanation of what occurred and if the physician and responsible party was notified.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: 1. Provide a smoking apron to Resident 17 for one of one saampled resident (Resident 17) as indicated on his care plan. This deficiency had the potential for the resident to burn himself.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Label a bottle of ClearLax (a medication used to treat occasional constipation), with the date opened. This failure had the potential to result in residents being administered expired medication that may be less effective, potentially leading to inadequate bowel movement relief.

Inspectors wroteBased on interview and record review the facility failed to ensure there was a comprehensive care plan for three out of twelve Residents (Resident 33, and 4). 1. The facility failed to have a comprehensive care plan for restraints (are devices that limit a patient's movement) care plan for Resident 4. 2. The facility failed to have a comprehensive care plan for an indwelling urinary catheter ([IDC] a tubing inserted into the bladder to collect urine) for Resident 33. These deficient practice placed Residents 33 and 4 at risk of not having their needs met.

Inspectors wroteb. During a review of Resident 69's admission record, dated 1/26/2024, the admission record indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included, encephalopathy (damage or disease that affects the brain), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at a safe temperature for 11 of 11 residents two of twenty sampled (Residents 23 and 243). This finding had the potential to cause food borne illness (illness from contaminated food). This failure had the potential to call meal dissatisfaction, decreased food intake and place residents at risk for unplanned weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure there was a revised care plan for using an Incentive Spirometer ([IS] a device that measures the volume of the air inhaled into the lungs during inspiration) for one out of six sampled Residents (Resident 3). This deficient practice had the potential to affect Resident 3's provision of care.

Inspectors wroteBased on observation and interview the facility failed to provide oral hygiene for one out of six Resident (Resident 4). The failure also resulted in the potential for dental problems and compromise resident's physical health and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six Residents (Resident 3) had an incentive spirometer ([IS] a device used to expand the lungs to prevent respiratory infection) at bedside. This deficient practice of not having the IS device available for Resident 3 had the potential for a respiratory infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a consent from resident representative for having bedrails up for one out of six Residents (Resident 4). This failure had the potential to put residents at risk of falls and entrapment due to the use of side rails. Findings. During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), respiratory failure (life-threatening condition of breathing failure that can occur in very ill people). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use the correct sized scoop for 11 of 11 residents receiving pureed (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) diets. These failures had the potential for a highly susceptible population of residents to be at risk for receiving meals that did not meet their nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use the correct sized scoop for 11 of 11 residents on pureed (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) diets. These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for residents by failing to: 1. Discard an open package of marshmallows with an open date of 12/24/2024. 2. Remove soiled disposable gloves and perform hand hygiene before picking up dinner rolls. These deficient practices had the potential to result in foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection control practices were followed by failing to wear gloves when one of three laundry aid staff wear gloves while handing soiled linens. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for all the residents in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for one of three sample residents (Resident 1) by failing to develop a refusal of wearing a WanderGuard (is discreet powerful, triggering alarms and locking monitored doors to prevent wander-prone residents from leaving unattended) bracelet care plan for Resident 1 with high risk of elopement. This deficient practice had a potential to result in inconsistent implementation of the care plan that may placed Resident 1 at risk of inadequate supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed as a high risk for elopement (to leave a secured institution without notice or permission) and had episode of leaving the facility without notifying staff as indicated in care plan. This failure has the potential for Resident 1 sustain an accidental injury while outside the facility's premises without supervision from staff.