The Care Center on Hazeltine, LLC

In the surveyor’s words

From the most serious findings on record at The Care Center on Hazeltine, LLC, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 7, 2024

  Based 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). […]

• Actual harm, isolatedF600Mar 22, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF755Dec 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Dec 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF658Nov 7, 2024

  Based 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). […]