Hamilton Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Aug 20, 2021

  Based on staff interview and record review, the facility did not consult with the physician for 1 Resident (R) (R1) of 1 residents sampled when the resident experienced a change in condition in R1's right second toe. R1's physician was not consulted in a timely manner on 5/18, 5/21, and 5/24/2021 when the wound on R1's right second toe deteriorated and presented the potential need to alter treatment. R1's second toe subsequently became infected and gangrenous and required amputation. The facility's failure to provide timely updates and consultation with R1's physician related to R1's wound condition and treatment created a finding of Immediate Jeopardy (IJ), which began on 5/18/2021. Surveyor notified Nursing Home Administrator (NHA)-A of the IJ on 8/19/2021 at 1:00 PM. […]

• Actual harm, isolatedF689Jul 8, 2024

  Based on observation, staff and resident interview, and record review, the facility did not provide adequate supervision for 1 resident (R) (R1) of 4 sampled residents. The failure to supervise R1 led to R1 being able to verbally and physically abuse another resident, R2. On 5/23/24, staff observed R1 exit R2's room and state, I'm going to kick your ass. R2 reported to staff that R1 had thrown a Styrofoam cup of coffee creamers at R2. Following the incident, the facility did not implement any interventions to ensure the safety of R1, R2, or other residents. On 5/24/24, Licensed Practical Nurse (LPN)-D observed R1 in the hallway outside R2's room. R1 appeared agitated and was repeatedly stating, Shut the f*** up. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 26 residents residing in the facility. The facility did not consistently monitor and document warewasher (dishwasher) wash and rinse cycles. Findings include: During an initial tour of the kitchen beginning on 7/10/23 at 8:30 AM, Dietary Manager (DM)-D indicated the facility followed the Wisconsin Food Code. DM-D confirmed the facility's dishwashing machine was a single tank, conveyor, dual temperature machine and indicated the wash cycle temperature should reach at least 160 degrees Fahrenheit (F) and the rinse cycle temperature should reach at least 180 degrees F. […]

• No harm, potential for more than minimal, widespreadF880Jul 12, 2023

  Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection. The facility did not implement a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 26 residents in the facility. The facility did not identify where Legionella and other opportunistic waterborne pathogens can grow and spread. […]

• No harm, potential for more than minimal, widespreadF812Jun 15, 2022

  Based on observation, staff interviews, and record review, the facility did not ensure food was prepared, stored, and served under sanitary conditions. The practices had the potential to affect all 26 residents. Staff did not monitor warewashing machine (dishwasher) internal surface temperature. Dietary Aide (DA)-F did not perform hand hygiene when moving from dirty to clean dishes or between residents during meal service. Staff served beverages which were opened and undated and thawed and undated. […]