Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Hamilton Grove Healthcare And Rehabilitation, Llc during CMS and state inspections, most recent first.
Air mattress settings were not matched to resident weight for multiple residents with pressure injury risk, impaired mobility, incontinence, and cognitive impairment. Surveyors observed mattresses set at incorrect weights, including settings far above or below the residents’ documented weights, and one resident had no active air mattress order even though the mattress remained in use. Staff confirmed the mattresses were intended for pressure prevention and that the setting should correspond to the resident’s weight.
A resident with bipolar disorder, chronic pain syndrome, edema, neuralgia, and neuritis, and with a BIMS of 15/15, was observed being transported backwards in a recliner chair from the hallway to the lounge area. The CNA acknowledged residents should be moved forward facing, and the LPN/UM, DON, and LNHA all stated that pulling a resident backwards was not appropriate and was a dignity issue.
Failure to follow up on a psychiatrist’s recommended GDR for quetiapine. A resident with major depressive disorder, PTSD, and paranoid schizophrenia was receiving antipsychotic medication, and the psych note recommended reducing Seroquel from 50 mg HS to 25 mg HS for 7 days, then discontinuing it. The MAR showed the medication continued as ordered, but the chart lacked documentation that the PCP or resident representative addressed the recommendation, and the consultant pharmacist also noted the need for follow-up.
Missing Pre-Employment Background Check: The facility failed to complete a criminal background check before an CNA began work, despite policies stating that all prospective employees must be screened and may not start until required checks are completed and approved. Surveyors found no evidence of a background check in the employee file, and the LNHA could not provide additional information when the finding was presented.
A resident was discharged from the facility, but the MDS record did not include a discharge assessment. Survey review found the last MDS on file was a quarterly assessment, and the MDS Coordinator confirmed the discharge MDS was missed. The LNHA later acknowledged that no discharge MDS had been completed for the resident at discharge.
Failure to revise the care plan for a resident receiving enteral tube feeding. The resident had dysphagia, a gastrostomy tube, GERD, and severe cognitive impairment, and the chart showed NPO orders plus enteral feeding orders. The ICCP included aspiration risk and tube feeding focus areas, but staff acknowledged the care plan was not updated when the diet changed from PO to NPO and tube feedings began.
An LPN signed a smoking-related physician order as completed on multiple shifts for a resident who was identified as a smoker, but later could not explain the entries and stated she never saw the resident smoke. The resident had anxiety disorder and schizoaffective disorder, bipolar type, was cognitively intact on MDS, and had a care plan and smoking evaluation indicating supervision with smoking and staff control of cigarettes and a lighter. The RN/UM and DON confirmed that if the MAR was signed, the cigarettes should have been given.
A resident who was dependent for toileting was found soaked with urine and later soiled with urine and feces, with staff confirming the resident should not have been left in that condition and that no overnight incontinence care was documented. Another resident with dementia and dependence for ADLs was observed with long, unclean fingernails despite an order for nails to be kept clean, trimmed, and filed; a CNA admitted the nail care was not done, and an LPN had signed it as completed.
An LPN performed tracheostomy care for a resident with a trach, severe cognitive impairment, and orders for trach care every shift, but did not use the sterile gloves provided in the trach care kit and instead handled sterile supplies with bare hands and nonsterile gloves. The LPN placed nonsterile items on the draped bedside table and used nonsterile exam gloves during parts of the procedure, despite the facility policy requiring sterile gloves and aseptic technique for trach care. The UM and DON stated that sterile gloves from the kit should be used and that nonsterile items should not be placed on the sterile field.
The facility failed to complete annual performance evaluations for CNAs. Surveyors requested the records for five randomly selected CNAs, but the LNHA and HRD could not provide any performance reviews. The HRD stated the CNAs were unionized and that the facility had no policy for performance evaluations, despite the facility policy requiring personnel files to include performance evaluations.
Medication Left Unattended at Resident Bedside: A resident with glaucoma, bilateral ocular hypertension, end stage renal disease, intact cognition, and highly impaired vision was observed with two unidentified tablets left in a medication cup on the overbed table after the RN had signed the MAR showing 1400 meds were administered. The LPN/UM and RN both acknowledged that meds should not be left at the resident's bedside and that the nurse should remain with the resident to ensure the medications are taken.
Medication Error Rate Exceeded Threshold: Surveyors observed two LPNs administer incorrect constipation medications to two residents during med pass, resulting in a 7.14% medication error rate. One resident ordered sennosides-docusate sodium 8.6-50 mg received Geri-Kot (Senokot) 8.6 mg, and another resident ordered senna plus 8.6-50 mg received Senokot 8.6 mg. Staff acknowledged the errors and stated the meds were not the same and that the 5 rights and three checks were not followed.
A cognitively impaired resident with dysphagia was ordered a pureed diet with nectar-thick liquids and had a care plan identifying aspiration risk and the need for thickened liquids. A family member brought in a smoothie from outside and, after asking an RN about it, was told the resident was supposed to receive nectar-thick liquids; however, the RN did not verify whether the smoothie was given, did not document any follow-up, and did not notify the physician. No incident report was completed, and the care plan was not updated with interventions regarding outside food, contrary to facility policy requiring reporting and physician notification of incidents.
A resident with severe cognitive impairment was mistakenly given another resident's medications by an agency LPN who failed to verify the resident's identity and did not report the error. The error was not documented, and the facility only learned of the incident after the resident was hospitalized for nausea, vomiting, and an upper GI bleed. The incident was not reported or documented by the nurse, and staff were unaware until notified by the hospital.
A resident in an LTC facility was involved in a sexual encounter with an LPN, which was witnessed by a CNA. Despite the resident's cognitive intactness and fear expressed during the incident, the facility failed to report the event to authorities, citing it as consensual. The facility's investigation was incomplete, and the incident was not documented in the resident's medical records, leading to an Immediate Jeopardy situation.
A facility failed to report an allegation of sexual abuse involving a resident and an LPN to the NJDOH. The incident was considered consensual by the resident, who had intact cognition and various medical conditions. Despite the facility's policy requiring such incidents to be reported, the DON and LNHA did not notify authorities, leading to a deficiency finding.
A resident with an indwelling catheter did not receive scheduled urology and nephrology consultations due to oversight in a LTC facility. The Unit Manager/LPN was unaware of the orders due to absence, and the ADON admitted the orders were missed during an in-house transfer. There was no facility policy for admitting residents or transcribing physician's orders, contributing to the deficiency.
The facility failed to provide the required 12 hours of in-service training for CNAs, with none of the reviewed CNAs meeting the mandated hours. Additionally, two CNAs did not receive abuse prevention training. The deficiency was attributed to a lack of policy and oversight due to staffing changes, as acknowledged by the DON.
A facility failed to thoroughly investigate an alleged incident of sexual abuse between a resident and an LPN. The resident, with intact cognition, reported consensual oral sex with the LPN, which was witnessed by another staff member. The facility did not complete an incident report, notify the resident's physician promptly, or document the investigation thoroughly, including missing interviews with the resident's roommate and written statements from witnesses.
A resident was observed without heel booties, contrary to physician orders for continuous use to prevent skin breakdown. The LPN acknowledged the oversight, and the DON confirmed the requirement for booties when in a recliner. The facility's policy mandates adherence to physician orders for such devices.
A resident was observed smoking without a required smoking apron, contrary to their care plan, while supervised by the Director of Activity. The resident's care plan and smoking evaluation indicated the need for a smoking apron and assistance with lighting cigarettes. The Registered Nurse Unit Manager and DON acknowledged the oversight, noting the care plan should have been updated to reflect the resident's current needs.
The facility failed to ensure timely physician visits and documentation for two residents with severe cognitive impairments. One resident had no physician notes since admission, and another had no notes since January, despite a readmission. The LPN and DON confirmed the lack of documentation, and the Medical Director acknowledged the oversight.
A resident with severe cognitive impairment and multiple diagnoses developed several pressure injuries, but the facility failed to update the care plan with new interventions. Despite documentation of the injuries and communication among staff, the care plan was not revised to address the resident's wound care needs, as required by facility policy.
A facility failed to document a registered nurse's assessment of a reported injury for a resident with severe cognitive impairment receiving hospice care. An LPN noted a mark on the resident's forearm, informed the shift supervisor, and attempted to contact the NP, but no further documentation was made. The RN shift supervisor observed the resident but did not document his findings, leading to a deficiency.
Air mattress settings were not matched to resident weight
Penalty
Summary
The facility failed to provide preventive care consistent with professional standards of practice for residents at risk for pressure injuries and failed to ensure that air mattresses were accurately set according to resident weight. Surveyors observed multiple residents in bed with air mattress settings that did not match their documented weights, including settings of 330 pounds, 180-230 pounds, 325 pounds, 80 pounds, and 540 pounds. The report identified this deficient practice for four residents who had orders or care plan interventions related to pressure prevention or skin breakdown. One resident had diagnoses including hemiplegia, hemiparesis, muscle weakness, and cognitive communication deficit, with severe cognitive impairment on the MDS and a care plan addressing risk for skin breakdown, incontinence, and impaired mobility. The resident had an order for an air mattress for pressure prevention and a documented weight of 210.8 pounds, yet the mattress was observed set at 330 pounds on one occasion and 180-230 pounds on another. A nurse confirmed the resident had the air mattress because of pressure ulcer risk. Another resident had diagnoses including bed confinement status, chronic pain syndrome, and dementia, with severe cognitive impairment on the MDS, impaired extremities, and an indicator for pressure injury. The resident’s care plan addressed risk for skin breakdown related to incontinence and decreased mobility, and included an air mattress and pressure relieving mattress. The resident had a documented weight of 147.2 pounds and a new right lateral foot arterial ulcer was noted in the wound assessment record, while the air mattress was observed set at 180-230 pounds. A nurse stated the mattress setting was adjusted to the resident’s weight and that the setting determines the amount of air in the mattress to relieve pressure. A third resident with diagnoses including unspecified symptoms involving cognitive function and awareness and nontraumatic intracerebral hemorrhage had severe cognitive impairment, was at risk for pressure injury, and had a care plan for impaired mobility and incontinence with an air mattress intervention. The resident’s documented weight was 147.2 pounds, but the mattress was observed set at 325 pounds on one occasion and 80 pounds on another. A fourth resident with muscle weakness, muscle wasting, and chronic pain syndrome had a care plan for decreased mobility and risk for skin breakdown with an air mattress intervention, but the order for the air mattress had been discontinued and no active order was listed. Despite this, the mattress was observed set at 540 pounds, and the UM stated the setting should be adjusted by weight and that nurses should be signing out an order for placement and function of the air mattress.
Resident Transported Backwards in a Recliner Chair
Penalty
Summary
The facility failed to ensure a resident was transported from one area of the unit to another in a dignified manner. During an initial tour of the unit, a surveyor observed a CNA transport Resident #45 in a recliner chair facing backwards from the hallway near the resident's room to the lounge area across from the nursing station. The resident's EMR showed diagnoses including bipolar disorder, chronic pain syndrome, localized edema, neuralgia, and neuritis. The most recent quarterly MDS dated 2/27/26 indicated a BIMS score of 15 out of 15, showing cognitively intact cognition, and also showed the resident required a wheelchair for transfers. The resident's comprehensive care plan included interventions for falls risk, knee pain, arthritis, ambulatory dysfunction, and antidepressant use, including assistance with transfers as needed and escort/transport to activities as needed. When interviewed, the CNA stated residents should be transported forward facing and acknowledged she should have turned the resident around. The LPN/UM stated residents should be pushed forward and not pulled backwards because it was a dignity issue. The DON and LNHA also acknowledged that staff should not have pulled the resident backwards down the hallway, and the facility policy stated residents are to be treated with courtesy, consideration, and respect for dignity and individuality.
Failure to Follow Up on Recommended GDR for Antipsychotic Medication
Penalty
Summary
The facility failed to follow up on a psychiatrist’s recommendation for a gradual dose reduction (GDR) of quetiapine for one resident who was receiving antipsychotic medication. The resident had diagnoses including major depressive disorder, PTSD, and paranoid schizophrenia, and the quarterly MDS dated 1/16/2026 showed a BIMS score of 00 out of 15, indicating cognition could not be assessed. The resident was observed sitting in a reclining area in the hallway near the nursing station and had a splint on the left hand/wrist. The psychiatric progress note dated 1/5/2026 documented an assessment/plan recommending discontinuation of the current Seroquel order and starting Seroquel 25 mg at bedtime for 7 days, then discontinuing it, with the note stating that a dose reduction was recommended. The note also stated that recommendations were discussed with facility staff, who would await approval from the PCP and then obtain consent from the appropriate decision-maker. The physician order summary showed quetiapine 50 mg at bedtime for schizophrenia, with the order dated 10/8/2025 and a discontinue date of 2/2/2026. The January and February 2026 MARs showed the quetiapine order was administered as ordered from 1/6/2026 through 2/2/2026. Review of the progress notes did not show documentation that the GDR was addressed by the PCP or the resident representative, and the same GDR recommendation appeared again in the psychiatric progress note dated 2/3/2026. The consultant pharmacist’s monthly report dated 1/13/2026 also noted the psych consult recommendation for GDR and requested follow-up documentation. Facility staff, including the RN/UM and DON, acknowledged during interview that they would expect documentation showing the recommendation was addressed, but no such documentation was present in the record reviewed.
Missing Pre-Employment Background Check
Penalty
Summary
The facility failed to implement its abuse policy by not completing a criminal background check before the first day of work for 1 of 96 employees, Employee #4, a CNA. Employee #4 had a date of hire of 2/28/25 and first day of work of 2/28/25, and the reviewed file contained no evidence of a background check completed before employment began. During the survey, the team reviewed newly hired employee files since the last survey and identified this missing background check. On 3/13/26 at 2:02 PM, the survey team presented the finding to the LNHA, DON, Regional Nurse Consultant, and the President of Clinical Services, and the LNHA could not provide additional information regarding the finding. The facility’s Resident Abuse/Neglect Policy and Procedure stated that all prospective employees are carefully screened, including background checks, and that all staff are screened upon hire. The Hiring and Recruitment policy also stated that employees may not begin work until required screening procedures are completed and approved, and referenced NJAC 8:39-9.3(b).
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge MDS assessment for one resident who was discharged from the facility on 11/3/25. Survey review on 3/11/26 found that the resident’s electronic medical record showed the discharge had occurred, but the last MDS on file was a quarterly assessment and there was no discharge assessment completed. The MDS Coordinator confirmed that the resident was discharged and that a discharge MDS should have been completed, stating that the assessment was missed. The LNHA later acknowledged that no discharge MDS assessment had been completed for the resident when discharged.
Failure to Revise Care Plan for Resident Receiving Tube Feeding
Penalty
Summary
The facility failed to revise an individual comprehensive care plan for a resident receiving enteral tube feeding. Resident #1 was admitted with diagnoses including dysphagia, gastrostomy, and gastro-esophageal reflux disease without esophagitis. The most recent comprehensive MDS dated 12/30/25 showed a BIMS score of 00 out of 15, indicating severely impaired cognition, and section K noted the resident had a feeding tube on admission. The individualized comprehensive care plan contained a focus area for aspiration risk related to dysphagia and another focus area for receiving enteral feedings to meet nutrition and hydration needs, with interventions such as administering feedings as ordered, monitoring for intolerance, checking residuals as ordered, administering flushes as ordered, and maintaining NPO status. The medical record also included physician orders for NPO diet and enteral feeding one time a day with a total volume of 1400 ml. During interview, the LPN/UM stated care plans were updated every 3 months, annually, and as needed with changes in the resident's plan of care, and acknowledged the care plan should have been updated when the resident's diet changed from PO to NPO. The DON confirmed the care plan should have been updated when the diet order changed and tube feedings were started, and stated it was the responsibility of the unit manager, DON, and nursing team to update care plans. The LNHA also acknowledged that a care plan should be updated when there were any changes in the resident's care.
Failure to Follow Smoking Order Documentation
Penalty
Summary
The facility failed to ensure nursing staff followed a physician order and acceptable standards of clinical practice for Resident #142, who was identified as a smoker. The resident was admitted with diagnoses including anxiety disorder and schizoaffective disorder, bipolar type, and had a quarterly MDS dated 2/25/2026 showing a BIMS score of 15/15, indicating cognitive intactness. The care plan included a focus that the resident required supervision with smoking because the resident chose to smoke despite the possible ill effects. The smoking evaluation also indicated the resident smoked, and the physician order directed that cigarettes and a lighter be kept by staff and that 5 cigarettes be given on the 7-3 and 3-11 shifts every day. Review of the February and March 2026 MARs showed an LPN signed the smoking order as completed on multiple day shifts, including 3/12/2026. During interview, the LPN stated she was the resident’s assigned nurse, said she never saw the resident smoke, and could not explain why she signed the order as completed. The RN/UM stated the resident was periodically a smoker and that if the MAR was signed as done, it meant it should have been done. The DON stated that if nurses signed the MARs indicating cigarettes were given, they should have been giving them and should not sign if they were not. The facility policy on documentation stated that clinical documentation is used to enhance continuity of care and show what must be carried out to monitor outcomes of care.
Failure to Provide Timely Incontinence Care and Nail Care
Penalty
Summary
The facility failed to provide timely incontinence care for a dependent resident who was observed with a completely saturated incontinence brief and urine stains on the top sheet. During incontinence rounds, the resident was found soaked with urine, and later was also observed soiled with urine and feces, with urine and feces stains on the bed padding and fitted sheet. Staff interviews confirmed the resident should not have been left in that condition, and the last documented incontinence care had been completed the prior evening with no documentation of care during the overnight shift. The resident had diagnoses including type 2 diabetes, muscle weakness, difficulty walking, depression, anxiety disorder, and hypertension, and the MDS indicated severe cognitive impairment and dependence for toileting. The resident’s care plan identified a risk for skin breakdown and included interventions to offer or assist with toileting during care, before and after meals and activities, at bedtime, and to provide prompt incontinence care. The RN/UM, LPNs, and CNA involved stated that the resident should not have been left saturated and that the condition could lead to skin breakdown. The DON stated the expectation was for all shifts to round on residents, change residents if soiled at least two times each shift and as needed, and that no resident should be saturated and soiled like that. The facility also failed to provide nail care during ADL care for another resident. During an initial tour, the resident was observed with long fingernails on both hands and a black substance under two nails. The resident had diagnoses including unspecified dementia, Alzheimer’s disease, and hemiplegia and hemiparesis following cerebral infarction, and the MDS showed moderate cognitive impairment and dependence for ADL care. The care plan noted the resident could be combative during ADL care, and the physician’s order required nails to be clean, trimmed, and filed as needed. A CNA stated nail care was part of morning care but admitted it was not done because the resident was resistant, and the nurse later acknowledged the nail care had been signed as completed even though the resident’s nails remained long and unclean.
Tracheostomy Care Performed Without Sterile Technique
Penalty
Summary
The facility failed to ensure tracheostomy care was completed using sterile technique for one resident who had diagnoses including autistic disorder, aphagia, unspecified asthma, and COPD with acute exacerbation. The resident’s MDS indicated severe cognitive impairment, rare or no understanding, dependence on staff for activities of daily living, and a need for tracheostomy care. The care plan identified the resident as at risk for complications related to having a tracheostomy and directed staff to perform tracheostomy care every shift. During direct observation, an LPN performed tracheostomy care and was seen placing nonsterile items on a draped bedside table, opening a tracheostomy care kit, opening sterile gauze and a disposable inner cannula, and emptying sterile saline into the open gauze packet. The LPN then reached into the packet with bare hands to remove the sterile gauze and placed it into the kit basin. Although sterile gloves were present in the kit, the LPN did not use them during the preparation. The LPN later used nonsterile exam gloves to wipe the tracheostomy site, removed and discarded the inner cannula, and then continued care using nonsterile gloves and newly opened sterile gauze to dry the site before placing a new inner cannula and sterile slit-gauze at the tracheostomy site. The resident had physician orders for tracheostomy care every shift, oxygen via trach collar every shift, and suctioning as needed for increased secretions. In interviews, the LPN stated tracheostomy care required aseptic technique and that the sterile gloves in the kit should be used, but did not remember whether those gloves were used. The UM and DON both stated that sterile gloves from the tracheostomy care kit should be used and that nonsterile items should not be placed on the sterile field. The facility’s tracheostomy care policy required hand hygiene, gathering sterile equipment, putting on sterile gloves, and using aseptic technique to cleanse the stoma site.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to evaluate the performance of Certified Nursing Assistants (CNAs) on an annual basis. During review of records and facility documents, the surveyor requested the education and performance reviews for five randomly selected CNAs, but no performance evaluations were provided. The Licensed Nursing Home Administrator could not provide the evaluations when asked, and the Human Resources Director also could not provide them. The Human Resources Director stated that there were no performance evaluations for the last year for CNAs because they are unionized, and that the facility had no policy for performance evaluations. Review of the facility’s Hiring and Recruitment policy, last reviewed in 8/2025, showed that personnel files were to contain performance evaluations and be maintained in accordance with state and federal requirements, including NJAC 8:39-43.17(b).
Medication Left Unattended at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were administered according to standards of practice for one resident. On 3/6/26 at 1:30 PM, the surveyor observed the resident lying in bed, awake, and eating lunch with a medication cup containing two unidentified tablets on the overbed table. The Licensed Practical Nurse/Unit Manager acknowledged the cup contained one pink tablet and one white tablet. The resident stated they thought they had taken all of their medications. The LPN/UM stated the nurse should stay with the resident during medication administration to ensure all medications were taken and that medications should never be left at the resident's bedside. At 1:45 PM the same day, the Registered Nurse stated the resident had told her they were going to swallow the medications and acknowledged that medication should never be left unattended at the resident's bedside. Review of the EMR showed the resident had diagnoses including primary open-angle glaucoma, bilateral ocular hypertension, and end stage renal disease, with a BIMS score of 15/15 and highly impaired vision. The March 2026 MAR showed the RN signed for all 1400 medications as administered, including Abilify 10 mg and nephro vitamins 0.8 mg, despite the observed tablets remaining in the medication cup.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below 5%, with surveyors observing 2 medication errors during 28 doses administered by 2 nurses, resulting in a 7.14% error rate. On 3/11/26, an LPN on the Klockner Unit administered Geri-Kot (Senokot) 8.6 mg one tablet to Resident #2 even though the order was for sennosides-docusate sodium 8.6-50 mg one tablet daily for constipation. The resident’s record showed diagnoses including anemia, joint pain, and constipation. The LPN stated that Senokot was the only product available at the facility and acknowledged administering it. The RN/UM later stated the nurse should have performed the three checks and that the LPN did not follow the five rights during medication administration. Also on 3/11/26, an LPN on another unit administered Geri-Kot (Senokot) 8.6 mg two tablets to Resident #197 when the order was for senna plus 8.6-50 mg, two tablets by mouth two times a day. The resident’s record showed diagnoses including muscle weakness and essential hypertension. The LPN confirmed giving Senokot and stated that senna plus and Senokot were the same and both had 8.6 mg. The LPN/UM stated the nurses were expected to perform three checks and review physician orders before administration, and the DON stated Senna and Senokot were different medications and that the nurses should have held the medication if it was not available. The facility policy required medications to be administered safely and effectively and directed staff to review the 5 rights at each step of medication administration.
Failure to Ensure Ordered Nectar-Thick Liquids and Follow-Up on Outside Food
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively impaired resident consistently received nectar-thick liquids as ordered and to implement interventions to prevent the resident from receiving liquids inconsistent with the prescribed diet. The resident had diagnoses including metabolic encephalopathy, dysphagia (oral phase), and unspecified dementia with severely impaired cognitive skills for daily decision making, as documented on the quarterly MDS. Physician orders specified a regular diet with pureed texture and nectar (mildly thick) liquids, and the care plan identified a risk for aspiration related to dementia and the resident’s preference not to be assisted during meals, with interventions including monitoring for aspiration signs and providing thickened liquids as ordered. On a documented date, the resident’s family member brought an outside smoothie into the facility and asked RN #1 if it was acceptable to give it to the resident. RN #1 informed the family member that the resident was supposed to receive nectar-thick liquids, but the family member stated that the smoothie looked acceptable and that the resident would only have a taste. The progress note recorded that the smoothie cup contained approximately 45 cc (1.5 oz) of smoothie and that RN #1 did not witness the smoothie being given to the resident. There was no documentation that RN #1 followed up with the family member to determine whether the smoothie was actually given or how much was consumed. The record review and interviews further showed that there was no incident/accident report completed for this event, and no documentation that the physician was notified of the potential administration of an inappropriate fluid consistency, despite facility policy requiring all incidents and accidents to be reported to the nursing supervisor and the attending physician. The DON and UM acknowledged that the family member should have been educated, the physician notified, and the care plan updated with new interventions related to outside food, but these actions were not taken. The facility also did not implement measures to prevent recurrence of similar incidents involving outside food inconsistent with ordered diet and fluid thickness.
Significant Medication Error Due to Failure to Verify Resident Identity and Report Incident
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's medications to a resident with severe cognitive impairment. The resident, who had a history of traumatic subdural hemorrhage, dysphagia, pleural effusion, metabolic encephalopathy, anemia, and was severely cognitively impaired, received medications including Rivaroxaban, Nifedipine, Flomax, and Insulin Lispro that were not prescribed for him. The nurse did not verify the resident's identity prior to administration, as required by facility policy, and did not report the error to the supervisor or the primary care physician. Following the administration of the incorrect medications, the resident developed nausea and vomiting and was subsequently hospitalized for an upper gastrointestinal bleed. The medication error was not documented in the resident's medical record or medication administration record. The facility only became aware of the incident after being notified by the hospital several days later, as the nurse involved did not report the error or document it in any facility records. Interviews with facility staff revealed that neither the CNA nor the unit manager were aware of the medication error at the time it occurred. The nurse responsible for the error was not available for interview, and the facility's investigation began only after external notification. The lack of immediate reporting and documentation of the medication error, as well as failure to follow established medication administration protocols, contributed to the deficiency.
Failure to Report and Investigate Sexual Abuse Incident
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member, specifically a Licensed Practical Nurse (LPN). The incident involved a resident who was cognitively intact and had a history of major depressive disorder and anxiety. The resident reported engaging in a sexual act with the LPN in their room, which was witnessed by a Certified Nursing Assistant (CNA). The resident expressed fear during the encounter, indicating a lack of consent, yet the facility did not report the incident to the appropriate authorities. The Director of Nursing (DON) and other facility staff were informed of the incident but failed to take immediate and appropriate action. The DON did not report the incident to the state health department or law enforcement, citing the resident's claim of consensuality as the reason. The facility's investigation was incomplete, and the incident was not documented in the resident's medical records. The facility's policies on abuse and neglect were not followed, as the incident was not reported within the required timeframe. Interviews with staff revealed a lack of understanding of the facility's abuse reporting procedures. The Licensed Nursing Home Administrator (LNHA) and other staff members were unsure about the necessity of reporting the incident, leading to a delay in addressing the situation. The facility's failure to report and investigate the incident properly resulted in an Immediate Jeopardy situation, highlighting significant deficiencies in the facility's abuse prevention and response protocols.
Removal Plan
- LPN#1 was removed from the facility
- Resident #59 was assessed
- The resident's physician was notified
- The incident was reported to the New Jersey Department of Health
- The abuse and neglect policy was updated
- The police were called
- All staff were educated on the facility abuse policies and procedures
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to report an allegation of sexual abuse involving a resident and a staff member to the New Jersey Department of Health (NJDOH) as required. The incident involved Resident #59, who had a Brief Interview of Mental Status (BIMS) score indicating intact cognition and was diagnosed with conditions including diabetes, respiratory disease, anxiety disorder, and depression. On 10/15/24, a staff member observed Resident #59 in a compromising position with an LPN. During an investigation, the resident admitted to performing oral sex on the LPN, stating that the encounter was consensual but inappropriate. Despite the resident's request for privacy and the belief that the encounter was consensual, the facility did not report the incident to the NJDOH or the police. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that the incident should have been reported within two hours of the allegation, as per federal regulations and the facility's policy. The facility's policy on abuse and neglect clearly states that any form of abuse, including sexual abuse, should be reported to the appropriate authorities. The failure to report the incident was identified as a deficiency during the survey, as the facility did not adhere to the required protocols for reporting suspected abuse, neglect, or theft.
Failure to Schedule Required Consultations for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as Resident #55, from the time of admission on 8/28/24 until the surveyor's inquiry. The resident, who had an indwelling catheter, was observed without a urinary drainage bag while in a wheelchair, although it was noted that a leg bag was used when the resident was out of bed. The resident's comprehensive care plan highlighted a risk for urinary tract infection related to catheter use, and physician's orders included catheter care every shift and follow-up consultations with urology and nephrology. However, the facility did not schedule the required consultations. The Unit Manager/LPN, responsible for checking physician's orders and setting up consults, was unaware of these orders due to personal reasons that kept her away from work in September. The Assistant Director of Nursing (ADON) acknowledged that the orders for the consults were missed during an in-house transfer of the resident, and there was no facility policy for admitting residents or transcribing physician's orders, leading to the oversight.
Deficiency in CNA In-Service Training and Abuse Prevention Education
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 12 hours of mandatory in-service training, as evidenced by a review of five CNA files. The surveyor found that none of the five CNAs had completed the necessary training hours for the current 12-month period. Specifically, the CNAs had completed between 5.5 and 8.25 hours of training, falling short of the mandated 12 hours. Additionally, two of the CNAs did not receive abuse prevention training, which is a critical component of their education. The deficiency was further highlighted during interviews with facility staff. The Director of Nursing (DON) acknowledged that the facility lacked a policy related to CNA education and that there was a gap in ensuring CNAs received their training due to staffing changes. The previous educator responsible for the training had been on leave and subsequently left the role, leading to a lapse in oversight. The DON and the Licensed Nursing Home Administrator (LNHA) were identified as responsible for ensuring staff completed their education, but the facility's documentation did not adequately quantify the training hours completed.
Inadequate Investigation of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of sexual abuse involving a staff member and a resident. The incident involved a resident with intact cognition, as indicated by a BIMS score of 15 out of 15, and diagnoses including diabetes, respiratory disease, anxiety disorder, and depression. The resident reported engaging in oral sex with an LPN in their room, which was witnessed by another staff member. Despite the resident's claim that the act was consensual, the facility did not complete an incident report or notify the resident's primary physician promptly. The investigation conducted by the facility was incomplete and lacked thorough documentation. Interviews were conducted with six alert and oriented residents on the LPN's assignment, but did not include the resident's alert and oriented roommate. There was no documentation of an assessment of the resident after the incident, and no evidence that non-alert and oriented residents were assessed for inappropriate sexual contact. Additionally, there were no written statements from the witness or others involved in the incident. The facility's policies on abuse and neglect, as well as risk management, were not followed. The policies require that an incident report be completed, the attending physician be notified, and all interviews and statements be documented in writing. The Director of Nursing acknowledged that the attending physician should have been notified at the time of the incident and that proper documentation was necessary. The failure to adhere to these policies resulted in a deficient practice in handling the alleged incident of sexual abuse.
Failure to Apply Heel Booties as Ordered
Penalty
Summary
The facility failed to ensure that heel booties were consistently applied to Resident #72 to prevent skin breakdown. During an observation, the surveyor noted that the resident was sitting in a reclining chair wearing only socks, with no heel booties, despite physician orders requiring heel booties to be worn at all times. The resident's medical record indicated severe cognitive impairment and no existing pressure ulcers, with a care plan intervention for booties to be worn for skin protection. The LPN responsible for Resident #72 confirmed that the booties were not on the resident and acknowledged signing the Treatment Administration Record as if the order had been completed. The Director of Nursing stated that both nurses and certified nursing assistants are responsible for ensuring heel booties are applied, and confirmed that booties should be worn when the resident is in a recliner. The facility's policy mandates the application of splints and similar devices as per physician's orders, which was not adhered to in this instance.
Failure to Follow Smoking Safety Protocols for Resident
Penalty
Summary
The facility failed to ensure that a resident's care plan and smoking evaluation were followed, leading to a deficiency in providing adequate supervision and safety measures for a resident who smoked. The surveyor observed a resident in a wheelchair smoking outside with supervision from the Director of Activity (DOA), who lit the resident's cigarette. However, the resident was not using a smoking apron, which was required according to their care plan. The DOA mentioned that the resident did not use a smoking apron because they did well without it, despite the care plan's directive. The resident's electronic medical record and smoking evaluation indicated that the resident required a smoking apron and assistance with lighting cigarettes. The Registered Nurse Unit Manager confirmed that the resident's care plan included the use of a smoking apron and acknowledged that it should have been used each time the resident smoked. The Director of Nursing (DON) stated that the resident did not need a smoking apron and that the care plan should have been updated. The facility's smoking policy required that care plans be kept current and updated as needed, which was not adhered to in this case.
Failure to Conduct Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the attending physician conducted face-to-face visits and wrote progress notes for residents as required by regulations. Specifically, two residents were not seen by their attending physicians within the mandated timeframes. Resident #28, who was admitted with diagnoses including metabolic encephalopathy and unspecified dementia, had no history and physical or physician progress notes documented since their admission in February 2024. Similarly, Resident #167, admitted with metabolic encephalopathy and dementia, had no attending physician progress notes since January 2024, despite being readmitted in July 2024. The deficiency was identified through observations, interviews, and record reviews conducted by the surveyor. The Licensed Practical Nurse/Unit Manager and the Director of Nursing confirmed the absence of required documentation for both residents. The facility's policy, which mandates physician visits every thirty days for the first ninety days and at least every sixty days thereafter, was not adhered to. The Medical Director acknowledged the oversight, stating that the attending physicians should see residents within 72 hours of admission, which was not the case for the residents in question.
Failure to Update Care Plan for Resident with Pressure Injuries
Penalty
Summary
The facility failed to update and revise the care plan for a resident, identified as Resident #3, who was admitted with multiple diagnoses including acute embolism, thrombosis, atherosclerotic heart disease, hypertension, metabolic encephalopathy, dementia, anxiety disorder, osteoarthritis, mood disorder, and depression. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for activities of daily living. Despite these conditions, the care plan was not updated to reflect new interventions for pressure injuries that developed over time. The resident's admission observation documented several skin issues, including a pressure ulcer and deep tissue injuries. Weekly wound notes from the wound physician detailed the progression of these injuries, including a pressure injury on the right heel that evolved from unstageable to stage 3, and additional deep tissue pressure injuries and stage 3 pressure injuries on various parts of the body. Despite these documented changes, the care plan did not include new interventions for these specific pressure injuries. Interviews with facility staff, including the RN Unit Manager and the DON, revealed that while new wounds were documented in nurses' notes and communicated to relevant parties, the care plan was not revised accordingly. The facility's policy required that care plans be updated with any changes in the resident's condition, but this was not adhered to in the case of Resident #3. The DON acknowledged the oversight, confirming that the care plan was not updated to address the resident's wound care needs.
Failure to Document RN Assessment of Injury
Penalty
Summary
The facility failed to adhere to acceptable standards of nursing practice by not documenting a registered nurse's assessment of a reported injury of unknown origin for one resident. The incident involved a resident who was receiving hospice services and had severe cognitive impairment due to dementia, Parkinson's Disease, and Type II diabetes. On a specific date, a Licensed Practical Nurse (LPN) was informed by a family member about a mark on the resident's right inner forearm. The LPN notified the shift supervisor and attempted to contact the Nurse Practitioner (NP) but was unable to reach them. However, there was no further documentation regarding the mark in the resident's medical records. The Assistant Director of Nursing (ADON) stated that any report of a bruise or injury should trigger the abuse protocol, which includes a nursing assessment. The Nurse Practitioner confirmed that she did not observe any skin issues during her visit a week after the incident. The shift supervisor at the time, an RN, admitted to observing the resident's skin but did not document his findings, stating he got distracted. He mentioned that he did not see any bruise, blister, or raised area and would have investigated further if he had observed an injury. The lack of documentation and follow-up assessment by a registered nurse led to the deficiency identified by the surveyors.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hamilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Mercerville Llc | 1 mi | ★★★★★ | 0 | 0 |
| Spring Hills Post Acute Hamilton | 1.8 mi | ★★★★★ | 2 | 0 |
| Avant Rehabilitation And Care Center | 2.2 mi | ★★★★★ | 14 | 0 |
| Preferred Care At Hamilton | 2.4 mi | ★★★★★ | 0 | 0 |
| Avalon Rehabilitation And Healthcare Center | 2.8 mi | ★★★★★ | 19 | 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.