Hamilton Manor Nursing Home

Based on observations, interviews, and record review, the facility failed to ensure alleged violations involving abuse were responded to timely and failed to ensure residents were protected from potential further abuse while the investigation was in progress for one (1) of four (4) residents reviewed (Resident #1). Specifically, Certified Occupational Therapy Assistant #1 reported on 04/28/2026 they witnessed Certified Nursing Assistant #1 strike Resident #1 on the head on 04/24/2026. The allegation was not immediately reported as required by facility policy, which delayed initiation of the facility investigation and delayed removal of Certified Nursing Assistant #1 from resident access pending investigation. The findings include:The facility Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting Policy, dated December 2016, included a staff person who witnesses or suspects abuse involving a resident must immediately report the suspicion to their immediate supervisor. The facility must prevent further potential abuse while the investigation is in…

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 observations, interviews, and record review conducted during the Recertification Survey from 06/12/2025 to 06/18/2025, the facility did not ensure a resident who displayed or was diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for one (1) (Resident #22) of one (1) resident reviewed for dementia care. Specifically, the facility did not ensure the development and implementation of a person-centered care plan that included interventions specific to Resident #22's dementia, did not address the resident's behaviors, goals, or interventions required and did not address the use antipsychotic medication or the monitoring of. The finding is: The facility policy Care Plans, Comprehensive Person-Centered, revised March 2022, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #22 had diagnoses that included…

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 interviews and record review conducted during a Recertification Survey from 06/12/2025 to 06/18/2025, the facility did not ensure the Medication Review Regimen policy to address the pharmacist reported irregularities was implemented within the required times frame for two (2) (Residents #22, #23 and #28) of five (5) residents reviewed for drug regimen reviews. Specifically, the consultant pharmacist's reported irregularities were not acted upon by facility's Medical Director, attending physician or designee in a timely manner. The findings include but are not limited to: 1. Resident #23 had diagnoses that included dementia with behavioral disturbance, diabetes (a group of diseases that affects how the body uses blood sugar), and hypertensive heart disease with heart failure (condition resulting from chronic high blood pressure causing heart complications). The Minimum Data Set (a resident assessment tool), dated 04/15/2025, documented the resident had severe cognitive impairment and received several…

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 interviews and record review conducted during an Abbreviated Survey (NY00336619), for one (Resident #1) of three residents reviewed, the facility did not ensure adequate supervision and monitoring systems were in place to prevent a resident from elopement (when a resident leaves the facility without supervision with a possible threat to their health and safety). Specifically, Resident #1 had mild cognitive impairment with a history of wandering and eloped from the facility during a power outage. Resident #1 was absent from the facility for approximately two hours and was found approximately one mile away. This is evidenced by the following: The undated facility policy, Elopement, included if a resident is found to be at risk for elopement, an individualized care plan will be developed. If a resident does leave the building the Missing Resident Plan (emergency procedure used to locate a missing resident), will be put into effect immediately. The facility procedure Elopement Prevention Protocol, dated…

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 observations and interviews conducted during a Recertification Survey it was determined that for two (Wings one and three) of three wings, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, exhaust ventilation in required areas was not provided or was not functional. The findings are: Observations on 2/7/24 at 10:06 AM included a soiled utility room directly adjacent to a clean utility room with a shared a partial wall. The shared wall was observed to have approximately one-foot openings near the top and bottom. In the center between the two rooms was a ceiling exhaust fan that was not functional. The clean utility room was observed to contain storage of nursing supplies and oxygen concentrators, and the soiled utility room contained black plastic garbage receptacles and a flushing rim sink (hopper). In an interview at this time the Maintenance Manager stated that they have a couple of fan motors that they could use to replace the broken one. Observations on 2/7/24 at…

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 interviews and record reviews conducted during the Recertification Survey, it was determined for 9 (Resident #9, #16, #20, #26, #33, #35, #38, #40, #41) of 12 residents reviewed for Baseline Care Plans, the facility did not ensure a Baseline Care Plan was developed and implemented for each newly admitted resident that included the instructions needed to provide effective care within 48 hours of a resident's admission and that a summary of the Baseline Care Plan was provided to the resident and/or their representative. Specifically, Residents #26, #33 and #38 did not have a Baseline Care Plan developed and implemented within 48 hours of their admission. For Resident #9, #16, #26, #33, #35, #38, #40, and #41, the facility could not provide documented evidence that the residents or their representatives (including for residents who had severely impaired cognition) had been provided with a written summary of the Baseline Care Plan that included, but not limited to, a summary of the resident's physician and…

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 the Recertification Survey, from 4/27-[DATE], it was determined that the facility did not ensure for 1 (Resident #13) of 13 residents reviewed had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive that would be honored. Specifically, the physician's orders did not match the resident's Medical Orders for Life Sustaining Treatment (MOLST) wishes. Review of the facility policy MOLST - Medical Orders for Life Sustaining Treatment and Advance Directives dated as last reviewed on [DATE], revealed that a MOLST will be reviewed monthly by the nurse to ensure that each resident's code status is current and has been included on the physician's order sheet. Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), depression, and anxiety. The Minimum Data Set assessment…

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 observations, interviews and record reviews conducted during the Recertification Survey on 4/27/22 to 5/2/22, it was determined that the facility did not develop and implement a Comprehensive Care Plan (CCP) that included measurable objectives to meet the resident's medical, nursing and psychosocial needs that include the resident's goals, desired outcomes and preferences to attain or maintain the resident's highest practicable well-being. Specifically, there was a lack of care planning to address the use and monitoring of an anti-coagulant (blood thinner medication used to prevent strokes). This is evidenced by the following: The Long Term Care Facility Resident Assessment Instrument 3.0, dated October 2019, also referred to as the Minimum Data Set (MDS) Assessment manual includes in Section N, medications, that a resident's medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes. Residents taking medications in these medication categories (that include anti-coagulant or blood thinner…

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 observations, interview, and record review conducted during the Standard Recertification Survey completed on 5/2/22, it was determined that the facility did not operate in compliance with all applicable State regulations and codes. Specifically, a fire incident was not reported to the New York State Department of Health (NYSDOH) and was not properly documented. The findings are: 1. On 4/27/22 at 9:35 a.m. the surveyor asked the Environmental Services Director (ESD) if there had been any fires since the last survey. The ESD stated that last winter there was a small fire in the furnace room for the kitchen. On 4/27/22 at 11:10 a.m. it was observed that there was a door leading to a small furnace room outside the facility adjacent to the kitchen. Further interview with the ESD on 4/29/22 at 9:25 a.m. included that the fire department and fire marshal inspected the furnace after it was repaired and said it was OK, but the ESD did not think that the incident was reported. 2. Record review on 4/29/22 at 9:50 a.m. revealed a service report from the furnace repair vendor dated…

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.