Hamilton Grove

In the surveyor’s words

From the most serious findings on record at Hamilton Grove, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 6, 2022

  Based on record review and interview, the facility failed to identify a injury of unknown origin in the pelvic region and inner thigh/groin area as a potential injury of sexual abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in a delay in investigation, reporting and protection of the resident during the investigation. (Resident B) The immediate jeopardy began on 6/26/22 at 10:30 P.M., when the Director of Nurses was notified of purple bruising in streaks on the Mons Pubis (a rounded mass of fatty tissue lying over the joint of the pubic bones) and bilateral inner thigh/groin region. The Administrator was notified of the immediate jeopardy on 7/1/22 at 4:38 P.M. […]

• Immediate jeopardy, isolatedF610Jul 6, 2022

  Based on record review and interview, the facility failed to immediately investigate an injury of unknown origin in the pelvic region and inner thigh/groin area as a potential injury of sexual abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in a delay of the investigation of potential sexual abuse. (Resident B) The immediate jeopardy began on 6/26/22 at 10:30 P.M., when the Director of Nurses was notified of purple bruising in streaks on the Mons Pubis (a rounded mass of fatty tissue lying over the joint of the pubic bones) and bilateral inner thigh/groin region. The Administrator was notified of the immediate jeopardy on 7/1/22 at 4:38 P.M. […]

• Actual harm, isolatedF686Jul 3, 2024

  Based on interview and record review, the facility failed to prevent unstageable pressure ulcers from developing and failed to provide necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing on the bilateral heels of a resident who was admitted without pressure ulcers, for 1 of 3 residents review for pressure ulcers. (Resident C) This deficient practice resulted in the development of a facility-acquired Deep Tissue Injury (DTI) on the left heel that deteriorated to an unstageable pressure injury and the development of a facility-acquired Deep Tissue Injury (DTI) and DTI on the right heel that deteriorated to a stage three pressure injury with signs and symptoms of infection and required debridement. […]

• No harm, potential for more than minimal, widespreadF804Apr 4, 2023

  Based on observation, record review and interview, the facility failed to ensure the cook followed the recipes for pureed chicken. This deficient practice had the potential to affect 6 of 6 residents who required pureed food. (Cook 24) Finding includes: During an observation of the pureed food process, conducted on 3/28/23 at 9:29 A.M., Cook 24 placed 10 - 4 ounce scoops of diced cooked chicken into the food processor and added approximately 2 cups of water. After pureeing the mixture, she added two additional cups of water. Review of the recipe for pureed chicken indicated the chicken was to be pureed with chicken broth. […]

• No harm, potential for more than minimal, widespreadF812Apr 4, 2023

  Based on observation, record review and interview, the facility failed to ensure food was stored in accordance with professional standards for food safety for 1 of 1 kitchens. This deficient practice had the potential to affect 74 of 74 residents who received food from the kitchen. (Main Kitchen) Findings include: 1. During a tour of the kitchen, conducted on 3/27/23 at 9:44 A.M., with the senior FSS (Food Service Supervisor), the following was observed: There were 4 cases of unpasteurized eggs in the walk in refrigerator. […]