Accela Post Acute Care at Hamilton

Inspectors wroteBased on interviews, medical record review and review of pertinent facility documents on 10/20/2025 and 10/24/2025, it was determined that the facility failed to: a.) ensure that pressure ulcers were initially documented, assessed, and measured weekly as required by professional standards of practice; b.) implement and update care plans (CP) after a change in condition; c.) provide treatment and services to prevent two facility acquired pressure ulcers; one stage 3 and one stage 4. A review of Resident #3's Electronic Medical Record (EMR) revealed the resident arrived to the facility with no evidence of a pressure ulcer. Additional review of the EMR revealed a lack of adherence to physician orders, lack of monitoring, a failure to implement CP, and a lack of assessments resulting in Resident #3 developing a stage 3 and a stage 4 pressure ulcer within 9 days of admission. [...]

Inspectors wroteComplaint #: 2638834Based on interview and review of facility documents on 10/20/25, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 2 of 14 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Reports completed by the facility for the weeks of 09/28/25 through 10/11/2025, revealed that the facility failed to provide RN coverage for all shifts on 09/28/25 and 10/06/2025. The surveyor reviewed the facility's policy titled Staffing updated October 2017 which indicated under Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment and under Policy Interpretation and Implementation 1. [...]

Inspectors wroteRepeat Deficiency Based on observations, interviews, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. [...]

Inspectors wroteComplaint # NJ 183474 Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to document the circumstance for which randomly selected residents, from the facility provided discharge list from 9/1/24 to 2/14/25, were discharged to another long-term care (LTC) facility, for 7 of 7 residents (Resident #182, #183, #184, #185, #186, # 187, #188) reviewed. This deficient practice was evidenced by the following: 1. The surveyor reviewed the electronic medical record (EMR) for Resident #182. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Polyosteoarthritis, unspecified (a condition that involves break down of [NAME] in multiple joints leading to pain, stiffness, and reduced mobility). [...]

Inspectors wroteComplaint #NJ00183474 Refer to F 622 Based on interviews, record review and review of facility documentation, it was determined that the facility failed to provide written notification of the transfer to the Office of the Long-Term Care (LTC) Ombudsman (LTCO) for 7 of 7 residents (Resident #182, #183, #184, #185, #186, # 187, #188) reviewed for transfer to another LTC facility. This deficient practice was evidenced by the following: 1. The surveyor reviewed the electronic medical record (EMR) for Resident #182. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Polyosteoarthritis, unspecified (a condition that involves break down of [NAME] in multiple joints leading to pain, stiffness, and reduced mobility). [...]

Inspectors wroteREFER to F756 Based on observation, interviews and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times from December 2024 until surveyor inquiry February 2025. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteREFER to F698 Based on observation, interview and record review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from December 2024 until surveyor inquiry for one (1) of six (6) residents, (Resident #21), reviewed for medication management. The deficient practice was evidenced by the following: On 2/4/25 at 10:09 AM, the surveyor interviewed Resident #21, who stated that they had been here (in the facility) since late November but had gone to the hospital for a week in January and returned. The resident also stated that they (the nurses) frequently run out of their medications. The resident added specifically I don't get my Renvela (Sevelamer) (a medication used to lower the amount of phosphorous in the blood when receiving dialysis). [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required for 3 of 5 randomly selected CNA (CNA # 3, #4, #5) files reviewed for in-service training. This deficient practice was evidenced by the following: On 2/07/25 at 9:17 AM, the surveyor reviewed in-service education hours for five randomly selected CNA files which were provided by the Director of Nursing (DON). The surveyor reviewed the following for the 2023 to 2024 calendar year, corresponding with the CNA hire dates: CNA #3 was hired on 4/1/22, CNA #4 was hired on 6/15/23, and CNA #5 was hired on 1/19/23. The facility could not provide evidence of in-service education training for the current 12-month period from hire date. [...]

Inspectors wroteBased on interviews and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure reference checks were completed for 6 of 10 newly hired employee files reviewed. This deficient practice was evidenced by the following: On 2/7/25, the surveyor reviewed Ten (10) randomly selected new employee files which revealed the following: 1. Licensed Practical Nurse (LPN)/Unit Manager with a Date of Hire (DOH) of 7/22/24, did not have a previous employee reference on file. 2. LPN #2 with a DOH of 7/22/24, did not have a previous employee reference check on file. 3. LPN/Nurse Supervisor with a DOH of 7/22/24, did not have a previous employee reference check on file. 4. Registered Nurse #1 with a DOH 7/30/24, did not have a previous employee reference check on file. 5. [...]

Inspectors wroteComplaint #NJ00176931 Based on interviews, record review and pertinent facility documents, it was determined that the facility failed to investigate an allegation of poor nursing care for 1of 4 residents (Resident #232) reviewed for abuse. This deficient practice was evidenced by the following: A review of the facility provided Reportable Event Record Report dated 319/2024, revealed the facility reported an event alleging that the resident had poor nursing care while at the facility to the New Jersey Department of Health (NJDOH). The surveyor reviewed the electronic medical record (EMR) for Resident #232. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 2/5/25, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. The deficient practice was identified for two (2) of five (5) residents, (Resident #21 and #82), that were administered medications by two (2) of three (3) nurses that were observed. The deficient practices were evidenced by the following: 1. On 2/5/25 at 8:36 AM, during the morning medication administration pass, the surveyor observed Licensed Practical Nurse (LPN#1) administering medications to Resident #21. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to prevent the potential for cross contamination by placing a resident with open wounds on Enhanced Barrier Precautions (EBP), meaning a gown and gloves be worn when performing high contact care, for one of two residents (Resident #7) with open wounds. The deficient practice was evidenced by the following: On 2/4/25 at 10:21 AM, the surveyor observed Resident #7 self-propelling their wheelchair in the hallway. The resident stated they can wheel the chair but can not stand. The surveyor observed a dressing on the right leg. The surveyor reviewed the electronic medical record (EMR) for Resident #7. [...]

Inspectors wroteComplain #: NJ171631 Based on interview and record review on 05/13/2024 and 05/14/2024, it was determined that the facility failed to accurately encode a resident's wound in the Minimum Data Set (MDS) assessment for 1 of 5 residents (Resident #2) reviewed for MDS accuracy. This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023, under Section M: Skin Conditions .M0210 Unhealed Pressure Ulcers/Injuries .Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers. Code 1, yes: [...]

Inspectors wroteComplaint #: NJ 171631 Based on interview, medical record review, and review of other pertinent facility documentation on 5/13/2024 and 5/14/2024, it was determined that the facility failed to develop a Baseline Care Plan (BCP) for a newly admitted resident with a Sacral wound. This deficient practice was identified for Resident #2, 1 of 5 residents reviewed for BCP. This deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the admission Record, Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to End Stage Renal Disease (gradual loss of kidney function), Major Depressive Disorder, Difficulty in Walking and Anemia (deficiency of red blood cells in the blood). [...]

Inspectors wroteComplaint #: NJ171631 Based on interview, observation, record review, and facility policy reviewed on 5/13/2024 and 5/14/2024, it was determined that the facility failed to provide 1 of 5 residents (Resident #2) reviewed for Activities of Daily Living (ADLs) with showers twice a week as scheduled. The Certified Nursing Aide (CNA) also failed to follow their job description. This deficient practice was identified for Resident #2, and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the admission Record, Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to End Stage Renal Disease (gradual loss of kidney function), Major Depressive Disorder, Difficulty in Walking and Anemia (deficiency of red blood cells in the blood). [...]

Inspectors wroteComplaints: NJ 157428, NJ 160764, NJ 161041, NJ 162453, NJ 167007 Based on observations, interviews, and record review, the facility failed to respond in a timely manner to the resident's requests for assistance for one Resident (R)27 of 27 sample residents.

Inspectors wroteComplaint #: NJ 151270, NJ 162453 Based on interview, record review and review of facility policy, the facility failed to notify the responsible party/family of one Resident (R)5 of 27 sample residents regarding R5's return to the facility with the x-ray and treatment results after the resident's emergency room visit.

Inspectors wroteComplaint # NJ 166867 Based on interview, record review, and policy review, the facility failed to ensure the resident assessment accurately reflected the resident's skin conditions for one (Resident (R) 9) of 27 sampled residents. This failure could result in the residents' individual needs not being addressed.

Inspectors wroteComplaint # NJ 167007 Based on interviews, record review, and review of facility policy, the facility failed to provide a baseline care plan within 48 hours of admission for three residents (Resident (R) 3, R26 and R27) reviewed for base line care plans out of 30 sampled residents.

Inspectors wroteComplaint #: NJ 155628, NJ 158542, NJ167007, NJ 166867 Based on record review, interviews, and facility policy review, the facility failed to ensure wound care treatment was documented as provided according to physician orders for one Resident (R)3 out of 27 sample residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure 12 hours of required in-service training was provided for one (Certified Nurse Aide (CNA) 4) of five CNAs whose training records were reviewed.

Inspectors wroteComplaint # NJ 161041 Based on observation and interview, the facility failed to secure resident medications in one of four medication carts and one of one treatment cart to prevent an unauthorized person from accessing the residents' medications.

Inspectors wroteComplaint #: NJ 167007 Based on observation, interview, and record review, the facility failed disinfect glucometers after use for one (Resident (R) 21) of one resident observed receiving a fingerstick blood sugar check and failed to perform pressure ulcer dressing changes in a manner to prevent cross-contamination for one (R26) of one sampled resident observed during dressing changes.

Inspectors wroteBased on observation, interview and review of pertinent facility documents it was determined that the facility failed to a.) ensure the soiled and clean laundry areas were maintained and operated in a sanitary manner to prevent infection control breaches and b.) maintain mop bucket systems in a sanitary manner. This deficient practice was evidenced by the following: On 1/11/23 at 12:10 PM, the surveyor observed the hallway leading to the laundry area as well as both the soiled and clean laundry rooms in the presence of a second surveyor which revealed the following: 1. In the hallway just prior to entering the soiled laundry room, there was a yellow mop bucket that had a shallow amount of dark colored soiled standing water and a soiled mop head. 2. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to routinely post the Nursing Home Resident Care Staff Report (NHRCSR) since 12/23/22 (13 days) in a place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 1/5/23 at 9:45 AM, the surveyor observed the NHRCSR dated 12/23/22 for the day, evening, and night shift. Each shift indicated a census of 39. The NHRCSR was observed posted behind the mounted glass wall display case to the left of the receptionist desk in the front lobby. [...]

Inspectors wroteBased on observation, interview, and record review of pertinent facility documents, it was determined that the facility failed to notify the Centers for Medicare & Medicaid Services (CMS) and apply for a change in ownership and facility name change upon 30 days of their sale in July 2021 in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: [...]

Inspectors wroteBased on observation and interview on 10/16/2020, in the presence of the facility Maintenance Director and laundry staff member, it was determined that the facility failed to maintain 2 of 2 commercial clothes dryer drums in a safe and effective operating condition. This deficient practice was evidenced by the following: On 10/16/2020 at 11:52 AM, the surveyor observed 2 of 2 commercial clothes dryer drums in the facility laundry room. Both dryer drums contained a heavy coating of an unknown brown plastic-like substance embedded into the rear vents on the interior of the stainless steel rotating drums. The substance covering the vent holes could produce a delay in the heating process and cause an unsafe and ineffective operating condition. At that time, the surveyor interviewed the facility Maintenance Director and laundry staff worker. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that Medical Transport Staff (MTS) implemented the appropriate infection control precautions for donning and doffing Personal Protective Equipment (PPE) prior to entering and upon exiting a resident's room. The resident was on droplet transmission-based precautions for the observation of signs and symptoms of COVID-19. This deficient practice was identified for 2 of 2 MTS observed during the transport of 1 of 1 resident (Resident #6) and was evidenced by the following: On 10/19/20 at 10:19 AM, the surveyor observed a sign posted outside of Resident #6's door that indicated, STOP. Further instructions on the sign indicated that if a person was to enter the resident's room, an isolation gown, eye protection, and a surgical mask over a KN95 mask must be worn. [...]