Hamilton Pointe Health and Rehab

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 1, 2021

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent a fall during a mechanical lift transfer and ensure 2 staff members transferred a resident with a mechanical lift; and failed to properly secure the straps of the lift sling, resulting in a fall from the mechanical lift. This resulted in multiple facial fractures, a neck fracture, and resulting [CONDITION(S)]. This affected 1 of 3 residents reviewed for falls. (Resident B) The immediate jeopardy began on 11/9/21 when 1 staff member transferred a resident using a mechanical lift, without securing the straps of the sling, resulting in a fall from the lift. The Administrator and Assistant Director of Nursing were notified of the immediate jeopardy at 4:00 P.M. […]

• Actual harm, isolatedF689Apr 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure adequate safety measures were in place to prevent accidents for 2 of 3 residents reviewed. This deficient practice resulted in Resident C requiring hospitalization , sutures, and a subarachnoid hemorrhage. (Resident B, Resident C) Findings include: 1. On 4/8/25 at 1:28 p.m., Resident C's clinical record was reviewed. Resident C was admitted on [DATE] and discharged to the hospital on 2/26/25. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect following cerebral infarction, cerebral infarction due to thrombosis of right middle cerebral artery, muscle weakness (generalized),… […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2025

  Based on observation, interview, and record review, the facility failed to ensure dishwasher temperatures were within range and food was prepared under sanitary conditions for 2 of 2 kitchen observations. The temperature on the final rinse of the dishwasher did not reach required levels, floors were sticky, and bulk food was outdated. (Kitchen)Findings include:1. On 7/29/25 at 9:17 A.M., an initial tour of the kitchen was completed with the Kitchen Manager. During the initial tour, the following was observed:A dishwasher cycle was observed. The final rinse temperature was 175 degrees Fahrenheit (F). […]

• No harm, potential for more than minimal, widespreadF882Aug 6, 2025

  Based on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The full time director of nursing was unable to provide documentation of infection prevention certification, and did not currently dedicate at least part time to the role of IP for 1 of 1 staff members reviewed for IP. Finding includes:During an interview on 8/5/25 at 10:07 A.M., the full-time Director of Nursing (DON) indicated she was managing the Infection Preventionist (IP) role, and dedicated about two hours each working day to the infection prevention program tasks. […]

• No harm, potential for more than minimal, widespreadF925Aug 6, 2025

  Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests during 2 of 2 kitchen observations. Gnats were observed in the dry storage room and flies were observed in the food holding area. (Kitchen)Findings include:On 7/29/25 at 9:17 A.M., an initial tour of the kitchen was completed with the Kitchen Manager. Gnats were observed in the dry storage room. On 8/1/25 at 10:51 A.M., a follow-up visit of the kitchen was completed with the Kitchen Manager. Mexican corn and Spanish rice were observed on the steam table and were not covered. A fly was observed flying around the uncovered food. On 8/5/25 at 9:04 A.M., the Kitchen Manager indicated there was an open drain in the dry storage room which was where the pests were coming from. […]