Hamilton Park Nursing And Rehabilitation Center
Hamilton Park Nursing and Rehabilitation Center in Brooklyn, NY — inspection on February 25, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 02/24/2025 at 12:09 PM, the Maintenance Technician stated they ran out of compound to patch the holes in the walls and that the resident's room is not homelike because of the way the bathroom looks.
During an interview with the Maintenance Director on 02/21/2025 at 11:35 AM, they stated they were not aware of the holes in the bathroom.
During a follow-up interview on 02/24/2025 at 01:49 PM, the Maintenance Director stated they are aware of the missing bathroom tiles when they did their rounds a few weeks ago but had other repairs to do.
They stated they will repair the bathroom on the 6th floor as well.
On a subsequent interview with the Maintenance Director on 02/25/2025 at 11:01 AM, they stated the leak in the bathroom in room [ROOM NUMBER] must have occurred the week before since the bathroom was recently painted.
They stated the orange expansion foam under the toilet was applied because the toilet was dropping.
The foam will be cut off and sheet rock will be replaced soon.
The Maintenance Director stated they have a maintenance book at the nurse's station and is not sure if the issues in the bathroom were reported.
The Maintenance Director further stated the room is tough to repair because both residents have to come out of the room to fix the issues and they cannot return until the paint smell is gone.
During an interview on 02/24/2025 at 02:42 PM, the Director of Housekeeping stated shower scrubbing is done once a month.
They stated they noticed the missing tiles and that maintenance is aware of the issue.
The Director stated that some stains lighten when their cleaned but do not go away.
During an interview on 02/25/2025 at 03:02 PM, the Administrator stated they made rounds on the 5th floor last month and on the 6th floor 3 months ago.
The Administrator stated they did not identify any concerns during these rounds. 10 NYCRR 415.5 (h)(2)
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Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228
reviewed, and revised by a team of health professionals.
record review and interview during the Recertification Survey conducted from 02/18/2025 to
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 severe impairment in cognition.
A social service notes dated 12/30/2024 at 12:32 PM documented a quarterly comprehensive care plan meeting was held with interdisciplinary team and resident remains in hospice.
A comprehensive care plan related to hospice care was initiated on 12/17/2023.
There was no documented evidence the care plan was reviewed and revised after each quarterly review assessments dated 03/12/2024, 06/12/2024, and 09/24/2024.
On 02/21/2025 at 10:28 AM, Registered Nurse #1 was interviewed and stated Resident #33 is currently in hospice.
They stated either the Registered Nurses or the Social Workers are responsible for reviewing the care plans quarterly.
On 02/21/2025 at 1:17 PM, Social Worker #1 was interviewed stated Resident #33 is on hospice and is currently being seen by the Hospice Care Team.
Social Worker #1 stated the care plan for hospice was initiated on 12/17/2023 and that they missed the quarterly review and updates.
They stated that Nursing or Social Service are responsible for reviewing and updating the care plans.
On 02/25/2025 at 10:31 AM, the Director of Nursing was interviewed stated the facility only has a few residents in hospice and does not understand why the care plan related to hospice was not reviewed and updated.
The Director of Nursing stated they will speak with the nursing and other departmental staff to update the necessary care area to prevent this issue from happening again. 10 NYCRR 415.11(c)(2)(i-iii)
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Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228
#102 was assessed for adverse effects related to the missed Venlafaxine doses.
Venlafaxine doses.
On 02/21/2025 at 11:49 AM, Licensed Practical Nurse #3, was interviewed and stated they were the medication nurse for the day shift on 02/07/2025, 02/08/2025, 02/18/2025, 02/19/2025, and 02/20/2025.
They stated Resident #102 was not administered Venlafaxine because the medication was not in the cart.
Licensed Practical Nurse #3 stated Venlafaxine had been missed for over 3 or 4 days.
Licensed Practical Nurse #3 stated they did not inform the Charge Nurse and the physician that Venlafaxine was not available, and that they reported it to the nursing supervisor and the Assistant Director of Nursing on 02/20/2025.
On 02/24/2025 at 09:55 AM, License Practical Nurse #2 was interviewed and stated they were the medication nurse for the day shift on 02/17/2025.
They stated Resident #102's Venlafaxine was not administered because it was not available in the medication cart.
They stated they told the charge nurse on 02/17/2025 but cannot recall if they followed up with the pharmacy or if they endorsed it to the next shift.
License Practical Nurse #2 stated they did not monitor Resident #102 for adverse reactions to missed Venlafaxine dose.
On 02/24/25 at 03:19 PM, License Practical Nurse #1 was interviewed and stated they were the medication nurse for the evening shift on 02/18/2025.
Licensed Practical Nurse #1 stated Resident #102's Venlafaxine was not administered because it was not available and was not in the medication cart.
Licensed Practical Nurse #1 stated they did not notify the physician that Venlafaxine was not available and did not monitor Resident #102 for negative effects of missed Venlafaxine dose.
On 02/25/2025 at 10:38 AM, Physician #1 was interviewed and stated they were made aware a few days ago that Resident #102 was not administered Venlafaxine, and they instructed the staff to call the pharmacy to get a STAT delivery.
Physician #1 stated they had not received a call on the earlier dates that Venlafaxine was not available.
On 02/25/2025 at 09:39 AM, the Director of Nursing was interviewed and stated they were not aware that Resident #102's Venlafaxine was not administered due to not being available.
The Director of Nursing stated nursing supervisors are trained to inform the physician when a medication is not available to see if an alternative can be suggested. 10 NYCRR 415.11(c)(3)(i)
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that Resident #102's Venlafaxine was not administered due to not being available.
They stated nurses
alternative can be suggested.
10 NYCRR 415.12(m)(2)
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Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228
is responsible for checking and putting specific items on the resident's tray by reading the meal
the resident's tray and meal ticket and everyone including the final checker missed the allergy.
10 NYCRR 415.14(d)(4)
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Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228
During an interview on 02/18/2025 at 01:07 PM, Certified Nursing Assistant #4 stated they did not touch the lettuce and bun with their bare hands.
They stated they used wipes to clean their hands and that they washed their hands before they touch the bread and cut the sandwich for Resident #95.
During an interview on 02/24/2025 at 03:04 PM, Registered Nurse # 3 stated staff should not touch food with their bare hands because it is unsanitary even if they washed their hands.
During an interview on 02/25/2025 at 11:40 AM, the Infection Preventionist stated gloves must be used when handling sandwich.
They stated sandwiches are assembled and wrapped in the kitchen and staff must put on gloves when handling them. 10 NYCRR 415.14 (h)
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Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228
02/18/2025 to 02/25/2025, the facility did not ensure infection control practices and procedures
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 documented Triad Hydrophilic Wound Dress External Paste, apply to sacrum topically every shift for pressure ulcer; cleanse wound with normal saline, pat dry, apply Triad paste and cover with foam dressing.
On 02/24/2025 at 10:18 AM, wound care observation was conducted for Resident #130 with Licensed Practical Nurse #4.
Licensed Practical Nurse #4 came into the room, placed down the supplies, and washed their hands.
Licensed Practical Nurse #4 donned gloves, then removed Resident #130's soiled dressing from the wound on their Sacrum.
Without removing the soiled gloves and without performing hand hygiene, Licensed Practical Nurse #4 proceeded to clean the wound.
After cleaning the wound, Licensed Practical Nurse #4 removed their gloves performed hand hygiene, donned clean gloves, then applied the treatment and placed the clean dressing on the wound.
Licensed Practical Nurse then removed their gloves and performed hand hygiene.
On 02/24/2025 at 10:30 AM, Licensed Practical Nurse #4 was interviewed and stated they were instructed to remove the soiled dressing, cleanse the wound, then remove gloves and perform hand hygiene before applying treatment.
On 02/24/2025 at 10:43 AM, Registered Nurse #4 was interviewed and stated that hand hygiene is supposed to be performed after removing the soiled dressing and before cleaning the wound.
On 02/25/2025 at 12:54 PM, the Director of Nursing was interviewed and stated that hand hygiene is supposed to be performed after removing the soiled dressing, then again after cleaning the wound and also before applying the treatment and clean dressing. 10 NYCRR 415.19(b)(4)
During dining observation on 02/18/2025 at 12:31 PM, Resident #342 was in the unit dining area sitting with their next of kin.
The Resident's lunch tray had a container of mushroom soup. Resident #343's lunch meal ticket dated 2/18/2025 documented pureed cream of mushroom soup.
The bottom of the meal ticket documented that Resident #343 had allergy to mushrooms and it was highlighted in red.
The Resident's next of kin removed the mushroom soup from the Resident's tray.
The Dietary Admission Nutrition Risk assessment dated [DATE] documented that Resident #343 had food allergies to Mushroom.
A medical progress note dated 02/18/2025 documented Resident #343 had allergies to pork and mushroom.
A care plan on allergies was initiated for Resident #841 on 10/21/2024.
The facility interventions include alerting appropriate discipline for any drug and food allergy.
On 02/18/2025 at 12:32 PM, Resident #343's next of kin was interviewed and stated that Resident is allergic to mushroom.
On 02/18/2025 at 02:13 PM, Certified Nursing Assistant #1 was interviewed and stated they were not trained to read the allergies in the meal tickets and that it is the nurse who checks for allergies.
On 02/18/2025 at 02:18 PM, Certified Nursing Assistant #2 was interviewed and stated they gave the lunch tray to Resident #343 but did not look at the diet or the allergies listed on the meal ticket.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335710 B.
Wing 02/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.