Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Spring Hills Post Acute Hamilton during CMS and state inspections, most recent first.
A resident admitted without pressure ulcers developed both stage 3 and stage 4 pressure injuries within days due to the facility's failure to perform and document required skin assessments, implement and update care plans after a change in condition, and provide or document ordered wound care and preventive interventions. Staff interviews and record reviews confirmed that documentation and care practices were not followed as required by policy.
The facility did not ensure RN coverage for at least eight consecutive hours on two days, as shown by staffing reports and confirmed by interviews and policy review.
The facility failed to document the reasons for transferring seven residents to another LTC facility. Despite social service notes indicating discussions about transfers, there was no specific documentation justifying these actions. Interviews with staff revealed inconsistencies in understanding the reasons for transfers, and the facility did not adhere to its policy of providing written notice with specific reasons for transfers.
The facility failed to notify the LTC Ombudsman of resident transfers to other facilities, as required by policy. Seven residents with various medical conditions were transferred without the necessary written notifications. The DON confirmed that notifications were only sent for hospital discharges, not for transfers to other LTC facilities.
The facility failed to ensure CNAs received the required 12 hours of in-service training, as evidenced by missing education records for CNAs hired in 2022 and 2023. The LNHA acknowledged the lapse, noting shared responsibility with the corporate team for ensuring compliance with training requirements.
A facility failed to investigate an allegation of poor nursing care for a resident with Type 2 Diabetes Mellitus and unspecified dementia. Despite staff awareness of procedures for reporting and investigating abuse, no investigation was conducted for the reported event. The facility's policies require investigation and reporting of all allegations, but this was not followed, as confirmed by the LNHA.
A facility failed to accurately encode a resident's sacral wound in the MDS assessment, despite documentation and staff confirmation of the wound's presence. The MDS dated December 7, 2023, incorrectly indicated no pressure ulcer, although the resident was admitted with a sacral ulcer and seen by wound care. The error was attributed to a previous MDS coordinator who no longer works at the facility.
A facility failed to develop a Baseline Care Plan (BCP) for a newly admitted resident with a sacral wound, despite the resident's complex medical conditions. Interviews with the LPN and DON confirmed the absence of a BCP, which is required within 48 hours of admission to ensure effective, person-centered care. The facility's policy mandates the inclusion of initial goals and orders in the BCP, but this was not done.
A resident with multiple medical conditions requiring assistance with ADLs did not receive scheduled showers on several occasions, as documented in their care plan. The CNA responsible admitted to not documenting refusals or providing showers, although claiming bed baths were given instead. Interviews with facility staff confirmed the lack of documentation and adherence to policy.
Failure to Prevent, Assess, and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure that pressure ulcers were properly documented, assessed, and managed according to professional standards and facility policy. A resident was admitted with no evidence of pressure ulcers, as confirmed by admission assessments and transfer documentation. Despite this, within nine days of admission, the resident developed both a stage 3 and a stage 4 pressure ulcer. There was no evidence of weekly skin assessments, and the initial wound assessment was not completed when the wounds were first identified. The care plan addressing the pressure injuries was not initiated until several days after the wounds were discovered, and there was a lack of documentation regarding family notification about the new wounds. Physician orders for wound care were not consistently implemented or documented. The electronic medical record showed no evidence of daily wound assessments or that wound care was provided as ordered. Documentation for interventions such as barrier cream application and turning/repositioning was frequently missing across multiple shifts, both before and after the wounds were identified. Interviews with staff, including the Unit Manager, DON, LPNs, and CNAs, confirmed that required documentation and care practices were not followed, and that if care was not documented, it was considered not done according to facility policy. Facility policies required comprehensive skin assessments upon admission, daily skin inspections, weekly risk assessments, and prompt care plan updates following changes in condition. These policies also mandated thorough documentation of wound care, skin condition, and family notification. The review of the resident's records and staff interviews revealed that these standards were not met, resulting in the development and inadequate management of two facility-acquired pressure ulcers.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours per day for two out of fourteen days reviewed. This deficiency was identified through a review of the Nurse Staffing Reports for the weeks of 09/28/25 through 10/11/2025, which showed that there was no RN coverage for all shifts on 09/28/25 and 10/06/2025. The facility's own staffing policy, updated in October 2017, requires sufficient numbers of staff, including licensed nurses, to be available 24 hours a day to provide direct resident care services. The surveyor confirmed these findings through interviews and document review.
Failure to Document Reasons for Resident Transfers
Penalty
Summary
The facility failed to document the circumstances for which seven residents were discharged to another long-term care facility. The surveyor's review of the electronic medical records (EMR) for these residents revealed a lack of documentation supporting the reasons for their transfers. Despite the presence of social service notes indicating discussions about transfers, there was no specific documentation justifying the necessity of these transfers. Interviews with the residents and their representatives suggested that the facility's change in management and focus towards short-term rehabilitation might have influenced these transfers, but this was not documented in the residents' records. Interviews with the facility's staff, including the Social Worker (SW), Licensed Nursing Home Administrator (LNHA), and Director of Nursing (DON), revealed inconsistencies in the understanding and communication of the reasons for the transfers. The SW mentioned that residents and their families were informed about the change in management and the facility's new focus, but she could not recall any facility-initiated discharges. The LNHA and DON also could not provide specific reasons for the transfers, and there was no written notification of discharge provided for the residents in question. The facility's policy requires that residents and their representatives be notified in writing at least thirty days prior to a transfer or discharge, including the specific reason for the transfer. However, the facility failed to adhere to this policy, as there was no documentation of the reasons for the transfers in the residents' medical records. This lack of documentation and communication led to confusion and dissatisfaction among the residents and their families, as evidenced by their statements during interviews with the surveyors.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide written notification of the transfer to the Office of the Long-Term Care Ombudsman for seven residents who were transferred to another LTC facility. This deficiency was identified through interviews, record reviews, and facility documentation. The residents involved had various medical conditions, including polyosteoarthritis, Type 2 Diabetes Mellitus, unspecified dementia, Parkinsonism, amyotrophic lateral sclerosis, urinary tract infection, and cellulitis. Their cognitive statuses varied, with BIMS scores ranging from 8 to 15, indicating levels from moderately cognitively impaired to cognitively intact. The facility's policy required that residents and their representatives be notified in writing at least 30 days prior to transfer or discharge, and a copy of the notice be sent to the Ombudsman. However, the Director of Nursing confirmed that the Social Worker only notified the Ombudsman's office if a resident was discharged to a hospital, and no written notifications were provided for the residents transferred to other LTC facilities. The surveyors were unable to obtain any additional documentation or written notifications from the facility. The surveyors discussed the concerns with the Director of Nursing and the President of Nursing, but no further information was provided. The facility's policy, revised in March 2021, clearly stated the requirement for written notification to the Ombudsman, which was not adhered to in these cases, leading to the identified deficiency.
Failure to Provide Mandatory In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the mandatory 12 hours of in-service training as required. This deficiency was identified during a review of in-service education hours for five randomly selected CNA files. Specifically, the facility could not provide evidence of in-service education training for CNAs hired on specific dates in 2022 and 2023, indicating a lapse in compliance with the required training hours for the current 12-month period from their hire dates. The Licensed Nursing Home Administrator (LNHA) acknowledged the inability to locate the education records for the CNAs in question and stated that the responsibility for ensuring the completion of annual education on regulatory topics, such as abuse prevention, was shared with the corporate team. The LNHA admitted to not being fully aware of the exact topics required but recognized the importance of the training to ensure CNAs have the necessary skills. The facility's policy and job descriptions for the Human Resource Director and Director of Nursing Services outlined responsibilities for maintaining training records and ensuring compliance with continuing education requirements, which were not met in this instance.
Failure to Investigate Allegation of Poor Nursing Care
Penalty
Summary
The facility failed to investigate an allegation of poor nursing care for a resident, identified as Resident #232, who was reviewed for abuse. The resident was admitted with diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and unspecified dementia. The facility reported an event alleging poor nursing care to the New Jersey Department of Health, but upon review, there were no progress notes or documentation of an investigation into the allegation. Interviews with various staff members, including LPNs, the DON, and the LNHA, revealed that they were aware of the procedures for reporting and investigating abuse allegations. They described the types of abuse and the steps they would take, such as notifying the DON, reporting to the NJDOH, and conducting an investigation. However, despite these procedures, the LNHA confirmed that no investigation was conducted for the reported event concerning Resident #232. The facility's policies on abuse prevention and grievance handling require that all allegations be investigated and reported within specified timeframes. Despite these policies, the facility did not conduct an investigation into the allegation of poor nursing care for Resident #232, as confirmed by the LNHA. The survey team presented these concerns to the facility's leadership, but no additional information or investigations were provided.
Inaccurate MDS Coding of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to accurately encode a resident's wound in the Minimum Data Set (MDS) assessment, which is a tool used to facilitate the management of care. This deficiency was identified during a survey conducted on May 13 and 14, 2024. The surveyor reviewed the medical record of a resident who was admitted with a sacral wound with slough. Despite this, the MDS assessment dated December 7, 2023, incorrectly indicated that the resident did not have a pressure ulcer. The resident's admission evaluation and subsequent documentation showed that the resident was seen by wound care for a sacral ulcer on December 5, 2023. Interviews with facility staff revealed that the previous MDS coordinator, who no longer works at the facility, miscoded the assessment. The current MDS Coordinator confirmed the error, stating that the MDS should have reflected the presence of the sacral ulcer. The facility's policy on comprehensive assessments, dated April 2023, requires that assessments be conducted in accordance with the criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. This oversight in accurately coding the resident's condition led to the identified deficiency.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a Baseline Care Plan (BCP) for a newly admitted resident with a sacral wound. This deficiency was identified during a survey conducted on 5/13/2024 and 5/14/2024. The resident, who was admitted with medical conditions including End Stage Renal Disease, Major Depressive Disorder, Difficulty in Walking, and Anemia, was found to have a sacral wound with slough upon admission. Despite the facility's policy requiring a BCP to be developed within 48 hours of admission, no such plan was initiated for the resident's wound care. Interviews with facility staff, including the LPN/Unit Manager and the Director of Nursing (DON), confirmed that a BCP should have been in place to address the resident's immediate needs, including the sacral wound. The DON explained that the BCP serves as a roadmap for all departments to provide effective, person-centered care. However, upon review, it was acknowledged that the BCP was not initiated as required. The surveyor was unable to reach the admitting nurse for further clarification. The facility's policy, revised in 04/2023, clearly states the necessity of a BCP to include initial goals, physician orders, dietary orders, and therapy orders within 48 hours of admission.
Failure to Provide Scheduled Showers and Document Care
Penalty
Summary
The facility failed to provide a resident with showers twice a week as scheduled, which was a requirement for their care. The resident, who was admitted with medical conditions including End Stage Renal Disease, Major Depressive Disorder, Difficulty in Walking, and Anemia, was cognitively intact and required partial/moderate assistance with activities of daily living (ADLs). The resident's care plan specified assistance with bathing/showering twice a week on Wednesdays and Saturdays during the 7:00 A.M. to 3:00 P.M. shift. However, documentation revealed that showers were not provided on multiple scheduled days in December 2023 and January 2024, with no records of the resident refusing showers on those dates. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed that the CNAs were responsible for providing and documenting showers. The CNA admitted that if the ADL sheet was left blank, it likely meant the showers were not done, although she claimed the resident often refused showers and was given bed baths instead. The Director of Nursing (DON) also confirmed that blank spaces in the documentation indicated tasks were not completed. The facility's policy required documentation of both provision and refusal of showers, which was not adhered to in this case.
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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 |
| Preferred Care At Hamilton | 1 mi | ★★★★★ | 0 | 0 |
| Hamilton Grove Healthcare And Rehabilitation, Llc | 1.8 mi | ★★★★★ | 17 | 0 |
| Avalon Rehabilitation And Healthcare Center | 2.5 mi | ★★★★★ | 19 | 0 |
| Avant Rehabilitation And Care Center | 4.1 mi | ★★★★★ | 14 | 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.