Hamilton Health Services

Inspectors wroteBased on staff interview and record review, the facility did not report an allegation of exploitation to the State Agency (SA) for 1 resident (R) (R14) of 2 sampled residents. The facility was informed on 1/7/26 that Licensed Practical Nurse (LPN)-F accepted money from R14. The facility did not report the allegation of exploitation to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate an allegation of exploitation for 1 resident (R) (R14) of 2 sampled residents. The facility was informed on 1/7/26 that Licensed Practical Nurse (LPN)-F accepted money from R14. The facility did not thoroughly investigate the allegation of exploitation.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was palatable and served at an appetizing temperature for 1 resident (R) (R6) of 5 sampled residents. During observations of meal service, food held in the steam table and reheated food served to residents did not reach or maintain palatable temperatures.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 6 residents (R) (R23, R20, R12, R11, R24, and R13) of 12 sampled residents. R23 had a tracheostomy. R23's MDS assessments, dated 1/23/24, 4/24/24, 7/25/25, 8/27/24, and 9/16/24, did not indicate R23 received tracheostomy care. R12 was discharged from Hospice services on 5/12/24. R12's MDS assessments, dated 5/24/24 and 8/24/24, indicated R12 still received Hospice services. R20 was prescribed antiplatelet medication. R20's MDS assessments, dated 9/25/23, 12/26/23, 3/26/24, 6/26/24, and 8/27/24 did not indicate R20 received antiplatelet medication. In addition, R20 had a Preadmission Screening and Resident Review (PASRR) Level II Screen completed on 10/26/23. R20's MDS assessment, dated 8/27/24, indicated a PASRR Level II Screen was not completed. [...]

Inspectors wrote2. Between 9/9/24 and 9/11/24, Surveyor reviewed R13's medial record. R13 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, hypertension, dementia, post-traumatic stress disorder (PTSD), depression, and anxiety. Surveyor reviewed R13's monthly pharmacy recommendations from October 2023 to the present. A monthly pharmacy review, dated 11/22/23, indicated the pharmacist made a recommendation to address R13's chlorhexidine administration, warfarin monitoring, Levemir and metformin monitoring, and Zoloft and trazodone monitoring. The facility was unable to provide a physician's response to the recommendation. A monthly pharmacy review, dated 12/29/23, indicated the pharmacist made a recommendation to address R13's as needed (PRN) diazepam use. The facility was unable to provide a physician's response to the recommendation. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure written notification of coverage change and the financial liability for continued stay at the facility was provided when Medicare Part A benefits ended for 2 residents (R) (R26 and R10) of 5 sampled residents. The facility did not provide R26 with an Advanced Beneficiary Notice (ABN) form that contained the daily rate for which R26 was liable if R26 chose to remain in the facility after R26's Medicare Part A benefits ended. The facility did not provide a Notice of Medicare Non-Coverage (NOMNC) form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R10 when R10's Medicare Part A benefits ended.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Significant Change Minimum Data Set (MDS) assessment was completed for 1 resident (R) (R12) of 12 sampled residents. The facility did not complete a Significant Change MDS assessment when R12 discharged from Hospice services.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R11) of 1 resident received the necessary care and services to prevent and monitor weight loss or gain. Staff did not notify R11's physician of a significant weight gain and did not follow the physician's order for weight monitoring.

Inspectors wroteBased on staff interview and record review, the facility did not monitor for adverse reactions of a high-risk medication for 1 resident (R) (R20) of 5 residents reviewed for unnecessary medications. R20 was prescribed lamotrigine (an anticonvulsant medication). The facility did not monitor for adverse reactions or side effects of the high-risk medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R11 and R24) of 5 sampled residents were monitored for adverse consequences of an antipsychotic medication. R11 was prescribed aripiprazole (an antipsychotic medication) for schizoaffective disorder. The facility did not complete an Abnormal Involuntary Movement Scale (AIMS) (a rating scale that helps identify and monitor side effects of antipsychotic medications) when R11 admitted to the facility on antipsychotic medication. R24 was prescribed lithium carbonate (an antipsychotic medication) for bipolar disorder. The facility did not complete an AIMS or implement monitoring for adverse reactions to the antipsychotic medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 25 opportunities which resulted in a 12% medication error rate that affected 1 resident (R) (R14) of 4 residents observed during medication administration. On 9/9/24, R14 was administered three medications in the wrong form per the manufacturer's instructions.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R13) of 5 sampled residents was offered a pneumococcal vaccine. R13's medical record did not contain documentation that R13 was offered a pneumococcal vaccine.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide adequate supervision for 1 resident (R) (R1) of 4 sampled residents. The failure to supervise R1 led to R1 being able to verbally and physically abuse another resident, R2. On 5/23/24, staff observed R1 exit R2's room and state, I'm going to kick your ass. R2 reported to staff that R1 had thrown a Styrofoam cup of coffee creamers at R2. Following the incident, the facility did not implement any interventions to ensure the safety of R1, R2, or other residents. On 5/24/24, Licensed Practical Nurse (LPN)-D observed R1 in the hallway outside R2's room. R1 appeared agitated and was repeatedly stating, Shut the f*** up. LPN-D did not attempt to redirect R1 or implement any interventions to supervise R1 before LPN-D left the area. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to Nursing Home Administrator (NHA)-A and the State Agency (SA) for 2 residents (R1 and R2) of 4 sampled residents. On 5/23/24, R1 entered R2's room, threw a Styrofoam cup full of coffee creamers at R2, and verbally threatened R2. Staff did not report the allegation of abuse to NHA-A and the facility did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R1 and R2) of 4 sampled residents. On 5/23/24, R1 entered R2's room and threw a Styrofoam cup full of creamers at R2. The incident was not thoroughly investigated to ensure further abuse was prevented and resulted in another allegation of abuse involving R1 and R2 on 5/24/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure physician visits were completed timely for 2 residents (R) (R2 and R4) of 5 sampled residents. R2 was admitted to the facility on [DATE]. R2 was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. R4 was admitted to the facility on [DATE]. R4 was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter.

Inspectors wroteBased on staff interview and record review, the facility did not ensure laboratory services were provided timely for 1 Resident (R) R2) of 5 sampled residents. The facility did not have a process in place to audit for expired lab supplies which caused a delay in obtaining a Respiratory Panel for R2.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 26 residents residing in the facility. The facility did not consistently monitor and document warewasher (dishwasher) wash and rinse cycles.

Inspectors wroteBased on staff interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection. The facility did not implement a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 26 residents in the facility. The facility did not identify where Legionella and other opportunistic waterborne pathogens can grow and spread. The facility did not document flushing or other measures to prevent the growth of opportunistic waterborne pathogens such as Legionella in identified areas where such pathogens may grow.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for 1 Resident (R) (R11) of 1 resident. The facility did not apply R11's Tubigrips (compression stockings) per R11's physician order and plan of care.

Inspectors wroteBased on staff interview and record review, the facility did not ensure neurological checks were completed per policy after a fall for 1 Resident (R) (R21) of 4 residents reviewed for falls. Staff did not consistently complete neurological checks after R21 fell on 7/1/23.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 29 opportunities which resulted in a 6.9% medication error rate that affected 2 Residents (R) (R21 and R2) of 11 residents observed during medication pass. Licensed Practical Nurse (LPN)-H administered insulin lispro (rapid acting insulin) to R21 forty seven minutes before dinner was scheduled to be served. In addition, LPN-H did not prime the insulin pen with 2 units of insulin prior to administration. LPN-H administered insulin aspart (rapid acting insulin) to R2 sixty four minutes before dinner was scheduled to be served.