Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Grove during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was discharged home, but the responsible party was not provided with the required written Notice of Medicare Non-Coverage or bed-hold information. Although the resident received and signed the NOMNC, staff confirmed that the responsible party, who was designated as the resident's representative, did not receive these notifications, and the facility could not produce the relevant policy when requested.
A resident with multiple chronic conditions was discharged without a documented discharge care plan, and the responsible party was not invited to participate in care planning meetings. Despite facility policy requiring involvement of the resident and their representative, neither were included in the discharge planning process.
The facility did not notify a physician of changes in condition and missed or refused medication doses for two residents with complex medical histories. One resident missed several scheduled medications without documentation or physician notification, while another experienced a low blood pressure reading that was not reported to the medical provider or family, contrary to facility policy.
Two residents receiving antipsychotic medications did not receive required quarterly AIMS assessments as per facility policy. One resident with multiple psychiatric and medical diagnoses had not had an AIMS assessment for several months, and another resident with a psychotic disorder had only one AIMS assessment documented in the past year, despite daily antipsychotic use. The DON confirmed that the facility's policy for quarterly monitoring was not followed.
Surveyors found that the facility did not consistently label, date, or dispose of opened and expired food items in the kitchen. During inspection, multiple food products were observed either expired or lacking required dates, and the CDM confirmed that opened foods should be dated and used within three days. The facility's policy also required proper labeling and timely disposal, but these procedures were not followed, potentially affecting all residents receiving meals.
Surveyors observed that a resident's personal refrigerator contained multiple expired and spoiled food items, including undated juice with visible spoilage and a bowl of moldy, unidentifiable food. Staff interviews revealed uncertainty about who was responsible for cleaning out personal refrigerators, despite facility policy requiring proper labeling, dating, and disposal of stored food.
The facility failed to accurately transcribe and administer medications for two residents. One resident with heart failure did not receive Lasix as ordered, and a vitamin supplement was not administered correctly. Another resident with multiple diagnoses missed several medication doses due to a lack of coordination between the facility and pharmacy, and failure to notify the physician of missed doses.
A resident with multiple sclerosis and impaired mobility developed unstageable pressure ulcers on both heels due to the facility's failure to implement and monitor necessary interventions. Despite being at moderate risk, the resident's condition deteriorated, with inconsistent documentation and lack of communication among staff contributing to the issue.
The facility failed to develop person-centered care plans for four residents, leading to inadequate management of activities, behaviors, ADLs, and dementia care. Observations and interviews confirmed that the care plans were not tailored to the residents' specific needs.
A facility failed to provide adequate ADL care for a resident dependent on staff for bathing, hygiene, and dressing. Observations showed the resident was not shaved and had long, dirty fingernails. The care plan lacked documentation on the resident's refusal of care, and staff interviews confirmed no proper plan was in place to address these refusals.
The facility failed to provide adequate activities for three residents, leaving them unengaged and unsupported in their physical, mental, and psychosocial well-being. Observations showed residents sitting alone without activities, and care plans were not person-centered or effectively implemented.
The facility failed to secure a resident's cigarettes at the Nurse's Station, despite a care plan and facility policy requiring smoking materials to be kept by staff. The resident was found with smoking materials in his room on multiple occasions, and staff interviews confirmed that the cigarettes should have been secured.
The facility failed to prevent a resident with severe cognitive impairment from wandering into other residents' rooms. Despite interventions like Velcro STOP signs and a wandergard, the resident continued to enter rooms, causing frustration among other residents. Staff were often unaware of the resident's location and had to manually redirect her.
The facility failed to ensure shift narcotic count sheets were completed and documented every shift for one of the two narcotic books observed. Missing signatures indicated that narcotics were not counted every shift, contrary to the facility's policy.
The facility failed to ensure that a resident receiving an opioid and an anti-anxiety medication had appropriate indications and was monitored for adverse side effects. The resident's records lacked documentation for why the medications were given and did not show any nonpharmacological interventions tried prior to administering the medications. The ADON confirmed that the medications should not have been given together and that proper documentation and assessment were not followed.
The facility failed to remove expired medications from the medication cart and did not adequately monitor the medication refrigerator's temperature, leading to a large build-up of ice. Interviews with RNs confirmed these lapses, and a policy on these procedures was not provided before the survey exit.
The facility failed to ensure proper catheter orders and care for a resident with severe cognitive impairment and an indwelling catheter. There were no physician's orders for the catheter, and intake and output were not consistently documented as required. The facility's Catheter Care Policy was not followed, and the Director of Nursing confirmed the deficiency.
Failure to Notify Responsible Party of Medicare Non-Coverage and Bed-Hold Policy
Penalty
Summary
The facility failed to provide the required written Notice of Medicare Non-Coverage (NOMNC) to the responsible party for a resident who was discharged home with family. The resident, who had multiple diagnoses including a fractured sacrum, chronic bronchitis, COPD, repeated falls, altered mental status, depression, anxiety, and liver cancer, was admitted and later discharged from the facility. Documentation showed that the resident was cognitively intact and required varying levels of assistance with activities of daily living. The resident participated in care planning and expressed a goal to return home, but the responsible party did not participate in the care plan meeting. Record review and staff interviews confirmed that while the resident personally received and signed the NOMNC form, the responsible party—identified in the admission agreement as the resident's representative—was not provided with the NOMNC or any bed-hold information as required by facility policy. The DON and Administrator both acknowledged that the responsible party had not been sent the necessary notifications. Additionally, when requested, the facility was unable to provide a policy for Admission, Transfer, and Discharge.
Failure to Develop Discharge Care Plan and Involve Resident Representative
Penalty
Summary
The facility failed to develop and implement a discharge care plan for one resident who was reviewed for discharge planning. The resident, who had multiple diagnoses including a fractured sacrum, chronic bronchitis, COPD, repeated falls, altered mental status, depression, anxiety, and liver cancer, was admitted and later discharged home with family. Although the resident was cognitively intact and participated in therapies and goal setting for discharge, there was no evidence that a discharge care plan was created or included in the comprehensive care plan. Additionally, the discharge assessment did not indicate involvement of the resident or the resident's responsible party in the discharge planning process. The facility also did not ensure that the resident's responsible party, who was identified as the resident's representative in the admission agreement, was invited to participate in care planning meetings. Interviews with the DON and Administrator confirmed that neither the resident's family nor responsible party were provided invitations or notifications for care plan meetings, despite facility policy requiring their involvement. Documentation showed that the resident was notified of Medicare non-coverage and signed the appropriate form, but this did not substitute for the required discharge planning and involvement of the resident's representative.
Failure to Notify Physician of Change in Condition and Missed Medications
Penalty
Summary
The facility failed to notify a physician of changes in condition and missed medication doses for two residents. For one resident with multiple diagnoses including dementia, depression, anxiety, and cardiovascular conditions, the Medication Administration Record showed missed and refused doses of olanzapine, melatonin, and pravastatin on several dates. There was no documentation explaining why the medications were not administered on one occasion, nor any evidence that the physician was notified of the refusals or missed doses. The Assistant Director of Nursing confirmed the lack of documentation and was unable to determine why the medications were not given or if the physician had been informed. For another resident with diagnoses such as vascular dementia, chronic kidney disease, and a history of cerebrovascular events, a nursing progress note documented a low blood pressure reading. The clinical record did not show that the medical provider or family was notified of this low blood pressure. Interviews with nursing staff and the Director of Nursing confirmed that the nurse should have re-checked the blood pressure and notified the physician, but there was no evidence this occurred. Facility policies required notification of physicians and families for acute condition changes and documentation of medication refusals, which was not followed in these cases.
Failure to Perform Required Quarterly AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to ensure adequate monitoring of antipsychotic medications for two residents who were prescribed these drugs. For one resident with diagnoses including dementia, major depressive disorder, and generalized anxiety disorder, the record showed that an Abnormal Involuntary Movement Scale (AIMS) assessment was last completed on 12/2/2024, with no further documentation of quarterly assessments as required by facility policy. The Director of Nursing confirmed that the resident had not received the required quarterly AIMS assessments while on olanzapine. For another resident with psychotic disorder with delusions and major depressive disorder, documentation revealed that only one AIMS assessment was completed in the past year, despite the resident receiving daily antipsychotic medication and the care plan specifying quarterly AIMS assessments. The DON acknowledged that the required quarterly assessments had not been performed for this resident in 2024. The facility's policy mandates AIMS assessments on admission, quarterly, with changes in condition or medication, or as needed, but this was not followed for these two residents.
Failure to Properly Label, Date, and Dispose of Opened and Expired Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in a sanitary manner in the kitchen, specifically regarding the labeling, dating, and disposal of opened and expired food items. During a kitchen inspection with the Certified Dietary Manager (CDM), several food items in the walk-in cooler, such as smoked turkey, cut up purple and white onions, premade chicken salad, and Virginia ham, were found either expired or lacking an opened on or use by date. Additionally, other items including leaf tarragon, ranch powder, red food coloring, and chopped chives were found open without proper labeling or had expired. The CDM confirmed during an interview that all opened food should be dated with the day it was opened and used within three days or discarded. The facility's policy, as provided by the Administrator, required all foods to be properly labeled and dated, and for prepared or opened food items to be discarded if left over for more than 72 hours. These observations and interviews demonstrated that the facility did not consistently follow its own food storage and labeling policies, potentially affecting all residents who received meals from the kitchen.
Expired and Spoiled Food Found in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary environment by not properly disposing of expired food in a resident's personal refrigerator. During an observation, surveyors found multiple expired food items, including a container of parmesan cheese, single-serve cups of chocolate and vanilla pudding, and two cups of juice with no dates, both of which showed signs of spoilage such as separation and a thick white substance. Additionally, a bowl with a lid contained unidentifiable, moldy food with no date. When interviewed, an RN was unsure who was responsible for cleaning out residents' personal refrigerators, while the DON stated it was the nurse's responsibility. The facility's policy required food to be labeled, dated, and discarded per safe food storage guidelines, but this was not followed in this instance.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility failed to ensure accurate transcription and timely administration of medication and supplement orders for two residents. Resident C, who had diagnoses including chronic obstructive pulmonary disease and heart failure, had a physician's order to increase Lasix to 80 mg per day. However, the medication was only administered twice over a period of more than a month. Additionally, an order to increase Occuvite to twice daily was not properly transcribed, resulting in it being administered only once daily. The Assistant Director of Nursing (ADON) acknowledged that there was no system in place to audit new physician orders for accuracy and timeliness until September, when the Interdisciplinary Team (IDT) began reviewing new orders during morning meetings. Resident J, diagnosed with multiple sclerosis, cerebral palsy, and seizures, did not receive several medications as ordered upon admission. The facility's pharmacy did not send medications because they were informed that the resident had brought his own supply, and the nursing staff directed the pharmacy not to send additional medications. Despite this, there were no nursing notes indicating that the physician was notified of the missed doses. The facility's policy required a second nurse to review transcribed orders for accuracy, but this process was not followed, leading to multiple missed doses of critical medications.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of unstageable pressure ulcers and did not provide necessary treatment and services to promote healing and prevent infection for a resident who was admitted without pressure ulcers. The resident, who had multiple sclerosis, edema, neuropathy, and hypertension, was at risk for pressure ulcers due to impaired mobility and required substantial staff assistance. Despite being identified as at moderate risk for pressure ulcers, the resident developed deep tissue injuries on both heels, which deteriorated into more severe pressure injuries. The facility's care plan for the resident included interventions such as daily skin observation, Braden Scale assessments, heel protectors, and moisturizing the heels. However, these measures were not effectively implemented or monitored. The resident's pressure ulcers were not promptly assessed or documented, and there was a lack of communication and coordination among the nursing staff, nurse practitioners, and wound care specialists. The facility also failed to provide complete pressure relief to the resident's heels, both in bed and out of bed, and did not adequately address the resident's refusal to wear pressure-relieving boots. The facility's documentation was inconsistent and incomplete, with missing assessments and evaluations of the resident's pressure ulcers. The nursing staff continued to document outdated treatments, and there was no evidence of timely wound culture results or appropriate adjustments to the care plan. The facility's failure to monitor and evaluate the impact of interventions, as well as revise them as necessary, contributed to the deterioration of the resident's condition and the development of additional pressure ulcers.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for activities, behaviors, ADLs, and dementia care for four residents. Resident 25 was observed not participating in activities and was often found in bed. Her care plan did not reflect her preferences and needs, as she had severe cognitive impairment and exhibited delusions and physical behaviors. Despite interventions like providing reading material and one-on-one interactions, the care plan was not effective, and the Activity Director confirmed it was not person-centered. Nurses' notes indicated frequent episodes of yelling and confusion, which were not adequately addressed in the care plan. Resident 23 had a care plan that did not adequately address his dementia and behavior disturbances. The care plan included general interventions like calling the resident by his preferred name and keeping routines consistent, but it was not tailored to his specific needs. The Infection Prevention Nurse confirmed that the care plan was not person-centered. Resident 36 was observed with poor personal hygiene, including unshaved facial hair and dirty fingernails. His care plan did not document his refusal of ADLs, and the ADON confirmed that there should have been a care plan addressing his refusals. Resident 53's care plan also lacked person-centered interventions for her severe cognitive impairment. The Assistant Director of Nursing confirmed that the care plan was not person-centered. The facility's policy on comprehensive care plans emphasized person-centered care, but this was not reflected in the care plans reviewed.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for a resident who was dependent on staff for bathing, hygiene, and dressing. Observations on two separate occasions revealed that the resident had not been shaved and had long fingernails with brownish-yellow matter under them. The resident's care plan indicated that he had issues with ADLs due to impaired cognition, decreased mobility, incontinence, generalized weakness, and medication use. However, the care plan lacked documentation regarding the resident's occasional refusal of shaving and nail care. Interviews with staff confirmed that the resident often refused these aspects of care, but there was no care plan in place to address these refusals, and the aide report sheet did not indicate what actions to take if the resident refused ADL care. The Assistant Director of Nursing (ADON) confirmed that there was no care plan for the resident's refusal of ADLs and that aides should report refusals to the nurse, who would then document it in interdisciplinary notes. The facility's policy on ADLs, dated 1/23/2024, stated that care and services would be provided for bathing, dressing, grooming, and oral care, but this policy was not effectively implemented for the resident in question. The lack of documentation and appropriate care planning led to the deficiency in providing necessary ADL care for the resident.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities that support the physical, mental, and psychosocial well-being of each resident for three of the four residents reviewed. Resident 36 was observed multiple times sitting in the common area without engaging in any activities. Despite the activity aide's announcements, no activities were conducted, and the resident was left unengaged. The resident's care plan indicated a need for assistance with activities and a preference for sports on TV, but these preferences were not met consistently. The Activity Director acknowledged the need for more activities on the Center Unit and identified issues with transporting dementia residents to activities. Resident 25 was observed sleeping in her room during multiple observations and did not participate in scheduled activities. The resident's care plan indicated a preference for staying in her room and engaging in activities like watching TV, reading, and working on puzzles. However, the care plans were not person-centered, and the resident's participation in activities was minimal. The Activity Director admitted that the care plans did not have effective interventions for the resident. Resident 53 was observed sitting alone and unengaged during multiple observations. The resident's care plan lacked documentation of activity refusals and did not include an Activities Care Plan. The resident participated in a limited number of activities in March and April. Staff interviews revealed that the resident was not consistently invited to activities, and one-on-one interactions were infrequent. The Activities Director confirmed that the facility did not have a process to document activity invitations and refusals, and the resident did not participate in many activities during the observed months.
Failure to Secure Resident's Cigarettes
Penalty
Summary
The facility failed to secure a resident's cigarettes at the Nurse's Station for a resident who was reviewed for smoking. During an observation, the resident was found with an ashtray containing ashes, cigarette butts, and cigarettes in his room, despite a care plan indicating that smoking materials should be kept at the Nurse's Station. The resident's record review revealed multiple diagnoses, including cerebral infarction, hemiplegia, generalized anxiety, and vascular dementia. The care plan also noted that the resident had a history of selling cigarettes to Assisted Living Residents and required supervision for smoking. Despite these interventions, the resident was observed with smoking materials in his room on multiple occasions, and staff interviews confirmed that the cigarettes should have been secured at the Nurse's Station. During a random observation, a housekeeper, who was also the resident's sister, was seen taking the resident outside to smoke and was unaware that the cigarettes should not be in the resident's room. Interviews with the CNA, RN, and DON confirmed that the resident should not have had smoking materials in his room. The facility's Smoking Policy, provided by the DON, indicated that all smoking materials should be maintained by activities staff during the day and nursing staff after 5 PM and on weekends. The policy also required residents and family members to turn in smoking materials after smoking. Despite these policies, the resident's cigarettes were not properly secured, leading to the deficiency.
Failure to Prevent Wandering of Resident with Dementia
Penalty
Summary
The facility failed to prevent a resident with dementia from wandering into other residents' rooms. Resident 53, who has severe cognitive impairment and a history of wandering due to Alzheimer's Disease and dementia, was observed entering other residents' rooms multiple times. Interviews with other residents revealed that Resident 53 often took their belongings, which were always returned, but caused frustration and inconvenience. Staff interviews indicated that the interventions listed in Resident 53's care plan, such as Velcro STOP signs, were ineffective, and staff had to manually redirect the resident by taking her hand and leading her elsewhere. The care plan also included the use of a wandergard and providing a hazard-free environment, but these measures did not prevent the resident from wandering into other rooms. During observations, Resident 53 was seen entering various rooms, including during an interview with another resident by a State Surveyor. Staff, including RN 7 and CNA 9, were often unaware of Resident 53's location and had to escort her out of other residents' rooms. The Director of Nursing (DON) acknowledged that the current interventions were ineffective and stated that the staff would work to find better solutions. The facility's policies on elopement and dementia care emphasized the need for adequate supervision and individualized, non-pharmacological approaches, but these were not effectively implemented for Resident 53.
Failure to Complete and Document Shift Narcotic Counts
Penalty
Summary
The facility failed to ensure that shift narcotic count sheets were completed and documented every shift for one of the two narcotic books observed in the West Hall. During a medication storage observation, it was found that the narcotic sheets dated from January 12, 2024, to April 8, 2024, had missing signatures, indicating that narcotics were not counted every shift. Specifically, there were seven missing signatures for the day shift and twenty-six missing signatures for the evening and night shifts. RN 11 confirmed that narcotics should be counted every shift and documented on the sheet. The Director of Nursing provided the current policy, which mandates a 24-hour recording of controlled substance use, but the facility did not adhere to this policy.
Failure to Monitor and Document Medication Administration
Penalty
Summary
The facility failed to ensure that a resident who received an opioid and an anti-anxiety medication had an appropriate indication and was monitored for adverse side effects. Resident 7, who had diagnoses including dementia, depression, anxiety, and osteoarthritis, was observed multiple times either yelling or sleeping in her wheelchair. The resident's Medication Administration Record (MAR) indicated that she received Lorazepam and Morphine 10 times on the same dates and times, but the clinical record lacked documentation for why the medications were given. Additionally, there was no documentation of any nonpharmacological interventions tried prior to administering the medications. The Assistant Director of Nursing (ADON) confirmed that the medications should not have been given together and that nonpharmacological interventions should have been tried first. The ADON also indicated that a pain scale should have been documented when giving Morphine, and the resident should have been assessed for pain and documented on the chart. The facility's policies on pain management and unnecessary drugs were not followed, as there was no reassessment or documentation of the effectiveness of the medications or monitoring for adverse side effects such as itching.
Expired Medications and Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication cart and did not adequately monitor the medication refrigerator's temperature. During an observation, an opened bottle of lactulose liquid and two opened bottles of Guafenesin syrup were found on the medication cart, all of which had expired. Additionally, the medication refrigerator had a large build-up of ice, and temperature logs showed numerous instances of missing documentation for both AM and PM temperatures. Interviews with the responsible RNs confirmed that the expired medications should have been removed and that temperatures should be documented twice daily. A policy on these procedures was requested but not provided before the survey exit.
Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper catheter orders and catheter care for a resident with a catheter, and did not consistently document intake and output as ordered. Resident B, who had severe cognitive impairment and was dependent on others for all Activities of Daily Living, had an indwelling catheter for urinary retention. Despite the resident's condition and the presence of a catheter, there were no physician's orders regarding the Foley catheter or its care. Additionally, the Treatment Records from December 1, 2023, to January 30, 2024, lacked documentation of catheter care and intake and output measurements as required by the physician's orders. The resident's care plan indicated that the catheter should be changed as ordered by the physician, maintain a closed drainage system, and record intake and output in the medical record. However, there were multiple instances where intake and output were not documented across various shifts in December 2023 and January 2024. The facility's Catheter Care Policy, which mandates catheter care every shift and as needed, was not followed. The Director of Nursing confirmed that catheter orders and care should be documented in the facility's physician's orders and completed per order and facility policy.
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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.
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Nursing homes near New Carlisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller's Merry Manor | 2.2 mi | ★★★★★ | 0 | 0 |
| Briarcliff Health & Rehabilitation Center | 7.8 mi | ★★★★★ | 17 | 0 |
| West Bend Nursing And Rehabilitation | 9.7 mi | ★★★★★ | 6 | 0 |
| Healthwin Health & Rehabilitation | 11.2 mi | ★★★★★ | 34 | 0 |
| Wellbrooke Of South Bend | 12.1 mi | ★★★★★ | 19 | 0 |
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