Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Preferred Care At Hamilton during CMS and state inspections, most recent first.
A resident at risk for skin breakdown developed a stage 3 pressure ulcer due to the facility's failure to implement and document necessary interventions. The care plan was not updated with recommended treatments, and there was a delay in starting wound care. Staff failed to document the resident's skin condition consistently, and the primary care physician and nurse practitioner did not address the issue in a timely manner.
The facility failed to maintain proper kitchen sanitation and food handling practices, with issues such as improper handwashing, incorrect use of beard nets, unsanitary storage, and unlabeled food items. Staff members were observed not following infection control protocols, including inadequate hand hygiene and sweating over food. The Infection Preventionist confirmed that education on these practices was provided, and the Licensed Nursing Home Administrator acknowledged the deficiencies.
A facility failed to follow professional standards for PICC line dressing changes for a resident with a PICC line in the left chest wall. The dressing was observed to be unlabeled and undated, and the resident reported it had not been changed since insertion. Medical records lacked orders for PICC line observation or dressing changes. Interviews with staff confirmed the facility's process was not followed, and the survey team acknowledged the concerns.
A facility failed to document pain assessments before administering morphine sulfate to a resident with thoracic discitis and cervical spondylopathy. Despite the resident's regular pain medication schedule, 84 out of 131 doses lacked documented pain level assessments. The DON and LPN confirmed the absence of required documentation, contrary to the facility's pain management policy.
A facility failed to adequately monitor a resident's use of psychoactive medications, despite the resident's moderate cognitive impairment and dependence on staff for daily activities. The resident was prescribed multiple psychotropic medications, but there was no documentation of behavior or side effect monitoring as required by the facility's policy. Interviews with staff revealed inconsistencies in monitoring practices, and the Director of Nursing acknowledged that monitoring was not conducted daily as the policy specified.
The facility failed to maintain resident dignity during feeding assistance and catheter management. An LPN stood while feeding a resident, despite available seating, and meal slips labeled residents as 'feeders,' which staff acknowledged as undignified. Additionally, a resident's catheter drainage bag was exposed without a privacy bag, visible from the hallway. Facility policies lacked guidance on these dignity concerns.
The facility failed to maintain a clean and homelike environment on the South Side nursing unit. Observations revealed dirty linen on the floor, a cracked trash can without a liner, and a toilet with a brown substance. A bag with used Foley catheter leg bags was improperly tied to a handrail. The DON, IP, and ESD acknowledged these issues, which violated the facility's policies on linen handling and routine cleaning.
A resident with severe cognitive impairment and a history of falls had a care plan that was not updated to include the use of a fall mat and bed positioning against the wall, despite these interventions being in place. The facility's policies required care plan updates following falls, which were not followed in this instance.
A facility failed to properly manage respiratory care for two residents, leading to deficiencies in labeling, dating, and storing oxygen equipment. One resident's oxygen tubing was found unbagged and exposed, while another's equipment lacked proper labeling. Both residents' care plans did not include necessary respiratory interventions, contrary to facility policies. Staff interviews confirmed these oversights, highlighting gaps in infection control and care planning.
The facility failed to adhere to professional standards in pharmaceutical services and documentation, as evidenced by missing signatures and incorrect narcotic tablet counts on medication carts. LPNs confirmed these discrepancies, and the DON acknowledged the need for immediate documentation as per policy.
The facility failed to maintain the kitchen garbage dumpster area, as observed by a surveyor with the FSD and LNHA. Food debris and disposable gloves were scattered on the ground, and a half-full garbage compactor was left open and unused. The FSD and LNHA acknowledged the area should have been clean and containers closed. The facility's policy requires the trash area to be clean, odor-free, and pest-free, with sealed and covered containers.
A facility failed to properly store soiled linen and sanitize medical equipment, leading to potential cross-contamination. A CNA was observed using the same bags for dirty linen and briefs across multiple residents, while soiled medical equipment was improperly stored in a medication room. These actions violated the facility's infection control policies, as confirmed by the LPN, Unit Manager, and Infection Preventionist.
A facility failed to conduct a new PASRR level one assessment for a resident newly diagnosed with psychosis. Initially admitted in 2021, the resident's PASRR assessment did not indicate a mental illness, but a 2024 MDS assessment showed severe cognitive impairment and a psychotic disorder. The social worker admitted a level two PASRR was not completed after the new diagnosis, and the DON confirmed the oversight.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development and worsening of a stage 3 pressure injury for a resident. The resident, who was admitted with Parkinson's disease and protein calorie malnutrition, was identified as being at risk for skin breakdown due to bladder incontinence and immobility. Despite this, the facility did not update the resident's care plan to reflect the need for a moisture barrier cream after it was discontinued, nor did they document regular skin checks as required. The resident developed moisture-associated skin damage (MASD) on the right buttocks, which progressed to a stage 3 pressure injury. The facility did not update the care plan with new interventions recommended by the Wound Care Consultant, such as using an alternating pressure mattress and specific cushions to reduce pressure. Additionally, there was a delay in starting the recommended wound treatment, and the facility failed to document the resident's skin condition consistently. The facility's staff, including the Licensed Practical Nurse, Infection Preventionist, and Director of Nursing, were unable to provide explanations for the lack of documentation and updates to the care plan. The primary care physician and nurse practitioner also failed to document and address the resident's skin condition in a timely manner. The facility's policies on skin assessment and wound treatment management were not followed, contributing to the deficiency.
Kitchen Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain kitchen sanitation and proper food handling practices, leading to potential risks of foodborne illness. During an initial tour of the kitchen, the surveyor observed several deficiencies, including improper handwashing techniques by the Food Service Director and the Licensed Nursing Home Administrator, who did not meet the required 20 seconds of lathering with soap. Additionally, a staff member with a long beard wore a beard net incorrectly, leaving beard hair exposed, which was confirmed by the Food Service Director as inappropriate. Further observations revealed unsanitary storage practices, such as scoopers stored inside bins of powdered mashed potatoes and flour, causing the lids to remain open and potentially allowing rodent access. Several containers of dried herbs were opened and not dated, and an apple pie in the walk-in freezer was not labeled or dated. Clean dessert bowls were stored uncovered near a dusty exhaust fan and refrigerator cooling system, and cutting boards on the drying rack were pitted and had deep cut marks. During a follow-up tour, additional issues were noted, including a staff member washing hands without proper lather time and another staff member sweating over a tray of mashed potatoes, with sweat dripping into the food. The Infection Preventionist confirmed that infection control education, including proper hand hygiene and the use of hair and beard nets, was provided to all staff. The Licensed Nursing Home Administrator acknowledged the deficiencies in personal hygiene, hand hygiene, and kitchen sanitation, as well as the need for proper labeling and dating of kitchen supplies.
Failure to Follow PICC Line Dressing Change Protocol
Penalty
Summary
The facility failed to ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC) site consistent with professional standards of practice. This deficiency was identified for one resident who had a PICC line located in the left chest wall. The surveyor observed that the dressing on the PICC line was not labeled or dated, and the resident reported that the dressing had not been changed since it was inserted. The medical records, including the Order Summary Report, Medication Administration Record (MAR), and Treatment Administration Record (TAR), did not reflect any orders for PICC line observation or dressing changes. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the facility's process was not followed, as the PICC line data set should have been discussed with the physician, and orders should have been placed in the electronic medical record. The facility's policy required that the PICC dressing be changed weekly or if soiled, and the dressing should be labeled with the date, time, and initials of the person who changed it. The survey team, including the Licensed Nursing Home Administrator (LNHA), DON, IP, and the Regional Nurse, acknowledged the surveyor's concerns regarding the deficiency.
Failure to Document Pain Assessments Before Administering Medication
Penalty
Summary
The facility failed to ensure appropriate monitoring and assessment of pain prior to administering pain medication to a resident. This deficiency was identified for 84 out of 131 doses of morphine sulfate administered to a resident who was prescribed the medication for moderate to severe pain. The resident, who had diagnoses including thoracic discitis and cervical spondylopathy, was observed wearing a back brace and using a cane, indicating ongoing pain management needs. Despite the resident's intact cognition and regular pain medication schedule, the facility did not document pain level assessments prior to administering the medication as required. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) confirmed that pain level assessments were not documented for each dose of pain medication administered. The facility's pain management policy required pain management to be consistent with professional standards, including recognition, assessment, treatment, and monitoring of pain. However, the Medication Administration Record (MAR) showed that pain assessments were not conducted for numerous doses across November, December, and January, as indicated by the absence of documented pain levels. The DON acknowledged the lack of proper documentation, and the LPN confirmed that the MAR was marked with an X where pain assessments were missing.
Inadequate Monitoring of Psychoactive Medication Use
Penalty
Summary
The facility failed to adequately monitor the use of psychoactive medication for Resident #85, as identified during a survey. The resident, who was admitted with chronic respiratory failure and diabetes mellitus, had a moderate cognitive impairment with a BIMS score of 7 out of 15. The resident was dependent on staff for activities of daily living and was prescribed multiple psychotropic medications, including trazodone, lorazepam, buspirone, and valproic acid, for conditions such as depression, anxiety, and mood disorder. Despite these prescriptions, there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicating that the facility was monitoring the resident's behavior or side effects related to these medications. Interviews with facility staff, including a CNA, LPN, and LPN/Unit Manager, revealed inconsistencies in the monitoring practices for psychotropic medication use. The CNA noted that the resident required complete care and occasionally became anxious and confused but did not exhibit aggressive behavior. The LPN confirmed that the resident's behaviors were not consistently documented, and there were no physician's orders for behavior or side effect monitoring. The LPN/Unit Manager stated that monitoring was typically done for 14 days following a new medication or change, but was unsure of the facility's behavior monitoring protocol. The facility's policy on Behavior Management, Intervention, and Monitoring required daily monitoring and documentation of drug side effects for residents on psychotropic medications. However, the Director of Nursing (DON) stated that monitoring was only done by exception or during gradual dose reduction, not daily as the policy specified. This lack of consistent monitoring and documentation for Resident #85's psychotropic medication use constituted a deficiency in the facility's care practices.
Failure to Maintain Resident Dignity in Feeding and Catheter Management
Penalty
Summary
The facility failed to promote and maintain resident dignity during feeding assistance and for a resident with a urinary catheter. During a dining observation, an LPN was seen standing while feeding a resident with severe cognitive impairment, despite available seating. This was confirmed by both the CNA and the LPN, who acknowledged that proper feeding assistance should involve sitting alongside the resident to maintain eye contact and dignity. Additionally, meal slips for three residents labeled them as 'feeders,' a term considered undignified by the facility's staff and administration. In another instance, a resident with a suprapubic catheter was observed with their catheter drainage bag exposed and not placed in a privacy bag, allowing the contents to be visible from the hallway. The facility's policy did not include storing Foley catheter bags in privacy bags, although staff acknowledged the importance of using privacy bags for maintaining resident dignity. The resident involved was cognitively intact and aware of their catheter status. The facility's policies on dining and urinary catheter management were reviewed, revealing gaps in ensuring resident dignity. The Dining and Meal Assistance policy emphasized not standing over residents while assisting them with meals and avoiding undignified labels. However, the Urinary Catheters policy lacked guidance on using privacy bags for catheter drainage bags, which was identified as a dignity concern by the staff.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on the South Side nursing unit. During an observation, a surveyor identified several environmental concerns, including a bag of dirty linen left on the floor near a resident's dresser, a cracked trash can without a liner, and a toilet with a brown substance splattered around the rim. Additionally, a clear bag filled with used Foley catheter leg bags was tied to a handrail in a resident's bathroom. The resident confirmed that they did not place the bag there, and the Unit Manager/LPN acknowledged the inappropriate placement of the bag due to infection control concerns. Interviews with the Director of Nursing (DON), Infection Preventionist (IP), and Environmental Services Director (ESD) revealed that the facility's policies were not followed. The DON and IP confirmed that soiled linen should be immediately taken to the soiled utility room and not left in resident rooms. The ESD stated that housekeepers follow a daily schedule and that CNAs should notify housekeeping for immediate cleaning if a resident has an accident. The facility's Linen Handling and Routine Cleaning and Disinfection policies emphasize the importance of handling and cleaning to prevent contamination and infection, which were not adhered to in this instance.
Failure to Update Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls who used a fall mat. This deficiency was identified during a survey when the resident was observed in bed with a fall mat on the floor and the bed pushed against the wall. Despite these observations, the resident's care plan did not include interventions for the use of fall mats or the bed being against the wall. The resident, who had severe cognitive impairment and a history of falls, was admitted with diagnoses including failure to thrive, hypertension, chronic pain, and anxiety. The care plan was last updated following a fall on 11/17/24, but it did not reflect the current interventions in place. The facility's policies required that care plans be reviewed and updated following a resident fall, which was not adhered to in this case. During a meeting with the Director of Nursing, Licensed Nursing Home Administrator, Regional Director of Nursing, and Infection Preventionist, it was confirmed that the care plan should have included the fall mat and bed positioning. This oversight was a violation of the facility's Fall Policy and Care Plan Process policy, which mandates timely updates to care plans based on assessments and reassessments.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to properly label, date, and store respiratory equipment, leading to potential contamination risks. During an initial tour, a surveyor observed a resident with an oxygen concentrator and nasal cannula tubing that was unbagged and exposed to air. The resident's medical records indicated a need for oxygen due to shortness of breath, but the individualized comprehensive care plan (ICCP) did not include a focus area for respiratory care or interventions for oxygen administration. Interviews with the Unit Manager and Infection Preventionist confirmed that the tubing should be stored in a bag when not in use to prevent contamination. Another resident was observed receiving oxygen via nasal cannula at 4 liters per minute, but the oxygen tubing and humidification bottle were not labeled or dated. The resident, who had chronic respiratory failure and diabetes mellitus, was unsure when the equipment was last changed. The surveyor noted that the oxygen tubing had illegible writing, and the humidification bottle lacked labeling. The facility's policy required weekly changes and dating of the tubing, but there was no physician's order for the humidification bottle. The Director of Nursing confirmed that the ICCP for this resident did not include oxygen administration. The facility's policies on oxygen administration and care plan processes were reviewed, revealing gaps in labeling and dating requirements for humidification bottles and the storage of oxygen tubing. The care plan policy emphasized the need for individualized plans based on assessments, but the deficiencies in the residents' care plans indicated a failure to adhere to these guidelines. The Director of Nursing acknowledged these oversights during interviews with the survey team.
Deficiency in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards of practice and did not accurately document the administration of controlled medications. This deficiency was identified during a review of two out of three medication carts. On one occasion, the surveyor, accompanied by an LPN/Unit Manager, found that the Individual Patient Controlled Substance Administration Record sheet for a resident's morphine extended release tablets was not signed by the nurse who administered the medication. The inventory sheet indicated there should be 10 tablets, but only 9 were present. Similarly, another resident's morphine ER tablets were not properly documented, with the inventory sheet showing a discrepancy between the expected and actual tablet count. Further observations revealed similar issues with another medication cart, where the declining inventory sheet for a resident's oxycodone immediate release tablets was not signed by the administering nurse, and the tablet count was incorrect. Interviews with the LPNs confirmed the missing signatures and incorrect narcotic tablet counts. The Director of Nursing acknowledged that the declining inventory sheets should be completed immediately when medication is dispensed, as per the facility's Medication Administration policy.
Improper Waste Disposal in Kitchen Dumpster Area
Penalty
Summary
The facility failed to properly dispose of and maintain waste in the kitchen garbage dumpster area. During an initial tour, the surveyor, along with the Food Service Director (FSD) and the Licensed Nursing Home Administrator (LNHA), observed food debris, including bread slices and other unidentifiable disposed food and disposable gloves, scattered on the ground. Additionally, a half-full garbage compactor was found with its door wide open and not actively being used by staff. The FSD acknowledged that the dumpster area should have been maintained and cleaned, and that leaving the garbage compactor open and having food debris on the ground was unacceptable and could promote rodents. The LNHA later acknowledged that the dumpster area should have remained clean, and the garbage containers should have been closed when not in use. A review of the facility's Dumpster Area policy, revised in November 2024, stated that the trash area should be clean, odor-free, and free from pest infestation, with trash containers sealed, leak-proof, and covered at all times to prevent exposure to waste. The policy also required that all trash be placed inside the dumpster.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
The facility failed to ensure that soiled linen and soiled incontinent briefs were properly stored in a sanitary manner, as observed on the South Unit. During a dining observation, a surveyor noted a bag of dirty linen and a bag of trash containing dirty protective briefs on the floor of a resident's room. A Certified Nursing Assistant (CNA) was seen feeding a resident with these bags placed in front of the bed. The CNA admitted to using the same bags for multiple residents to avoid wasting bags, which was against the facility's policy. The Licensed Practical Nurse (LPN) and the Unit Manager confirmed that this practice was inappropriate and posed an infection control issue due to the risk of cross-contamination. Additionally, the facility failed to ensure that soiled medical equipment was sanitized prior to storage, as observed in the North Medication Storage Room. A surveyor found a soiled oxygen concentrator with a humidification bottle and three soiled tube feeding pumps stored in the medication room. The LPN/Unit Manager acknowledged that the soiled equipment should have been placed in the soiled utility room for housekeeping to process, as storing it in the medication room could lead to cross-contamination with sterile supplies and medication preparation areas. The facility's policies on linen handling and cleaning and disinfection of nursing equipment were not adhered to, contributing to these deficiencies. The Infection Preventionist and the Director of Nursing confirmed that the staff should not have been taking dirty linen and equipment from room to room and that soiled equipment should be processed in the soiled utility room. These lapses in protocol were identified as infection control issues that could potentially lead to cross-contamination and the spread of infection within the facility.
Failure to Conduct New PASRR Assessment for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment for a resident who was newly diagnosed with a mental illness. The resident, initially admitted in 2021, had a new diagnosis of psychosis in December 2022. The initial PASRR level one assessment, completed in June 2021, did not indicate a mental illness diagnosis. However, the most recent Minimum Data Set (MDS) assessment in October 2024 showed the resident had severe cognitive impairment and a diagnosis of anxiety and psychotic disorder. During the survey, the social worker acknowledged that a level two PASRR was not completed following the new diagnosis. The social worker stated that the psychiatrist communicated the new diagnosis to the nurse, who then informed the social worker. The Director of Nursing confirmed that the PASRR should have been completed, indicating a lapse in the facility's process for coordinating assessments with the PASRR program.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 731 citations issued within 25 miles in the last 12 months — including the 22 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hamilton Square
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Hills Post Acute Hamilton | 1 mi | ★★★★★ | 2 | 0 |
| Complete Care At Mercerville Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| Avalon Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 19 | 0 |
| Hamilton Grove Healthcare And Rehabilitation, Llc | 2.4 mi | ★★★★★ | 17 | 0 |
| Avant Rehabilitation And Care Center | 4.6 mi | ★★★★★ | 14 | 0 |
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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.