Hackett Hill Healthcare Center

In the surveyor’s words

From the most serious findings on record at Hackett Hill Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF635Dec 17, 2025

  Based on interview and record review, it was determined that the facility failed to have physician's orders at admission for a wound that resulted in hospitalization for 1 of 4 residents reviewed for wound care (Resident identifier is #3).Findings include:Review on 12/17/25 of Resident #3's medical record revealed he/she was admitted on [DATE].Review on 12/17/25 of Resident #3's Clinical Admission assessment, dated 11/5/25, revealed a puncture wound present on admission to the right groin.Review on 12/17/25 of Resident #3's Vascular Surgery Discharge summary dated [DATE], revealed discharge instructions for daily wound treatment to the right groin wound.Review on 12/17/25 of Resident #3's admission orders revealed no treatment orders for the right groin wound.Review on 12/17/25 of Resident… […]

• No harm, potential for more than minimal, widespreadF880Apr 24, 2026

  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). […]

• No harm, potential for more than minimal, patternF812Mar 24, 2022

  Based on observation, interview and record review, it was determined that the facility failed to store prepared foods and maintain sanitation of kitchen equipment to prevent foodborne illness in 2 out of 2 kitchenettes and 1 of 1 kitchen observed. Findings include: Kitchen Observation on [DATE] at 8:40 a.m. revealed staff personal items including coats, shoes and socks stored on shelves and floor under an open storage rack used for clean dining linens in the kitchen. Interview on [DATE] at 8:42 a.m. with Staff I (Food Service Director) confirmed the above finding and confirmed that staff store personal items on the shelves daily Observation on [DATE] at 8:45 a.m. revealed dry tan/brown debris on the top and around the dishwasher and on the floor in the dish room. […]

• No harm, potential for more than minimal, patternF881Mar 24, 2022

  Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to a system to monitor antibiotic use for 4 of 4 months reviewed of line lists reviewed in a final sample of 18 Residents. Findings include: Interview on 3/24/22 at approximately 10:20 a.m. with Staff C (Infection Preventionist) revealed that he/she will review the facility's Infection Control Report Forms to assess if a resident that was receiving antibiotic either met or did not meet criteria to be on the antibiotic. Staff C stated that he/she did not document this assessment in the patient chart or on the antibiotic line listing. Staff C stated that he she had not had anyone not meet criteria for the appropriate use of antibiotics in January or February 2022. […]

• No harm, potential for more than minimal, isolatedF658Apr 24, 2026

  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] [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. […]