Hamilton Park Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Hamilton Park Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Feb 25, 2025

  Based on observation, record review, and interviews during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident in 2 (5th and 6th Floor) of 4 resident units observed during Environmental Task. Specifically, resident bathrooms had missing tiles, mismatched and peeling paint, and grime build up. Additionally, the closet door in a resident's room was observed with rust-colored stain. […]

• No harm, potential for more than minimal, patternF658Feb 25, 2025

  Based on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025 the facility failed to ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was evident in 1 (Resident #102) of 5 residents reviewed for psychotropic medications out of 38 total sampled residents. Specifically, licensed nursing staff failed to administer medication as per the physician's order and according to professional nursing standards of clinical practice. Additionally, the nursing staff failed to notify the physician when significant medication was not administered and ensure that the resident was clinically monitored for adverse reactions. […]

• No harm, potential for more than minimal, patternF760Feb 25, 2025

  Based on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025 the facility did not ensure residents are free of any significant medication errors. This was evident in 1 (Resident #102) of 5 residents reviewed for psychotropic medications out of 38 total sampled residents. Specifically, Resident #102 was not administered 7 doses of Venlafaxine (an anti-depressant) as ordered by a physician. The findings are: The facility Policy titled Administering Medications with a revised date of 01/2025 documented medications must be administered in safe and timely manner, and as prescribed. […]

• No harm, potential for more than minimal, isolatedF657Feb 25, 2025

  Based on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025 the facility did not ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident in 1 of 2 residents reviewed for care planning and hospice care out of 38 total sampled residents. Specifically, Resident #33's Comprehensive Care Plan related to hospice care was not reviewed and revised quarterly after each assessment. […]

• No harm, potential for more than minimal, isolatedF806Feb 25, 2025

  Based on observation, record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that residents were served food that accommodated their allergies and intolerances. This was evident in 1 (Resident #343) of 38 total sampled residents. Specifically, Resident #343, who had a documented allergy to Mushroom, received a lunch tray containing mushroom soup. The findings are: The facility document titled Allergy Policy with a revised date of 01/2025 documented all food allergies will be communicated to the Food Service Director for immediate identification on the resident food profile. Tickets should reflect the resident's known food allergies. Resident #343 had diagnoses of Heart Failure, Dementia, and Hypertension. […]