Hawthorne Center for Rehabilitation and Healing of

In the surveyor’s words

From the most serious findings on record at Hawthorne Center for Rehabilitation and Healing of, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 17, 2022

  Based on review of the medical record, incident logs, policy and procedure review, interviews with administrative, nursing and therapy staff, the resident's physician, and the resident's representatives it was determined the facility failed to provide a systematic process to carry out their abuse policy for one (Resident #2) of two residents reviewed for abuse. The facility failed to take actions to report, investigate and prevent abuse to its residents. The facility failed to suspend staff alleged to perpetrate abuse and failed to thoroughly investigate to determine the root cause of the reported abuse to ensure the safety of the resident involved and ensure that all facility residents would remain safe from a similar incident. […]

• Immediate jeopardy, isolatedF609Feb 17, 2022

  Based on review of the medical record, incident logs, policy and procedure review, interviews with administrative, nursing and therapy staff, the resident's physician, and the resident's representatives it was determined the facility failed to [MEDICATION(S)] to promptly report alleged abuse of one (Resident #2) of two residents reviewed for abuse. On 1/11/2022 a nursing staff member reported to the Assistant Director of Nursing (ADON) that they overheard a nurse verbally abusing Resident #2, telling him in foul language to stop getting out of bed. […]

• Immediate jeopardy, isolatedF610Feb 17, 2022

  Based on review of the medical record, incident logs, policy and procedure review, interviews with administrative, nursing and therapy staff, the resident's physician, and the resident's representatives it was determined the facility failed to provide a systematic process to carry out their abuse policy for one (Resident #2) of two residents reviewed for abuse. The facility failed to failed to thoroughly investigate to determine the root cause of the reported abuse and failed to suspend staff alleged to perpetrate abuse to ensure the safety of the resident involved and ensure that all facility residents would remain safe from a similar incident. […]

• Actual harm, isolatedF760Feb 17, 2022

  Based on interview and record review the facility failed to prevent a significant medication error for one (Resident #10) of three sampled residents. The facility administered Normal Saline ordered for Resident #2 Intravenously without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #10 was admitted on [DATE] and discharged on [DATE]. Record review showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 or severe impairment. She required extensive assistance for bed mobility, transfers and toileting. […]

• No harm, potential for more than minimal, patternF761Mar 13, 2024

  Based on observation, record review, and interview, the facility failed to ensure medications with shortened shelf life once opened were dated in three (100, 200/500, and 600) out of six medication carts, failed to ensure two medications in pre-filled syringes were not stored mixed together in one (600) out of six medication carts and one (300/400) out of three medication rooms, and expired medications had been removed from two (300 and 600) out of six medication carts. The facility failed to ensure medications were not left unattended and inaccessible to unauthorized staff, residents, and visitors for three (Residents #98, #74, and #314) of 45 sampled residents. Findings included: An observation was made during medication administration on 3/11/24 at 11:53 a.m. with Staff B, RN. […]