Hazelhurst Court Care and Rehabilitation Center

Inspectors wroteBased on observation, interviews, and policy titled Food Storage the facility failed to ensure that food was properly labeled and dated and in sanitary conditions to prevent foodborne illness. The practice has the potential to affect 55 residents of 58.

Inspectors wroteBased on interview and observation, the facility failed to ensure adherence to established laundry maintenance protocols related to dryer lint trap cleaning. This deficient practice has the potential to affect 58 residents. Findings Include:During an observation on 03/28/2026 at 8:40 AM it was observed that the lint filter of the second dryer that is located near the window had not been cleaned. During an interview on03/28/2026, at 10:52 AM, the Environmental Services Director (ESD) stated that lint traps are required to be cleaned after each use or, at a minimum, every hour, with staff required to document completion. However, the ESD confirmed that the lint trap in the second dryer had not been cleaned in accordance with facility policy. The ESD also confirmed that if the lint filters are not cleaned it could cause a fire.

Inspectors wroteBased on record review and interviews with staff and family representative, and facility policy titled, Resident Trust Fund, the facility failed to notify the resident and/or residents' responsible party when their personal funds were within $200 of the Social Security Income (SSI) limit and when accounts had exceeded the amount for one of 39 accounts reviewed, resident (R)45.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to follow the comprehensive care plan for a resident requiring assistance with personal hygiene (nail care) and oxygen therapy management for two of 24 residents (R) (R28 and R31) sampled. This deficient practice had the potential to place the residents at risk for unmet care needs.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure nail care was provided for one of 24 sampled residents (R) (R28) reviewed for Activities of Daily Living (ADL) care. Specifically, R28 was observed with long, untrimmed fingernails with visible debris containing a brown substance underneath the nail beds.

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the facility's policy titled, Respiratory System Management, the facility failed to ensure a concentrator was in working order so that the physician's order for oxygen administration was followed for one of 14 residents (R) (R31) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that the Advanced Directive care plan was implemented for one of 11 sampled residents (R)(R1). This failure resulted in CPR not being provided for R1, whose Advanced Directive care plan specified she was a Full Code. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:15 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Removal Plan was received on [DATE]. [...]

Inspectors wroteBased on staff interviews, record review, and review of facility policies titled Emergency Response Management and Cardiopulmonary Resuscitation (CPR), the facility failed to assess and implement life-sustaining measures for one of 11 sampled residents (R)(1). This failure resulted in CPR not being provided for R1, who was found unresponsive, and whose Advanced Directives specified attempting CPR. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:15 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Removal Plan was received on [DATE]. [...]

Inspectors wroteBased on staff interviews, record reviews, and the Director of Nursing (DON) job description, facility nursing administration failed to provide effective oversight to ensure that facility nursing staff assessed and implemented the correct Advance Directive for one of 11 sampled residents (R)(1) reviewed for Advanced Directives. This failure resulted in CPR not being provided for R1, whose Advanced Directive care plan specified she was a Full Code. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and DON were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:15 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. [...]

Inspectors wroteBased on observation, record review, resident and staff interviews, and the facility policy, MENUS, the facility failed to ensure they offered an appealing option of similar nutritive value to residents for lunch and dinner meals and failed to provide preferences for meals for one resident (R) 30. This deficient practice had the potential to affect 50 of 53 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Food Storage the facility failed to discard food from the stand-up cooler by the expiration date. This deficient practice had the potential to affect 50 of 53 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to wash/sanitize hands and change gloves during tracheostomy care for one of one resident (R) (14) reviewed for tracheostomy care, and the facility failed to properly dispose of soiled items. This failure increased R14's risk for infection.

Inspectors wroteBased on Observations, staff interviews, and review of facility documents, the facility failed to maintain a clean and homelike environment for one of 24 rooms (Rm 33). Specifically, the facility failed to ensure RM [ROOM NUMBER] privacy curtain was free of brown stains, and a white chalky substance on the curtain.

Inspectors wroteBased on record reviews and interviews, and review of the facility's policy Transfer/Discharge Outside the Facility, the facility failed to provide a written reason for transfer to the resident or their representative for one of two residents reviewed for hospitalization, resident (R) 17.

Inspectors wroteBased on record reviews, interviews, and review of the facility's policy Bed Hold, the facility failed to provide a notice of bed hold for one of two residents (R)(R17) reviewed for hospitalization.

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the facility's policy titled, RAI/Care Planning Management, the facility failed to follow the care plan related to providing oxygen as ordered for three of 13 Residents (R) (R12, R7, and R14) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the facility's policy titled, Respiratory System Management Standard, the facility failed to ensure that the physician's order for oxygen administration was followed for three of 13 Residents (R) (R12, R7, and R14) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Disposal of Garbage/Rubbish , the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner.

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility policy titled, Use of Restraints. The facility failed to ensure that one of 59 residents (R) (R1) was free from physical restraints while in the facility. The deficient practice had the potential to prevent R1 from attaining and maintaining their highest practicable well-being and ensuring that their dignity and quality of life was maintained.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Respiratory System Management Standard, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of one resident (R) (R#19) reviewed for tracheostomy (trach) care. Specifically, the facility failed to provide tracheostomy care supplies to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R#19's risk for compromise airway and respiratory distress.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to wash/sanitize hands and change gloves during tracheostomy care for one of one resident (R) (#19) reviewed for tracheostomy care. This failure increased R#19's risk for infection.