Minnie Hamilton Health Care

Inspectors wroteBased on observation, Resident Council interview, and staff interview the facility failed to ensure residents know how to file a grievance and could do so anonymously if they desired. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census 23. Findings Include:a)Resident CouncilDuring the Resident council meeting on 08/12/25 at 10:30 AM, The Resident Council as a whole said that they did not know how to file a grievance. An observation on 08/12/2025 at 11:06 AM, revealed that there are no grievance forms readily available to residents on the unit. During an interview on 08/12/25 at 11:10 PM, The Activity Director (AD) went behind the nurses station and pulled a concern form out of the file cabinet and stated, I didn't know these had to be available for residents to get on their own. [...]

Inspectors wroteBased on observation and staff interview the facility failed to treat each resident with respect and dignity during a meal. This is a random opportunity of discovery. Resident Identifier: #14. Facility Census: #23. Findings Include: a) Resident #14 On 08/12/2025 at 12:23 PM Certified Nurse Aide (CNA) #28 was observed standing in the dining room assisting Resident #14 with her lunch meal. When the CNA was told she can not stand and assist a resident with meals, she stated I can't get a chair in here. I replied that she can move the resident if needed but she can not stand, it is a dignity issue. She obtained a chair and assisted the resident. This was confirmed with Cheif Exeucitive Officer on 08/12/2025 at 1:15 PM.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to develop/implement a care plan related to hand rolls for contractures. This failed practice was found true for (1) one of 12 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifier #16. Facility Census 23. Findings Include:a)Resident #16An observation on 08/11/25 at 2:50 PM, revealed that Resident #16 had contractures to both left and right hands. A record review on 08/11/25 at 3:30 PM, of Resident #16's order shows an order that reads as follows: Hand rolls to both hands due to immobility, contractures, and seizures. An observation on 08/12/25 at 9:00 AM, revealed Resident #16 in his room watching television in his Geri Chair. Resident did not have hand rolls in place as ordered by the physician. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to follow Physicians orders for neurological checks for unwitnessed falls and hand rolls for a resident.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to promptly provide and/or obtain from an outside resource routine and emergency dental services to meet the needs of medicaid funded residents. This failed practice was found true for (1) one of (1) one resident reviewed for dental during the Long-Term Care Survey Process. Resident identifier #2. Facility Census 23. Findings Include:a)Resident #2The initial observation on 08/11/25 at 1:13 PM, revealed Resident #2 lying in bed. Residents' teeth appear to be broken off with the gum line. A record review on 08/12/25 at 1:54 PM, revealed a dental assessment worksheet completed on 05/16/24 and 08/12/24 marked as the Resident #2 having no problems with his teeth and/or gums. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident was not neglected. The facility failed to provide services to a resident that was necessary to avoid physical harm. This was true for 1 (one) of 1 (one) resident's reviewed during the Long Term Survey Process. Resident #8 had an area on her breast that had not been identifeid by the facility. The resident suffered actual physical harm. The facility had not identified this as an area that needed assessed despite showering and dressing the resident daily. The area on the resident's breast was biopsied by a determatorly group and diagnosed as melanoma. Facility census: 24. Resident identifier: #8.

Inspectors wroteBased on record review and staff interview, the facility failed to provide services to a resident that was necessary to avoid physical harm. This was true for 1 (one) of 1 (one) resident's reviewed during the Long Term Survey Process. Resident #8 had an area on her breast that had not been identifeid by the facility. The resident suffered actual physical harm. The area on the resident's breast was biopsied by a determatorly group and diagnosed as melanoma. Facility census: 24. Resident identifier: #8.

Inspectors wroteBased on record review and staff interview the facility failed prevent the development of pressure ulcers/injuries (PU/PI's) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development and promote the healing of existing pressure ulcers/injuries. The physician elected This was true for 1 (one) of 2 (two) residents reviewed for the Long Term Survey Process. Facility census: 24. Resident identifier: #11.

Inspectors wroteBased on facility record and staff interview, the facility failed to implement adverse event monitoring, and failed to implement performance improvement program activities that focus on quality of care. This was discovered during the long term care survey process and had the potential to affect all of the residents. Census 24.

Inspectors wroteThe facility failed to maintain a quality assessment and assurance committee. This was discovered during the review of the facilities Quality Assurance Assessment committee during the Long Term Care survey Process. The Medical Director/designee and the Administrator did not attend the meetings. has the potential to affect all of the residents. Identifiers: Medical Director, Administrator. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to develop and implement written policies and procedures to prohibit and prevent neglect and for these written policies to include the following components. This practice had the potentail to affect more than an isolated number of residents. Facility census: 24. Resident identifier: #8.

Inspectors wroteBased on record review and staff interview the facility failed to create/revise a care plan for Resident #8 with a new diagnosis of depression which was severe with psychotic symptoms. Resident #11 had newly developed pressure areas. The care plan was not updated to identify the approaches and intervention being used for the healing of those pressure areas. Facility Census: 24. Resident identifiers:

Inspectors wroteBased on staff interviews and observation the facility failed to maintain a medication error rate less than 5 %. Med error rate 7.41%. This was true for 2 (two) of 5 (five) residents observed during the Long-Term Survey Process. Facility census: 24. Resident identifiers: Resident #7, Resident #15.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure pans were being stored properly. A random opportunity for discovery found wet pans stacked together. This failed practice had the potential to affect more than a minimum number of residents residing in the facility. Facility Census: 24.

Inspectors wroteBased on observation and staff interview the facility failed to ensure safe cleaning and disinfection of resident care equipment (glucometers). The glucometers were shared among residents according to the manufacturers recommendations. The glucometer was used on 11 of 24 residents on the unit. Facility census: 24.

Inspectors wroteThe facility failed to have the Ombudsman information posted for wheel chair residents to easily read. This was a random observation. Facility census:

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to ensure all alleged violations of neglect are reported to the appropriate state agencies. This was true for 1 (one) of 1 (one) resident's reviewed during the Long Term Survey Process. Facility census: 24. Resident identifier:

Inspectors wroteBased on record review, staff interview and observation the facility to ensure that each resident who experienced a significant change in status was comprehensively assessed using the Center for Medicare and Medicaid Services (CMS) specified Resident Assessment Instrument (RAI) process. Resident #11 experienced a significant weight loss while receiving enteral feedings and developed two (2) pressure ulcers. This was true for 1 (one) of 24 residents reviewed for the Long Term Survey Process. Resident identifier: #11. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure and new Preadmission Screening and Resident Review (PASARR) was not completed for a resident having a new medical diagnosis for major depressive disorder. This was found for one (1) of one (1) resident reviewed. Resident identifier: #8. Facility Census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This was true for 1 (one) of 12 residents reviewed during the Long Term Care Survey process. Facility census: 24. Resident identifier: Resident #11.

Inspectors wroteBased on staff interview and observation the facility failed to ensure safe and secure storage (including limited access, and mechanisms to minimize loss or diversion) of all medication. This was a random opportunity for discovery. Facility census: 24.

Inspectors wroteBased on record review of facility staffing and staff interview, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. Facility census: 22.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of 12 resident rooms observed during the long term care survey process. Resident Identifier: 14. Facility Census: 22.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury and an allegation of verbal abuse by staff, were reported in a timely manner to the appropriate state agencies. The Federal regulation 483.12(c)(1) directs incidents involving serious bodily injury must be reported to the state survey agency within two (2) hours after the injury is noted. The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive the serious bodily injury report within two (2) hours. The guidance also instructs that OHFLAC and APS should receive an allegation of an abuse report within two (2) hours. [...]

Inspectors wroteBased on observation, facility documentation review, and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to complete the refrigeration temperature log for the coolers and freezer areas. The practice had the potential to affect a limited number of residents. Facility census: 22.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record pertaining to a Covid-19 booster. This practice affected one (1) of five (5), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #6. Facility census: #22.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The pneumonia vaccine policy was not updated in accordance with the Center for Disease Control (CDC) recommendations. This practice has the potential to affect all residents. Facility census: 22.

Inspectors wroteBased on facility documentation and staff interview, the facility failed to ensure current staff were fully COVID-19 vaccinated. This was true for one (1) of eight (8) staff members reviewed for compliance with COVID-19 vaccinations. Facility Census: 22. Findings Included: a) Staff Covid-19 Vaccinations Facility documentation review of the facility's Infection control practices found the facility was unable to provide the required staff COVID-19 documentation for completed vaccination in a two-dose series for Environmental Service Attendant #8. Continued review of facility documentation found Nurse Aide #8's first Pfizer vaccine was administered 07/18/22, No second dose was administered. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to designate a person to serve as the director of food and nutrition services who was a certified dietary manager within one (1) year of hire. The federal regulation 483.60(a)(2) states: If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who- (i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: A certified dietary manager; or A certified food service manager; or Has similar national certification for food service management and safety from a national certifying body; [...]

Inspectors wroteBased on facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP). This failed practice had the potential to affect all residents residing at the facility. Facility Census: 22.