Hamilton Park Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The findings include but are not limited to: A facility document titled Maintenance Policy with a revised date of 01/2025 documented the maintenance department is responsible for managing the maintenance function in the safest manner possible and providing the best service to the residents. The maintenance priorities include cosmetic/curb appeal. During multiple observations from 02/18/2025 to 02/25/2025, the following were observed: 1.) The bathroom in room [ROOM NUMBER] was observed with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Cross Reference: F760 - Residents Are Free of Significant Medication Errors The findings are: According to the New York State Educational Law Article 139, Section 6902, the practice of the profession of nursing includes the executing of medical regimens prescribed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. If a drug is withheld, refused, or given at a time other than the schedule time, the individual administering the medication shall initial and enter corresponding code into the Medication Administration Record space provided for the drug and dose. Resident #102 had diagnoses of Bipolar Disorder, Anxiety, and Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The findings are: The facility policy titled Minimum Data Set Guideline for Completion with a revised date of 01/2025 documented all members of the interdisciplinary team are responsible for reviewing, updating, and evaluating resident assessments and care plans. Resident #33 had diagnoses that included Anxiety Disorder, Depression, and Chronic Respiratory Failure. The Minimum Data Set assessment dated [DATE] documented Resident #33 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The Minimum Data Set assessment dated [DATE] documented #343 had moderately impaired cognition and required supervision or touch assistance for eating. During dining observation on 02/18/2025 at 12:31 PM, Resident #342 was in the unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during dining observation on the 6th Floor. Specifically, Certified Nursing Assistant #4 was observed touching a lettuce with their bare hands while preparing Resident #95's sandwich. The findings are: The facility policy titled Food Preparation and Handling with a revised date of 01/2005 documented all food will be prepared and handled using safe and sanitary methods. All staff will avoid bare-hand contact with ready to eat foods, as well as wear single use gloves and use serving utensils. On 02/18/2025 at 12:55 PM, Certified Nursing Assistant #4 was observed assisting Resident #95 with their sandiwch during lunch. Certified Nursing Assistant #4 was observed holding a piece of lettuce with their bare hand while they were assembling the sandwich and cutting the sandwich in 4 pieces with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #130) out of 38 total sampled residents. Specifically, Licensed Practical Nurse #4 failed to practice hand hygiene and glove changes during wound care. The findings are: The facility's policy titled Wound Dressings, Dry/Clean with a revised date of 01/2025 documented the purpose of the policy was to provide guidelines for the application of dry, clean dressings. Resident #130 had diagnoses of Stage 3 Pressure Ulcer of Sacral Region, Type 2 Diabetes Mellitus, and Malnutrition. The Minimum Data Set assessment dated [DATE] documented Resident #130 had intact cognition and Stage 3 pressure ulcers. The physician's order dated 02/12/2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a Recertification/Complaint survey from 2/2/23 to 2/9/23, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident # 178) of 2 residents reviewed for Care Planning out of 37 sampled residents. The findings are: The undated facility policy titled Baseline Care Plan (BCP) documented that Social Services shall coordinate with resident/resident's representative for the Care Plan meeting within 3 - 5 days from admission. It also documented that the Care Plan Summary shall be signed by all disciplines and resident/resident's representative. Resident's or his/her representative signature is attestation to participation and receipt of the copy. It further documented that the resident or representative shall receive a copy of the physician orders sheet or orders summary, care plans, and care plan conference summary. Resident # 178 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews conducted during the Recertification/Complaint survey from 2/2/23 to 2/9/23, the facility did not ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident for 4 out of 4 units (Unit 3, Unit 4, Unit 5, and Unit 6). Specifically, daily staffing was not observed posted in a prominent place for residents and visitors for all 4 units. The findings are: There was no facility policy related to daily nurse staffing posting. On 02/02/23 at 09:06 AM, 02/06/23 at 08:36 AM, 02/07/23 at 08:31 AM, 02/08/23 at 08:37 AM, and 02/09/23 at 08:24 AM observations of the facility entry way were made. Visitors were required to make a left turn and walk down a hallway to get to the two elevators used to access the units (Unit 3, Unit 4, Unit 5, and Unit 6) after entering the facility. There was no daily nurse staffing posted at the facility entrance, in the hallway leading to the elevators, or by the elevators that access the units. On 02/09/23 at 10:16 AM, the Staffing Coordinator (SC) was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the Recertification Survey initiated on 2/2/23 and completed on 2/9/23, the facility did not ensure a resident was adequately equipped to call for assistance through a communication system. This was evident for 1 (Resident #31) of 3 residents reviewed for Physical Environment. Specifically, Resident #31 was observed without a functioning call bell in place. The findings are: The facility's policy titled Answering the call bell created on 5/2017, and reviewed 5/2022, documented staff should ensure the call bell is always plugged in and report defective call bells to the nurse supervisor promptly. Resident #31 was admitted to the facility with diagnoses which included unspecified dementia, post-traumatic stress disorder and difficulty in walking. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #31 had moderate cognitive impairment with a BIMS (Brief Interview of Mental Status) score of 8 out of 15. Resident #31 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, multiple oxygen tubings were observed touching the floor on several occasions. (Resident # 156, Resident #96 and Resident #53) The findings are: 1. Resident # 156 was admitted to the facility with diagnoses which included Multiple Drug Resistant Organism, Pneumonia, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure and Shortness of Breath. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident cognition is moderately impaired and required extensive assistance with all Activities of Daily Living (ADLs). On 12/10/19 at 10:15 AM, on 12/11/19 at 10:02 AM, on 12/12/19 at 10:43 AM, on 12/12/19 at 02:26 PM, the resident's oxygen tubing was observed touching the floor. 2. Resident # 96 was admitted with diagnoses which include Chronic Obstructive Pulmonary Disease, and Heart Failure. The Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, dusty, dirty, and stained floor mats next to resident's beds were observed in 3 rooms (Rooms 518, 529, 542) and a resident's bed side table were dirty with a white film (room [ROOM NUMBER], 545). The finding is: The undated facility policy titled Cleaning Resident and Non-Resident Areas documented the purpose is to improve sanitation and ensure the highest level of cleanliness throughout the facility. To control cross contamination, the spread of bacteria and infection, and to maintain the outward appearance of the facility. Daily procedures for cleaning the residents rooms included clean floor mats every day with EPA approved bleach solution wipes and air dry them for 5 minutes and additionally clean mats as needed. Complete high dusting of furniture and clean horizontal surfaces with appropriate cleansers and equipment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews conducted during a recertification survey, the facility did not ensure that assessments accurately reflected the residents' status. Specifically, the Minimum Data Set (MDS) assessments did not identify the use of a wander/elopement alarm. This was evident for 1 of 1 resident reviewed for Physical Restraint (Resident #21) and 1 of 3 residents reviewed for Accidents (Resident #133) out of a sample of 38 residents. The findings are: The policy titled Wandering, Unsafe Resident dated April 2016 documented staff will identify and assess at risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for wandering or other safety issues. Nursing staff will document Wanderguard. 1). Resident #21 was admitted to the facility with diagnoses which included but were not limited to Cerebral Infarction, Hemiplegia or Hemiparesis, Difficulty Walking, Muscle Weakness, Cerebrovascular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs were developed. Specifically, a comprehensive care plan was not developed for a resident with hearing impairment. This was evident for 1 of 2 residents reviewed for Vision/Hearing out of a sample of 38 residents. (Resident #67). The finding is: The facility's policy and procedure Care Planning - Interdisciplinary Team revised November 2018 documented the care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team. Resident #67 was admitted with diagnoses that included Hypertension, Hypothyroidism and Dysphagia. The admission Minimum Data Set (MDS) dated [DATE] documented the resident with moderate impaired cognition, adequate hearing and no hearing aide. On 12/10/19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.