Hamilton Trace of Fishers

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures for infection control, related to hand hygiene during dressing changes for 1 of 3 residents reviewed for infection control. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a urinary catheter was provided with catheter care, monitoring, and documenting of urine outputs for 1 of 3 residents reviewed for catheters. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of beard restraints by dietary staff, separate storage of a personal lunch bag, ensure coverage of stored frozen food and ready-to-eat dessert, and distribution of food under sanitary conditions. This had the potential to affect 96 of 96 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to promote a dignified environment with not providing care and services timely and ensure a resident was dressed in street clothes while dining in the facility dining room for 14 of 18 residents reviewed for resident council, 3 of 7 residents reviewed for Activities of Daily Living, 1 of 4 residents reviewed for staffing and 2 of 2 residents randomly observed. (Resident D, Resident E, Resident F, Resident G, Resident H, Resident J, Resident K, Resident L, Resident M, Resident N, Resident O, Resident P, Resident Q, Resident R, Resident S, Resident T, Resident X, Resident V, Resident W, Resident Z, Resident DD, Resident EE and Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature for 14 of 14 residents reviewed for food. (Residents D, F, G, H, J, N, O, Q, R, T, X, 84, Z, and DD)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record was kept private and confidential by giving a resident the wrong medical record in error at discharge for 1 of 3 residents reviewed for discharge. (Resident B and Resident E)

Inspectors wroteBased on interview and record review, the facility failed to timely initiate and address a grievance for 1 of 2 residents reviewed for choices (Resident DD).

Inspectors wroteBased on interview and record review, the facility failed to ensure a timely Level I and Level II screening was obtained for 1 of 1 resident reviewed for Pre-admission Screening and Resident Review (PASRR). (Resident 16)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a discharge summary at the time of discharge for 1 of 3 residents reviewed for discharge. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to trim a resident's nails and assist a resident with transferring timely for 2 of 7 residents reviewed for activities of daily living (ADL) care. (Resident 200 and Resident 253)

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine a root cause analysis of falls and to implement fall interventions, as care planned, for 3 of 5 residents reviewed for falls. (Residents' F, 33 and 68)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a rationale for indication of use and ongoing administration of a prophylactic antibiotic for the prevention of urinary tract infections for 1 of 2 residents reviewed for antibiotic medications and 2 of 5 residents reviewed for unnecessary medications. (Resident 16, Resident L, and Resident 39)

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve a diet, as ordered by the physician, for 1 of 1 resident randomly observed for dining (Resident 16).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff donned a gown prior to administering medication using a nasogastric tube (nasal feeding tube), and prior to urinary catheter and colostomy care for residents on enhanced barrier precautions (EBP) for 1 of 1 resident reviewed for tube feedings and 1 of 1 resident randomly observed during care. (Resident 54 and Resident 210).

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the most recent survey results available in the survey binder with the potential to affect 97 of 97 residents currently residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments regarding restraint use and discharge location for 1 of 1 residents reviewed for Restraint use and 1 of 1 resident received for hospitalization . (Resident 5 and 106)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a gait belt was utilized during resident transfers and fall prevention measures were implemented during a residents' transfer that led to them being lowered to the ground for 1 of 6 residents reviewed for ADL (Activities of Daily Living) and 1 of 3 residents reviewed for accidents. (Resident 2 and 97)

Inspectors wrote2. The clinical record for Resident C was reviewed on 3/7/24 at 3:20 p.m. The diagnoses included, but were not limited to, chronic kidney disease, anxiety disorder, and depression. A physician order, dated 10/2/23, was noted for Wellbutrin SR (sustained release) tablet; 100 milligrams; twice a day from 10/2/23 to 10/6/23. A physician order, dated 10/3/23, was noted for bupropion (generic name for Wellbutrin) tablet; 100 milligrams; twice a day from 10/3/23 to 10/11/23. A pharmacy recommendation, dated 10/6/23, indicated a duplication of therapy and the recommendation to discontinue the order for bupropion tablet 100 milligrams or Wellbutrin tablet 100 milligrams. [...]

Inspectors wroteBased on observation and record review, the facility failed to maintain an infection prevention and control program by not ensuring a urinary catheter's tubing was off of the floor for 1 of 2 residents reviewed for a urinary catheter. (Resident 89)

Inspectors wroteBased on observation, interview and record review, the facility failed to provided an ongoing activity program on the memory care unit of the facility and assist a resident to the activity of her choice in a timely manner for 5 of 6 residents reviewed for activities. (Residents' 28, 61, 77, and 80, 318)

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attention was provided to a resident with concerns regarding missing clothing items and failed to ensure a grievance policy was developed for use with any resident concerns. This deficient practice has the potential to affect all 102 of 102 residents of the health care portion of the facility. (Resident 54)

Inspectors wroteBased on interview and record review, the facility failed to ensure a criminal background check was obtained for a new hire per facility policy for 1 of 10 personnel files reviewed. (Certified Nursing Assistant (CNA) 15)

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living by not ensuring twice weekly showers/complete bed baths and providing incontinent care timely for 1 of 4 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was provided to a wound care specialist appointment for 1 of 1 residents reviewed for pressure, and to administer eye drops, as ordered by the physician, and to timely inform the physician of a significant weight gain for 1 of 5 residents reviewed for unnecessary medications . (Resident B and Resident 31)

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions, as care planned, for 2 of 3 residents reviewed for accidents. (Residents 28 and 68)