HATHORNE HILL

Nursing Home Inspector

14 KIRKBRIDE DRIVE
DANVERS, MA 01923
Essex County
Phone: 978-774-6955
Provider Number: 225449
Last Inspection: 09/12/2016

About the Nursing Home

Number of Beds: 120
Number of Residents: 109
Beds Available: 11
Percent Occupancy: 91%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

8

Facility
14

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

8

2016
17

2015
3

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/12/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 10/17/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 10/17/2016
 

8/6/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Pattern : Minimal 4 9/14/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/14/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/14/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 9/14/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/14/2015
 

6/16/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 7/15/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

1/9/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/2/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 109 93.73 96.79
Registered Nurses 1.13 0.85 0.89
Licensed Practical / Vocational Nurses 0.79 0.91 0.84
Certified Nursing Assistants 2.05 2.24 2.30
Total Staff Hours 3.98 4.01 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 1 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 95 90 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95 94 95
of long-stay residents experiencing one or more falls with major injury 6 3 3
of long-stay residents who have depressive symptoms 0 2 2
of long-stay residents who lose too much weight 7 7 5
of long-stay residents who received an antianxiety or hypnotic medication 16 20 20
of long-stay residents who received an antipsychotic medication 12 18 18
of long-stay residents who self-report moderate to severe pain 3 4 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 6 20 18
of long-stay residents whose need for help with daily activities has increased 8 15 14
of long-stay residents with a catheter inserted and left in their bladder 4 1 1
of long-stay residents with a urinary tract infection 3 4 3
of low risk long-stay residents who lose control of their bowels or bladder 64 59 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 93 79 79
of short-stay residents who had an outpatient emergency department visit 10 10 11
of short-stay residents who made improvements in function 24 62 60
of short-stay residents who newly received an antipsychotic medication 1 2 1
of short-stay residents who self-report moderate to severe pain 17 14 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 89 82 82
of short-stay residents who were rehospitalized after a nursing home admission 25 22 22
of short-stay residents who were successfully discharged to the community 74 58 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0