Inspection Reports for
Hamilton Grove

This inspection relates to Intake 2664672 concerning failure to notify the responsible party of Medicare Non-Coverage and failure to involve the responsible party in discharge care planning for Resident B.

The facility failed to ensure the responsible party for one resident received a Notice of Medicare Non-Coverage at discharge and failed to develop and implement a complete discharge care plan involving the resident's responsible party. Interviews and record reviews confirmed these deficiencies.

The facility was found not in compliance with emergency preparedness requirements including lack of policies for sheltering in place, transfer arrangements with other LTC facilities, roles under a Secretary-declared waiver, and failure to conduct required emergency plan exercises. Life safety deficiencies included improper placement of smoke detectors, lack of GFCI protection on electrical receptacles near sinks, incomplete fire drill documentation, incomplete fire door inspection records, lack of testing documentation for patient care electrical equipment, and inadequate staff training on oxygen transfilling procedures.

The facility failed to notify physicians of residents' changes in condition and missed medication doses for 2 residents, failed to ensure timely monitoring of antipsychotic medications for 2 residents, and failed to maintain sanitary food storage practices in the kitchen and residents' personal refrigerators.

The facility was found deficient in multiple areas including failure to notify physicians of changes in residents' conditions and missed medications, inadequate monitoring of antipsychotic medications, failure to maintain sanitary food storage practices, and incomplete emergency binder information for residents.

The investigation was complaint-driven focusing on medication administration errors and transcription issues. The findings substantiated that medications were missed or not administered as ordered, with no physician notification documented.

The facility failed to ensure medication and supplement orders were accurately transcribed and medications were administered timely to 2 of 3 residents reviewed. Multiple medications were missed or administered incorrectly due to transcription errors and supply issues.

Complaint IN00441231 was substantiated with federal/state deficiencies cited at F755. Complaint IN00445596 was not substantiated with no deficiencies cited.

The facility failed to ensure medication and supplement orders were accurately transcribed and medications were administered timely to 2 of 3 residents reviewed (Residents C and J). Issues included missed doses, incorrect transcription of orders, and lack of physician notification for missed medications.

This citation relates to Complaint IN00436622. The investigation found substantiated failures in pressure ulcer prevention and treatment for Resident C.

The facility failed to prevent the development of unstageable pressure ulcers and did not provide adequate treatment or pressure relief interventions for Resident C's bilateral heel wounds. Documentation and communication lapses were noted, including lack of wound culture results, incomplete care plans, and failure to act on wound specialist recommendations.

Complaint IN00436622 was substantiated with federal/state deficiencies cited related to pressure ulcer care. Complaint IN00434205 was not substantiated with no deficiencies cited.

The facility failed to prevent the development of unstageable pressure ulcers 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 (Resident C) who was admitted without pressure ulcers. The resident developed facility-acquired deep tissue injuries that deteriorated to stage three and stage four pressure ulcers. Documentation and treatment were inadequate, and staff failed to provide complete pressure relief and timely wound care interventions.

The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain latching hardware on one smoke barrier door, use of objects to prop open resident room doors, uncovered penetrations in smoke barrier walls, and failure to conduct a required four-hour emergency generator run test within the last 36 months.

The facility failed to develop person-centered care plans for residents with dementia and activities of daily living needs, did not provide adequate activities to support residents' well-being, failed to secure cigarettes for a resident who smokes, did not prevent wandering into other residents' rooms, failed to complete narcotic counts every shift, and failed to remove expired medications and monitor medication refrigerator temperatures.

The facility was cited for multiple deficiencies including failure to develop and implement person-centered care plans for residents, inadequate assistance with activities of daily living, failure to provide meaningful personalized activities, unsecured cigarettes posing accident hazards, failure to prevent wandering of a resident with dementia, incomplete narcotic count documentation, failure to ensure appropriate medication monitoring and pharmacist reviews, unsecured medications in resident apartments, and failure to provide timely employee orientation and education on resident rights and abuse.

This citation relates to Complaint IN00425874.

The facility failed to ensure catheter orders and catheter care orders were in place for a resident with a catheter, and failed to consistently document intake and output as ordered for 1 of 2 residents reviewed for catheters. There were no physician orders for catheter care and no documentation of catheter care or intake and output on multiple dates.

Complaint IN00426075 - No deficiencies related to the allegations are cited. Complaint IN00425874 - Federal/State deficiencies related to the allegations are cited at F690.

The facility failed to ensure catheter orders and catheter care orders were in place for a resident with a catheter, and failed to ensure intake and output were consistently documented as ordered for that resident.

The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements due to failure of 3 of 5 corridor doors to have suitable automatic closing and latching mechanisms to resist smoke passage. The facility failed to implement a systemic plan of correction to prevent recurrence.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including deficiencies in emergency preparedness plans, fire safety, sprinkler system maintenance, exit door locking, and generator inspections.

The inspection was complaint-related, addressing issues such as failure to notify physicians of weight loss, grievance policy deficiencies, incomplete care plans, inadequate activities, improper treatment and documentation, medication labeling errors, food safety violations, and accident prevention failures.

The facility was found deficient in multiple areas including failure to notify physicians of significant weight loss, inadequate grievance policy communication, incomplete and outdated care plans, failure to provide meaningful activities, improper treatment and documentation of skin issues, inaccurate medication labeling, failure to follow food preparation recipes, and unsafe food storage practices.

Complaint IN00402235 was investigated with Federal/State deficiencies cited at F656 related to failure to notify physician of significant weight loss and other care plan issues.

The facility was found out of compliance in multiple areas including failure to notify physicians of significant weight loss, failure to provide grievance information to residents, failure to develop and update personalized care plans, failure to provide meaningful activities, untimely transcription of orders, improper labeling of medications, food safety violations, incomplete personnel reference checks, insufficient staff training, and failure to conduct required fire drills.