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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jamestowne Rehabilitation during CMS and state inspections, most recent first.
A resident with pressure ulcers experienced severe pain during wound care due to the facility's failure to assess and manage pain appropriately. Despite having orders for pain medication, the resident did not receive as-needed medication, and the LPN did not assess or address the resident's pain during the procedure. The facility's pain management policy and national guidelines were not followed, resulting in actual harm to the resident.
The facility did not adhere to the nutritional plans set by the RD, affecting all residents. Meals were not prepared as specified, with incorrect portions and missing components. A resident with dysphagia did not receive the prescribed pureed diet, lacking pureed bread and receiving incorrect items. Staff admitted to not following recipes, and pureed instructions were unavailable.
The facility failed to ensure proper hand hygiene during meal service, affecting several residents. A dietary aide did not perform hand hygiene between tasks, and the kitchen had multiple sanitation issues, including undated food items and improper storage. Additionally, there were no recorded temperatures for equipment and food items for several days, and staff did not wear beard coverings or sanitize equipment between uses.
The facility failed to maintain sanitary medication administration, implement Enhanced Barrier Precautions for residents with wounds, and ensure proper hand hygiene during blood glucose monitoring and wound care. An LPN was observed touching medication with bare hands, and residents with wounds lacked necessary precautions. Additionally, staff did not perform hand hygiene after glove removal, violating facility policies.
A resident, who required assistance due to recent hip surgery, was left in a soiled bed after an incontinent accident. Despite requesting help, an LPN told her that a CNA would not assist unless she changed her own brief, leading the resident to feel terrible and change herself. This incident violated the facility's policy on treating residents with dignity and respect.
A facility failed to administer IV therapy according to professional standards for a resident with a knee prosthetic infection. The resident's central line dressing was not dated, and an LPN was unsure of the last dressing change, despite orders for weekly changes. This was contrary to the facility's policy requiring dressing changes every seven days to prevent infection.
The facility failed to date oxygen tubing for two residents requiring oxygen therapy. One resident with traumatic brain dysfunction and another with a knee prosthetic infection had undated tubing, contrary to facility policy. LPNs confirmed the oversight, which should have been addressed by weekly changes.
Failure to Manage Pain During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with pressure ulcers, resulting in actual harm. Resident #142, who had a history of joint replacement surgery, emphysema, chronic obstructive pulmonary disease, and osteoarthritis, was not assessed or medicated for pain before, during, or after wound care. Despite having orders for routine and as-needed oxycodone for pain management, the resident did not receive any as-needed medication on the day of the incident. During an observation of wound treatment, the resident exhibited signs of severe pain, such as moaning and grimacing, while the LPN performed the procedure without assessing or addressing the resident's pain. The resident confirmed experiencing severe pain during the treatment and reported that the pain medication administered earlier did not alleviate her discomfort. The LPN admitted to focusing on completing the treatment rather than ensuring the resident's pain was managed. The facility's policy on pain assessment and management required staff to identify pain and develop interventions consistent with the resident's needs. However, the staff failed to adhere to these guidelines, as evidenced by the lack of pain assessment and medication administration for Resident #142. The National Pressure Ulcer Advisory Panel's guidance emphasizes coordinating care with pain medication administration to minimize pain, which was not followed in this case.
Failure to Follow Diet Plans and Prepare Meals as Prescribed
Penalty
Summary
The facility failed to prepare meals according to the nutritional plans set by the Registered Dietitian, affecting all residents. On a specific date, the lunch diet spreadsheet indicated that residents with regular, no added salt, or no concentrated sweet diets were to receive a beef French dip sandwich. However, observations revealed that the meal was not prepared as planned. A staff member served beef slices on a single slice of bread with gravy instead of the specified two ounces of beef on a roll with a quarter cup of broth. The staff member admitted to not reviewing the recipe book or spreadsheet for the correct portions, and the Registered Dietary Manager confirmed the meal was not served as planned. Additionally, the facility failed to provide a resident with a pureed diet as ordered by the physician. The resident, who had diagnoses including dysphagia, was supposed to receive a pureed beef French dip sandwich with bread, pureed broccoli, and vanilla ice cream. Instead, the resident was served without pureed bread, received less broccoli than required, and was given a frozen supplement instead of ice cream. The staff member acknowledged not following the recipe instructions, and it was confirmed that the pureed recipe instructions were not available for meal preparation. This oversight was against the facility's policy on modified texture foods.
Deficiencies in Hand Hygiene and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal service, affecting seven residents. Dietary Aide #70 did not perform hand hygiene after delivering meal trays to residents and wore gloves without removing them between tasks. The facility's policy required hand hygiene between resident contacts, but this was not followed, leading to potential cross-contamination. The kitchen had several sanitation issues, including undated and unlabeled food items, dirty air vents, and improper storage of food scoops. The facility's policies required food to be stored, labeled, and dated properly, but these were not adhered to. Additionally, there were no recorded temperatures for the refrigerator, freezer, dishwasher, or food items for several days, which was against the facility's policy of recording temperatures every shift. Staff in the kitchen did not wear beard coverings, and there were instances of improper glove use and failure to sanitize equipment between uses. The facility's policies required hair to be contained and equipment to be sanitized between uses, but these were not followed, leading to potential contamination of food prepared for residents.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered in a sanitary manner, affecting Resident #142. During an observation of medication administration, an LPN was seen dispensing an oxycodone tablet into his hand before placing it into a medication cup, which is against the facility's policy that prohibits touching medications with fingers. The resident, who was cognitively intact, had been admitted with diagnoses including aftercare following joint replacement surgery and chronic obstructive pulmonary disorder. The facility also did not implement Enhanced Barrier Precautions (EBP) for residents with wounds, affecting nine residents. These residents had various conditions, including surgical wounds, pressure ulcers, and other ulcers, but none had physician's orders for EBP. Observations revealed that there were no signs or personal protective equipment available outside the residents' rooms to indicate EBP, which was confirmed by the Infection Control Preventionist. Additionally, the facility failed to ensure proper hand hygiene during blood glucose monitoring and wound care. An LPN did not perform hand hygiene after checking a resident's blood sugar and doffing gloves, and another LPN did not wash hands after removing gloves during wound care for Resident #142. These actions were contrary to the facility's hand hygiene policy, which requires hand hygiene after removing gloves and handling potentially contaminated objects.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically affecting Resident #142. The resident, who was cognitively intact and required assistance with activities of daily living due to impairments and recent hip surgery, experienced an incident where she was left in a soiled bed after an incontinent accident. Despite ringing the call light for assistance, the resident was told by an LPN that a CNA would not assist her unless she changed her own brief, which made the resident feel terrible. The resident, feeling cold and uncomfortable, was compelled to change her brief herself before the CNA changed her bed linens. Interviews with staff and review of the facility's policy on resident rights confirmed the incident. The LPN admitted to relaying the CNA's message to the resident, and the CNA denied making such a statement. The facility's policy emphasized treating residents with respect and dignity, which was not upheld in this situation. The incident was corroborated by multiple staff members, including the Activity Director and Therapy Manager, who confirmed the resident's need for assistance and her upset state following the incident.
Failure in IV Therapy Administration
Penalty
Summary
The facility failed to ensure intravenous (IV) therapy was administered in accordance with professional standards of practice for a resident. Resident #143, who was admitted with a diagnosis of left knee prosthetic infection, required IV therapy for treatment. The physician's orders specified that the central line dressing should be changed once a week on Thursday. However, during an observation, it was noted that the dressing on the resident's central line was not dated. An interview with LPN #55 confirmed that the dressing was not dated and that the nurse was unsure when it had last been changed, despite the order for weekly changes. The facility's policy on central line dressing changes, dated 08/11/16, stated that dressings should be changed every seven days and as needed to prevent infection and catheter migration. This policy was not followed, as evidenced by the undated dressing and the uncertainty regarding the last dressing change, leading to a deficiency in the administration of IV therapy for Resident #143.
Failure to Date Oxygen Tubing for Residents
Penalty
Summary
The facility failed to ensure that oxygen tubing was dated for two residents who required oxygen therapy. Resident #145, who was admitted with diagnoses including traumatic brain dysfunction, coronary artery disease, and hypertension, had an order for oxygen therapy to maintain oxygen saturation at or above 92%. During an observation, it was noted that the oxygen tubing for Resident #145 was not dated. An interview with LPN #71 confirmed that the tubing was undated and should be changed weekly, but the nurse was unsure of the last change date. Similarly, Resident #143, admitted with a left knee prosthetic infection, also had an order for oxygen therapy to maintain saturation levels. The care plan indicated a potential for skin breakdown due to the use of oxygen tubing. During an observation, it was found that the oxygen tubing for Resident #143 was also undated. LPN #55 confirmed that the tubing should have been dated. The facility's policy on oxygen administration required that tubing be dated and changed weekly on the night shift.
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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) |
|---|---|---|---|---|
| Westover Retirement Community | 0.4 mi | ★★★★★ | 6 | 0 |
| Bradford Place Care Center | 1.2 mi | ★★★★★ | 34 | 0 |
| Berkeley Square Retirement Cen | 1.8 mi | ★★★★★ | 4 | 0 |
| Residence At Huntington Court | 3 mi | ★★★★★ | 2 | 0 |
| Golden Years Nursing Center | 3.1 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 June 2026) and official state health department websites.