Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Hamilton Health Services during CMS and state inspections, most recent first.
A cognitively intact resident with multiple chronic conditions gave an agency LPN a small amount of cash for gas after the LPN stated they could not get home without money. Another nurse instructed the LPN to return the money, and the resident later confirmed to the ADON that the money had been given and returned, explaining they knew the LPN from a prior facility and believed their relationship made the gift acceptable. The ADON reported the incident to the NHA, but the NHA decided it was not an allegation of exploitation and did not report it to the State Agency, contrary to the facility’s abuse, neglect, and exploitation reporting policy.
A resident with multiple chronic conditions and intact cognition reported giving an agency LPN a small amount of cash for gas after the LPN stated they could not get home, and the money was later returned. The facility’s policy requires immediate, comprehensive investigation of alleged abuse, neglect, or exploitation, including interviewing all involved persons and potential witnesses. However, after confirming the exchange of money with the resident, the ADON did not pursue further investigation, and the NHA determined it was not an exploitation allegation and did not interview other residents or staff to identify any similar concerns, resulting in a failure to conduct a thorough investigation as required by facility policy.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with a tracheostomy did not have their care documented, while another was incorrectly recorded as receiving Hospice services. A resident prescribed antiplatelet medication was documented as receiving anticoagulant medication, and a PASRR Level II Screen was not reflected. Additionally, a resident's fall and prescribed medications were not accurately recorded. These issues were confirmed by the facility's RN responsible for MDS assessments.
The facility failed to ensure physician acknowledgment of pharmacy recommendations for four residents, leading to deficiencies in medication management. Several pharmacy recommendations, including dose reductions and medication monitoring, were not followed up or documented. The facility lacked a process for regular pharmacy reviews and physician follow-up, contributing to these deficiencies.
The facility failed to provide necessary Medicare coverage notices to two residents when their Part A benefits ended. One resident did not receive an Advanced Beneficiary Notice (ABN) form, and another did not receive a Notice of Medicare Non-Coverage (NOMNC) form, despite the termination of benefits being facility-initiated. These deficiencies were confirmed through staff interviews and record reviews.
A facility did not complete a Significant Change MDS assessment for a resident discharged from Hospice services. The resident, initially admitted with diffuse large B-cell lymphoma and receiving palliative care, was discharged from Hospice, but only Quarterly MDS assessments were completed afterward. The RN responsible for MDS assessments and the NHA confirmed that a Significant Change MDS assessment was required.
A resident experienced a severe weight gain of 38.93% over several months, and the facility failed to notify the physician and follow weight monitoring protocols. Despite the resident's diagnoses and medications affecting appetite, no new nutritional interventions were documented, leading to a deficiency finding.
A facility failed to monitor a resident for adverse reactions to lamotrigine, prescribed for bipolar disorder. The resident's medical record lacked documentation of monitoring for side effects, which was confirmed by the NHA. The facility was unaware that monitoring was necessary for off-label use of anticonvulsant medications.
The facility failed to monitor adverse effects of antipsychotic medications for two residents. One resident, with schizoaffective disorder, was not assessed with an AIMS upon admission or when medication changes occurred. Another resident, with bipolar disorder, did not receive AIMS or adverse effect monitoring for lithium carbonate. These oversights were confirmed by the facility's President of Success, indicating non-compliance with the facility's psychotropic medication policy.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate. An LPN crushed and administered medications to a resident in forms contrary to the manufacturer's instructions, including extended and delayed release tablets. The resident had multiple diagnoses, and the error was confirmed by the DON.
A resident with chronic conditions, including COPD, was not offered a pneumococcal vaccine upon admission, as required by the facility's policy and CDC guidelines. The resident's medical record lacked documentation of the vaccine being offered or declined, which was confirmed by the facility's President of Success. This oversight represents a deficiency in following vaccination protocols.
A resident with a history of aggressive behavior was not adequately supervised, leading to repeated incidents of aggression towards another resident. Despite known risks and previous incidents, the facility failed to update the care plan or implement increased supervision, resulting in physical harm to another resident.
A facility failed to report a resident-to-resident altercation to the NHA and SA as required. One resident, with a history of mental health issues, threw a cup of coffee creamers and verbally threatened another resident. Despite being observed by an RN, the incident was not reported until the next day, violating the facility's policy on timely reporting of abuse allegations.
The facility did not thoroughly investigate an abuse incident where a resident threw a cup of creamers at another resident, leading to a repeat incident. Despite having policies in place, the facility failed to report the incident to administration or the SA and did not conduct necessary interviews or evidence handling.
The facility did not ensure timely physician visits for two residents, as required by regulations. One resident, with diagnoses including lymphoma, missed a scheduled visit in February, while another resident with multiple chronic conditions was not seen by a physician every 30 days for the first 90 days after admission. The facility's leadership confirmed the oversight and lack of documentation for these visits.
Failure to Report Allegation of Resident Exploitation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of exploitation to the State Agency as required by its abuse, neglect, and exploitation policy. The policy, revised 7/15/22, states that all alleged violations, including exploitation and misappropriation of resident property, must be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. Exploitation is defined in the policy as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The policy further requires that alleged violations be reported immediately, but not later than two hours if they involve abuse or serious bodily injury, or within 24 hours if they do not, and that results of investigations be reported to government agencies within five working days. The incident involved a resident with diagnoses including anxiety, depression, kidney failure, COPD, and type 2 diabetes, who had intact cognition with a BIMS score of 15 and was their own decision maker. On the evening in question, an agency LPN told the resident they did not have gas money to get home, and the resident gave the LPN eight dollars, which was later returned after another nurse instructed the LPN that accepting money from a resident was unacceptable. The next day, the ADON spoke with the resident, who confirmed giving and then having the money returned, and indicated they knew the LPN from a previous facility and believed their relationship made it acceptable to give money. The ADON reported the incident to the NHA. The NHA acknowledged being informed of the incident, but determined it was not an allegation of exploitation and did not report it to the State Agency, despite the facility’s policy requiring reporting of all alleged violations.
Failure to Thoroughly Investigate Allegation of Resident Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of exploitation involving one resident. The facility’s Abuse, Neglect and Exploitation policy requires immediate and comprehensive investigations of alleged abuse, neglect, or exploitation, including identifying and interviewing all involved persons, witnesses, and others who might have knowledge of the allegation, and focusing on determining whether exploitation occurred. The resident involved had diagnoses including anxiety, depression, kidney failure, COPD, and type 2 diabetes, and had a BIMS score of 15/15, indicating intact cognition and that the resident was their own decision maker. The resident reported that an agency LPN stated they did not have gas money to get home from work and accepted eight dollars from the resident, which was later returned. The resident stated they knew the LPN from a prior facility where the LPN had cared for them and believed their relationship made it acceptable to give the LPN money. The ADON was informed by a nurse that the LPN had accepted money from the resident and had instructed the LPN to return it. The ADON then spoke with the resident, who confirmed giving the LPN gas money and that it had been returned, and stated they felt it was acceptable due to their relationship with the LPN. After this interview, the ADON did not conduct any further investigation. The NHA was informed of the incident and determined it was not an allegation of exploitation, in part because the money was returned and the resident did not appear to have adverse psychosocial effects. The NHA confirmed that no additional residents or staff were interviewed to determine if there were similar concerns or if other residents had been affected, and the facility’s investigation contained no further interviews beyond the resident, despite policy requirements for a complete and thorough investigation of alleged exploitation.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for six residents, leading to discrepancies in their medical records. One resident with a tracheostomy did not have their tracheostomy care documented in multiple MDS assessments, despite having a medical order for such care and the presence of tracheostomy supplies. Another resident, who was discharged from Hospice services, was incorrectly documented as still receiving these services in subsequent MDS assessments. A resident prescribed antiplatelet medication was inaccurately recorded as receiving anticoagulant medication in their MDS assessments. Additionally, this resident had a Preadmission Screening and Resident Review (PASRR) Level II Screen completed, which was not reflected in their MDS assessment. Another resident's MDS assessment failed to document the administration of prescribed antianxiety medication. Further discrepancies were noted for a resident who experienced a fall resulting in a major injury, which was not recorded in their MDS assessment. This resident was also prescribed antipsychotic and antidepressant medications, which were not documented in their MDS assessments. Similarly, another resident's MDS assessment did not reflect the administration of prescribed antianxiety medication. These inaccuracies were confirmed through interviews with the facility's registered nurse responsible for MDS assessments.
Failure to Acknowledge Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendation reports were acknowledged by a physician for four residents, leading to deficiencies in medication management. For Resident 20, three out of six pharmacy recommendations were not acknowledged by a physician, and there was no follow-up for recommendations made in April, June, and July 2024. The resident was prescribed multiple medications for conditions including Parkinson's disease and bipolar disorder, and the pharmacy had recommended a gradual dose reduction for certain psychotropic drugs, which was not documented or followed up by the facility. Resident 13 also experienced a lack of physician acknowledgment for three out of nine pharmacy recommendations. The recommendations included monitoring and adjustments for medications related to diabetes, hypertension, and mental health conditions. The facility was unable to provide documentation of a physician's response to these recommendations, indicating a breakdown in the process of reviewing and acting upon pharmacy recommendations. Similarly, Resident 17 had three out of six pharmacy recommendations unacknowledged by a physician, including a dose reduction for sertraline and discontinuation of lovastatin. Additionally, the facility failed to act on a recommendation to decrease pantoprazole, despite a nurse practitioner's agreement. Resident 11's pharmacy reviews were inconsistently completed over seven months, with only two reviews available for that period. The facility lacked a process for ensuring regular pharmacy reviews and physician follow-up, contributing to these deficiencies.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide proper notification of coverage changes and financial liability to two residents when their Medicare Part A benefits ended. For one resident, identified as R26, the facility did not issue an Advanced Beneficiary Notice (ABN) form, which should have included the daily rate for which the resident would be liable if they chose to remain in the facility after their Medicare benefits ended. Despite signing a Notice of Medicare Non-Coverage (NOMNC) form indicating the end of benefits, R26 remained in the facility without receiving the necessary ABN form, as confirmed by the Nursing Home Administrator. Another resident, identified as R10, did not receive a NOMNC form when their Medicare Part A benefits ended. The facility's documentation incorrectly indicated that the termination of benefits was resident-initiated, which would not require a NOMNC form. However, interviews with the Director of Rehab and the President of Success revealed that the termination was facility-initiated, and the resident should have been provided with a NOMNC form. This oversight was acknowledged by the facility's staff during the surveyor's investigation.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who was discharged from Hospice services. The resident was admitted to the facility on Hospice services with diagnoses including diffuse large B-cell lymphoma and was receiving palliative care. The resident was discharged from Hospice services, but the facility only completed Quarterly MDS assessments following this discharge. During an interview, the Registered Nurse responsible for MDS assessments confirmed that a Significant Change MDS assessment should have been completed upon the resident's discharge from Hospice services. The Nursing Home Administrator also acknowledged that the MDS assessment should have been coded as a Significant Change MDS assessment according to the MDS manual guidelines.
Failure to Monitor and Report Significant Weight Gain
Penalty
Summary
The facility failed to ensure that a resident, identified as R11, received the necessary care and services to prevent and monitor significant weight gain. Despite the facility's Weight Monitoring policy, which requires regular weight checks and notification of significant weight changes to the physician and Registered Dietitian, R11 experienced a severe weight change of 38.93% over several months. The medical record review revealed that R11's physician was not adequately informed of the significant weight gain, and the facility did not follow the physician's order for weight monitoring after R11's return from a hospital admission. R11, who had diagnoses including Parkinson's disease, schizoaffective disorder, and bipolar disorder, was on medications that could affect appetite and weight. Despite multiple progress notes and weight assessments indicating significant weight gain, no new nutritional interventions or physician orders were documented. The facility's failure to document physician notification and to adhere to weight monitoring protocols contributed to the deficiency identified by the surveyor.
Failure to Monitor Adverse Reactions for High-Risk Medication
Penalty
Summary
The facility failed to monitor for adverse reactions of a high-risk medication, lamotrigine, prescribed to a resident diagnosed with bipolar disorder. The resident was prescribed 100 milligrams of lamotrigine once daily, but the medical record did not indicate any monitoring for adverse reactions or side effects associated with this medication. This oversight was identified during a review of the resident's medical record by a surveyor. Upon inquiry, the Nursing Home Administrator confirmed that there was no prior monitoring in place for the resident's anticonvulsant medication. The facility was not aware that monitoring for adverse reactions or side effects should be conducted for anticonvulsant medications, even when prescribed for off-label use. This lack of awareness and subsequent inaction led to the deficiency noted by the surveyor.
Failure to Monitor Adverse Effects of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure proper monitoring for adverse consequences of antipsychotic medications for two residents. Resident 11, who was admitted with diagnoses including schizoaffective disorder and bipolar disorder, was prescribed multiple antipsychotic medications such as aripiprazole and quetiapine. However, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) upon admission, when changes were made to the antipsychotic medication regimen, or when additional antipsychotic medications were prescribed. This lack of monitoring was confirmed by the facility's President of Success, who acknowledged that the necessary AIMS assessments were not conducted. Similarly, Resident 24, who had diagnoses including bipolar disorder and adverse effects of antipsychotic medication, was prescribed lithium carbonate. The facility did not perform an AIMS or implement monitoring for adverse side effects related to the antipsychotic medication upon admission. This oversight was also confirmed by the facility's President of Success, indicating a failure to adhere to the facility's psychotropic medication policy, which mandates regular monitoring and documentation of residents' responses to such medications.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate during medication administration observations. This deficiency was identified when a Licensed Practical Nurse (LPN) administered medications to a resident, R14, in forms that were contrary to the manufacturer's instructions. Specifically, the LPN crushed a 600 mg guaifenesin extended release (ER) tablet, a 20 mEq potassium chloride ER tablet, and a 20 mg omeprazole delayed release (DR) capsule, despite clear instructions not to crush or chew these medications. The error was observed during a surveyor's review of the medication administration process. R14, the resident affected by the medication errors, was admitted to the facility with multiple diagnoses, including cancer, hypertension, chronic kidney disease, dementia, and asthma. The resident's medical record indicated a physician's order allowing the crushing of medications permissible by the manufacturer. However, the LPN was unaware of the specific restrictions on the medications administered to R14. The Director of Nursing confirmed that extended and delayed release medications should not be crushed, highlighting a lapse in adherence to the facility's medication administration policy.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was offered a pneumococcal vaccine, as required by their own policy and CDC guidelines. R13's medical record lacked documentation indicating that the vaccine was offered or declined. The facility's policy mandates that each resident be assessed for pneumococcal immunization upon admission and be offered the vaccine unless contraindicated or previously immunized. However, R13's record did not reflect any such assessment or offer, despite the resident having chronic conditions like dementia, diabetes mellitus, and chronic obstructive pulmonary disease (COPD), which are risk factors for pneumococcal disease. During the survey, it was confirmed by the President of Success (VPS)-C that R13's medical record did not contain documentation of an offer or refusal of the pneumococcal immunization. R13 was admitted to the facility with a Minimum Data Set (MDS) assessment indicating intact cognition, which suggests that the resident was capable of making informed decisions regarding their health care. The absence of documentation and the failure to offer the vaccine represent a deficiency in adhering to the facility's vaccination policy and CDC recommendations.
Inadequate Supervision Leads to Resident Aggression
Penalty
Summary
The facility failed to provide adequate supervision for a resident, R1, who was known to have a history of aggressive behaviors due to schizoaffective disorder and bipolar disorder. R1's care plan included interventions such as calling family members, administering medications, and providing supervision during social gatherings. However, the care plan was not updated to reflect R1's increased aggressive behaviors towards staff and other residents. Despite multiple incidents of aggression, including verbal threats and physical actions, the facility did not implement increased supervision or other interventions to manage R1's behavior. On two separate occasions, R1 was able to enter another resident's room, R2, and engage in aggressive behavior. On the first occasion, R1 threw a Styrofoam cup of coffee creamers at R2 and verbally threatened them. The facility did not take any action to increase supervision or protect R2 after this incident. The following day, R1 was observed agitated in the hallway outside R2's room, but staff did not intervene or provide supervision. R1 subsequently entered R2's room again and threw a basket at R2, causing physical harm. The facility's failure to update R1's care plan and implement necessary interventions resulted in repeated incidents of aggression towards R2. Despite R1's history of aggressive behavior and the facility's policy on abuse prevention, there was no increased supervision or room changes to protect R2 and other residents. Interviews with staff confirmed that R1 was not on increased supervision, and interventions to redirect R1 were inconsistently applied.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the Nursing Home Administrator (NHA) and the State Agency (SA) as required by their policy. On 5/23/24, one resident entered another resident's room, threw a Styrofoam cup full of coffee creamers, and verbally threatened the other resident. Despite the incident being observed by a Registered Nurse (RN), it was not reported to the NHA or the Director of Nursing (DON) until the following morning, and the facility did not report the incident to the SA. The facility's policy mandates that all alleged violations involving abuse be reported immediately, or within a specified timeframe, depending on the severity of the incident. The involved residents had intact cognition, as indicated by their Minimum Data Set (MDS) assessments. The resident who initiated the altercation had a history of mental health issues and was at risk for inappropriate behaviors, as noted in their care plan. However, the facility did not adhere to its policy of timely reporting, resulting in a deficiency noted by the surveyor.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving two residents, R1 and R2. On 5/23/24, R1 entered R2's room and threw a Styrofoam cup full of creamers at R2. Despite this incident, the facility did not report it to administration or the State Agency (SA), nor did they conduct a thorough investigation to prevent further abuse. This lack of action resulted in another incident involving R1 and R2 the following day. R1 was admitted with diagnoses including Parkinson's disease, epilepsy, schizoaffective disorder, bipolar disorder, insomnia, and anxiety, with a BIMS score indicating intact cognition. R1's care plan noted a risk for behavior related to mental illness, including refusal of medications and inappropriate behavior. R2, admitted with diffuse large B-cell lymphoma and other conditions, also had intact cognition. The facility's policy required a thorough investigation of abuse allegations, including identifying responsible staff, handling evidence carefully, and interviewing all involved parties, but these steps were not followed in this case.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure timely physician visits for two residents, R2 and R4, as required by their policies and federal regulations. R2, who was admitted with diagnoses including large cell lymphoma and lymphedema, was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Specifically, after being seen in January, R2 was not seen again until March, missing the required February visit. Despite being scheduled, there was no documentation to confirm the February visit occurred. Similarly, R4, who had multiple diagnoses including Parkinson's disease and chronic pain syndrome, was not seen by a physician every 30 days for the first 90 days after admission. R4 was seen by a nurse practitioner in October and December, but not by a physician, and there was no record of a physician visit in November. The facility's leadership confirmed the oversight and lack of documentation for the required physician visits for both residents.
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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 Two Rivers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Ridge Health And Rehabilitation Center | 5.8 mi | — | 20 | 0 |
| Shady Lane Nursing Care Center | 7.8 mi | — | 0 | 0 |
| St Marys Home For The Aged | 8 mi | — | 10 | 0 |
| River's Bend Health Services | 8.8 mi | — | 13 | 0 |
| Complete Care At Manitowoc Llc | 10.8 mi | — | 6 | 0 |
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