Hackett Hill Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the water management plan accurately described the facility's water system, failed to identify all specific areas where Legionella and other opportunistic waterborne pathogens may grow, failed to outline control measures to prevent such growth, and failed to establish monitoring procedures with defined acceptable ranges that had the potential to affect the facility with a census of 62 residents.Findings include: Review on 4/22/26 of the facility's water management plan, review date of 3/25/26, revealed the following: The water management plan description and flow diagram section identified that water flowed through the boilers and heat up to 142 plus degrees (it did not specify Fahrenheit or Celsius). Further review revealed that on the domestic side, water was delivered at 142 plus degrees (it did not specify Fahrenheit or Celsius) to a mixing valve, where hot water is balance with cold water to a temperature of 105 to 120…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards for1 of 3 resident observed for medication administration and for 1 of 1 residents reviewed for general concerns in a final sample of 18 residents. (Resident identifiers are #43 and #56.)Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 639 .Before administering medication, it is critical that all information is correct. You should check for accuracy three times: 1. First check is when the medications are pulled or retrieved from the automated dispensing machine, the medication drawer, or whatever system is in place at the agency. 2. The second check is when preparation of the medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to ensure proper treatment and care for good foot health for 1 of 2 residents reviewed for ADLs (activities of daily living) in a final sample of 18 residents. (Resident identifier is #18.)Findings include: Observation on 4/22/26 at approximately 9:00 a.m. of Resident #18's left foot revealed his/her toenails were thick and elongated. Interview on 4/22/26 at approximately 9:00 a.m. with Resident #18 revealed he/she was unsure of the last time they were seen by a podiatrist.Observation and Interview on 4/23/26 at approximately 8:15 a.m. with Staff F (Unit Manager) of Resident #18's left foot confirmed his/her toenails were thick and elongated. Interview on 4/23/26 at approximately 8:40 a.m. with Staff F revealed that Resident #18 was last seen by a podiatrist on 9/25/25. Further interview revealed the podiatrist was last at the facility on 12/29/25.Review on 4/24/26 of Resident #18's last podiatrist note, dated 9/25/25, revealed, Progress note . Non-professional treatment is hazardous to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that the facility failed to ensure staff wear appropriate (Personal Protective Equipment) PPE and perform hand hygiene during a dressing change for 1 of 1 resident observed for wound care (Resident identifier is #4).Findings include:Observation on 12/17/25 at approximately 9:50 a.m. revealed Resident #4 had a sign for Enhanced Barrier Precautions (EBP) next to their door. Staff B (Wound Nurse) performed hand hygiene and donned gloves and a gown while preparing to perform Resident #4's sacral dressing change. Staff B removed the wound dressing from Resident #4's sacral wound. Staff B doffed his/her gloves and donned clean gloves without performing hand hygiene in-between. Staff B cleansed the wound, doffed their gown and gloves, and exited the room. Staff B did not perform hand hygiene and proceeded to retrieve additional supply from the treatment cart. Staff B returned to Resident #4's room and performed hand hygiene and donned gloves. Staff B did not donn a gown. Staff B applied treatment to Resident #4 wound and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to inform residents or resident's representative of the risk and benefits of psychotropic medication use for 2 out of 5 residents reviewed for unnecessary medications in final sample of 17 residents. (Resident identifiers are #16 and #50.) Findings include: Resident #16 Review on 3/12/25 of Resident #16's medical record revealed a physician's order for Ativan Oral Tablet 0.5 MG[milligram] (Lorazepam) Give 0.5 tablet by mouth two times a day for anxiety monitor for anxiousness, restlessness and other signs of anxiety, start date of 1/21/25. Further record review revealed there was no documentation of consent for the psychotropic medication use for Resident #16. Resident #50 Review on 3/12/25 of Resident #50's medical record revealed a physician's order for Buspirone HCL Oral tablet 15 MG (Buspirone HCL) Give 1 tablet by mouth two times a day for anxiety monitor for increased anxiousness, restlessness and other signs of anxiety, start date of 9/10/24. Further record review revealed there was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility failed to follow the professional standards of care for 3 residents in a final sample of 17 residents. (Resident identifiers are #33, #55 and #7.) Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication .` Resident #33…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to follow policies and procedures for 1 of 2 residents reviewed for Enhanced Barrier Precautions (EBP) (Resident identifier is #55) and 1 of 3 residents reviewed for disinfection of glucometer (Resident identifiers are #165 and #166). Findings include: Observation on 3/11/25 at approximately 11:40 a.m. of Staff C (Medication Nursing Assistant) revealed he/she went from Resident #165's room to Resident #166's room with a glucometer and a cup with alcohol wipes, lancets, and test strips in it, and no cleaning/disinfecting wipes. The glucometer was observed to not be visibly soiled. Review on 3/11/25 of Resident #165's and Resident #166's Medication Administration Record revealed provider orders for capillary blood glucose (CBG). Interview on 3/11/25 at approximately 11:40 a.m. with Staff C revealed that he/she tested capillary blood glucose for Resident #165 and then Resident #166. Further interview revealed he/she had not disinfected the glucometer between these residents. Staff C stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that the facility failed to maintain patient care equipment per manufacturer's instruction for 1 of 2 residents reviewed for respiratory care in a final sample of 17 residents. (Resident identifier is #7). Findings include: Interview on 3/11/25 at approximately 9:50 a.m. with Resident #7 revealed concerns that his/her Continuous Positive Airway Pressure (CPAP) machine parts needed replacement for a long time and no one is assisting with replacing the parts of his/her headpiece. Observation on 3/11/25 at 9:50 a.m. revealed that the head strap had brownish discoloration, areas of the head piece were in disrepair, and the tubing to the mask was yellowish in color. Interview on 3/12/25 at approximately 10:00 a.m. with Staff D (Clinical Lead) confirmed the above findings. Interview on 3/13/25 at approximately 10:40 a.m. with Staff K (Unit Manager) revealed that the face mask, tubing, and headgear have not been changed since Resident #7 was admitted to the facility. Review on 3/13/25 of Resident #7's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, it was determined that the hospice agency and the facility failed to provide collaborative services for 1 of 1 resident reviewed for hospice services in a final sample of 18 residents (Resident Identifier #44). Findings include: Review on 4/2/24 of Resident #44's care plan for hospice revealed the following: Hospice Nursing 2-3x (times) a week and PRN (as needed) to assess and manage symptoms, comfort/pain, and bowel function, date initiated: 2/26/24 Hospice Nursing Assistant 1-2x a week to complement ADL (activities of daily living) care and provide comfort, date initiated: 2/26/24 Hospice Social Work 1x month and PRN to provide psychosocial support related to end of life care, date initiated: 2/20/24 Hospice Volunteer 1x month and PRN for companionship, date initiated 2/20/24 Review on 4/2/24 of Resident #44's Hospice Certification and Plan of Care (POC) dated 2/19/24 - 5/18/24, revealed: Frequency/Duration of Visits: SN 7x week x1, 3x week x12; Master of Social Work (MSW) 1x month x1; and Chaplain (CH) 1x month x1 Review on 4/2/24 of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews it was determined that the facility failed to ensure the medication error rate was not 5 percent (%) or greater for 2 out of 4 residents observed for medication administration (Resident Identifiers #24 and #41). Findings include: Resident #24 Observation on 4/2/24 at approximately 7:30 a.m. of Staff A (Licensed Practical Nurse (LPN)) preparing medication for Resident #24 revealed Staff A was going to administer Aspirin 81 milligrams (mg). Further observation revealed Staff A removed Resident #24's Novolin N Insulin Pen and placed it on the medication cart. Staff A dialed the pen to 16 units. Staff A proceeded to administer the 16 units of insulin without rolling the pen (to ensure that the insulin in the pen was the correct dosage). Staff A did not prime the insulin pen and did not wait the 5 seconds prior to removing the insulin pen from Resident #24's abdomen. Review on 4/2/24 of Resident #24's April 2024 Medication Administration Record (MAR) revealed the following physician's orders: Novolin N Subcutaneous Suspension 100…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure open injectable medications were labeled in accordance with the manufacturer's instructions in 1 out of 2 medication carts and in 1 of 1 medication rooms observed and refrigeration temperatures were not monitored daily for medications storage in 1 out of 1 medication rooms observed. Findings include: Observation on 4/1/24 at approximately 8:10 a.m. of Webster Street Medication Cart revealed an open Lantus Insulin Pen without an open or open expiration date. Interview on 4/1/24 with Staff F (Registered Nurse) confirmed the above finding. Review on 4/2/24 of the Lantus Insulin Pen manufacturer's instructions revealed After 28 days, throw your opened Lantus pen away - even if it still has insulin in it. Observation on 4/1/24 at approximately 8:20 a.m. of the Derryfield Medication Room revealed an open vial of Tuberculin Purified Derivative without an open or open expiration date. Interview on 4/1/24 at approximately 8:20 a.m. with Staff G (Registered Nurse) confirmed the above…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.