Inspection visit
Inspection
Citations
38 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Epotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Epotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Epotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015GeneralS&S Epotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Epotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0024GeneralS&S Epotential for harm
Establish policies and procedures for volunteers.
- 0025GeneralS&S Epotential for harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Cno actual harm
Establish roles under a Waiver declared by secretary.
- 0030GeneralS&S Epotential for harm
List the names and contact information of those in the facility.
- 0036GeneralS&S Epotential for harm
Establish emergency prep training and testing.
- 0039GeneralS&S Epotential for harm
Conduct testing and exercise requirements.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0927GeneralS&S Epotential for harm
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F660 - Quality of life
Plan the resident's discharge to meet the resident's goals and needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0886GeneralS&S Epotential for harm
Perform COVID19 testing on residents and staff.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FAQ · About this visit
Common questions about this visit
What happened during the May 13, 2021 survey of HATHAWAY MANOR EXTENDED CARE?
This was a inspection survey of HATHAWAY MANOR EXTENDED CARE on May 13, 2021. The surveyor cited 38 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HATHAWAY MANOR EXTENDED CARE on May 13, 2021?
Yes, 38 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.