Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hamilton Pointe Health And Rehab during CMS and state inspections, most recent first.
Two residents received ongoing O2 therapy via nasal cannula without corresponding practitioner orders, despite documented use in vital signs, skilled notes, and NP progress notes, and one resident’s care plan specifying oxygen flow rates. One resident with COPD, pulmonary hypertension, and CHF was on O2 at varying flow rates over multiple days before any O2 orders appeared in the medical record, and another resident with COPD and CKD was started and titrated on O2 after low O2 sats and POA concerns, again without documented practitioner orders. Staff interviews confirmed that O2 requires a physician order and that orders typically define parameters, and the facility’s policy required O2 to be administered only under a physician’s order (except in emergencies) with weekly tubing changes.
A resident with multiple comorbidities had a surgical wound on the left foot, but clinical documentation repeatedly recorded the wound as being on the right foot due to an initial charting error by the wound nurse. This mistake was carried over in subsequent nursing notes and weekly skin observations, resulting in persistent inaccuracies in the resident's medical record. Staff interviews confirmed that documentation was often based on previous entries rather than direct assessment.
A medication cart was left unlocked and unattended with medications and a computer displaying a resident's clinical information visible. An LPN left the cart to respond to a possible emergency, contrary to facility policy requiring medications to be secured and resident privacy protected.
Staff did not use Enhanced Barrier Precautions during incontinence and wound care for a resident with a pressure ulcer, and a care plan for EBP was missing. Additionally, there were no physician orders in place for the care of a resident's colostomy, contrary to facility policy requiring such orders for ostomy care.
Dishwasher temperatures were not maintained within the expected sanitizing range, with repeated missing or low temperature logs and a final rinse observed at 175 degrees F. Surveyors also found a sticky dry storage floor and a bulk container of Cheerios labeled with an expired use-by date. The Kitchen Mgr stated the dishwasher was high-temp and that sanitization strips were not used.
The facility failed to designate a qualified IP for its infection prevention and control program. The full-time DON said she was handling the IP role and spending about two hours each workday on infection prevention tasks, but she could not provide documentation of infection prevention certification. The Administrator confirmed the facility had a full-time DON, and the IP job description required specialized infection prevention training and at least part-time work.
Pest Control and Food Protection Deficiency: The kitchen was not free of pests during 2 of 2 observations. Gnats were seen in the dry storage room, and uncovered Mexican corn and Spanish rice were observed on the steam table with a fly flying around the food. The Kitchen Manager stated an open drain in the dry storage room was where the pests were coming from.
Missing care plans and monitoring for falls, palliative care, and seizures: A resident with dementia and a recent hip fracture had a fall-related care plan that did not prevent use of an unlocked wheeled bedside table, and the table remained in the room even though a smaller table was not within reach. Another resident admitted under palliative services had no palliative care plan in the chart. A third resident with epilepsy had a seizure with tremors and headache, but the record lacked post-seizure observation documentation.
Infection control protocols were not followed for a resident with a suprapubic catheter and for routine equipment use. A resident’s catheter bag was observed on the floor and later hanging above bladder level, and two CNAs provided direct care without a gown despite EBP orders. An LPN performed catheter care on another resident without PPE, and an RN did an Accu-Chek and returned the glucometer to the med cart without cleaning it. Blood pressure and pulse oximetry equipment were also observed with taped repairs.
The facility did not notify the families of two residents after significant changes in their conditions, including a fall with mental status change and multiple seizure episodes. In both cases, required notifications to family, physician, or palliative care were not documented or made in a timely manner, despite facility policy and care plan requirements.
A resident with dry eyes had eye drops observed at the bedside during a med pass, but the LPN did not address them until asked and stated there was no order or assessment allowing self-administration. Record review showed the resident had an order for PRN eye drops, no care plan for self-administration, and no self-administration assessment on file, despite an MDS showing no cognitive impairment.
A resident with a right humerus fracture and mild cognitive impairment fell and had a call don't fall sign placed as an immediate intervention, but the falls care plan was not updated to include that intervention. Although the sign was later observed in the room and falls were discussed in the morning clinical meeting, the care plan remained unchanged and did not reflect the current intervention.
A resident with an indwelling urinary catheter did not receive catheter care in accordance with the physician’s order when staff used larger catheter sizes than ordered. The resident had diagnoses including ulcerative colitis, anxiety, and depression, and was observed with bloody urine and bleeding from the vaginal area. An RN stated catheter size should match the MD order, and the facility policy required catheter use to follow physician orders, including catheter size.
The facility failed to maintain accurate medical record documentation for two residents. One resident with a Foley catheter had a progress note documenting a catheter size that staff said did not exist, while another resident with renal failure and dementia had records that repeatedly referenced hospice even though the MDS and current orders indicated comfort measures only and no hospice order was present.
Two residents experienced accidents due to inadequate supervision and failure to follow care plan interventions, including one resident left unattended on a commode who suffered a fall and head injury, and another resident who fell from a mechanical lift when only one staff member was present during transfer, contrary to policy requiring two staff.
The facility failed to ensure proper infection control practices as staff members entered isolation rooms without appropriate PPE. Activity Staff, CNAs, and an RN were observed not following droplet precaution protocols, despite clear signage and available PPE. The facility had isolation rooms for Influenza A and RSV, with recent Norovirus cases affecting residents and staff.
The facility failed to maintain sanitary conditions in food service, with observations of improper glove use, bare hand contact with plates, and unsanitary kitchen conditions. Dietary aides did not follow proper procedures for changing gloves and handling food, leading to potential contamination. The facility's policies on food handling and cleaning were not adequately followed.
A facility failed to provide immediate physician orders for a newly admitted resident with multiple pressure wounds, including a stage IV ulcer. Despite the facility's policy requiring immediate care orders, no wound treatment orders were recorded until three days post-admission. Staff interviews confirmed that treatments should have been initiated upon admission, highlighting a lapse in adherence to care protocols.
Staff at the facility failed to respect resident privacy during care, as observed in multiple instances where staff entered rooms without knocking and did not ensure privacy during medical procedures. Despite having guidelines, the facility lacked a formal privacy policy, leading to a deficiency in maintaining residents' rights to privacy and dignity.
The facility failed to assess residents for their ability to self-administer medications, as observed in four cases where medications were found in residents' rooms without necessary assessments or orders. A resident with cognitive impairment had throat lozenges without an order, another had a nasal spray without verification of a current order, and a third had an inhaler and Tylenol without documentation. Additionally, a resident with diabetes had glucose shots without a self-administration evaluation, contrary to facility policy.
The facility failed to serve food at palatable temperatures, as evidenced by resident complaints and a test tray showing inadequate food temperatures. Residents reported meals were not hot, and a Resident Council meeting noted delays in food delivery. On one occasion, a test tray showed carrots at 116°F, below the required 135°F. The Dietary Manager confirmed the expected temperature range, and the facility's policy requires hot food to be served at a minimum of 135°F.
The facility was found to have unsanitary conditions in the kitchen and dining areas, with food items left open to air, expired, or improperly stored. Additionally, an employee failed to change gloves after handling trash during food preparation, violating the facility's glove usage policy.
The facility failed to ensure a sanitary environment and proper hand hygiene, leading to infection control deficiencies. Uncovered washbasins and toothbrushes were observed in residents' bathrooms, and staff did not sanitize hands when entering or exiting rooms with enhanced barrier precautions, contrary to facility policy.
The facility failed to maintain a pest-free environment, with gnats observed in various areas including resident rooms, offices, and the kitchen. A resident reported issues with gnats, and the ADON suggested they might have been stirred up by recent pipe flushing. The facility's pest control policy aims to provide a safe environment free of pests, but the presence of gnats indicates a failure to adhere to this policy.
The facility failed to accurately complete MDS assessments for two residents. One resident, with a malignant neoplasm, was incorrectly marked as not receiving opioids, despite records showing administration of such medications. Another resident, with a history of CVA, was inaccurately marked as not receiving antiplatelet medication, although it was administered. The MDS Coordinator acknowledged these errors.
The facility failed to adhere to physician orders for two residents, one with dementia and epilepsy and another with renal failure, regarding nutritional supplements and weight monitoring. Resident 55 experienced significant weight loss due to missed nutritional supplement administrations, while Resident S had numerous missing or incorrect weight entries, impacting their care plans.
A facility failed to adequately assess a resident before administering narcotic medication and did not have a person-centered care plan for narcotic use. The resident, who had asthma and atrial fibrillation, was receiving opioid pain medication without a care plan for monitoring side effects. A discrepancy in resuscitative measures was noted, as the care plan inaccurately indicated the resident was a full code. The resident's condition deteriorated, leading to a significant drop in oxygen saturation and inability to swallow medications. Emergency services were called, but CPR was not initiated as the resident stopped breathing.
Two residents experienced multiple falls due to the facility's failure to complete post-fall assessments and update care plans with new interventions. Despite being at risk for falls, one resident had incomplete neurological assessments after a fall, and another had no new interventions added to their care plan after falls.
Two residents in a LTC facility experienced inadequate pain management. One resident suffered an unintentional narcotic overdose due to improper monitoring and medication administration errors. Another resident's preference for non-pharmacological pain relief was not honored, as the facility did not provide a heating pad or alternative methods. The facility's policies on medication administration and monitoring were not effectively followed, leading to these deficiencies.
A facility was found to have a medication error rate of 12% during a survey. An LPN administered chewable tablets incorrectly and handled a medication patch without gloves for a resident with dementia. Another resident with diabetes received an insulin injection without proper technique, as the LPN did not keep the needle in the skin for the required time. These actions violated the facility's medication administration policies.
The facility failed to accurately document a glucometer reading for a resident and did not complete post-fall assessments for another resident. An LPN recorded a blood sugar reading that differed from the summary provided later. Additionally, a resident with hemiplegia experienced a fall, but the post-fall assessment was incomplete, lacking documentation for several shifts. The Regional Nurse Consultant confirmed the need for complete documentation as per policy.
The facility failed to post accurate daily staffing sheets for six out of seven days, omitting actual hours worked for various shifts by RNs, LPNs, and CNAs. The DON was unaware of the requirement to designate actual hours for half shifts, despite a policy mandating this information be posted daily.
Failure to Obtain Practitioner Orders for Oxygen Therapy and Equipment Management
Penalty
Summary
The deficiency involves the facility’s failure to obtain practitioner orders for oxygen therapy and to ensure appropriate oxygen therapy management for two residents receiving supplemental O2. For one resident with diagnoses including chronic pulmonary disease, pulmonary hypertension, acute diastolic congestive heart failure, and dependence on supplemental oxygen, the admission MDS was coded for oxygen therapy, and the care plan documented that the resident would receive oxygen at 2–3 L/min as ordered. Clinical documentation, including an admission/readmission evaluation, vital signs, daily skilled notes, and nurse practitioner progress notes, showed that this resident was receiving oxygen via nasal cannula on multiple dates in November at flow rates up to 4.5 L/min. However, a review of physician orders for November revealed no orders for oxygen therapy, even though the resident was documented as being on oxygen throughout that period. Oxygen orders, including continuous oxygen at 2 L/min via nasal cannula with titration as needed and weekly tubing changes, did not appear until December. For another resident with COPD and chronic kidney disease, surveyors observed the resident on oxygen via nasal cannula at 2.5 L/min and the resident reported being placed on oxygen upon readmission from the hospital. Progress notes documented that, following concerns from the resident’s POA about low O2 readings, staff initiated oxygen at 2 L/min and then increased it to 3 L/min when saturations remained in the high 80s to mid-90s, and daily skilled notes showed the resident on oxygen on multiple dates. A nurse practitioner note also documented the resident on 2 L of oxygen. Despite this, the record review did not identify corresponding practitioner orders for oxygen therapy. Staff interviews confirmed that residents are required to have physician orders for oxygen therapy and that orders typically specify oxygen parameters, and the facility’s oxygen administration policy stated that oxygen must be administered under a physician’s order except in emergencies, with tubing and delivery devices changed weekly and as needed.
Inaccurate Documentation of Wound Location in Resident Medical Record
Penalty
Summary
The facility failed to ensure accurate clinical records for a resident with a surgical wound. Specifically, documentation inconsistently recorded the location of the wound, with multiple entries indicating the wound was on the right plantar foot when it was actually on the left. This error originated from the initial wound note, where the wound nurse mistakenly charted the right foot instead of the left, and this incorrect information was subsequently carried over in ongoing documentation. Weekly skin observations and progress notes continued to reflect the incorrect wound location, and some weekly observations even failed to note the presence of a surgical wound. The resident involved had a complex medical history, including a displaced bimalleolar fracture of the left lower leg, diabetes, hemiplegia, lymphedema, morbid obesity, and chronic heart failure. The care plan and physician orders correctly referenced a surgical wound on the left foot, but nursing documentation and skin observation forms repeatedly listed the wound as being on the right foot. Interviews with staff confirmed that documentation was based on previous notes rather than direct observation, leading to persistent inaccuracies in the resident's clinical record.
Unsecured Medication Cart and Breach of Resident Privacy
Penalty
Summary
A medication cart on the 400 unit was observed to be left unlocked with a medication cup containing six pills on top, and a computer displaying a resident's picture and clinical record information. The cart was unattended for several minutes while the assigned LPN left the area to respond to a possible resident emergency on another unit. The LPN later confirmed that medications should not be left unattended and that the cart should have been locked before leaving. Facility policy requires all medications to be stored in locked compartments and for medications to be under the direct observation of the administering staff or locked during medication pass. The policy also mandates the protection of resident privacy during medication administration. The observed incident failed to meet these requirements, resulting in unsecured medications and a breach of resident privacy.
Failure to Follow Enhanced Barrier Precautions and Maintain Ostomy Care Orders
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an unstageable pressure ulcer. During incontinence and wound care, two Qualified Medication Aides and a Wound Nurse did not don EBP supplies as required by physician orders and facility policy. The resident's clinical record also lacked a care plan related to EBP, despite an active order for EBP until the wound was healed. The Assistant Director of Nursing confirmed that EBP should have been used during these care activities. Additionally, for a resident with a colostomy, there were no physician orders in place for the care of the ostomy, as confirmed by review of the clinical record, Treatment Administration Record, and Electronic Medication Administration Record. The facility's policy requires licensed nurses to provide ostomy care under the orders of the attending physician, specifying the type of ostomy, frequency of pouch change, and type of equipment. This omission was acknowledged by nursing staff and was not in accordance with facility policy.
Dishwasher Temperatures, Sticky Dry Storage Floor, and Expired Bulk Food Label
Penalty
Summary
The facility failed to ensure dishwasher temperatures were within the required range and that food was prepared and stored under sanitary conditions during kitchen observations. On 7/29/25, surveyors observed a dishwasher cycle with a final rinse temperature of 175 degrees Fahrenheit, while the Kitchen Manager stated she expected a high-temperature dishwasher to reach at least 180 degrees Fahrenheit. The Dishwasher Chart for July 2025 was reviewed and identified the unit as a low-temperature dishwasher, with multiple entries showing missing wash and rinse temperatures across the month and several recorded final rinse temperatures below the expected range, including 165, 170, 171, 169, 179, 130, 178, 170, 165, 163, and 166 degrees Fahrenheit. The Kitchen Manager also indicated staff checked temperatures three times a day. During the same kitchen observation, the floor in the dry storage area was sticky, and a bulk container of Cheerios had a label indicating it must be used by 7/24/25. On 8/1/25, a follow-up kitchen visit again found the dishwasher final rinse temperature at 175 degrees Fahrenheit, and the Kitchen Manager stated the dishwasher was a high-temperature dishwasher and that sanitization strips were not used to test it. The dry storage floor was still sticky, and the bulk Cheerios container still had the expired use-by label.
Lack of Qualified Infection Preventionist Designation
Penalty
Summary
The facility failed to ensure designation of a qualified Infection Preventionist (IP) for the infection prevention and control program. During interview, the full-time DON stated she was managing the IP role and spending about two hours each working day on infection prevention program tasks, while the Administrator confirmed the facility had a full-time DON. When documentation of infection prevention certification was requested, the DON was unable to provide any certification. The Administrator also provided a job description for Infection Preventionist stating minimum qualifications included specialized training in infection prevention and control and working at least part time.
Pest Control and Food Protection Deficiency
Penalty
Summary
The facility failed to ensure the kitchen was free of pests during 2 of 2 kitchen observations. During an initial tour of the kitchen with the Kitchen Manager, gnats were observed in the dry storage room. On a follow-up kitchen visit with the Kitchen Manager, Mexican corn and Spanish rice were observed on the steam table and were not covered, and a fly was observed flying around the uncovered food. The Kitchen Manager later indicated there was an open drain in the dry storage room, which was where the pests were coming from. The Administrator also provided a current Maintenance Policy stating that the Director of Plant Operations will monitor contract services for pest control and assure the building is kept free of infestations of rodents or insects by maintaining window screens in good repair and eliminating sites of breeding and entry.
Missing care plans and monitoring for falls, palliative care, and seizures
Penalty
Summary
Resident L had a history of falling, dementia, and a displaced intertrochanteric fracture of the right femur. The resident’s assessments showed severe cognitive impairment and a high fall risk before the fracture, and after the hospital stay for surgical fixation of the right intertrochanteric femur fracture, the resident’s fall risk remained documented. A nursing note described an unwitnessed fall in which the resident was found on the floor next to a roommate’s bed, with a bedside table on the floor, severe right hip pain, external rotation of the right foot, and a shortened right leg. The DON later stated the resident fell while using the roommate’s bedside table to balance himself while attempting to sit on the roommate’s bed. The fall-related care plan included a bedside table with locked wheels, but observations after the fall showed a large wheeled bedside table remained in the room and its wheels were not locked. A smaller stationary table was also present but was not within reach of the resident’s bed or recliner. The DON stated the facility tried to replace the wheeled table with the smaller table, but the resident and family did not like it, so the wheeled table was left in the room. Resident S had COPD and was admitted under palliative care services with a terminal diagnosis and oxygen dependency, and a care plan conference was completed with the resident and family. However, the clinical record did not contain a care plan related to palliative care services. Resident M had epilepsy and was prescribed multiple anticonvulsants. After a witnessed seizure with tremors, blinking, and headache, the record lacked documentation of post-seizure observation or changes in condition. The DON stated staff should monitor the resident and notify the family and physician after a seizure.
Infection Control Failures With Catheter Care and Equipment Disinfection
Penalty
Summary
The facility failed to ensure proper infection control protocols for residents with indwelling catheters and during routine equipment use. Resident S had diagnoses including neurogenic bladder and obstructive uropathy, was cognitively intact, required partial to moderate assistance with toileting, and had a suprapubic catheter with Enhanced Barrier Precautions ordered. On observation, Resident S’s catheter bag was seen uncovered and lying on the floor beside the bed, and later was observed hanging on the arm of the motorized wheelchair above the level of the bladder. During a bed bath and perineal care, two CNAs provided direct care to Resident S without wearing a gown, despite the resident’s EBP order for gown and gloves during direct care. The facility also failed to maintain and disinfect equipment appropriately. A wrist blood pressure cuff/monitor on the medication cart had several layers of tape attached to the top, and the 800 Hall vitals machine’s oxygen saturation tubing had tape wrapped around the connection, with discolored tape ends. RN 3 was observed performing an Accu-Chek on a resident and returning the glucometer to the medication cart without cleaning it. LPN 2 was also observed performing catheter care on Resident 10 without wearing PPE while the resident was on Enhanced Barrier Precautions. The DON stated she was unaware of the tape on the equipment at first, later explained that parts had broken and tape had been used to keep them together, and indicated staff education was needed.
Failure to Notify Families of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the families of two residents regarding significant changes in their conditions. For one resident with a history of falls and impaired balance, the family was not informed of a fall and subsequent mental status change until they visited and observed the change themselves. The resident's Power of Attorney confirmed that notification only occurred after the family discovered the incident, and the assigned nurse acknowledged that the family should have been contacted at the time of the fall but was not due to other tasks being prioritized. In another case, a resident with epilepsy and a seizure disorder experienced multiple seizures, but there was no documentation of family, physician, or palliative care notification following these events. The resident's care plan specifically required notification of palliative services with all changes in condition. The DON confirmed that staff are expected to monitor and notify the family and physician after a seizure, but this did not occur. The facility's policy also requires notification of the resident, physician, and family or legal representative when there is a change requiring such notification.
Missing Self-Administration Assessment for Eye Drops
Penalty
Summary
The facility failed to ensure a self-administration assessment was completed for a resident who had eye drops in the room and was observed with medication access during a medication pass. On 8/1/25 at 6:55 A.M., a bottle of eye drops with no label was seen on the resident’s bedside table while the resident was lying in bed. After the resident’s medications were given, the LPN did not address the bottle until asked about it, then took it to the medication cart. The LPN stated the resident had an order for eye drops but did not have an order to self-administer them and did not have a self-administration assessment on file. A separate labeled bottle of eye drops for the resident was also observed in the medication cart, and the LPN stated the resident’s family sometimes brought in items such as the eye drops and the bottle would be returned to them. Record review showed the resident had diagnoses including dry eyes and a quarterly MDS dated 5/31/25 indicating no cognitive impairment and no behaviors. The resident required supervision or touching assistance for bed mobility and transfers. Current physician orders included Refresh Tears 0.5% solution, 1 drop in each eye every hour as needed for dry eyes, dated 5/13/25. The resident’s clinical record lacked a care plan related to self-administration of eye drops and lacked a self-administration assessment for eye drops. The facility’s Self Administration of Medications policy stated that a resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely.
Falls Care Plan Not Updated to Reflect Current Intervention
Penalty
Summary
The facility failed to revise a resident’s plan of care to reflect current interventions for falls. Resident 2 had diagnoses including a fracture to the right humerus and, on the most recent quarterly MDS dated 7/7/25, was noted to have mild cognitive impairment and no falls since the prior assessment. The resident’s current falls care plan, last revised on 7/30/25, did not include the intervention of a call don't fall sign in the resident’s room. A progress note dated 6/13/25 documented that Resident 2 fell and did not remember how it happened, and an immediate intervention was a call don't fall sign in place. An IDT note dated 6/16/25 stated the resident had fallen and would be evaluated upon return from the hospital for any new interventions. On 7/31/25, the resident’s room was observed with a call don't fall sign on the bathroom door, but the care plan had not been updated to include that intervention. The MDS Coordinator stated that falls were discussed at the morning clinical meeting and that new interventions would be added to the care plan, but for this resident the sign was not added after the fall and hospital stay.
Incorrect Foley Catheter Size Used
Penalty
Summary
The facility failed to ensure appropriate services and treatment for a resident with an indwelling urinary catheter when the catheter size used did not match the physician’s order. Resident B had diagnoses including ulcerative colitis, anxiety, and depression, and the most recent quarterly MDS dated 7/17/25 indicated no cognitive impairment and use of an indwelling urinary catheter. The physician’s orders specified a Foley catheter size of 16 French with a 30cc balloon, and the care plan included changing the catheter system when clinically indicated or ordered. The record showed that on 4/22/25 the resident’s indwelling catheter was changed using an 18 French catheter anchored with 20cc normal saline, and on 7/13/25 the catheter was replaced with a 20 French catheter after it was unable to flush. During observation on 8/4/25, the resident’s urine was noted to be bloody with bleeding from the vaginal area. An RN stated that the catheter size should be the size ordered by the physician and staff should not deviate from that size. The facility policy stated that use of an indwelling urinary catheter would be in accordance with physician orders, including the diagnosis or clinical condition, catheter size, and frequency of change if applicable.
Inaccurate Documentation for Catheter Care and Hospice Status
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for a resident with an indwelling urinary catheter. Resident B’s record showed diagnoses including ulcerative colitis, anxiety, and depression, and the quarterly MDS indicated no cognitive impairment and use of a Foley catheter. The physician order specified a 16 French/30 cc Foley catheter, and the care plan directed catheter changes when clinically indicated or ordered. However, a progress note documented that the catheter was changed with a 15g/30cc catheter, and the RN later stated urinary catheters come in sizes 14, 16, 18, or 20 and that there was no size 15g catheter, suggesting the entry may have been a documentation error. The facility also failed to accurately document the care status of Resident 21. The resident had diagnoses including renal failure, dementia, anxiety, depression, and psychotic disorder, and the quarterly MDS indicated mild cognitive impairment and that the resident was not on hospice. Current orders included comfort measures and no further hospitalizations or diagnostics, but there was no hospice order. Despite this, the care plan referenced hospice-related interventions, and psychiatry progress notes repeatedly stated the resident was recently placed on hospice and that hospice discontinued medications such as olanzapine and Namenda. The DON stated the resident was on comfort care through the facility NP and that the psychiatric provider likely assumed hospice because of the comfort care order, but the record contained hospice references without a hospice service order.
Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure adequate safety measures and supervision were in place to prevent accidents for two of three residents reviewed. One resident, who had a history of cerebrovascular accident (CVA) with left hemiplegia, unsteady gait, and required substantial assistance with transfers and toileting, was left unattended on a commode despite care plan interventions specifying two-person assistance and not to be left alone. This resident experienced a fall in the bathroom after staff briefly exited the room to retrieve linens, resulting in a head injury, laceration, and subarachnoid hemorrhage that required hospitalization. Documentation and interviews revealed inconsistencies in staff awareness and implementation of updated care plans, particularly regarding the required level of assistance and supervision for this resident. Another resident, with diagnoses including mild cognitive impairment, history of falls, and reduced mobility, was being transferred using a mechanical lift by only one staff member, contrary to facility policy and manufacturer guidelines requiring two staff for such transfers. During the transfer, the mechanical lift struck the bed frame, causing the resident to fall out of the sling and onto the floor. Staff statements and interviews confirmed that only one CNA was present during the transfer, and the care plan for this resident required a mechanical lift with two-person assistance for all transfers. The facility's policies on safe handling, transfers, and fall prevention were not consistently followed, as evidenced by the incidents involving both residents. Staff interviews indicated a lack of awareness or adherence to updated care plans and required procedures, contributing to the accidents. These deficiencies resulted in significant harm to one resident and placed both residents at risk for injury.
Inadequate PPE Use in Isolation Rooms
Penalty
Summary
The facility failed to maintain proper infection control practices and ensure the use of Personal Protective Equipment (PPE) when entering isolation rooms on three observed halls. Multiple staff members, including Activity Staff 2, CNA 6, CNA 2, CNA 3, and RN 2, were observed entering rooms with droplet precaution signs without donning the required PPE. Specifically, Activity Staff 2 entered a room with droplet precautions without wearing any PPE and subsequently entered other non-isolation rooms. CNA 6 also entered a room under droplet precautions without PPE. CNA 2 donned PPE but failed to tie the gown at the neck, contrary to the facility's policy. CNA 3 and RN 2 entered a room with droplet precautions without any PPE, despite the presence of PPE and signage indicating the need for it. The Director of Nursing (DON) confirmed that the staff were expected to follow the droplet precaution signs posted on the isolation rooms. The facility had rooms on isolation for Influenza A and Respiratory Syncytial Virus (RSV), and Norovirus had recently affected some residents and staff. The facility's policies on infection prevention and control, transmission-based precautions, and PPE usage were provided, indicating the requirements for PPE use in such situations.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner, as observed during two separate inspections of the kitchen and meal service. The kitchen floor was found to have debris along the walls, behind and under tables, equipment, racks, and in the dry pantry. Dietary Aide 2 was observed preparing salads without changing gloves after touching various surfaces and items, including a food scale and refrigerator handles, which could lead to contamination. Additionally, Dietary Aide 3 handled plates with bare fingers, and Dietary Aide 5 licked his fingers while organizing meal tickets, which were later sent with the plates of food to residents. Further observations revealed that Dietary Aide 4 touched plates with bare fingers where food was placed, and Dietary Aide 6 confirmed that gloves should be worn when touching food and changed after touching non-sterile surfaces. The facility's policies on food handling and kitchen cleaning were reviewed, indicating that employees should wash hands and change gloves after contact with non-sterile surfaces, and that cleaning tasks are assigned to specific positions. However, these policies were not adequately followed, leading to the cited deficiencies.
Failure to Provide Immediate Wound Care Orders for New Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident B, received immediate physician orders for the treatment of pressure wounds upon admission. Resident B, who was admitted in June 2024, had multiple pressure wounds, including a stage IV pressure ulcer on the right buttock and unstageable pressure ulcers. Despite the presence of these wounds, there were no recorded orders for wound treatments from the date of admission until three days later. The facility's policy requires that a physician or other qualified healthcare professional provide written or verbal orders for a resident's immediate care upon admission, which was not adhered to in this case. Interviews with facility staff revealed that wound treatments should have been initiated upon admission, even if temporary, until a full assessment could be conducted by the facility's wound nurse. However, treatments were only clarified and initiated several days after admission. The facility's Director of Nursing provided the current admission orders policy, which mandates that essential care orders be in place consistent with the resident's condition upon admission. This deficiency was identified during a complaint investigation related to Resident B's care.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to respect the privacy of residents during routine care and medical procedures, as observed in multiple instances. Staff members, including a Registered Nurse (RN), a Qualified Medication Aide (QMA), and a Licensed Practical Nurse (LPN), were seen entering residents' rooms without knocking or announcing themselves. This lack of privacy was noted in six random observations involving different residents. Additionally, during an insulin administration, the LPN did not close the door or draw the curtain, further compromising the resident's privacy. The Director of Nursing (DON) acknowledged the absence of a formal privacy policy, although a Nurse Aide Procedure check-off form was available, which instructed staff to knock and identify themselves before entering a resident's room and to maintain privacy by closing curtains, drapes, and doors. Despite these guidelines, the staff's actions did not align with the expected standards, leading to a deficiency in maintaining residents' rights to privacy and dignity.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administer medications were properly assessed for their ability to do so. This deficiency was observed in four residents who had medications in their rooms without the necessary assessments or orders. Resident 7, who had a moderate cognitive impairment and required assistance with daily activities, was found with throat lozenges in her room without an order or assessment for self-administration. The nurse acknowledged the presence of the medication but did not remove it, indicating a lack of adherence to the facility's policy. Similarly, Resident S, who had no cognitive impairment but required assistance with mobility and toileting, was found with a nasal spray in her room. The nurse was unsure if there was a current order for the nasal spray and left it in the room without verifying the necessary documentation. Resident 150, who also had no cognitive impairment, was found with an inhaler and unlabeled Tylenol in his room, again without the required self-administration order or assessment. The unit manager was uncertain about the policy for medications in resident rooms, highlighting a lack of clarity and enforcement of procedures. Resident 6, who was cognitively intact and had diabetes, was observed with glucose shots on her bedside table. Despite the need for these medications, there was no self-administration evaluation or order in her clinical record. The facility's policy required an interdisciplinary team assessment and documentation for self-administration, which was not followed in these cases. This oversight in ensuring proper assessments and orders for self-administration of medications led to the deficiency identified by the surveyors.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, as evidenced by multiple resident complaints and a test tray showing inadequate food temperatures. On several occasions, residents reported that their meals were not hot, with specific instances noted on 5/29/24 and 5/30/24. During a Resident Council meeting on 5/31/24, it was mentioned that food trays stayed in the hallways too long, causing the food to become cold. On 6/3/24, the process of serving lunch was observed, revealing delays between food preparation and delivery. The lunch cart was delivered to the 400 hall at 11:56 A.M. but was not immediately distributed, with staff beginning distribution at 12:01 P.M. A test tray obtained at 12:12 P.M. showed that the carrots were at 116°F, below the facility's policy requirement of at least 135°F for hot food. The Dietary Manager confirmed the expected temperature range for serving hot food, and the facility's Food Temperature Monitoring policy, revised in 12/22, was provided, indicating the requirement for hot food to be served at a minimum of 135°F.
Sanitation and Glove Usage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, as observed during three separate kitchen inspections. In the reach-in freezer, items such as a slice of orange melon and small ice cream containers were left open to air, and in the walk-in freezer, french fries and a bag of mixed vegetables were similarly exposed. The walk-in refrigerator contained a broken egg, expired rice, and a boiled egg on the floor, along with other items like a bag of grapes and a container of boiled eggs in liquid that were open to air. Additionally, the dry pantry had packets of sugar, salt, and pepper on the floor, and the walk-in refrigerator had bacon on the floor and standing water by the shelves. In the main dining room's holding refrigerator, expired chocolate and fat-free milk containers were found, along with a whole milk container lacking a use-by date. The facility also failed to adhere to proper glove usage standards during food preparation. An employee was observed preparing pureed chicken without changing gloves after handling trash, which is against the facility's Glove Usage With Food Contact policy. The Dietary Manager acknowledged that staff were responsible for cleaning out the refrigerator daily, yet expired items were still present. The facility's policies on leftovers and glove usage were not followed, contributing to the unsanitary conditions observed during the survey.
Infection Control Deficiencies in Resident Care and Hand Hygiene
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent infection transmission, as evidenced by multiple observations of uncovered resident care items and inadequate hand hygiene practices. Specifically, uncovered washbasins were found on the floor in Resident 7's bathroom on two separate occasions, and an uncovered washbasin was observed in the sink of Resident 46's bathroom. Additionally, an uncovered toothbrush was noted on the back of the sink in Resident 20's bathroom, with staff indicating a lack of provided covers for these items. Furthermore, staff failed to adhere to hand hygiene protocols in rooms with enhanced barrier precautions. Qualified Medication Aide (QMA) 23 was observed entering and exiting Resident 37's room without sanitizing hands, despite a sign indicating the necessity of hand hygiene. Similarly, QMA 23 entered Resident D's room with a blood pressure machine and failed to perform hand hygiene before and after room entry. These actions were contrary to the facility's Enhanced Barrier Precautions policy, which mandates hand sanitization before entering and upon leaving rooms to prevent the transmission of multidrug-resistant organisms.
Facility Fails to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by multiple observations of gnats in various areas of the facility. During the survey, gnats were observed in a resident's room, the Nursing Manager's office, the ADON's office, the main dining room, the 300 hall nurse station, and the dry pantry in the kitchen. Resident 84 reported a problem with gnats in her room, which was confirmed by observation. The ADON suggested that the gnats might have been stirred up when the fire department flushed some pipes over the weekend. The facility's current pest control policy, dated 3/7/23, states that it is the policy of the facility to maintain an effective pest control program and provide a safe environment free of pests. However, the presence of gnats in multiple areas indicates a failure to adhere to this policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) Assessment for two residents, leading to discrepancies in their medical records. Resident 6, diagnosed with malignant neoplasm of the descending colon, was reported as cognitively intact and not receiving opioids during the 7-day lookback period of the MDS assessment dated 4/28/24. However, the Medication Administration Record (MAR) for April 2024 indicated that Resident 6 received oxycodone-acetaminophen multiple times and had a fentanyl patch applied on several occasions within the lookback period. The MDS Coordinator acknowledged that the MDS should have reflected the administration of opioids. Similarly, Resident 7, with a history of cerebrovascular accident (CVA) and moderate cognitive impairment, was inaccurately marked as not receiving antiplatelet medication in the MDS assessment dated 5/7/24. Despite this, the MAR for May 2024 showed that clopidogrel, an antiplatelet medication, was administered during the 7-day lookback period. The MDS Coordinator confirmed the error and noted the absence of a facility policy for MDS assessments, relying instead on the Resident Assessment Instrument (RAI) manual for guidance.
Failure to Follow Physician Orders for Nutrition and Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders for two residents regarding their nutritional and weight management needs. Resident 55, who has diagnoses including dementia and epilepsy, was noted to have a significant unplanned weight loss of over 10% in six months. Despite physician orders for weekly weight monitoring and specific nutritional supplements, there were multiple instances where the nutritional supplements were not administered as ordered, with no documented reasons for these omissions. This lack of adherence to physician orders contributed to the resident's continued weight loss. Resident S, diagnosed with renal failure, had physician orders for daily weight monitoring, especially before dialysis, to manage potential weight fluctuations. However, the clinical record showed numerous missing weight entries over a two-month period, and some recorded weights were later crossed out without re-weighing or proper documentation. The Unit Manager indicated that weights were sometimes deleted if they seemed inconsistent, but there was no formal policy to guide this practice. This inconsistency in following physician orders and documenting weights could impact the resident's care and treatment plan.
Failure to Provide Adequate Assessment and Care Plan for Narcotic Use
Penalty
Summary
The facility failed to provide adequate care for Resident P by not conducting a thorough assessment prior to administering narcotic medication and not implementing a person-centered care plan for narcotic use. Resident P, who was cognitively intact and had diagnoses including asthma and atrial fibrillation, was receiving opioid pain medication. The clinical record lacked a care plan addressing the potential adverse side effects of narcotic pain medications. Additionally, there was a discrepancy in the care plan regarding resuscitative measures, as it inaccurately indicated the resident was a full code despite having a 'Do Not Resuscitate' order. On the day of the incident, Resident P was administered Norco multiple times, and later in the evening, the resident's oxygen saturation dropped significantly. Despite being alert and oriented earlier, Resident P was unable to rouse or swallow medications at bedtime. Emergency services were called, but CPR was not initiated as the resident stopped breathing. The LPN involved acknowledged the chaotic situation and the failure to update the electronic medication administration record to reflect that the resident did not take the medications. The facility also lacked a policy for monitoring adverse side effects of narcotic medications.
Failure to Update Care Plans and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that post-fall assessments were completed and care plans were updated to prevent falls for two residents. Resident 40, who has a history of falls and moderate cognitive impairment, experienced seven falls over a period of time. Despite interventions being added to the care plan after each fall, such as providing a reacher, placing non-skid strips, and adding a cushion to the wheelchair, the resident continued to fall. Notably, after the seventh fall, neurological assessments were incomplete, indicating a lapse in following the facility's protocol for unwitnessed falls. Resident 83, who has hemiplegia and muscle weakness, was identified as being at high risk for falls. The resident experienced two unwitnessed falls while attempting to go to the bathroom. After the first fall, neurological assessments were conducted, but after the second fall, no neurological assessments were documented, and no new interventions were added to the care plan. This indicates a failure to adhere to the facility's policy of updating care plans with new interventions after each fall. The Director of Nursing acknowledged that neurological assessments should be completed per policy for unwitnessed falls or suspected head injuries and documented in the electronic medical record. However, the facility's failure to consistently perform and document these assessments, as well as update care plans with relevant interventions, contributed to the deficiency in providing adequate supervision and accident prevention for the residents.
Inadequate Pain Management and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in significant deficiencies. Resident T, who suffered from arthritis and gout, was not properly monitored for side effects of narcotic pain medication, leading to an overdose. Despite receiving scheduled pain medications, Resident T experienced moderate pain and was not adequately monitored for narcotic side effects, as required by physician orders. The resident was hospitalized due to an unintentional narcotic overdose, which was resolved with Narcan administration. Additionally, there were discrepancies in the administration of Norco, with instances of incorrect dosages being given, either more or less than prescribed, without documented reasons. Resident 6, who had a history of malignant neoplasm of the descending colon, anxiety disorder, and depression, reported constant pain and expressed a preference for non-pharmacological pain relief methods, such as a heating pad, which she used at home. However, the facility did not honor her preference, citing safety concerns about heating devices in resident rooms. Although the resident was receiving opioid medications, her care plan included non-pharmacological approaches, which were not implemented. The facility's staff indicated that thermal therapy could be provided through therapy services, but there was no clear process for continuing such treatment after discharge from therapy. The facility's policies on medication administration and monitoring were not effectively followed, contributing to the deficiencies in pain management. The Director of Nursing acknowledged the lack of monitoring for narcotic side effects and the absence of a specific policy for following physician orders. Additionally, there was no policy for the use of heat as a non-pharmacological pain relief method, leading to confusion among staff about how to provide such interventions. These failures highlight the need for improved adherence to professional standards of practice and resident care plans to ensure effective pain management.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate during a medication pass observation. Two residents were involved in the errors. For Resident 17, an LPN administered two chewable calcium carbonate tablets along with other medications in the same cup, which were meant to be chewed separately. Additionally, the LPN removed and applied a rivastigmine patch with bare hands, contrary to the facility's policy requiring gloves for such procedures. For Resident 6, the LPN administered an insulin injection without adhering to the proper technique. The LPN drew up 9 units of Admelog and injected it into the resident's abdomen without keeping the needle in the skin for the recommended duration to ensure absorption. This was against the facility's insulin administration policy, which specifies that the needle should remain in the skin for a count of five seconds. These actions were inconsistent with the facility's medication administration policies, contributing to the observed medication error rate.
Inaccurate Documentation of Glucometer Reading and Incomplete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure accurate documentation for a resident's glucometer reading and post-fall assessments for another resident. During an observation, an LPN performed a glucose reading on a resident and recorded a reading of 177. However, the blood sugar summary provided later indicated a reading of 175 for the same time. This discrepancy highlights a failure in maintaining accurate medical records as confirmed by an RN who stated that blood sugar readings should be documented accurately. Additionally, the facility did not complete post-fall assessments for a resident who had a fall in the shower. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was dependent on assistance for activities of daily living. The post-fall assessment initiated on the day of the fall lacked documentation for several shifts, indicating incomplete charting. The Regional Nurse Consultant confirmed that all blanks should be filled on the fall assessment sheet, as per the facility's policy on documentation in medical records.
Deficiency in Daily Staffing Sheet Posting
Penalty
Summary
The facility failed to ensure that accurately completed staff sheets were posted daily for six out of seven days during the survey period. On multiple occasions, the posted staffing sheets, which were observed sitting on a table across from the nurse's station, lacked the designation of actual shift hours worked for various nursing staff, including RNs, LPNs, and CNAs. Specifically, the sheets did not include the actual hours worked for certain shifts, such as the 2 P.M. to 10 P.M. shift for LPNs and CNAs, and the 6 A.M. to 2 P.M. shift for RNs. This omission was noted on several dates, including 5/28, 5/29, 5/30, 5/31, 6/3, and 6/4. During an interview, the Director of Nursing (DON) indicated they were unaware of the requirement to designate the actual hours worked for half shifts on the staffing sheets. The facility's policy, revised in October 2022, mandates that the total number and actual hours worked by nursing personnel responsible for direct care be posted daily prior to each shift. Despite this policy, the facility did not comply with the requirement, leading to the noted deficiencies in the staffing sheets.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 285 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Newburgh | 1.4 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare - Woodlands Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Newburgh Health And Rehab | 2.2 mi | ★★★★★ | 29 | 0 |
| Cypress Grove Rehabilitation Center | 2.9 mi | ★★★★★ | 7 | 0 |
| River Pointe Health Campus | 3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hamilton Pointe Health And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.