Hamilton Park Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident in 2 (5th and 6th Floor) of 4 resident units observed during Environmental Task. Specifically, resident bathrooms had missing tiles, mismatched and peeling paint, and grime build up. Additionally, the closet door in a resident's room was observed with rust-colored stain.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025 the facility failed to ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was evident in 1 (Resident #102) of 5 residents reviewed for psychotropic medications out of 38 total sampled residents. Specifically, licensed nursing staff failed to administer medication as per the physician's order and according to professional nursing standards of clinical practice. Additionally, the nursing staff failed to notify the physician when significant medication was not administered and ensure that the resident was clinically monitored for adverse reactions. Cross Reference: F760 - Residents Are Free of Significant Medication Errors

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025 the facility did not ensure residents are free of any significant medication errors. This was evident in 1 (Resident #102) of 5 residents reviewed for psychotropic medications out of 38 total sampled residents. Specifically, Resident #102 was not administered 7 doses of Venlafaxine (an anti-depressant) as ordered by a physician.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025 the facility did not ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident in 1 of 2 residents reviewed for care planning and hospice care out of 38 total sampled residents. Specifically, Resident #33's Comprehensive Care Plan related to hospice care was not reviewed and revised quarterly after each assessment.

Inspectors wroteBased on observation, record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that residents were served food that accommodated their allergies and intolerances. This was evident in 1 (Resident #343) of 38 total sampled residents. Specifically, Resident #343, who had a documented allergy to Mushroom, received a lunch tray containing mushroom soup.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during dining observation on the 6th Floor. Specifically, Certified Nursing Assistant #4 was observed touching a lettuce with their bare hands while preparing Resident #95's sandwich.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #130) out of 38 total sampled residents. Specifically, Licensed Practical Nurse #4 failed to practice hand hygiene and glove changes during wound care.

Inspectors wroteBased on record review and interviews conducted during a Recertification/Complaint survey from 2/2/23 to 2/9/23, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident # 178) of 2 residents reviewed for Care Planning out of 37 sampled residents.

Inspectors wroteBased on observation and interviews conducted during the Recertification/Complaint survey from 2/2/23 to 2/9/23, the facility did not ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident for 4 out of 4 units (Unit 3, Unit 4, Unit 5, and Unit 6). Specifically, daily staffing was not observed posted in a prominent place for residents and visitors for all 4 units.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey initiated on 2/2/23 and completed on 2/9/23, the facility did not ensure a resident was adequately equipped to call for assistance through a communication system. This was evident for 1 (Resident #31) of 3 residents reviewed for Physical Environment. Specifically, Resident #31 was observed without a functioning call bell in place.

Inspectors wroteBased on observations and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, multiple oxygen tubings were observed touching the floor on several occasions. (Resident # 156, Resident #96 and Resident #53)

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, dusty, dirty, and stained floor mats next to resident's beds were observed in 3 rooms (Rooms 518, 529, 542) and a resident's bed side table were dirty with a white film (room [ROOM NUMBER], 545). The finding is: The undated facility policy titled Cleaning Resident and Non-Resident Areas documented the purpose is to improve sanitation and ensure the highest level of cleanliness throughout the facility. To control cross contamination, the spread of bacteria and infection, and to maintain the outward appearance of the facility. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during a recertification survey, the facility did not ensure that assessments accurately reflected the residents' status. Specifically, the Minimum Data Set (MDS) assessments did not identify the use of a wander/elopement alarm. This was evident for 1 of 1 resident reviewed for Physical Restraint (Resident #21) and 1 of 3 residents reviewed for Accidents (Resident #133) out of a sample of 38 residents.

Inspectors wroteBased on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs were developed. Specifically, a comprehensive care plan was not developed for a resident with hearing impairment. This was evident for 1 of 2 residents reviewed for Vision/Hearing out of a sample of 38 residents. (Resident #67). The finding is: The facility's policy and procedure Care Planning - Interdisciplinary Team revised November 2018 documented the care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team. Resident #67 was admitted with diagnoses that included Hypertension, Hypothyroidism and Dysphagia. [...]