Hamilton Manor Nursing Home

In the surveyor’s words

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

• Actual harm, isolatedF760Jul 23, 2026

  Based on interviews and record review, the facility failed to ensure residents were free of significant medication errors for one of three residents reviewed (Resident #1). Specifically, Resident #1 received multiple doses of an anti-Parkinsonism medication (used to treat symptoms of Parkinson's disease) in error resulting in Resident #1 requiring hospitalization for an accidental overdose. Subsequently, Resident #1 experienced a decline in their physical functioning that required additional therapy services. This resulted in actual harm that was not Immediate Jeopardy for Resident #1. […]

• No harm, potential for more than minimal, patternF584Feb 12, 2024

  Based on observations and interviews conducted during a Recertification Survey it was determined that for two (Wings one and three) of three wings, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, exhaust ventilation in required areas was not provided or was not functional. The findings are: Observations on 2/7/24 at 10:06 AM included a soiled utility room directly adjacent to a clean utility room with a shared a partial wall. The shared wall was observed to have approximately one-foot openings near the top and bottom. In the center between the two rooms was a ceiling exhaust fan that was not functional. […]

• No harm, potential for more than minimal, patternF655Feb 12, 2024

  Based on interviews and record reviews conducted during the Recertification Survey, it was determined for 9 (Resident #9, #16, #20, #26, #33, #35, #38, #40, #41) of 12 residents reviewed for Baseline Care Plans, the facility did not ensure a Baseline Care Plan was developed and implemented for each newly admitted resident that included the instructions needed to provide effective care within 48 hours of a resident's admission and that a summary of the Baseline Care Plan was provided to the resident and/or their representative. Specifically, Residents #26, #33 and #38 did not have a Baseline Care Plan developed and implemented within 48 hours of their admission. […]

• No harm, potential for more than minimal, isolatedF610May 5, 2026

  Based on observations, interviews, and record review, the facility failed to ensure alleged violations involving abuse were responded to timely and failed to ensure residents were protected from potential further abuse while the investigation was in progress for one (1) of four (4) residents reviewed (Resident #1). Specifically, Certified Occupational Therapy Assistant #1 reported on 04/28/2026 they witnessed Certified Nursing Assistant #1 strike Resident #1 on the head on 04/24/2026. The allegation was not immediately reported as required by facility policy, which delayed initiation of the facility investigation and delayed removal of Certified Nursing Assistant #1 from resident access pending investigation. […]

• No harm, potential for more than minimal, isolatedF744Jun 18, 2025

  Based on observations, interviews, and record review conducted during the Recertification Survey from 06/12/2025 to 06/18/2025, the facility did not ensure a resident who displayed or was diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for one (1) (Resident #22) of one (1) resident reviewed for dementia care. Specifically, the facility did not ensure the development and implementation of a person-centered care plan that included interventions specific to Resident #22's dementia, did not address the resident's behaviors, goals, or interventions required and did not address the use antipsychotic medication or the monitoring of. […]