Inspection Reports for Hamilton Pointe Health and Rehabilitation Center
IN, 47630
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 93
Capacity: 141
Deficiencies: 0
Jun 25, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461760.
Findings
No deficiencies related to the allegations in Complaint IN00461760 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00461760 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 93
Total Capacity: 141
Inspection Report
Complaint Investigation
Census: 88
Capacity: 133
Deficiencies: 0
May 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459203 and IN00459604.
Findings
No deficiencies related to the allegations in complaints IN00459203 and IN00459604 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00459203 and IN00459604 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 72
Census Bed Type - SNF: 16
Census Bed Type - Residential: 45
Total Capacity: 133
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 18
Total Census: 88
Inspection Report
Re-Inspection
Census: 146
Deficiencies: 0
May 8, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00456869 and IN00456718 completed on April 10, 2025.
Findings
Hamilton Pointe Health And Rehab 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 IN00456869 and IN00456718. Both complaints were corrected.
Complaint Details
Investigation of Complaint IN00456869 and IN00456718; both complaints were corrected.
Report Facts
Census Bed Type Total: 146
Census Payor Type Total: 97
SNF/NF Beds: 75
SNF Beds: 22
Residential Beds: 49
Medicare Residents: 14
Medicaid Residents: 60
Other Payor Residents: 23
Inspection Report
Complaint Investigation
Census: 96
Capacity: 146
Deficiencies: 2
Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456632, IN00456718, and IN00456869 regarding safety and accident prevention at the facility.
Findings
The facility failed to ensure adequate safety measures to prevent accidents for 2 of 3 residents reviewed, resulting in serious injury including hospitalization and subarachnoid hemorrhage for Resident C. Additionally, the facility failed to report a major accident involving Resident C as required by state regulations. Another resident, Resident B, experienced a fall from a mechanical lift due to improper transfer procedures.
Complaint Details
Complaint IN00456632 had no deficiencies related to allegations. Complaint IN00456718 had deficiencies cited at F689 related to accident hazards and supervision. Complaint IN00456869 had deficiencies cited at F689 and F9999 related to accident prevention and failure to report major accidents. Resident C suffered a fall resulting in subarachnoid hemorrhage and hospitalization. Resident B fell from a mechanical lift due to improper transfer technique.
Severity Breakdown
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure adequate safety measures to prevent accidents for 2 of 3 residents reviewed, resulting in hospitalization and subarachnoid hemorrhage for Resident C. | SS=G |
| Failed to report a major accident involving Resident C to the state within required timeframe. | — |
Report Facts
Census Bed Type - Total: 146
Census Payor Type - Total: 96
Survey dates: 3
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed report and involved in facility management |
| CNA 2 | Named in interview regarding failure to follow two-person assist protocol for Resident C | |
| Therapy 1 | Provided therapy notes and care plan information for Resident C | |
| Assistant Director Of Nursing | ADON | Provided policies and interviews regarding transfer procedures and accident reporting |
| Director Of Nursing | DON | Attended Fall IDT meeting and provided information on transfer incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 7, 2025
Visit Reason
Paper compliance review related to the Investigation of Nursing Home Complaints IN00453228 and IN00453974 ending February 27, 2025.
Findings
Hamilton Pointe Health and Rehab 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 of the nursing home complaints.
Complaint Details
Investigation of Nursing Home Complaint IN00453228 and IN00453974; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 146
Deficiencies: 3
Feb 25, 2025
Visit Reason
This visit was for the investigation of multiple nursing home and residential complaints (IN00452314, IN00453974, IN00452718, IN00453228, IN00452493). The survey dates were February 25, 26, and 27, 2025.
Findings
The facility was found to have deficiencies related to food service sanitation and infection prevention and control practices, including failure to maintain sanitary food handling and improper use of personal protective equipment (PPE) in isolation rooms. Some complaints had no deficiencies cited, while others had federal/state deficiencies related to food safety and infection control.
Complaint Details
The investigation included Nursing Home Complaints IN00452314, IN00453974, IN00452718, IN00453228, and IN00452493 and Residential Complaints IN00452493, IN00453228, IN00453974. Complaints IN00452314, IN00452718, and IN00452493 had no deficiencies related to the allegations. Complaints IN00453974 and IN00453228 had federal/state deficiencies cited related to food safety and infection control.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure food was served in a sanitary manner; gloves were not changed, bare hands touched plates, fingers were licked, floors soiled in kitchen and meal service. | SS=D |
| Failed to ensure infection control practices were maintained and PPE was worn entering isolation rooms for 3 of 7 halls observed. | SS=E |
| Failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety. | — |
Report Facts
Census Bed Type - SNF/NF: 74
Census Bed Type - SNF: 24
Census Bed Type - Residential: 48
Total Census: 146
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 26
Total Census Payor: 98
Residential Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report as facility administrator |
| Dietary Aide 2 | Observed failing to change gloves and touching food and surfaces improperly during food preparation | |
| Dietary Aide 3 | Observed touching plates with bare fingers during meal preparation | |
| Dietary Aide 4 | Observed touching plates with bare fingers during meal plating | |
| Dietary Aide 5 | Observed licking fingers to separate meal tickets | |
| Dietary Aide 6 | Provided information about glove use during food prep | |
| Dietary Manager | Provided information about kitchen cleaning schedule | |
| Director of Nursing | DON | Provided policies on food handling, infection control, PPE use, and kitchen cleaning |
| Activity Staff 2 | Observed entering isolation room without PPE | |
| CNA 6 | Observed entering isolation room without PPE | |
| CNA 2 | Observed donning PPE improperly before entering isolation room | |
| CNA 3 | Observed entering isolation room without PPE | |
| RN 2 | Observed entering isolation room without PPE |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 21, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00448583 ending December 10, 2024.
Findings
Hamilton Pointe Health and Rehab 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00448583 was reviewed and found to be in compliance.
Inspection Report
Complaint Investigation
Census: 156
Capacity: 156
Deficiencies: 1
Dec 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448583 regarding federal and state deficiencies related to admission physician orders for immediate care.
Findings
The facility failed to ensure that a newly admitted resident had immediate physician orders for pressure wound treatments upon admission. Orders for wound treatments were not recorded until three days after admission, despite the resident having multiple pressure wounds on admission.
Complaint Details
Complaint IN00448583 was substantiated with federal and state deficiencies cited at F635 related to admission physician orders for immediate care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a newly admitted resident had immediate orders for pressure wounds. | SS=D |
Report Facts
Census total: 156
Licensed capacity: 156
Survey dates: 2
Medicare residents: 12
Medicaid residents: 58
Other payor residents: 31
Pressure wound treatment delay: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report |
| RN 2 | Interviewed and indicated wound treatments should have been placed on admit | |
| RN 3 | Interviewed and indicated triage should be called for orders if no orders sent on admit | |
| DON | Provided current admission orders policy |
Inspection Report
Follow-Up
Census: 103
Capacity: 115
Deficiencies: 0
Jul 19, 2024
Visit Reason
This Post Survey Review (PSR) was conducted as a follow-up to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/25/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as with the Life Safety Code requirements including fire safety and sprinkler systems. No deficiencies were cited during this follow-up survey.
Report Facts
Certified beds: 115
Census: 103
Inspection Report
Re-Inspection
Census: 103
Capacity: 153
Deficiencies: 0
Jul 18, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 5, 2024, and was conducted in conjunction with the PSR to the Investigation of Complaint IN00435563 completed on June 5, 2024.
Findings
Hamilton Pointe Health and Rehab 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 Recertification and State Licensure Survey.
Complaint Details
Investigation of Complaint IN00435563 was included in this visit; no deficiencies were cited indicating compliance.
Report Facts
Census Bed Type - SNF/NF: 79
Census Bed Type - SNF: 24
Census Bed Type - Residential: 50
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 27
Inspection Report
Re-Inspection
Census: 103
Capacity: 153
Deficiencies: 0
Jul 18, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00435563 completed on June 5, 2024, conducted in conjunction with a PSR to the Recertification and State Licensure Survey and State Residential Licensure Survey completed on June 5, 2024.
Findings
Hamilton Pointe Health and Rehab 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 IN00435563. The complaint was corrected.
Complaint Details
Complaint IN00435563 was investigated and found to be corrected.
Report Facts
Census Bed Type - SNF/NF: 79
Census Bed Type - SNF: 24
Census Bed Type - Residential: 50
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 91
Census Payor Type - Other: 27
Inspection Report
Life Safety
Census: 90
Capacity: 115
Deficiencies: 2
Jun 25, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness and fire safety regulations.
Findings
The facility was found not in compliance with emergency preparedness requirements due to failure to maintain a current documented facility-based and community-based risk assessment reviewed within the past twelve months. Additionally, the facility failed to provide a complete facility-specific written fire safety plan that accurately identifies all life safety systems, including the location of smoke barriers.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment reviewed within the most recent twelve month period. | SS=F |
| Failed to provide a complete facility-specific written fire safety plan that identifies where smoke barriers are located in the facility. | SS=F |
Report Facts
Certified beds: 115
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Named as facility administrator during exit conference |
| Director of Plant Operations | Present during record review and interview regarding emergency preparedness and fire safety plan deficiencies |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 20
Jun 5, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey in conjunction with the Investigation of Complaint IN00435563.
Findings
The facility was found deficient in multiple areas including resident privacy, medication self-administration assessments, accuracy of MDS assessments, comprehensive care planning, nutrition and weight monitoring, quality of care related to narcotic administration, fall prevention and post-fall assessments, pain management, nurse staffing postings, medication administration errors, food safety and temperature control, infection prevention and control, pest control, staff licensure, and reporting of injuries of unknown source.
Complaint Details
Complaint IN00435563 - Federal deficiencies related to the allegations are cited at F684 and F9999.
Severity Breakdown
SS=E: 6
SS=D: 6
SS=C: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Facility failed to ensure privacy of residents during medication administration and room entry. | SS=E |
| Facility failed to ensure residents who self-administer medications were properly assessed. | SS=E |
| Facility failed to ensure accuracy of MDS assessments for unnecessary medications. | SS=D |
| Facility failed to develop and implement comprehensive care plans consistent with resident rights and needs. | SS=D |
| Facility failed to ensure physician orders were followed for nutrition and weight monitoring. | SS=D |
| Facility failed to provide care by thorough assessment prior to narcotic administration and accurate care plans for resuscitative measures. | SS=D |
| Facility failed to ensure post fall assessments were completed and care plans updated to prevent falls. | SS=D |
| Facility failed to ensure pain management consistent with professional standards, care plans, and resident preferences. | SS=D |
| Facility failed to post accurate nurse staffing sheets daily. | SS=C |
| Facility failed to maintain medication error rate below 5%, with observed medication administration errors. | SS=D |
| Facility failed to ensure accurate documentation of blood glucose readings and post-fall assessments. | SS=D |
| Facility failed to ensure food was served at palatable temperatures. | SS=E |
| Facility failed to store and prepare food under sanitary conditions, including uncovered food and expired items. | SS=E |
| Facility failed to maintain resident records that were complete, accurate, and readily accessible. | SS=D |
| Facility failed to establish and maintain an infection prevention and control program to prevent transmission of infections. | SS=E |
| Facility failed to report an injury of unknown source to the Indiana Department of Health. | — |
| Facility failed to conduct fire and disaster drills every six months in conjunction with the local fire department. | — |
| Facility failed to maintain current and valid licenses for Qualified Medication Aides. | — |
| Facility failed to ensure medications were given as ordered by the physician. | — |
| Facility failed to ensure medications were labeled correctly and had open dates on medication carts. | — |
Report Facts
Survey dates: May 28, 29, 30, 31, June 3, 4, 5, 2024
Census: 53
Medication error rate: 12
Number of medication errors: 3
Number of shifts worked: 5
Number of fire drills: 12
Weight loss percentage: 10.65
Number of falls: 7
Number of gnats observed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 19 | Licensed Practical Nurse | Named in medication administration errors and insulin administration observation |
| RN 31 | Registered Nurse | Provided guidance on medication administration and privacy |
| QMA 23 | Qualified Medication Aide | Named in privacy and hand hygiene findings |
| Administrator | Provided policy and interview responses related to multiple findings | |
| DON | Director of Nursing | Provided policy and interview responses related to multiple findings |
| Medical Records employee | Provided policies and information related to documentation and food safety | |
| Dietary Manager | Provided kitchen tour and food safety observations | |
| RN 57 | Registered Nurse | Observed and interviewed related to medication and privacy findings |
| Regional Clinical Nurse 9 | Provided interview related to narcotic monitoring and care plans | |
| Medical Records employee | Provided policies on leftovers and glove usage | |
| HR Director | Responsible for licensure compliance |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 2
Jun 5, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00435563, conducted in conjunction with the Recertification and State Licensure Survey and State Residential Licensure Survey.
Findings
The facility failed to provide thorough assessment and appropriate care planning related to narcotic medication administration and resuscitative measures for one resident (Resident P). Additionally, the facility failed to report an injury of unknown source for another resident (Resident D) to the Indiana Department of Health as required.
Complaint Details
Complaint IN00435563 was substantiated with federal deficiencies cited at F684 and F9999 related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide care by thorough assessment prior to narcotic medication administration and implementation of a person-centered care plan for narcotics, and inaccurate resuscitative care plan for Resident P. | SS=D |
| Failed to report an injury of unknown source to the Indiana Department of Health for Resident D. | — |
Report Facts
Survey dates: 9
Census Bed Type - Total residents: 141
Census Payor Type - Total residents: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report. |
| LPN 45 | Mentioned in relation to Resident P's medication administration and incident on 4/23/24. | |
| Regional Clinical Nurse 9 | Interviewed regarding respiratory distress recognition and care plan accuracy for Resident P. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 158
Deficiencies: 0
Mar 12, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00428866, which included the investigation of a residential complaint with the same number.
Findings
No deficiencies related to the allegations in Complaint IN00428866 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00428866 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total Capacity: 158
Census Payor Type Total: 103
Census Bed Type SNF/NF: 21
Census Bed Type SNF: 82
Census Bed Type Residential: 55
Census Payor Type Medicare: 16
Census Payor Type Medicaid: 63
Census Payor Type Other: 24
Inspection Report
Complaint Investigation
Census: 104
Capacity: 115
Deficiencies: 0
Feb 21, 2024
Visit Reason
An investigation of Complaint Number IN00428258 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
No Federal/State deficiency related to the allegation was cited. The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable codes.
Complaint Details
Complaint Number IN00428258 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Facility capacity: 115
Census: 104
Inspection Report
Complaint Investigation
Census: 104
Capacity: 155
Deficiencies: 0
Feb 19, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00428371 and included a Covid 19 Focused Infection Control Survey.
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 regarding the complaint investigation and Covid 19 survey.
Complaint Details
Complaint IN00428371 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 78
Census SNF beds: 26
Census Residential beds: 51
Total licensed capacity: 155
Census Medicare residents: 14
Census Medicaid residents: 65
Census Other payor residents: 25
Total census: 104
Inspection Report
Complaint Investigation
Census: 101
Capacity: 154
Deficiencies: 0
Nov 14, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00421099 and IN00420974.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00421099 and Complaint IN00420974 were investigated; no deficiencies related to the allegations were cited for either complaint.
Report Facts
Census Bed Type Total: 154
Census Payor Type Total: 101
Census by Bed Type: 83
Census by Bed Type: 18
Census by Bed Type: 53
Census by Payor Type: 14
Census by Payor Type: 58
Census by Payor Type: 29
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00415372 ending August 29, 2023.
Findings
Hamilton Pointe Health and Rehab 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 Investigation of Complaint IN00415372 Survey.
Complaint Details
Investigation of Complaint IN00415372; paper compliance review found facility in compliance.
Inspection Report
Complaint Investigation
Census: 99
Capacity: 151
Deficiencies: 2
Aug 28, 2023
Visit Reason
This visit was for the investigation of Complaint IN00415372 regarding dialysis services at the facility.
Findings
The facility failed to ensure necessary dialysis care and medication administration for 2 residents. Post dialysis assessments were not completed for Resident B, and Resident C did not receive medications as ordered according to blood pressure parameters.
Complaint Details
Complaint IN00415372 was investigated with federal/state deficiencies cited at F698 related to dialysis care and medication administration.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete post dialysis assessments for Resident B on specified dates. | SS=D |
| Failure to administer Midodrine medication as ordered for Resident C based on blood pressure parameters. | SS=D |
Report Facts
Census total residents: 99
Total licensed capacity: 151
Dialysis residents reviewed: 2
Medication doses held: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report |
| RN 1 | Provided information about missed post dialysis assessments and medication administration | |
| LPN 1 | Provided information on facility protocol for dialysis assessments and medication parameters | |
| Assistant Director of Nursing | Provided current policies on dialysis and medication administration |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 157
Deficiencies: 0
Aug 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414871.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00414871 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - Total Capacity: 157
Census Payor Type - Census: 103
Inspection Report
Complaint Investigation
Census: 100
Capacity: 151
Deficiencies: 0
Jul 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411193.
Findings
No deficiencies related to the allegations in Complaint IN00411193 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00411193 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 82
Census Bed Type - SNF: 18
Census Bed Type - Residential: 51
Census Bed Type - Total: 151
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 70
Census Payor Type - Other: 25
Census Payor Type - Total: 100
Inspection Report
Complaint Investigation
Census: 99
Capacity: 153
Deficiencies: 0
Mar 30, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405087, IN00403784, IN00398199, and IN00396831 at Hamilton Pointe Health and Rehab.
Findings
No deficiencies related to the allegations in any of the complaints 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
Complaints IN00405087, IN00403784, IN00398199, and IN00396831 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF beds: 22
Census SNF/NF beds: 77
Census Residential beds: 54
Total licensed capacity: 153
Census Medicare residents: 16
Census Medicaid residents: 61
Census Other payor residents: 22
Total census: 99
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 30, 2022
Visit Reason
The inspection was conducted for the Recertification, State Licensure, and Investigation of Complaint IN00387822, including paper compliance to the State Residential Survey completed on November 22, 2022.
Findings
Hamilton Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the Recertification, State Licensure, and Investigation of Complaint IN00387822 survey.
Complaint Details
Complaint IN00387822 was investigated and found to be corrected.
Inspection Report
Life Safety
Census: 93
Capacity: 115
Deficiencies: 0
Dec 29, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid participating providers and suppliers. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and hard wired smoke detectors in corridors and resident sleeping rooms.
Report Facts
Certified beds: 115
Census: 93
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 12
Nov 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00391521, IN00387822, and IN00383534. The visit included a State Residential Licensure Survey.
Findings
The facility was substantiated for complaints IN00391521, IN00387822, and IN00383534. Deficiencies were cited related to notification of changes, transfer/discharge notice, bed hold notice, care plan revisions, pressure ulcer care, accident prevention, respiratory care, dialysis care, psychotropic medication management, radiology services, infection control, and medication administration.
Complaint Details
Complaint IN00391521 - Substantiated with no deficiencies cited. Complaint IN00387822 - Substantiated with deficiencies cited at F580 and F776. Complaint IN00383534 - Substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 9
SS=E: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to notify resident's family timely of a delay in STAT X-Ray order following a fall resulting in hip fracture. | SS=D |
| Failed to provide transfer/discharge notice to residents upon transfer to ER for 2 residents. | SS=D |
| Failed to provide bed hold notice to residents upon transfer to ER for 2 residents. | SS=D |
| Failed to revise comprehensive care plans timely for nutrition, advanced directives, and care planning for 4 residents. | SS=E |
| Failed to provide care consistent with professional standards to prevent pressure ulcers; resident developed stage II pressure ulcer. | SS=D |
| Failed to ensure proper supervision to prevent accident hazards; resident had box cutter in possession and medication cart was unlocked. | SS=D |
| Failed to change oxygen tubing weekly for 2 residents receiving oxygen therapy. | SS=D |
| Failed to ensure weights were taken as ordered for a resident receiving dialysis. | SS=D |
| Failed to provide contraindications for gradual dose reduction trials for residents on psychotropic medications for 2 residents. | SS=D |
| Failed to obtain STAT radiology services timely for a resident with recent hip replacement and fall. | SS=D |
| Failed to properly prevent and/or contain COVID-19 for 3 residents and failed to maintain infection control during perineal care for 1 resident. | SS=E |
| Failed to ensure infection control practices during medication administration; staff handled medications with bare hands. | — |
Report Facts
Survey dates: 2022-11-14 to 2022-11-22
Facility census: 48
STAT X-Ray delay: 18
Pressure ulcer size: 1
Pressure ulcer size: 0.5
Pressure ulcer size: 0.1
Weight measurements: 104
Weight measurements: 132.4
Dialysis weights: 211.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Cates | Administrator | Signed the report |
| DON | Director of Nursing | Provided interviews and information on multiple findings including radiology, infection control, care plans, and policies |
| LPN 1 | Licensed Practical Nurse | Observed handling medications with bare hands |
| CNA 6 | Certified Nurse Aide | Observed providing incontinence care and call light placement; interviewed about care practices |
| QMA 15 | Qualified Medication Aide | Observed providing incontinence care |
| LPN 9 | Licensed Practical Nurse | Interviewed about oxygen tubing change frequency |
| RN 1 | Registered Nurse | Interviewed about dialysis weight orders |
| CNA 17 | Certified Nurse Aide | Observed near medication cart |
| QMA 15 | Qualified Medication Aide | Observed locking medication cart |
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