Hamilton Pointe Health and Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's had orders from the attending practitioner for oxygen therapy use and maintenance of equipment for 2 of 3 residents reviewed for oxygen therapy. (Resident B, Resident E)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate clinical records were in place for 1 of 3 residents reviewed for wounds. A wound to the left extremity was documented as right extremity (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were kept secure and stored in a locked cart and that residents' privacy rights were protected in 1 of 1 random observations of a medication cart. ( Unit 400, Resident H)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were used for a resident with a wound, orders were in place for care of an ostomy, for 1 of 2 residents observed for incontinence care, and 1 of 1 residents reviewed for ostomy care. (Resident C, Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dishwasher temperatures were within range and food was prepared under sanitary conditions for 2 of 2 kitchen observations. The temperature on the final rinse of the dishwasher did not reach required levels, floors were sticky, and bulk food was outdated. (Kitchen)

Inspectors wroteBased on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The full time director of nursing was unable to provide documentation of infection prevention certification, and did not currently dedicate at least part time to the role of IP for 1 of 1 staff members reviewed for IP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests during 2 of 2 kitchen observations. Gnats were observed in the dry storage room and flies were observed in the food holding area. (Kitchen)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the development and implementation of care plans for 1 of 3 residents reviewed for notification of change, 1 of 2 residents reviewed for urinary tract infections (UTI) or catheter, and 1 of 3 residents reviewed for falls. A resident on comfort measures did not have a care plan related to palliative care, monitoring was not completed following a seizure, and a fall intervention was not in place. (Resident S, Resident M, Resident L)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper infection control protocols) for 1 of 2 residents for catheter and 3 random observations of cleaning equipment and using Personal Protective Equipment (PPE). ( Licensed Practical Nurse (LPN) 2 Registered Nurse (RN) 3, Certified Nursing Assistant (CNA) 6, CNA 10, Resident S, Resident 10)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment was completed for a resident who self administered medications for 1 of 1 random observation. A bottle of eye drops was observed in a resident's room. (Resident 13)

Inspectors wroteBased on record review and interview, the facility failed to notify the residents' families for 2 of 3 residents reviewed for notification of changes. A resident's family was not notified of a change in the resident's physical condition and a resident's fall. (Resident F, Resident M)

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a resident's plan of care to reflect current interventions for 1 of 3 residents reviewed for accidents. A resident's falls care plan was not updated to reflect implementation of a call don't fall sign. (Resident 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate services and treatment related to catheter placement for 1 of 3 residents reviewed for catheter use. A resident with an indwelling urinary catheter received the wrong size catheter. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation for 1 of 2 residents reviewed for change of condition, and 1 of 2 residents reviewed for urinary tract infections (UTI) or catheter. (Resident B, Resident 21)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate safety measures were in place to prevent accidents for 2 of 3 residents reviewed. This deficient practice resulted in Resident C requiring hospitalization, sutures, and a subarachnoid hemorrhage. (Resident B, Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained and Personal Protective Equipment (PPE) was worn entering isolation rooms for 3 of 7 halls observed. (300 Hall, 500 Hall, 900 Hall ).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen, 1 of 1 observations of meal service. Gloves were not changed, bare hands touched plates, fingers were licked, floors soiled. (Kitchen)

Inspectors wroteBased on interview and record review, the facility failed to ensure a newly admitted resident had immediate orders for pressure wounds for 1 of 3 residents reviewed for pressure wounds. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the privacy of residents was respected for 6 of 6 random observations and 1 of 1 insulin administrations observed. Staff did not knock on doors when entering, and left the door open when administering injections. (Resident D, Resident 45, Resident 37, Resident 6, Resident 7, Resident S, Resident 150)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who self administered medications were assessed for ability to self administer those medications for 4 of 4 random observations. Medications were observed in rooms where the resident lacked a self administration of medication assessment. (Resident 7, Resident S, Resident 150, Resident 6)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (400 Hall)

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions during 3 of 3 kitchen observations. Food was left open to air, expired food was not disposed of from the refrigerator, and gloves were not used according to professional standards. (Kitchen, Main Dining Room, [NAME] 21)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection for 6 of 6 random observations. Resident care items were observed uncovered in bathrooms, and staff did not sanitize hands entering or exiting rooms with enhanced barrier precautions as indicated. (Resident 37, Resident D, Resident 7, Resident 46, Resident 20)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an environment free of pests based on 8 (eight) random observations of gnats during the survey. (800 Nursing Hall, Kitchen, 300 Nursing Hall, Nurses Station, Dining Room, Resident room [ROOM NUMBER], ADON (Assist Director of Nursing) Office, and Nursing Manger Office)

Inspectors wroteBased on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 2 of 5 residents reviewed for unnecessary medications. (Resident 6, Resident 7)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for 2 of 2 residents reviewed for nutrition. (Resident 55 and Resident S)

Inspectors wroteBased on interview and record review, the facility failed to provide care by thorough assessment of a resident prior to narcotic medication administration and implementation of a person centered care plan for the use of narcotics, and a care plan that reflected accurate resuscitative measures for 1 of 2 residents reviewed for expiration in the facility. (Resident P)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure post fall assessments were completed and care plans were updated to prevent falls for 2 of 4 residents reviewed for accidents. (Resident 40, Resident 83)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management consistent with professional standards of practice, care plans, and the resident's goals and preferences were provided for 2 of 2 residents reviewed for pain management. A resident was not monitored for side effects of narcotic pain medication resulting in an overdose, pain medication was not given as prescribed, and a resident's preference for non-pharmacological pain relief was not honored. (Resident T, Resident 6)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 3 residents (Resident 6, Resident 17) observed during medication pass. Three medication errors were observed during 25 opportunities for error in medication administration. This resulted in a medication error rate of 12%.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation for 1 of 1 residents observed for a glucometer reading, and 1 of 3 residents reviewed for falls. A blood glucose was documented incorrectly, and post-fall assessments were not completed following a fall. (Resident 6, Resident 86)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurately completed staff sheets were posted daily for 6 of 7 days during the survey. (5/28, 5/29, 5/30, 5/31, 6/3, 6/4)

Inspectors wroteBased on interview, and record review, the facility failed to revise comprehensive care plans for 1 of 3 residents reviewed for nutrition, 1 of 31 residents reviewed for advanced directives, and 2 of 6 residents reviewed for care planning. Care plans were not updated to reflect correct code status, when an antibiotic was completed, when a resident resolved a urinary tract infection, and was not updated to reflect a significant weight loss. (Resident 88, Resident 353, Resident 4, Resident 63)

Inspectors wroteBased on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 for 3 of 33 residents reviewed for infection control, and 1 of 6 residents observed for care. (Resident 23, Resident 39, Resident 31, Resident 4)

Inspectors wroteBased on observation, interview and record review, the facility failed to notify a resident's family related to the need to alter treatment in 1 of 4 residents reviewed for falls. A resident's family was not notified of a delay for a STAT (immediate) X-Ray order following a fall that resulted in a hip fracture.(Resident G)

Inspectors wroteBased on record review and interview, the facility failed to provide transfer/discharge notice to the resident upon transfer to the ER (emergency room) for 2 of 6 residents reviewed for hospitalizations. Residents were not provided with transfer/discharge notice. (Residents 20, Resident 91)

Inspectors wroteBased on record review and interview, the facility failed to provide Bed Hold notice to resident upon transfer to the ER (emergency room) for 2 of 6 residents reviewed for hospitalizations. Residents were not provided with Bed Hold notice. (Residents 20, Resident 91 )

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers in 1 of 2 residents reviewed for pressure ulcers. A resident dependent on staff developed a stage II pressure ulcer on the left buttock. (Resident 4)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper supervision was provided to prevent accident hazards for 1 of 5 residents reviewed for accidents. A resident was observed to carry a box cutter that staff was unaware he had in his possession. A medication cart was observed to be unlocked. (Resident 57, Hall 400)

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the safety of residents during the administration of oxygen therapy by not changing oxygen tubing weekly for 2 of 2 residents. (Resident 28, Resident 77)

Inspectors wroteBased on interview, and record review, the facility failed to ensure the necessary care and services were provided for 1 of 1 residents reviewed for dialysis. A resident's weights were not taken as ordered. (Resident 15).

Inspectors wroteBased on interview and record review, the facility failed to provide contraindications for gradual dose reduction trials for residents on psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 54, Resident 67)

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain radiology services as ordered by the physician for 1 of 1 resident needing STAT(immediate) X-Ray procedures. A resident with a recent left hip replacement due to left hip fracture from a fall, fell and did not receive STAT radiologic images timely. (Resident G)