Inspection Reports for
Hamilton Pointe Health and Rehabilitation Center

This citation relates to Intake 2702057 and involves failure to have physician orders for oxygen therapy for residents B and E, as well as failure to maintain oxygen equipment properly.

The facility failed to ensure that two of three residents reviewed for oxygen therapy had physician orders for oxygen use and proper maintenance of oxygen equipment. Observations, record reviews, and interviews confirmed missing or incomplete oxygen therapy orders and inconsistent documentation of oxygen administration.

The facility failed to ensure accurate clinical records for one of three residents reviewed for wounds, documenting a wound on the wrong extremity repeatedly. The wound nurse acknowledged the initial documentation error, which was perpetuated in subsequent notes, and the facility policy on documentation was reviewed.

The facility failed to ensure medications were kept secure in a locked cart and residents' privacy was protected during medication administration, as observed with an unlocked medication cart and exposed resident information on a computer screen.

This citation relates to Intake 2597338. The complaint investigation found failures in infection control practices and documentation/orders for ostomy care.

The facility failed to ensure Enhanced Barrier Precautions were used during incontinence and wound care for Resident C, and no physician orders were in place for the care of Resident D's colostomy despite care plans indicating ostomy care needs.

This citation relates to complaint 2567193. The complaint involved failure to notify family members about changes in residents' conditions, specifically falls and seizure activity.

The facility failed to notify the families of two residents about significant changes: Resident F's family was not informed of a fall and subsequent mental status change until the family visited, and Resident M's family was not notified after seizure activity. The facility's policy requires notification of such changes, which was not followed.

The complaint investigation included issues related to medication self-administration, family notification failures, incomplete care plans, catheter care errors, infection control breaches, and kitchen sanitation problems.

The facility failed to ensure proper assessments for medication self-administration, timely family notification of resident changes, development and revision of care plans, appropriate catheter size and care, infection prevention protocols including PPE use, dishwasher temperature compliance, and pest control in the kitchen.

Complaint IN00456632 had no deficiencies related to allegations. Complaint IN00456718 had deficiencies cited at F689 related to accident hazards and supervision. Complaint IN00456869 had deficiencies cited at F689 and F9999 related to accident prevention and failure to report major accidents. Resident C suffered a fall resulting in subarachnoid hemorrhage and hospitalization. Resident B fell from a mechanical lift due to improper transfer technique.

The facility failed to ensure adequate safety measures to prevent accidents for 2 of 3 residents reviewed, resulting in serious injury including hospitalization and subarachnoid hemorrhage for Resident C. Additionally, the facility failed to report a major accident involving Resident C as required by state regulations. Another resident, Resident B, experienced a fall from a mechanical lift due to improper transfer procedures.

This citation relates to Complaints IN00456718 and IN00456869. The investigation found substantiated issues with supervision and safety protocols leading to falls and injuries for Residents B and C.

The facility failed to ensure adequate safety measures to prevent accidents for two residents, resulting in actual harm including hospitalization and a subarachnoid hemorrhage. Deficiencies included inadequate supervision during transfers and use of mechanical lifts, failure to follow care plans for assistance levels, and lapses in communication among staff.

This citation relates to Complaint IN00453228 and IN00453974.

The facility was found to have deficiencies in food service safety, including unsanitary food handling practices and contaminated surfaces, and in infection prevention and control, including failure to properly don personal protective equipment (PPE) when entering isolation rooms.

The investigation included Nursing Home Complaints IN00452314, IN00453974, IN00452718, IN00453228, and IN00452493 and Residential Complaints IN00452493, IN00453228, IN00453974. Complaints IN00452314, IN00452718, and IN00452493 had no deficiencies related to the allegations. Complaints IN00453974 and IN00453228 had federal/state deficiencies cited related to food safety and infection control.

The facility was found to have deficiencies related to food service sanitation and infection prevention and control practices, including failure to maintain sanitary food handling and improper use of personal protective equipment (PPE) in isolation rooms. Some complaints had no deficiencies cited, while others had federal/state deficiencies related to food safety and infection control.

Complaint IN00448583 was substantiated with federal and state deficiencies cited at F635 related to admission physician orders for immediate care.

The facility failed to ensure that a newly admitted resident had immediate physician orders for pressure wound treatments upon admission. Orders for wound treatments were not recorded until three days after admission, despite the resident having multiple pressure wounds on admission.

This citation relates to Complaint IN00448583. The complaint was substantiated as the facility did not have immediate wound treatment orders for Resident B upon admission.

The facility failed to ensure that Resident B, admitted in June 2024 with multiple pressure wounds, had immediate physician orders for wound treatments upon admission. Orders were not recorded until several days after admission, and wound measurements were missing from the initial report.

The facility was found not in compliance with emergency preparedness requirements due to failure to maintain a current documented facility-based and community-based risk assessment reviewed within the past twelve months. Additionally, the facility failed to provide a complete facility-specific written fire safety plan that accurately identifies all life safety systems, including the location of smoke barriers.

Complaint IN00435563 - Federal deficiencies related to the allegations are cited at F684 and F9999.

The facility was found deficient in multiple areas including resident privacy, medication self-administration assessments, accuracy of MDS assessments, comprehensive care planning, nutrition and weight monitoring, quality of care related to narcotic administration, fall prevention and post-fall assessments, pain management, nurse staffing postings, medication administration errors, food safety and temperature control, infection prevention and control, pest control, staff licensure, and reporting of injuries of unknown source.

Complaint IN00435563 was substantiated with federal deficiencies cited at F684 and F9999 related to the allegations.

The facility failed to provide thorough assessment and appropriate care planning related to narcotic medication administration and resuscitative measures for one resident (Resident P). Additionally, the facility failed to report an injury of unknown source for another resident (Resident D) to the Indiana Department of Health as required.

This citation relates to complaint IN00435563.

The facility failed to provide thorough assessment prior to narcotic medication administration and did not implement a person-centered care plan for narcotic use. The care plan inaccurately reflected resuscitative measures for Resident P, who experienced respiratory distress and ultimately stopped breathing without CPR being initiated. The facility lacked a policy for monitoring adverse side effects of narcotic medications.

The facility was found deficient in multiple areas including failure to ensure resident privacy, incomplete assessments for self-administration of medications, inaccurate Minimum Data Set (MDS) assessments, failure to follow physician orders, inadequate pain management, incomplete post-fall assessments, medication administration errors, improper food temperature and handling, unsanitary kitchen conditions, incomplete staffing records, and presence of pests.

This Federal tag relates to Complaints IN00415372.

The facility failed to provide necessary dialysis care and services for 2 residents, including missing post dialysis assessments and failure to administer medications as ordered according to blood pressure parameters. Documentation and nursing protocols were not consistently followed.

Complaint IN00415372 was investigated with federal/state deficiencies cited at F698 related to dialysis care and medication administration.

The facility failed to ensure necessary dialysis care and medication administration for 2 residents. Post dialysis assessments were not completed for Resident B, and Resident C did not receive medications as ordered according to blood pressure parameters.

Complaint IN00391521 - Substantiated with no deficiencies cited. Complaint IN00387822 - Substantiated with deficiencies cited at F580 and F776. Complaint IN00383534 - Substantiated with no deficiencies cited.

The facility was substantiated for complaints IN00391521, IN00387822, and IN00383534. Deficiencies were cited related to notification of changes, transfer/discharge notice, bed hold notice, care plan revisions, pressure ulcer care, accident prevention, respiratory care, dialysis care, psychotropic medication management, radiology services, infection control, and medication administration.

This Federal tag relates to Complaint IN00387822.

The facility was found deficient in multiple areas including failure to notify family timely about treatment changes, failure to provide required transfer and bed hold notices for hospitalizations, failure to update care plans for nutrition, advanced directives, and infections, failure to prevent pressure ulcers due to inadequate repositioning and call light accessibility, failure to supervise residents to prevent hazards such as possession of a box cutter and unlocked medication cart, failure to change oxygen tubing weekly, failure to obtain resident weights as ordered for dialysis, failure to obtain STAT X-rays timely due to mobile radiology service delays, and failure to properly implement infection control measures including PPE use and glove changes during care.