The Care Center on Hazeltine, LLC

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication emergency kits ([eKIT] - storage container for emergency use medications) containing Controlled Substances ([CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Medications) for 12/2025, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) 2. Reconcile one (1) medication eKIT containing CSs for 12/2025, in one (1) of two (2) inspected Medication Carts (Medication Cart 1.) As a result, control and accountability of CSs and availability of medications did not follow state and federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and proper food handling practices by failing to: 1. Ensure bins containing potatoes and onions were labeled with a date of when they were received. 2. Ensure one sweet and sour sauce container was clean with no residue left outside of the container. 3. Ensure the ice machine water filter was changed according to its replace date and according to the manufacturer's policy. 4. Ensure the residents' refrigerator temperature log was updated daily for three dates. 5. Ensure chocolate milk and vanilla and chocolate ice cream inside the residents' refrigerator were labeled with name and date. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a resident's representative with information regarding formulating an advance directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for one of 12 sampled residents (Resident 16). This deficient practice had the potential for Resident 16 and their representative to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order by failing to notify a resident's physician regarding a resident having signs and symptoms of bleeding for one of six sampled residents (Resident 2). This deficient practice had the potential to result in worsening symptoms and negatively affect the delivery of care and services to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) of a resident's discharge from the facility for one of three sampled residents (Resident 54). This deficient practice had the potential for the ombudsman to not be aware of any potential issues from the discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) tubing was not coiled and allowed the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine) for one of one sampled resident's (Resident 9). This deficient practice had the potential for Resident 9 to develop a urinary tract infection (UTI- an infection in the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures, in one (1) of two (2) inspected medication carts (Medication Cart 1) by failing to ensure eye drops were stored separately from orally administered medications. This deficient practice had the potential to increase the risk of infections for residents in the facility and to receive medications in the wrong route (internal versus external routes) possibly leading to adverse health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's water pitcher was not placed on the floor for one of one sampled resident (Resident 16). This deficient practice had the potential to result in contamination of the drinking water that can lead to waterborne diseases caused by pathogens (bacteria, viruses, parasites) spread through contaminated water, leading to symptoms like diarrhea and vomiting.

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedure titled Abuse Prohibition and Prevention Program, for one of three sampled residents (Resident 1) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) was not assigned to Resident 1 after an allegation of emotional abuse was made. This deficient practice resulted to Resident 1 feeling uncomfortable and had the potential to place Resident 1 at risk for further abuse that could have resulted in Resident 1 needing additional care or emotional support.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 33) when on 11/3/2024 at 7:00 a.m., Resident 47 (roommate) threw a cup at Resident 33 hitting Resident 33's forehead. This deficient practice resulted in Resident 33 being subjected to physical abuse by Resident 47 while under the care of the facility. Resident 33 sustained a laceration (a deep cut or tear in the skin) on the forehead and required transfer to General Acute Care Hospital 1 (GACH 1). Resident 1 received sutures (a stitch or a row of stitches holding together the edges of a wound). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (fatty area beneath the skin) administration sites of insulin (a hormone that lowers blood sugar) for one (Resident 30) of five sampled residents investigated for unnecessary medications. This deficient practice had the potential for adverse effects (undesired harmful effect resulting from a medication) of same site subcutaneous administration of insulin such as lipodystrophy (when fat cells accumulate under the skin from repeated injections in the same place).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who receive apixaban (a medication that treats and helps prevents blood clots in the heart and blood vessels) were accurately monitored for side effects (an often harmful and unwanted effect) for one of six sampled residents (Resident 13). This deficient practice had the potential to result in Resident 13 experiencing adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the anticoagulant including unusual bruising (a mark on the skin that occurs when small, bleeding from the gums or nose, and having blood in the stool.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic drugs (any drug that affects behavior, mood, thoughts, or perception in excessive dose, excessive duration, without adequate monitoring) for one of six sampled residents (Residents 10) by failing to ensure Resident 10 received the correct dose of duloxetine (medication that is used to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]) as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from significant medication error by failing to administer the correct dose of duloxetine (medication used to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]) as ordered by the physician for one of three sample residents (Resident 10). This deficient practice resulted in an administration of excessive dose of duloxetine to Resident 10 and had the potential to place the resident at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment (being weakened) or decline (gradually become less) in the resident's mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and sanitary environment and food storage practices in the kitchen when: 1. A single sausage patty was observed exposed and unwrapped on top of an open box containing an unsealed bag of the same sausage patties in Freezer 1. 2. An undated bottle of Gatorade belonging to a staff member was stored in Refrigerator 2. 3. Shelves intended to hold clean trays were observed stained, with crumbs and dust. 4. Two plastic bins holding clean utensils were observed with reddish food residue and crumbs and placed on dusty shelves. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when Licensed Vocational Nurse 1 (LVN 1) did not wash hands between administering medications via gastrostomy tube (also known as a G-Tube, is a flexible that is inserted through the abdominal wall and into the stomach to provide nutrition and fluids) and giving an insulin (a hormone that lowers the level of sugar in the body) injection to Resident 32. This deficient practice had the potential to cause Resident 32 to develop an infection.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for one of five sampled residents (Resident 14) by failing to develop and implement a comprehensive person-centered care plan addressing Resident 14`s problem with communication. This deficient practice had the potential to result in Resident 14 not being able to communicate requests, needs or concerns which could lead to inadequate care of Resident 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 14) was provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in his preferred language. This deficient practice had the potential to prevent the resident from communicating with the staff and receiving care in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard a medicated ointment belonging to Resident 8 from one of one inspected treatment carts after the resident had been discharged . This deficient practice resulted in the facility staff still being able to access a discharged resident's medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the nutritional needs for one of three sampled residents (Resident 12) by failing to provide a fortified diet (a food that has extra nutrients [important substances you get from food that help your body survive and grow] added to it) as ordered by the physician. This deficient practice had the potential to result in Resident 12's decreased nutritional intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Resident 1 and Resident 2) when on 3/10/2024 Certified Nurse Assistant 2 (CNA 2) witnessed Resident 2 punch Resident 1 in the stomach area; and then Resident 1 punch Resident 2's right side of the face. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was an adequate indication for the use of permethrin cream (a medication used to treat scabies [a condition caused by tiny insects called mites] that infest and irritate a person's skin) and ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (an undesired harmful effect resulting from a medication or other intervention) such as burning, itching, numbness, rash, redness, stinging, swelling of the skin, weakness, uncontrollable shaking of a part of the body, and chest discomfort.

Inspectors wrotec. A review of Resident 49's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 49's MDS dated [DATE], indicated that Resident 49's cognitive skills for daily decision making was severely impaired. The MDS also indicated that Resident 49 required extensive assistance with bed mobility, dressing, and personal hygiene. A review of Resident 49's Care Plan titled, ADL: [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the attending physician assess and documented in the resident`s medical record the rationale for extending Ativan (medication is used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) for 30 additional days for one of two sampled residents (Resident 47) reviewed for Unnecessary Medications. 2. Provide non-pharmacological interventions (health interventions that are not primarily based on medication) to Resident 11 prior to administering as needed (prn) Ativan on multiple dates for one (Resident 11) of five sampled residents investigated for unnecessary medications. These deficient practices had the potential to result in unnecessary medications and had the potential to result in adverse reaction or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to document temperatures for the medication refrigerator. 2. Failed to ensure a bottle of Bismuth Subsalicylate (medication used to treat diarrhea [loose, watery and possibly more-frequent bowel movements]) that was labeled open on 11/17/2020 (approximately three years ago) was discarded. 3. Failed to ensure a bottle of Milk of Magnesia (medication to treat an upset stomach) was labeled with its open date (the date at which a new medication is first opened). These deficient practices had the potential to compromise the therapeutic effectiveness medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one of three sampled staff (Maintenance Assistant [MA]) did not wear gloves while walking in the facility's hallway. 2. Failing to ensure one of three sampled staff (Certified Nursing Assistant 2 [CNA 2]) removed their used gloves prior to exiting a resident room and failing to ensure CNA 2 performed hand hygiene (washing of hands) after removing a set of gloves. 3. Failing to ensure the facility's Infection Preventionist (IP) was able to articulate the facility's water management process to reduce the risk of Legionnaire's disease (a severe form of pneumonia [lung inflammation usually caused by infection]). 4. Facility failed to ensure the water management program was reviewed by the Infection Control Committee on an annual basis. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs]) by failing to ensure the facility's monthly surveillance monitoring report was completed for 9/2023 and 10/2023. This deficient practice had the potential for residents to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote one of three sampled resident's (Resident 4) dignity by failing to ensure Certified Nursing Assistant (CNA 1) was not standing over Resident 4 while assisting the resident with feeding. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence that education about an advanced directive (written document that indicated a person's wishes regarding medical treatment if that person is no longer able to communicate) was provided for one of three residents (Resident 17) investigated under the Advance Directives care area. This deficient practice violated Resident 17's and/or their representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict due to lack of communication regarding Residents 17's wishes about their medical treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean comfortable and homelike environment for one of one sampled resident (Resident 35) by failing to repair peeling paint in the restroom door and failing to ensure that there was no hole in the drywall above Resident 35's bed. This deficient practice had the potential to negatively affect the residents' comfort and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a patient achieve outcomes that improve their quality of life) with measurable goals and objectives including person-centered interventions addressing a resident's hearing loss problem for one of one sampled resident (Resident 44) investigated under the care area Communication-Sensory. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 44.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled (Resident 44) resident investigated under the care area communication and sensory was provided a medical hearing consult promptly (the resident had been waiting approximately two months) after the resident was assessed to have a hearing loss problem. This deficient practice resulted in a delay in delivering the necessary care and services to maintain the resident`s ability to communicate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 11) had on bilateral (both sides) heel protectors (device that can help prevent and treat heel pressure sores), as ordered by the physician, investigated for pressure ulcer/injury (a skin injury that occurs when an area of skin is under constant or prolonged pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) policy by failing to ensure one of five sampled residents (Resident 36) was provided education regarding the pneumococcal vaccine. This deficient practice had the potential for Resident 36 to not be aware of the risks and benefits of the pneumococcal vaccine.