Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Hamilton, Llc during CMS and state inspections, most recent first.
Improper Food Labeling and Wet-Nested Dishware: The kitchen had unlabeled opened and prepared foods in the reach-in refrigerator and walk-in cooler, including pre-sliced cheese, breakfast foods, and portioned canned fruits, with no open dates or use-by dates. Surveyors also observed wet-nested plate covers staged for lunch service, and the FSD and DON confirmed that opened foods should be dated and dishware should not be wet nested to prevent bacterial growth.
A resident with multiple medical conditions and a care plan indicating fall risk was found in bed without the call light within reach. The call light was attached to a bed rail out of reach, and the resident reported being unable to summon help. The CNA confirmed the call light should have been accessible, and facility policy requires call lights to be within reach.
Surveyors found multiple rooms with broken furniture, soiled surfaces, offensive odors, and insect infestations, along with overflowing trash and unaddressed maintenance issues. Several residents reported missing socks that had not been returned from laundry for over a month, with large bags of unpaired socks found in the laundry room. Staff acknowledged these deficiencies, which were not documented or addressed according to facility policy.
Failure to Follow Ordered Weight Monitoring: A resident with anoxic brain damage, functional quadriplegia, gastrostomy feeding, aphasia, and severe cognitive impairment did not have weights obtained as ordered. The record lacked several required weekly and monthly weights, and the UM, RD, and DON confirmed that the ordered weight schedule was not followed for this resident receiving enteral nutrition.
A resident with COPD, epilepsy, and vascular dementia had no physician order for oxygen despite a care plan calling for oxygen as needed per order. Surveyors observed a portable O2 tank in the resident's room that was heavily soiled, with insects around it, and undated nasal cannula tubing lying on the floor. An LPN acknowledged the tubing was not dated or properly stored and stated the resident did not have an oxygen order.
Multiple incidents occurred in which residents with cognitive and psychiatric disorders engaged in physical altercations, including one resident pulling another's sweater and being struck in the face, and another resident running over a peer's foot with a wheelchair and being punched in the head. These events were witnessed by staff and other residents, and the facility did not prevent the physical abuse, despite policies ensuring residents' rights to safety.
A resident with severe cognitive impairment and a prescribed dysphagia puree diet was given a piece of donut by the Director of Recreation during an outdoor activity, leading to choking and subsequent cardiac and respiratory arrest. The resident was dependent on staff for daily activities, and the incident occurred despite previous staff training on dietary orders. The resident was transferred to a hospital after emergency interventions were performed.
A facility failed to ensure that a physician conducted face-to-face visits and documented progress notes for a resident with end-stage renal disease and major depressive disorder at least once every sixty days. The absence of documentation for March through May 2024 was confirmed by staff interviews, and no additional records were provided to verify compliance.
Improper Food Labeling and Wet-Nested Dishware
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices to prevent food borne illness. During a kitchen tour, the surveyor observed three blocks of pre-sliced cheese wrapped in plastic film in a reach-in refrigerator with no open date or use-by date, along with a foil-covered plate of breakfast foods that also had no label, opened date, or use-by date. In the walk-in cooler, the surveyor observed a tray of souffle cups containing individually portioned canned fruits and pureed canned fruits, and neither the containers nor the tray were labeled with open dates or use-by dates. The surveyor also observed several stacks of plate covers on a rolling cart near the tray assembly line that were wet nested and intended for use during the upcoming lunch service. The Food Service Director confirmed that opened or leftover foods should be labeled with prepared/opened dates and use-by dates, and that dishware and serving vessels should not be wet nested to prevent bacterial growth. Facility administration later acknowledged that opened and prepared foods need to be labeled with an open date and use-by date, and that wet nesting of dishes should not occur to prevent bacterial growth.
Call Light Not Kept Within Reach of Resident
Penalty
Summary
A deficiency was identified when a resident was observed in bed without the call light pull cord within reach. The call light was affixed to the upper aspect of the right-side rail, making it inaccessible to the resident. When asked, the resident stated they could not find the string to call for help. The resident's medical record indicated diagnoses including diabetes mellitus, malignant neoplasm of the breast, and osteoarthritis of the right knee. The most recent Minimum Data Set (MDS) assessment showed the resident had intact cognition but required maximum assistance for activities of daily living. The resident's individualized care plan included interventions to ensure the call light was within reach due to a risk for falls. During the survey, the assigned CNA confirmed that the call light should have been placed within the resident's reach. Facility policy also required that call lights be positioned conveniently and within reach of residents. The failure to ensure the call light was accessible constituted a failure to reasonably accommodate the resident's needs and preferences.
Failure to Maintain Clean, Homelike Environment and Return Personal Items
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in several resident rooms, as evidenced by multiple observations of disrepair and unsanitary conditions. In three resident rooms, surveyors observed broken furniture such as dressers and armoires, peeling paint with exposed plaster and sheet rock, cracked and soiled walls, and heavily soiled bathroom floors and toilets. Additionally, portable oxygen tanks were found to be heavily soiled with rust and brown substances, and there were swarms of flying insects present in some rooms. Overflowing trash cans, scattered garbage, and sticky substances on bedside tables were also noted, contributing to an overall unpleasant and offensive smell in the affected areas. Maintenance and housekeeping staff acknowledged these issues, and it was confirmed that necessary repairs and cleaning had not been documented or addressed as required by facility policy. The facility also failed to ensure that residents' personal clothing items, specifically socks, were returned after laundering. Multiple residents reported missing socks, stating that they had informed both housekeeping and nursing staff on several occasions, but the items had not been returned for over a month. During a resident council meeting, all attending residents confirmed the ongoing issue of missing socks. The housekeeping staff responsible for laundry admitted to being too busy to pair or deliver socks for over a month, and the Housekeeping Director confirmed receiving several complaints from residents about missing items. Surveyors observed five large plastic bags full of residents' socks in the laundry room, which both the Housekeeping Director and staff acknowledged as unacceptable. A review of facility policies revealed requirements for laundry to be returned within 24-72 hours and for the environment to be maintained in a safe, clean, and homelike manner. Despite these policies, the facility did not meet the standards for cleanliness, maintenance, or the timely return of residents' personal belongings, as evidenced by the observations and interviews conducted during the survey.
Failure to Follow Ordered Weight Monitoring
Penalty
Summary
The facility failed to monitor the nutritional status of one resident by not following physician orders for scheduled weight checks. The resident was admitted with anoxic brain damage, functional quadriplegia, gastrostomy for enteral feeding, and aphasia, and the annual MDS reflected severe cognitive impairment. The physician order summary included orders to obtain the resident’s weight weekly for a 4-week period starting 8/16/24, then monthly on the 1st day of the month on day shift, including a later order dated 12/24/24 for monthly weights on the 1st day of the month. The medical record did not show weights obtained on 9/6/24 as required by the weekly order, on 10/1/24 or 11/1/24 as required by the monthly order, or on 1/1/25, 3/1/25, or 5/1/25 as required by the later monthly order. During interviews, the UM stated weights were done at least monthly and more often if ordered, with CNAs obtaining the weights and reporting them to the UM or nurse for documentation. The RD stated CNAs were responsible for obtaining weights and that following the physician order was important for residents receiving enteral nutrition. The DON confirmed that a physician’s order for a specific weight schedule should be followed accurately and acknowledged that monitoring weights was important in monitoring nutritional status. The LNHA and DON later confirmed that the weights were not taken per the physician order.
Missing Oxygen Order and Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident with diagnoses including COPD, epilepsy, and vascular dementia. The resident's care plan included interventions to administer oxygen as needed per physician order and to monitor oxygen saturation on room air and on oxygen, but the current physician order summary did not show an order for oxygen and the MDS did not indicate that the resident received oxygen therapy. The resident had severe cognitive impairment with a BIMS score of 5 out of 15. During observation, surveyors found a portable oxygen tank in the resident's room on the left side of the bed. The tank was heavily soiled with a brown substance, insects were flying around it, and the nasal cannula tubing was undated and lying on the floor. An LPN acknowledged that the tubing was not dated, was on the floor, and that the oxygen tank was heavily soiled. The LPN later stated the resident did not have an oxygen order and was unsure why the oxygen was in the room. The DON confirmed that the resident should have had a physician's order for oxygen per the care plan and that the tubing should have been dated and stored in a plastic bag for infection control measures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, as evidenced by multiple incidents involving four residents. In one incident, a resident with severe cognitive impairment and a history of dementia, depression, and anxiety pulled on another resident's sweater, prompting the second resident, who was moderately cognitively impaired and had schizoaffective and mood disorders, to swing and hit the first resident in the face. Staff responded to the altercation after hearing yelling, and it was noted that the first resident was known to wander and enter other residents' rooms. In another incident, a resident with paranoid schizophrenia, bipolar depression, and moderate cognitive impairment ran over another resident's foot with a wheelchair while heading to a smoking area. The second resident, who was severely cognitively impaired and had schizophrenia and mood disorders, reacted by punching the first resident in the head. This altercation was witnessed by staff and other residents, and it was confirmed that the two residents had a confrontation due to proximity and a rush to access the smoking area. The facility's policy states that residents have the right to be free from abuse, neglect, and exploitation, including freedom from physical abuse. Despite this, the incidents described show that the facility did not prevent resident-to-resident physical abuse, as altercations occurred resulting in physical contact and potential for injury. The events were substantiated through interviews, record reviews, and self-reports, indicating a failure to ensure residents' rights to safety and protection from abuse.
Failure to Adhere to Prescribed Diet Leads to Choking Incident
Penalty
Summary
The facility failed to ensure a safe environment for a resident who had a physician's order for a dysphagia puree diet with nectar-thickened liquids. During an outdoor activity program, the Director of Recreation provided the resident with a bite-sized piece of a soft donut, which was not consistent with the prescribed diet. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, began coughing and showed signs of choking. The activity staff wheeled the resident back into the facility, where nursing staff performed the Heimlich maneuver and removed food particles. The resident became unresponsive, and cardiopulmonary resuscitation (CPR) was initiated. Emergency Medical Services (EMS) were notified, and the resident was transferred to an acute care hospital emergency room. The resident was admitted with cardiac arrest, respiratory arrest, and choking due to food in the larynx. The incident highlighted a failure in the facility's supervision and adherence to dietary orders, as the staff member involved had previously been in-serviced about resident diets and verification with nursing staff. The deficient practice created an immediate jeopardy to the health and well-being of the resident, as the food provided was not of the prescribed consistency. This incident had the potential to impact all residents on pureed diets and other consistencies. The facility's failure to follow the prescribed diet and ensure proper supervision led to a serious health event for the resident.
Removal Plan
- The staff member was suspended pending investigation and subsequently terminated.
- All residents on puree diets were identified and verified that plan of care was in place and being followed.
- Staff was immediately educated on identification of resident diets and ensured only food consistent with the diet is provided.
- Residents on altered diets identification procedure updated to include utilization of a colored dot on the resident door tag as well as on the resident bracelet. All staff were educated on the new process. Resident diet list will be printed by reception daily and provided to all nursing units and the recreation program. The procedure will be audited by the Director of Nursing/Designee.
- Staff was immediately educated on resident diet consistencies. Understanding will be audited by Director of Nursing/Designee.
- Staff was immediately educated on how to identify residents' diet. Understanding will be audited by Director of Nursing/Designee.
Failure to Conduct Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days. This deficiency was identified for one resident, who was admitted with diagnoses including end-stage renal disease, dependence on dialysis, and major depressive disorder. The resident had a Brief Interview for Mental Status score indicating moderately impaired cognition. A review of the physician's progress notes revealed no documented evidence of visits or examinations by the physician from March 2024 through May 2024. Interviews with facility staff, including the Unit Manager and the Director of Nursing, confirmed the absence of progress notes for the specified period. The Unit Manager noted that the last progress note from the primary doctor was in February 2024, with no notes found for March, April, and May 2024. The Director of Nursing acknowledged the lack of documentation and stated that the physician had recently started documenting in the computer. Despite requests, the facility did not provide additional documentation to support that the required visits and notes were completed.
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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 Passaic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Chestnut Hill Llc | 0.6 mi | ★★★★★ | 0 | 0 |
| Atlas Rehabilitation Healthcare At Daughters Of Mo | 2.3 mi | ★★★★★ | 2 | 0 |
| Alaris Health At The Chateau | 3.4 mi | ★★★★★ | 4 | 0 |
| Complete Care At Regent Llc | 3.7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Fair Lawn Edge | 3.8 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.