Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Respiratory And Nursing Center during CMS and state inspections, most recent first.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments on time for four residents. Record review showed delayed quarterly assessments for residents with diagnoses including mood disorder, anxiety, Alzheimer's disease, CHF, diabetes, depression, borderline personality disorder, and bipolar disorder. An MDS nurse verified the assessments were not completed within the required timeframe, and the facility policy required quarterly assessments no later than 92 days from the prior assessment.
Failure to obtain written authorization for resident funds management. The facility was managing a resident’s funds without authorization from the resident or the resident’s representative. The BOC confirmed the funds were being managed by the facility, and the facility policy stated residents were to be informed of fund procedures and were not required to deposit funds with the facility.
A resident died, but the facility had not yet disbursed the remaining funds in the resident’s account to the resident’s representative. The BOC confirmed the resident’s death and that the funds had still not been sent to the family.
Failure to complete quarterly care conferences for two residents. One resident with ESRD, HTN, and anemia had no documented care conference, and another resident with bipolar disorder, borderline personality disorder, and type 1 DM had only two care conferences in the past year. The SSD confirmed quarterly care conferences were required, and the facility policy supported resident participation in care planning.
Failure to monitor and address significant weight loss: A resident with DM2, MDD, and chronic pancreatitis had repeated unplanned weight loss over several months, with missed re-weights and incomplete weekly weight monitoring after an MD order. The RD repeatedly requested re-weights and later recommended an appetite stimulant and increased supplements, but staff confirmed the re-weights were not obtained and the appetite stimulant was not started until later.
The facility failed to ensure hand hygiene was completed during catheter care for a resident with a urinary catheter when a CNA kept soiled gloves on and touched clean linens and oxygen tubing. The facility also failed to implement EBP for a resident receiving hemodialysis, as no EBP sign or PPE was available despite the DON confirming the resident was supposed to be on EBP for a dialysis chest port.
A resident with cerebral infarction, COPD, and respiratory failure, who was dependent on staff for transfers and required a Hoyer lift with two-person assist, slid from a mechanical lift during a chair-to-bed transfer. A CNA conducted the transfer with the resident’s family member instead of a second trained staff member, despite facility policy requiring two trained staff for all mechanical lift transfers. During the lift, the CNA attempted to reposition the sling, the resident began screaming and moving, the lift was lowered, and the resident slid to the floor, later being evaluated in the ED for a fall from the mechanical lift.
Two residents with severe cognitive impairment received each other’s medications when an LPN in orientation, supervised by an RN who remained on the unit but did not enter the room, confused the residents sharing a room and failed to follow the six rights of medication administration. One resident received multiple psychotropic and other medications not ordered for them, while the other received several different medications, also not ordered, and was later found unresponsive and sent to the hospital, where a complicated UTI was diagnosed.
A resident with Huntington's and Alzheimer's was sent to the ED for evaluation but was refused readmission by the facility, despite a discharge appeal ruling ordering readmission. The facility issued an emergency discharge notice without specific reasons and failed to provide necessary physician documentation. Staff communications confirmed the decision not to readmit the resident, violating the facility's transfer and discharge policy.
A facility failed to accurately complete discharge notices for a resident with Huntington's and Alzheimer's diseases. Despite knowing that the identified discharge location had denied admission, the facility issued a 30-day and an emergency discharge notice without updating the discharge location. The resident was transferred to the hospital, and no alternative placement was identified, violating the facility's policy requiring updated discharge notices.
A facility failed to readmit a resident after hospitalization, despite a discharge appeal ruling ordering readmission. The resident, with Huntington's and Alzheimer's diseases, was initially sent to the hospital for psychological evaluation. The facility cited safety concerns and noncompliance as reasons for discharge but did not attend the appeal hearing. The decision not to readmit was made by the Regional Director of Operations and communicated internally, leading to a deficiency.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to timely complete quarterly Minimum Data Set (MDS) assessments for four residents out of 18 sampled. Review of the medical records and staff interviews showed that Resident #26, admitted with mood disorder and anxiety disorder, had a quarterly MDS dated 03/12/26 that was not completed until 04/15/26. Resident #39, admitted with Alzheimer's disease, depression, and congestive heart failure, had a quarterly MDS dated 03/19/26 that was not completed and should have been submitted by 04/02/26. In both cases, MDS Nurse #284 verified during interview that the quarterly assessments were not completed within the required timeframe. Additional record review showed Resident #2, admitted with type two diabetes mellitus, major depressive disorder, and anxiety disorder, had a quarterly MDS dated 03/09/26 that was not completed until 04/09/26. Resident #11, admitted with borderline personality disorder, bipolar disorder, and type one diabetes mellitus, had a quarterly MDS dated 12/28/25 that was not completed until 01/19/26. MDS Nurse #284 verified these quarterly MDS assessments were also not completed within the required timeframe. The facility policy titled MDS 3.0 Completion, revised 04/16/26, stated that a quarterly assessment should be completed using an assessment reference date no later than 92 days from the most recent prior quarterly or comprehensive assessment.
Failure to Obtain Written Authorization for Resident Funds Management
Penalty
Summary
The facility failed to ensure written authorization was obtained to manage Resident #55’s funds. Review of the resident’s funds record showed there was no authorization from the resident or the resident’s representative for the facility to manage the funds. During interview, the Business Office Coordinator confirmed that the facility was managing Resident #55’s funds but had not obtained written authorization from either the resident or the representative. The facility policy titled Resident Funds, revised December 2009, stated that residents would be informed of the procedures for managing funds and were not obligated to deposit their funds with the facility.
Failure to Timely Disburse Resident Funds After Death
Penalty
Summary
The facility failed to timely disburse resident funds following the death of Resident #94. Record review showed that Resident #94 expired in July 2025, but the funds remaining in the resident's account had not yet been disbursed to the resident's representative. During interview, the Business Office Coordinator confirmed the resident's death and stated that the facility had not yet disbursed the remaining funds to the resident's family.
Failure to Complete Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure quarterly care conferences were completed for two residents. Resident #8 was admitted with diagnoses including ESRD, hypertension, and anemia, and an MDS assessment dated 01/07/26 showed intact cognition; however, there was no documentation that any care conference had been completed, and the SSD verified the facility had not held one for this resident. Resident #11 was admitted with diagnoses including borderline personality disorder, bipolar disorder, and type 1 diabetes mellitus, and an MDS assessment dated 12/28/25 showed intact cognition; the record showed care conferences only on 07/18/25 and 09/25/25, with no additional conferences completed over the last 12 months. The SSD verified that care conferences were to be completed quarterly and that Resident #11 had only received two in the last year. The facility policy stated that residents were to be informed of and participate in care planning and treatment, and that requests for care plan meetings and revisions to the person-centered plan of care would be honored.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to implement timely interventions to monitor for and prevent unplanned weight loss for one resident who had diagnoses including type 2 diabetes mellitus, major depressive disorder, and chronic pancreatitis. The resident’s weight decreased from 190.8 lbs. on 09/05/25 to 176 lbs. on 10/16/25, a 7.76% loss in under 30 days. On 10/16/25, the dietitian recommended a re-weight to rule out scale discrepancies, but no re-weight was recorded. The resident continued to lose weight, including 163 lbs. on 11/14/25, 161 lbs. on 12/03/25, 150 lbs. on 01/06/26, and 146 lbs. on 01/15/26. A physician order on 01/15/26 directed weekly weights for four weeks, but only one weight was obtained during that period, with no weekly weight recorded on 01/29/26. The resident later weighed 133 lbs. on 02/25/26, an 8.28% loss in 30 days. The dietitian recommended an appetite stimulant on 02/27/26, requested another re-weight on 03/05/26, and the MDS on 03/09/26 showed moderate cognitive impairment and need for staff assistance with ADLs. A physician order for Remeron 7.5 mg at bedtime was entered on 03/16/26, and the resident weighed 125 lbs. on 04/08/26. On 04/15/26, the dietitian again recommended increasing house supplement to three times daily, obtaining a re-weight, and weekly weights for four weeks. Staff confirmed the re-weights were not obtained and that the appetite stimulant was not started until 03/16/26 despite the earlier recommendation.
Infection Prevention Failures During Catheter Care and Dialysis Precautions
Penalty
Summary
The facility failed to ensure staff completed hand hygiene during catheter care for a resident with a urinary catheter. Resident #13 had diagnoses including gram-negative sepsis, type 2 diabetes mellitus, and hemiplegia/hemiparesis affecting the right side, and the MDS showed severe cognitive impairment with assistance needed for toileting and the presence of a urinary catheter. During observation of catheter care, CNA #260 did not remove soiled gloves after providing catheter care and then touched the resident’s clean sheets and oxygen tubing with her gloved hands. The CNA later verified that she did not change her gloves during or after catheter care. The facility also failed to ensure enhanced barrier precautions were implemented for a resident receiving hemodialysis. Resident #8 had diagnoses including ESRD, hypertension, and anemia, and the care plan noted hemodialysis three times weekly. During observation, the resident did not have an EBP sign or PPE available for patient care. The DON verified that the resident was supposed to be on EBP related to a dialysis chest port, and the facility policy stated EBP was used for prevention of transmission of MDROs and applied to residents with wounds or indwelling medical devices including hemodialysis catheters.
Failure to Use Two Trained Staff During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure appropriate supervision and adherence to policy during a mechanical lift transfer, resulting in a resident sliding from the lift. Resident #31 was admitted on 08/06/25 with diagnoses including cerebral infarction, COPD, and respiratory failure, and the MDS dated 11/13/25 documented that the resident was dependent on staff for transfers between surfaces. On 12/03/25 at 6:00 P.M., nursing progress notes recorded that the resident slid out of a Hoyer mechanical lift during a transfer and was subsequently assessed by staff and sent to the emergency room for evaluation. A hospital note confirmed the resident was evaluated in the emergency department for a fall from a mechanical lift and then returned to the facility. During interviews, the DON confirmed that on 12/03/25 the resident slid from the Hoyer lift while being transferred and that the transfer was performed by CNA #111 and the resident’s family member. The DON stated that facility policy requires two trained staff members for all mechanical lift transfers and that her expectation is that at least two trained staff always operate mechanical lifts. CNA #111 reported that she was transferring the resident from a chair to a bed using a Hoyer lift when the resident’s family member offered to assist; although the CNA said she would find another staff member, the family member insisted and the transfer was completed by the CNA and the family member. CNA #111 stated she attempted to reposition the Hoyer pad under the resident’s knees before initiating the lift, and when she began lifting, the resident started screaming and jiggling; she then lowered the lift and the resident slid to the floor. CNA #111 confirmed the resident had required a Hoyer lift since admission and was always a two-person assist for transfers with trained staff, and review of the facility’s Mechanical Lift policy dated 07/15/25 reiterated that staff must use the required number of trained staff and follow manufacturer instructions during transfers.
Medication Errors During Orientation Lead to Wrong-Resident Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, affecting two residents with severe cognitive impairment. One resident, admitted with seizure disorder, disorganized schizophrenia, and anxiety, had an MDS showing severe cognitive impairment. On the evening of 11/14/25, this resident was administered Ativan 1 mg, Metformin 500 mg, and Remeron 7.5 mg by LPN #188, despite having no orders for these medications. Another resident, admitted with dementia, type 2 diabetes mellitus, and schizoaffective disorder, also had an MDS indicating severe cognitive impairment. On the same evening, this resident was administered Lithium 750 mg, Lamictal 150 mg, Clozapine 300 mg, atorvastatin 20 mg, and Risperdal 1 mg, none of which were ordered for this resident. Following the incorrect medication administration, the second resident was found unresponsive later that night and was transferred to the hospital, where documentation showed admission for a complicated urinary tract infection. The facility’s medication error investigation determined that LPN #188 had administered medications prescribed for the second resident to the first resident and medications prescribed for the first resident to the second resident, after confusing the two residents who shared a room. At the time of the incident, LPN #188 was in orientation with RN #151. RN #151 reported that she instructed LPN #188 to administer medications and remained on the unit and available for questions but did not accompany him into the room during the medication pass. The facility’s medication administration policy required adherence to the six rights of medication administration and verification of the correct resident by comparing the medication source with the MAR prior to administration, which was not followed in this incident.
Inappropriate Resident Discharge and Readmission Refusal
Penalty
Summary
The facility failed to ensure an appropriate discharge process for a resident diagnosed with Huntington's disease, Alzheimer's disease with early onset, severe protein-calorie malnutrition, and repeated falls. The resident was sent to the Emergency Department (ED) for further psychological evaluation due to physical aggression, but there was no discharge order from the physician. Despite a 30-day discharge notice being issued, the facility refused to readmit the resident after the hospital determined the resident was ready to return. The facility's refusal to readmit the resident persisted even after a discharge appeal hearing ordered the facility to do so. The facility's actions included issuing an emergency discharge notice without specific information related to the discharge reasons and failing to provide documentation from the physician indicating the needs that could not be met at the facility. Interviews with staff and the resident's guardian revealed that the facility had decided not to readmit the resident, despite the appeal ruling. The facility's policy required documentation by a physician for transfers or discharges, which was not provided in this case. The facility's refusal to readmit the resident was communicated through text messages and meetings among staff, including the Administrator and Regional Director of Operations. The facility's policy on transfer and discharge was not followed, as the appeal was pending, and the necessary documentation was not provided. The deficiency was investigated under a specific complaint number, indicating noncompliance with regulatory requirements.
Failure to Accurately Complete Discharge Notices
Penalty
Summary
The facility failed to ensure that discharge notices were accurately completed for a resident with Huntington's disease, Alzheimer's disease with early onset, severe protein-calorie malnutrition, and repeated falls. The resident was transferred to the hospital, and a 30-day discharge notice was issued, indicating a specific nursing facility as the discharge location. However, the facility had prior knowledge that the identified nursing facility had denied the resident admission before issuing the discharge notice. Despite this, an updated discharge notice was not issued to reflect the change in discharge location. Additionally, an emergency discharge notice was issued with the same incorrect discharge location, even though the facility was aware that the resident had not been accepted for admission. The resident was transferred to the hospital, and the facility did not readmit the resident or identify an alternative placement. The facility's policy required that discharge notices include the specific location to which the resident is being transferred or discharged, and if there is a change in destination, a new notice is required. This policy was not followed, leading to the deficiency.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident, identified as Resident #8601, after hospitalization, which led to a deficiency. Resident #8601, who had been diagnosed with Huntington's disease, Alzheimer's disease with early onset, severe protein-calorie malnutrition, and repeated falls, was transferred to the hospital for further psychological evaluation due to physical aggression. Despite the hospital's notification that the resident was ready to return, the facility refused to readmit the resident, citing noncompliance with care, combativeness, and posing a safety risk as reasons for discharge. The facility issued a 30-day discharge notice to the resident and the guardian, with an effective discharge date. However, the facility did not attend the discharge appeal hearing, which resulted in an order to readmit the resident. Despite this order, the facility continued to refuse readmission, issuing an emergency discharge notice without specific information related to the discharge reasons. Interviews with the hospital social workers and the resident's guardian confirmed the facility's refusal to readmit the resident, even after the appeal decision. The decision not to readmit Resident #8601 was communicated internally among the facility's staff, including the Administrator, DON, and other department heads. The Regional Director of Operations made the final decision not to readmit the resident, which was communicated during a morning meeting. This refusal to comply with the discharge appeal ruling and the lack of proactive communication with the hospital and the resident's guardian contributed to the deficiency.
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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 Hamilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glen Meadows | 0.9 mi | ★★★★★ | 4 | 0 |
| Residence At Huntington Court | 1.4 mi | ★★★★★ | 2 | 0 |
| Liberty Station Health Campus | 2 mi | — | 0 | 0 |
| Birchwood Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Doverwood Village | 2.2 mi | ★★★★★ | 0 | 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.