Inspection Report Summary
The most recent inspection on July 2, 2025, found Hamilton Grove to be in compliance with applicable federal and state regulations with no deficiencies noted. Earlier inspections showed a pattern of deficiencies primarily related to emergency preparedness, life safety code compliance, medication management, and resident care planning. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved issues such as pressure ulcer care and medication administration errors. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with the most recent inspections showing compliance following prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
336% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
69% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Renewal
Deficiencies: 0
Jul 2, 2025
Visit Reason
The visit was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Hamilton Grove was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 59
Capacity: 85
Deficiencies: 10
Jun 3, 2025
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare and Medicaid participation requirements, including emergency preparedness and fire safety.
Findings
The facility was found not in compliance with emergency preparedness requirements including lack of policies for sheltering in place, transfer arrangements with other LTC facilities, roles under a Secretary-declared waiver, and failure to conduct required emergency plan exercises. Life safety deficiencies included improper placement of smoke detectors, lack of GFCI protection on electrical receptacles near sinks, incomplete fire drill documentation, incomplete fire door inspection records, lack of testing documentation for patient care electrical equipment, and inadequate staff training on oxygen transfilling procedures.
Severity Breakdown
SS=F: 8
SS=E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness policies include a means to shelter in place for residents, staff, and volunteers. | SS=F |
| Failed to ensure emergency preparedness policies include documented arrangements with other LTC facilities for resident transfer. | SS=F |
| Failed to ensure emergency preparedness policies include the role of the LTC facility under a waiver declared by the Secretary. | SS=F |
| Failed to conduct required emergency preparedness exercises at least twice per year and maintain documentation. | SS=F |
| Failed to ensure fire alarm smoke detectors were installed at least 36 inches from return air openings. | SS=E |
| Failed to provide GFCI protection for 6 electrical receptacles located within 6 feet of sinks. | SS=E |
| Failed to conduct quarterly fire drills for all shifts in all quarters. | SS=F |
| Failed to ensure annual inspection and testing of fire door assemblies included identification of doors inspected. | SS=F |
| Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE). | SS=F |
| Failed to ensure staff were properly trained on oxygen liquid transfilling procedures. | SS=F |
Report Facts
Facility capacity: 85
Census: 59
Electrical receptacles lacking GFCI: 6
Fire alarm smoke compartments: 7
Fire drills missing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catherine McClure | Executive Director | Named in relation to review of findings and exit conference |
| Lead Maintenance Technician | Interviewed and involved in record reviews and observations related to multiple deficiencies |
Inspection Report
Renewal
Census: 49
Capacity: 73
Deficiencies: 5
May 8, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted from April 30 to May 8, 2025.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in residents' conditions and missed medications, inadequate monitoring of antipsychotic medications, failure to maintain sanitary food storage practices, and incomplete emergency binder information for residents.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify a Physician of a resident's change in condition related to blood pressures and missed doses of medication for 2 of 5 residents reviewed (Residents 3 and 30). | SS=D |
| Failed to ensure adequate monitoring of antipsychotic medications timely for 2 of 3 residents reviewed (Residents 3 and 18). | SS=D |
| Failed to store food in a sanitary manner related to labeling and dating opened food and disposing of expired food in 1 of 1 kitchen reviewed, potentially affecting 49 residents. | SS=D |
| Failed to provide a sanitary environment related to disposing of expired food in a resident's personal refrigerator (Resident 3). | SS=D |
| Failed to ensure the Emergency binder was complete and accurate with all required resident information for 3 of 5 residents reviewed (Residents 3, 4, and 5). | — |
Report Facts
Census SNF/NF: 49
Census Residential: 24
Total Capacity: 73
Medicare Census: 3
Medicaid Census: 40
Other Payor Census: 6
Total Payor Census: 49
Number of expired food items observed: 9
Number of residents missing emergency binder face sheets: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cherry Smith | Corp Director of Clinical Services | Signed the report |
| RN 3 | Interviewed regarding notification of physician for vital signs and medication issues | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding policies and deficiencies related to medication monitoring and emergency binder |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication administration and facility policies |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed regarding food storage and sanitation practices |
| Administrator | Administrator | Provided policies and information about food labeling and emergency binder |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Feb 7, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00452792.
Findings
No deficiencies related to the allegations are cited. Hamilton Grove was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00452792.
Complaint Details
Complaint IN00452792 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 48
Census Bed Type: 23
Census Bed Type: 71
Census Payor Type: 5
Census Payor Type: 37
Census Payor Type: 6
Census Payor Type: 48
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Jan 10, 2025
Visit Reason
This visit was for the investigation of complaints IN00449557 and IN00449517.
Findings
No deficiencies related to the allegations in complaints IN00449557 and IN00449517 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00449557 and IN00449517 found no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 35
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Oct 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441231 and IN00445596. Complaint IN00441231 resulted in federal/state deficiencies cited, while Complaint IN00445596 had no deficiencies related to the allegations.
Findings
The facility failed to ensure medication and supplement orders were accurately transcribed and medications were administered timely to 2 of 3 residents reviewed (Residents C and J). Issues included missed doses, incorrect transcription of orders, and lack of physician notification for missed medications.
Complaint Details
Complaint IN00441231 was substantiated with federal/state deficiencies cited at F755. Complaint IN00445596 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure medication and supplement orders were accurately transcribed and medications were administered timely to residents. | SS=D |
Report Facts
Census SNF/NF beds: 49
Census Residential beds: 23
Total Census: 72
Medicare residents: 10
Medicaid residents: 33
Other payor residents: 6
Missed doses of Trazodone 150 mg: 5
Missed doses of Levothyroxine 200 mcg: 3
Missed doses of Levetiracetam 500 mg: 3
Missed doses of Melatonin 5 mg: 2
Missed doses of Saccharomyces 250 mg: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Treva Greaser | VP Operations/HFA | Signed the report as provider/supplier representative |
| ADON | Interviewed regarding medication order transcription and administration issues | |
| DON | Interviewed regarding medication administration and physician notification | |
| Pharmacist | Interviewed regarding medication orders and pharmacy supply issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2024
Visit Reason
Paper compliance review to the investigation of Complaint IN00441231 completed on October 22, 2024.
Findings
Hamilton Grove was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
Complaint IN00441231 was investigated and found to be in compliance.
Inspection Report
Follow-Up
Census: 47
Capacity: 75
Deficiencies: 0
Aug 19, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00436622 completed on July 3, 2024.
Findings
Hamilton Grove was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00436622.
Complaint Details
Complaint IN00436622 - Corrected.
Report Facts
Census SNF/NF: 47
Census Residential: 28
Total Capacity: 75
Census Medicaid: 40
Census Other: 7
Total Census: 47
Inspection Report
Re-Inspection
Census: 52
Capacity: 85
Deficiencies: 0
Jul 18, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/21/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this Life Safety Code PSR, Hamilton Grove was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable state codes. The facility was fully sprinkled, had a monitored fire alarm system, and all resident-accessible areas were sprinklered.
Report Facts
Facility capacity: 85
Census: 52
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Jul 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436622 and IN00434205. Complaint IN00436622 resulted in federal/state deficiencies related to pressure ulcer care, while complaint IN00434205 had no deficiencies cited.
Findings
The facility failed to prevent the development of unstageable pressure ulcers and failed to provide necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing on the bilateral heels of a resident (Resident C) who was admitted without pressure ulcers. The resident developed facility-acquired deep tissue injuries that deteriorated to stage three and stage four pressure ulcers. Documentation and treatment were inadequate, and staff failed to provide complete pressure relief and timely wound care interventions.
Complaint Details
Complaint IN00436622 was substantiated with federal/state deficiencies cited related to pressure ulcer care. Complaint IN00434205 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to prevent unstageable pressure ulcers and provide necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing on bilateral heels of a resident admitted without pressure ulcers. | SS=G |
Report Facts
Census SNF/NF beds: 54
Census Residential beds: 29
Total Census: 83
Medicare Census: 3
Medicaid Census: 43
Other Payor Census: 8
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3
Stage III pressure ulcer size: 2
Stage III pressure ulcer size: 2.5
Stage III pressure ulcer size: 0.1
Stage III pressure ulcer size: 0.75
Stage III pressure ulcer size: 0.8
Stage III pressure ulcer size: 0.1
Stage III pressure ulcer size: 0.3
Stage III pressure ulcer size: 0.3
Stage III pressure ulcer size: 0.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carlos Romero | Administrator | Signed the report |
| RN 4 | Registered Nurse | Previous wound nurse during April/May 2024, provided interview about wound care deficiencies |
| LPN 3 | Licensed Practical Nurse | Provided nursing progress notes and interview regarding wound care and culture orders |
| DON | Director of Nursing | Provided interviews regarding wound care deficiencies, documentation, and facility procedures |
| ADON | Assistant Director of Nursing | Provided interview about wound specialist procedures and report handling |
Inspection Report
Life Safety
Census: 54
Capacity: 85
Deficiencies: 4
May 21, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/21/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain latching hardware on one smoke barrier door, use of objects to prop open resident room doors, uncovered penetrations in smoke barrier walls, and failure to conduct a required four-hour emergency generator run test within the last 36 months.
Severity Breakdown
SS=E: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 1 of 4 smoke barrier doors; door by resident room 1112 failed to latch properly. | SS=E |
| Failed to ensure only hold open devices that release when the door is pushed or pulled were used; 3 resident room doors were propped open with trash bins. | SS=E |
| Failed to ensure penetrations through 2 of 2 smoke barrier walls were protected to maintain smoke resistance; barrier penetrations found above drop ceilings. | SS=E |
| Failed to maintain Emergency Power Standby System; four-hour run test for natural gas emergency generator not conducted within last 36 months. | SS=F |
Report Facts
Deficiencies cited: 4
Beds: 85
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carlos Romero | Administrator | Signed the report. |
| Lead Maintenance Technician | Interviewed and involved in observations related to deficiencies. | |
| Maintenance Director | Interviewed and involved in exit conference regarding deficiencies. |
Inspection Report
Renewal
Census: 52
Capacity: 80
Deficiencies: 13
May 6, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from April 29 to May 6, 2024.
Findings
The facility was cited for multiple deficiencies including failure to develop and implement person-centered care plans for residents, inadequate assistance with activities of daily living, failure to provide meaningful personalized activities, unsecured cigarettes posing accident hazards, failure to prevent wandering of a resident with dementia, incomplete narcotic count documentation, failure to ensure appropriate medication monitoring and pharmacist reviews, unsecured medications in resident apartments, and failure to provide timely employee orientation and education on resident rights and abuse.
Severity Breakdown
SS=E: 1
SS=D: 7
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to develop and implement personalized care plans for 4 of 15 residents reviewed. | SS=E |
| Failed to provide assistance for removal of facial hair and nail care for 1 resident. | SS=D |
| Failed to provide meaningful, personalized activities for 3 of 4 residents reviewed. | SS=D |
| Failed to secure a resident's cigarettes at the Nurse's Station for 1 resident who smoked. | SS=D |
| Failed to prevent a resident with dementia from wandering into other residents' rooms. | SS=D |
| Failed to ensure shift narcotic count sheets were completed and documented every shift for 1 of 2 narcotic books observed. | SS=D |
| Failed to ensure a resident who received an opioid and an anti-anxiety medication had appropriate indication and monitoring for adverse side effects. | SS=D |
| Failed to ensure expired medications were removed from medication cart and failed to monitor medication refrigerator temperature to prevent ice buildup. | SS=D |
| Failed to provide timely general orientation and education on resident rights and abuse prior to starting dates for 3 of 9 employee files reviewed. | — |
| Failed to have a QMA obtain authorization from a nurse before giving PRN medications for 2 of 5 residents reviewed. | — |
| Failed to ensure medications in a resident's apartment were secured from other residents. | — |
| Failed to have a pharmacist review a resident's medications at least every 60 days for 1 of 5 residents reviewed. | — |
| Failed to maintain signed copy of Resident Rights in residents' records for 2 of 5 residents reviewed. | — |
Report Facts
Survey dates: 6
Residents reviewed for care plans: 15
Residents reviewed for activities: 4
Missing narcotic count signatures: 33
Medication administration without nurse authorization: 5
Employee files reviewed: 9
Residents reviewed for pharmacist review: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 12 | Certified Nursing Assistant | Lacked timely general orientation and education on resident rights and abuse |
| Dietary Aide 13 | Dietary Aide | Lacked timely general orientation and education on resident rights and abuse |
| CNA 14 | Certified Nursing Assistant | Lacked timely general orientation and education on resident rights and abuse |
| RN 11 | Registered Nurse | Observed narcotic count sheets incomplete |
| ADON | Assistant Director of Nursing | Provided multiple policy clarifications and interviews regarding deficiencies |
| DON | Director of Nursing | Provided policies and education related to medication and care deficiencies |
Inspection Report
Renewal
Deficiencies: 0
May 6, 2024
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on May 6, 2024.
Findings
Hamilton Grove was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 26, 2024
Visit Reason
Paper compliance review to the investigation of Complaint IN00425874 completed on February 14, 2024.
Findings
Hamilton Grove was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
Complaint IN00425874 was investigated and found to be in compliance as of the review date March 26, 2024.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Feb 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00426075 and IN00425874. Complaint IN00426075 resulted in no deficiencies, while Complaint IN00425874 resulted in federal/state deficiencies cited at F690.
Findings
The facility failed to ensure catheter orders and catheter care orders were in place for a resident with a catheter, and failed to ensure intake and output were consistently documented as ordered for that resident.
Complaint Details
Complaint IN00426075 - No deficiencies related to the allegations are cited. Complaint IN00425874 - Federal/State deficiencies related to the allegations are cited at F690.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure catheter orders and catheter care orders were in place for a resident with a catheter, and failed to ensure intake and output were consistently documented as ordered. | SS=D |
Report Facts
Census: 59
Medicare residents: 3
Medicaid residents: 51
Other residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carlos Romero | Administrator | Signed the report |
| Director of Nursing | Interviewed regarding catheter orders and catheter care |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 90
Deficiencies: 0
Dec 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421628.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00421628 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 62
Census Residential beds: 28
Total Census: 62
Total Capacity: 90
Medicare residents: 5
Medicaid residents: 51
Other payor residents: 6
Inspection Report
Follow-Up
Census: 67
Capacity: 85
Deficiencies: 0
Aug 11, 2023
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted for the Life Safety Code survey to verify compliance following previous surveys.
Findings
At this Life Safety Code PSR, Hamilton Grove was found in compliance with Medicare/Medicaid participation requirements and the 2012 Life Safety Code. The facility was fully sprinkled and had appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 85
Census: 67
Inspection Report
Follow-Up
Census: 65
Capacity: 85
Deficiencies: 1
Jul 24, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code deficiencies cited on 04/26/23.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements due to failure of 3 of 5 corridor doors to have suitable automatic closing and latching mechanisms to resist smoke passage. The facility failed to implement a systemic plan of correction to prevent recurrence.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure 3 of 5 corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching, and would resist the passage of smoke. | SS=E |
Report Facts
Beds: 85
Census: 65
Deficient doors: 3
Total corridor doors observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carlos Romero | Administrator | Signed the report |
| Maintenance Director | Interviewed regarding door deficiencies | |
| Lead Maintenance Technician #1 | Interviewed and observed door deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 13, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey and Investigation of Complaint IN00402235 completed on April 4, 2023.
Findings
Hamilton Grove was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation.
Complaint Details
Investigation of Complaint IN00402235 completed on April 4, 2023; facility found in compliance.
Inspection Report
Life Safety
Census: 69
Capacity: 85
Deficiencies: 23
Apr 24, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including deficiencies in emergency preparedness plans, fire safety, sprinkler system maintenance, exit door locking, and generator inspections.
Severity Breakdown
SS=F: 11
SS=E: 6
SS=C: 3
SS=L: 2
SS=D: 1
Deficiencies (23)
| Description | Severity |
|---|---|
| Failed to maintain an Emergency Preparedness Plan based on a documented risk assessment and strategies for emergency events. | SS=F |
| Failed to develop and implement emergency preparedness policies addressing subsistence needs for staff and residents. | SS=F |
| Failed to develop and implement emergency preparedness policies and procedures for tracking location of staff and residents during emergencies. | SS=F |
| Failed to include use of volunteers and emergency staffing strategies in Emergency Preparedness Plan. | SS=C |
| Failed to include primary and alternate means for communication with staff and emergency management agencies in Emergency Preparedness Plan. | SS=C |
| Failed to include method for sharing emergency preparedness information with residents and families. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance per NFPA standards; generator lacked weekly inspections. | SS=F |
| Failed to ensure means of egress doors were readily accessible without requiring a tool or key from egress side; multiple exit doors were magnetically locked without posted codes. | SS=F |
| Restroom door in physical therapy locked with padlock from outside with no release from inside. | SS=F |
| Exit discharge from breakroom did not lead to a public way and had uneven walking surface. | SS=E |
| Occupational therapy storage room with combustible storage over 50 square feet was not protected as a hazardous area. | SS=E |
| Laundry room door was self-closing but did not latch into frame. | SS=E |
| Wires taped to sprinkler pipes in laundry and fire alarm control panel rooms. | SS=E |
| One sprinkler head in bathing room was loaded with lint and foreign material. | SS=E |
| Two corridor doors were propped open with kickstands and did not latch properly. | SS=E |
| Failed to conduct quarterly fire drills for 2 of 4 quarters. | SS=F |
| Trash receptacles in corridor exceeded allowed capacity and were not maintained properly. | SS=E |
| Two portable space heaters were found in occupational therapy gym and nurse's station. | SS=E |
| Failed to maintain written records of weekly generator inspections for 5 of 52 weeks. | SS=F |
| Failed to document transfer time to alternate power source on monthly load tests for 3 of 12 months. | SS=F |
| Failed to maintain adequate spare sprinklers and sprinkler wrench in cabinet. | SS=L |
| Failed to flush sprinkler system as recommended due to sediment buildup, resulting in Immediate Jeopardy. | SS=L |
| Failed to ensure flexible cords were not used as substitute for fixed wiring; power strip plugged into another power strip. | SS=D |
Report Facts
Deficiencies cited: 23
Facility capacity: 85
Census: 69
Fire drills missing: 2
Generator weekly inspections missing: 5
Generator monthly load tests missing cool down documentation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including emergency preparedness, sprinkler system issues, and generator inspections. | |
| Maintenance Technician #1 | Interviewed and acknowledged multiple deficiencies including emergency preparedness, sprinkler system issues, generator inspections, and fire safety concerns. | |
| Administrator | Notified of Immediate Jeopardy and participated in exit conference. |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 14
Apr 4, 2023
Visit Reason
This visit was for a State Residential Licensure Survey, including the Annual Recertification and Licensure Survey and the Investigation of Complaint IN00402235.
Findings
The facility was found out of compliance in multiple areas including failure to notify physicians of significant weight loss, failure to provide grievance information to residents, failure to develop and update personalized care plans, failure to provide meaningful activities, untimely transcription of orders, improper labeling of medications, food safety violations, incomplete personnel reference checks, insufficient staff training, and failure to conduct required fire drills.
Complaint Details
Complaint IN00402235 was investigated with Federal/State deficiencies cited at F656 related to failure to notify physician of significant weight loss and other care plan issues.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 2
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to notify physician of significant weight loss for 2 residents and resident refusal to wear preventative equipment. | SS=D |
| Failed to ensure information on how to file a grievance was made available and grievance official contact information was posted. | SS=E |
| Failed to develop and implement personalized care plans for 2 residents. | SS=D |
| Failed to update care plans for 4 residents after assessments. | SS=D |
| Failed to provide meaningful, personalized activities for 1 resident. | SS=D |
| Failed to transcribe orders timely, obtain order for completed treatment and document new skin issues for 3 residents. | SS=D |
| Failed to ensure over the counter medications were accurately labeled in medication rooms and carts. | SS=E |
| Failed to ensure food was stored in accordance with professional standards for food safety; unpasteurized eggs were stored in the refrigerator. | SS=F |
| Failed to prevent an open area pressure ulcer for 1 resident. | SS=D |
| Failed to ensure an intervention was implemented after a fall for 1 resident. | SS=D |
| Failed to ensure twelve fire drills were conducted in the past year and fire and disaster drills were conducted every six months with the local fire department. | — |
| Failed to ensure reference inquiries were completed for 2 of 5 newly hired employees. | — |
| Failed to ensure staff met requirements regarding First Aid training certification of 1 certified staff per shift for 3 of 21 shifts reviewed. | — |
| Failed to ensure 2 of 5 assisted living employees with hire dates greater than one year had been annually inserviced regarding resident rights. | — |
Report Facts
Survey dates: 7
Resident census: 44
SNF/NF beds: 74
Total beds: 118
Deficiencies cited: 14
Fire drills required: 12
Shifts without CPR/First Aid certified staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carlos Romero | Administrator | Signed report and mentioned in plan of correction |
| Employee 3 | Nurse | No documentation of reference inquiry found |
| Employee 15 | No documentation of reference inquiry found | |
| Employee 16 | No documentation of reference inquiry found | |
| Employee 1 | Nurse | No documentation of resident rights inservice in past 12 months |
| Employee 2 | Nursing Assistant | No documentation of resident rights inservice in past 12 months |
| Employee 13 | No documentation of resident rights inservice in past 12 months | |
| Employee 14 | No documentation of resident rights inservice in past 12 months |
Inspection Report
Re-Inspection
Census: 77
Capacity: 77
Deficiencies: 0
Aug 15, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00381027 completed on July 6, 2022.
Findings
Hamilton Grove was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00381027.
Complaint Details
Complaint IN00381027 - Corrected.
Report Facts
Census Bed Type: 77
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 14
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