Hazel Hawkins Memorial Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at Hazel Hawkins Memorial Hospital D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF700Mar 19, 2024

  Based on observation, interview, and record review, the facility failed to ensure proper use of bed rails (side rails, safety rails, and grab/assist bars) for 86 of 88 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 287, 387, 388, 389, and 390) when: 1. […]

• No harm, potential for more than minimal, patternF656Sep 19, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plans for 24 of 36 residents (Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6) who used bed rails or side rails (adjustable rigid bars attached to the side of a bed).These failures had the potential of unmet care needs for Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6's use of bed rails. Findings: 1. […]

• No harm, potential for more than minimal, patternF804Sep 19, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when: 1. Lunch was ready at 9:30 a.m. and was held at hot temperature for hours prior to meal service.2. The correct texture and recipe were not followed for pureed diet. These deficient practices had the potential to result in loss of nutrients and to decrease the food intake of residents and could negatively impact their nutritional status. Findings: 1.During a kitchen observation of the North Side on 9/17/25 at 9:27 a.m. with Dietary Supervisor (DS) and Dietary [NAME] (DC), DC stated she finished preparing pureed food at 9:10 a.m. […]

• No harm, potential for more than minimal, patternF880Sep 19, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. Registered nurse A (RN A) did not remove dirty gloves, perform hand hygiene (the act of cleaning hands with soap and water or an alcohol-based hand sanitizer to remove germs and prevent the spread of infections) and don (put on) a new pair of gloves before doing Resident 65's finger stick test (method of drawing drops of blood, most commonly used by people with high blood sugar to check their levels), and RN A did not perform hand hygiene after she picked the glove that fell on the floor and before putting on clean gloves prior to medication preparation;2. Registered nurse E (RN E) did not perform hand hygiene prior to medication administration;3. […]

• No harm, potential for more than minimal, patternF656Mar 19, 2024

  Based on observation, interview and record review, the facility failed to develop and implement, comprehensive, resident-centered, care plans for five out of twenty sampled residents, (Residents 51, 42, 47, 43 and 82), when the activity care plans of Residents 51, 42, 47, 43 and 82, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. […]