Complete Care at Hamilton, LLC

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following:On 09/02/2025 at 10:30 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and observed the following: 1. In the reach in refrigerator the surveyor observed 3 blocks of pre-sliced cheese wrapped in plastic film with no open date or use by date and a foil covered plate of breakfast foods with no label, opened or use by date. The FSD stated all opened or left over foods should have a prepared or opened on date and a use by date to prevent residents from receiving spoiled or expired foods. The FSD confirmed that the unlabeled foods would be discarded.2. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 22 residents reviewed for accommodation of needs (Resident #96), and was evidenced by the following: On 09/04/25 at 8:07 AM, the surveyor observed Resident #96 in bed. The surveyor observed the Resident's call light pull cord (used to summon staff for assistance) affixed to the upper aspect of the right-side rail, not within his/her reach. The resident stated, There should be a string around here somewhere, but I can't seem to find it, so I can't call for help. The surveyor reviewed the medical record for Resident #96. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteComplaint #NJ 401472 Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to a.) maintain a homelike environment that was clean, safe, and sanitary in 3 out of 24 resident rooms (rooms 114,116, and 123) and b.) ensure that personal clothing items, specifically socks, were returned after being laundered to 5 out of 5 residents who attended the resident council meeting (Resident #25, 67, 70, 83, 85). Additionally, Resident # 96 complained that their socks were not returned after being laundered. This deficient practice was evidenced by the following:1. On 9/2/2025 at 11:06 AM, the surveyor observed in room [ROOM NUMBER] a broken dresser drawer, peeling paint with exposed plaster and sheet rock to the right of the sink. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to monitor the nutritional status for 1 of 2 residents reviewed (Resident #2), specifically by not following a physician's orders for monitoring of Resident #2's weights. The deficient practice was evidenced by the following:On 9/3/25 at 11:29 AM, the surveyor observed Resident #2 in bed with the head of bed elevated, eye opened and not verbal. A review of Resident #2's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to obtain a physician's order for the administration of oxygen therapy and failed to ensure that respiratory equipment was stored in accordance with infection control measures for 1 of 2 residents reviewed for respiratory care (Resident # 44). This deficient practice was evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to protect resident's right to be free from resident-to-resident physical abuse four of five residents (R)7, R8, R13, and R14) reviewed for abuse out of 14 sampled residents. This had the potential to cause injuries to the residents.

Inspectors wroteComplaint #: NJ00178362, NJ00178481 Based on observations, interviews, record reviews and review of pertinent facility documents on 10/15/2024, it was determined that the facility failed to ensure a safe environment for a resident (Resident #1) who had a Physician's Order for a prescribed diet of dysphagia puree, Consistent Carbohydrate Diet (CCD), Thickened Liquid Nectar consistency. On 10/8/2024, Resident #1 who was sitting in a wheelchair, was attending an outdoor activity program with other residents. The Director of Recreation (DOR) had donuts cut into thirds for an afternoon lunch snack. The DOR gave Resident #1 a bite sized soft donut, when the resident reached out for it. The DOR left the resident with 3 other Activity Staff (AS). Resident #1 started coughing and observed choking. [...]

Inspectors wroteBased on interview, and record review, it was determined that 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 deficient practice was identified for 1 of 25 residents, Resident #45 was reviewed for physician visits and was evidenced by the following: On 6/23/24 at 10:59 AM, the surveyor observed Resident #45 lying in bed who was noted to be alert and responsive. On 6/24/24 at 9:33 AM, the surveyor reviewed the admission Record for Resident #45 which revealed the resident was admitted to the facility with diagnoses that included but were not limited to end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant); [...]

Inspectors wroteC#: NJ00170690 Based on interviews and record review, as well as review of pertinent facility documents on 1/30/24, the facility failed to use a two-person assistance interventions for 1 of 4 residents (Resident #2), as determined necessary by the Resident's comprehensive Care Plan (CP). The failure to follow this intervention during morning care on 01/20/24 for Resident#2,.who was combative towards the one staff member present at that time, resulted in the resident groaning in pain and his/her right upper arm swollen and requiring immediate transfer to an acute care hospital emergency room for further evaluation. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. As part of this failure, the facility did not have an effective antibiotic stewardship program, which had the potential to affect all residents of the facility. (Cross Reference F881)

Inspectors wroteBased on interview, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. The failure to have a system in place that monitors antibiotic use in accordance with established protocols had the potential to affect all 106 residents of the facility.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure allegations of abuse / neglect and/or the investigations were submitted to the New Jersey Department of Health (NJDOH) within the time limits of the policy and federal regulation for five of eight residents (Resident (R)14, R25, R91, R38, and R28) reviewed for abuse in a total sample of 28 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure three of three residents and their representatives (Resident (R) 25, R28, and R161) reviewed for facility initiated emergent hospital transfer, from a total sample of 28 residents, were provided with written transfer/discharge notice. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure three of three residents (Resident (R) 25, R28 and R161) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 28 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on record review, interviews, review of the Food and Drug Administration (FDA) warning (www.fda.gov), and policy review, the facility failed to ensure two (Resident (R) 33 and R14) of five residents reviewed for unnecessary medications out of a total sample of 28 residents, had adequate indications, behavior monitoring, and/or a Gradual Dose Reduction (GDR) while on psychotropic medications.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one (Resident (R) 36) of five residents reviewed for flu/pneumonia vaccinations and/or their representatives out of a total sample of 28 residents, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to re-offer R36 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) in accordance with nationally recognized standards. The facility failed to re-offer R36 the opportunity to be vaccinated with Pneumococcal conjugate vaccine (PCV13) and/or Pneumovax [Pneumococcal Polysaccharide Vaccine (PPSV23)] prior to 10/21/21 and/or offer one dose of Prevnar 20 (PCV20) after 10/21/21. [...]

Inspectors wrote2. Review of R7's profile, located in the Profile tab of the EMR revealed R7 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, type 2 diabetes, and dysphagia. Review of R7's POLST, located under the Miscellaneous tab of the EMR, revealed under the signatures section revealed a physician's stamp denoting the physician's printed name, signature, license number, and DEA (Drug Enforcement Administration), but failed to reveal the physician's phone number, date, and time. During an interview with the SSD1 on 05/23/23 at 3:59 PM, SSD1 acknowledged there was no date and time with the physician's stamp and the document lacked a date indicating when it was signed by the physician. [...]

Inspectors wroteBased on interviews, record review, review of facility reported incidents (FRI), and review of the facility policy, the facility failed to protect the rights of two of eight residents reviewed for abuse (Resident (R) 28 and R63) to be free from physical abuse by R38 out of a total sample of 28 residents.

Inspectors wroteBased on, staff interviews, record review, and policy review, the facility failed to ensure the right of one resident (Resident (R) 91) one resident to be free from physical restraints imposed for the purposes of convenience out of a total sample of 28 residents.

Inspectors wroteBased on record review, interview, review of Facility Reported Incidents (FRI), and policy review, the facility failed to ensure that a thorough investigation was documented regarding two resident-to-resident altercations involving one resident (Resident (R) 38), out of a sample of 28 residents. There was no evidence that the facility interviewed other current residents regarding the allegations.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to make a referral for a Level II Preadmission admission Screening and Resident Review (PASARR) evaluation for one (Resident (R) 54) of three sampled residents reviewed for PASARR Level II evaluations in a total sample of 28 residents after receiving new diagnoses of psychosis (out of touch with reality) and delusional disorder (firmly held beliefs not based in reality).

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure one resident (Residents (R) R54) and/or their representative was invited to participate in their quarterly care plan meetings out of a total sample of 28 residents. This failure would affect all residents and/or representatives who were scheduled for quarterly care plan meetings.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure one of 32 residents (Resident (R)25) reviewed during initial pool did not have an ill-fitting mattress. This failure had the potential to create an entrapment risk.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure that one of one resident (Resident (R) 42) reviewed for bed rail use out of a total sample of 28 residents had required documentation completed prior to the use of the side rails.