The Hamlet Rehabilitation and Healthcare Center at

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/12/2025 and completed on 2/20/2025, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practices, to promote healing and prevent infections. This was identified for one (Resident #11) of four residents reviewed for Pressure Ulcer/Injury. Specifically, Resident #11 had a Stage 4 Pressure Ulcer (full-thickness tissue loss that exposes bone, tendon, or muscle) on the left buttock and sacrum (bottom of the spine). Resident #11 had a Physician's order to cleanse the wound with Dakin's solution (a diluted bleach solution, used as antiseptic to clean and treat wounds); [...]

Inspectors wroteBased on observation, record review and interview during the Recertification Survey initiated on 2/12/2025 and completed on 2/20/2025, the facility did not ensure care and services for the provision of parenteral fluids were consistent with the professional standard of practice for each resident. This was identified for one (Resident #323) of two residents reviewed for Hydration. Specifically, Resident #323 was admitted on [DATE] with a Peripherally Inserted Central Catheter (a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) inserted to the left upper arm. There was no documented evidence the external length of the catheter was routinely measured to prevent migration and the care plan was not updated to include the measurement of the external length of the catheter. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/12/2025 and completed on 2/20/2025, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #7) of three residents reviewed for Respiratory care. Specifically, Resident #7, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had a Physician's Order to administer oxygen therapy at 2 liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen) as needed. The resident complained of feeling short of breath and was trying to place the nasal cannula to receive supplemental oxygen from the oxygen tank; however, the oxygen tank was empty. The finding is: [...]

Inspectors wroteBased on record review, and interviews during an abbreviated survey (NY00321603), the facility failed to prevent and protect an incident of verbal abuse for one (Resident #1) out of three residents reviewed for abuse. Specifically, the facility failed to immediately remove Certified Nursing Assistant #1 from Resident #1's room when Certified Nursing Assistant #1 was verbally abusive and displaying signs of physical aggression towards Resident #1. The incident was captured on a video recording made by Resident #1. The facility's census was 221. This resulted in harm that was not immediate jeopardy. The facility's abuse policy revised on 07/2023 documented in pertinent part Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY00326793) initiated on 11/16/2023 and completed on 11/22/2023, the facility did not ensure that a comprehensive person-centered care plan for each resident was developed or implemented that included measurable objectives and time frames to meet the resident's current needs. This was identified for one (Resident #391) of two residents reviewed for Urinary Catheter, one (Resident #81) of 2 residents reviewed for physical restraints and for one (Resident #130) of two residents reviewed for communication. Specifically, 1a) Resident #391 was re-admitted on [DATE] with a Peripherally Inserted Central Line (PICC) for Antibiotic Therapy. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 11/16/2023 and completed on 11/22/2023, the facility did not ensure that the Comprehensive Care Plan (CCP) for each resident was reviewed and revised by an interdisciplinary team to reflect the resident's current status. This was identified for one (Resident # 196) of five residents reviewed for Accidents and one (Resident #200) of four residents reviewed for Limited Range of Motion. Specifically, 1) Resident #196 had a physician's order, and a CCP developed, to utilize a Wanderguard bracelet due to wandering behavior. Facility staff were aware of the resident's behavior of removing the Wanderguard bracelet; however, the CCP was not updated to reflect the resident's behavior. [...]

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification Survey initiated on 11/16/2023 and completed on 11/22/2023, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision to prevent accidents. This was identified for one (Resident #87) of five residents reviewed for Accidents. Specifically, Resident #87 was observed on 11/22/2023 with multiple medications in a medication cup on their bedside table with no staff member in the vicinity. The resident was not assessed to safely self-administer medications. The finding is: The facility policy for administering medication dated 5/19/2023 did not address protocols to be followed related to medications being left unattended at the resident's bedside. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00326793) initiated on 11/16/2023 and completed on 11/22/2023 the facility did not ensure that medical care of each resident was supervised by a Physician and included Physician's orders for the resident's immediate care and needs. This was identified for one (Resident #391) of two residents reviewed for Urinary Catheter use. Specifically, a) Resident #391 was re-admitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) Line for Antibiotic Therapy. There were no physician's orders in place upon admission on [DATE] for the use of the PICC line for antibiotic therapy; for monitoring of the PICC line site, nor for dressing changes of the PICC line. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00323094), the facility did not have an effective system to monitor resident's bowel movements adequately. This issue was identified for one resident (Resident #1) out of the five residents reviewed. Specifically, Resident #1 was assessed to have constipation according to the Minimum Data Set (MDS). The Certified Nursing Assistant (CNA) records documented Resident #1 had no Bowel Movements (BM) or the bowel movement section was left blank on 15 days in [DATE]. There was no documented evidence that Resident #1's Physician or Nurse Practitioner were notified or that the facility implemented their bowel protocol. On [DATE], Resident #1 was diagnosed with a rectal fecal impaction based on an abdominal x-ray. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey completed on 7/22/2021, the facility did not ensure that services provided or arranged by the facility meet current professional standards of quality for one (Resident #175) of six residents reviewed for medication administration. Specifically, the nursing staff did not rotate the insulin injection administration sites. The finding is: The facility's Insulin Policy dated 8/2020 documented the injection site should be rotated. Resident # 175 was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, Pulmonary Embolism, and Transient Ischemic Attack. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 7/22/2021, the facility did not ensure that residents with limited ambulatory ability received appropriate services to maintain or improve their ambulatory ability for one (Resident #100) of 3 residents reviewed for Rehabilitation and Restorative services. Specifically, Resident #100 was discharged from skilled Physical Therapy (PT) services on June 1, 2021, with recommendations to start the Nursing Ambulation Program (NAP); however, the resident did not receive NAP services as recommended by the Rehabilitation Department. The finding is: The facility's policy titled Nursing Ambulation Plan (NAP)/ Standing Program dated 1/2021 documents the NAP/ Standing program will be provided by the Certified Nursing Assistant (CNA)s and any signs of decline would be reported to the nurse. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey completed on 7/22/2021, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This was identified for one (Resident #57) of two residents reviewed for ADLs. Specifically, Resident # 57, who required staff assistance to perform personal hygiene, was observed with untrimmed and soiled fingernails. The finding is: The facility's undated Nail Care policy documented fingernails are places where dirt and germs collect and should be cleaned every day. Nails are to be cut and filed regularly. The nails should be cut short and edges filed to make them smooth. If an injury occurs during nail care- notify the nurse. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey completed on 7/22/2021, the facility did not provide respiratory treatments and care consistent with professional standards of practice for one (Resident #175) of 4 residents reviewed for respiratory care. Specifically, Resident #175 had a Physician's order to administer oxygen at two liters per minute. The resident was observed receiving oxygen at a liter flow rate greater than the current physician's order. The finding is: The facility's policy for Oxygen Administration dated 11/2020 documented to verify the Physician order and to monitor and document the rate of oxygen flow, route, and rationale. Resident #175 was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, Pulmonary Embolism, and Transient Ischemic Attack. [...]