Hamilton Grove Healthcare and Rehabilitation, LLC

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries and ensure that air mattresses were accurately set according to the resident's weight. This deficient practice was identified for 4 of 4 residents (Residents #6, #7, #106, and #151) reviewed for risk of pressure ulcers and was evidenced by the following:1. On 3/6/26 at 10:50 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 330 pounds. On 3/10/26 at 11:48 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 180-230 pounds. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were transported from one area of the unit to another in a dignified manner. This deficient practice was identified for 1 of 1 residents (Resident #45) reviewed for dignity and was evidenced by the following. On 3/10/26 at 11:45 AM, during the initial tour of the [NAME] unit, the surveyor observed the Certified Nursing Assistant (CNA) transport Resident #45 in a recliner chair facing backwards from the hallway near room [ROOM NUMBER] to the lounge area across from the nursing station. The surveyor reviewed the electronic medical record (EMR) for Resident #45. 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 observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow up on a physician's recommendation for a gradual dose reduction (GDR) of an antipsychotic medication for 1 of 5 residents (Resident #5) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 3/6/2026 at 11:32 AM, the surveyor observed Resident #5 sitting in a reclining area in the hallway near the nursing station. The resident had a splint on their left hand/wrist. The surveyor reviewed the electronic medical record (EMR) for Resident #5. 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 interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete a criminal background check prior to the first day of work for 1 out of 96 employees (Employee #4). This deficient practice was identified for newly hired employee files reviewed since last survey from 10/28/24 and was evidenced as follows:During the facility survey dates of 3/10/26-3/16/26, the survey team reviewed the newly hired employee files since the last survey which revealed the following:For Employee #4, a Certified Nursing Assistant (CNA), with a date of hire (DOH) of 2/28/25 and first day of work as 2/28/25, there was no evidence of a background check prior to the start of employment. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a discharge Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 system selected residents with a MDS record over 114 days reviewed (Resident #208), and was evidenced by the following:On 3/11/26 at 11:16 AM, the surveyor reviewed the system selected MDS record over 114 days which revealed Resident #208 was overdue for a MDS assessment. A review of Resident #208's electronic medical record (eMR) revealed that the resident was discharged from the facility on 11/3/25. A review of the residents' MDS assessments revealed the last MDS completed was a quarterly assessment dated [DATE]. There was no assessment completed for the resident's discharge. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with an order for enteral tube feeding. This deficient practice was identified for 1 of 1 resident reviewed for tube feeding (Resident #1), and was evidenced by the following:On 3/6/26 at 11:26 AM, during the initial tour of the facility, the surveyor observed Resident #1 sleeping in their bed. The surveyor observed the enteral tube feeding running at 70 ml/hr (milliliters per hour). The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure nursing staff appropriately follow a physician orders (PO) and acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes. The deficient practice was identified for 1 of 2 residents (Resident #142) reviewed for smoking. 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that incontinence care was provided to a dependent resident in a timely manner. This deficient practice was identified for 1 of 10 residents (Resident #147) observed during incontinence care rounds and b.) provide a resident with nail care during activities of daily living (ADL) care. This deficient practice was identified for 1 of 7 residents reviewed for ADL care (Resident #195),This deficient practice was evidenced by the following:1. On 3/11/26 at 7:54 AM, during incontinence rounds with Registered Nurse/Unit Manager (RN/UM) #1, the surveyor observed Resident #147's incontinence brief completely saturated with urine, and yellow urine-like stains on multiple areas on the top sheet. [...]

Inspectors wroteBased on observation, interviews, record review, and review of facility documents, it was determined that the facility failed to ensure tracheostomy (a surgical opening directly into the trachea (windpipe) used to assist breathing) care was completed using sterile technique per facility policy and clinical guidelines. This deficient practice was identified for 1 of 4 residents (Resident #46) reviewed for respiratory care and was evidenced by the following:On 3/11/26 between 10:20 AM and 10:37 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform tracheostomy care for Resident #46. During that time, the LPN was first observed performing hand hygiene, then placing a nonsterile drape over a bedside table. She was then observed opening and placing a tracheostomy care kit on the drape. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of Certified Nursing Assistants (CNAs) on an annual basis. This deficient practice was identified for five (5) of five (5) CNAs whose randomly selected employee files were reviewed and was evidenced by the following:On 3/11/26 at 9:34 AM, the surveyor requested the education and performance reviews for five (5) randomly selected CNAs. The surveyor reviewed the education provided by the facility for the five (5) CNAs. No performance evaluations were provided. On 3/11/26 at 11:10 AM, the performance evaluations were requested from the Licensed Nursing Home Administrator (LNHA) who could not provide them. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure medications were administered to a resident according to standards of practice. This deficient practice was identified for 1 of 36 (Resident #9) residents reviewed and was evidenced by the following:On 3/6/26 at 1:30 PM, the surveyor observed Resident #9 lying in their bed, awake, eating their lunch which was on their overbed table. The surveyor observed a medication cup with two (2) unidentified medication tablets in it, on the overbed table. At that time, the surveyor requested the Licensed Practical Nurse/Unit Manager (LPN/UM) come to the room. The LPN/UM acknowledged that in the medication cup there were two tablets: one pink and one white. At this time, the resident stated that they thought they took all their medications. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a medication error rate below 5%. This deficient practice was identified for 2 of 5 residents (Resident #2 and #197) on 2 of 4 units. The surveyor observed 2 nurses administered 28 doses of medication and there were 2 errors resulting in a medication error rate of 7.14%. The deficient practice was evidenced by the following: 1. On 3/11/26 at 8:55 AM, during the morning medication administration pass, the surveyor observed the Licensed Practical Nurse (LPN #1) on the Klockner Unit, preparing the medications (meds) for Resident #2 using the electronic Medication Administration Record (eMAR) while pulling the medications. The surveyor observed an order for one tab of sennosides-docusate sodium 8.6 -50 mg for constipation. [...]

Inspectors wroteComplaint #: 2788031Based on interviews, record reviews, and review of other pertinent documentation, it was determined that the facility failed to ensure that a cognitively impaired resident received nectar thick liquids (slightly thicker consistency than water, coats a spoon) as ordered and failed to develop interventions to ensure that the resident did not receive liquids that were inconsistent with their ordered diet. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for diet accuracy and was evidenced by the following:Resident #2 was no longer in the facility; a closed record review was conducted. A review of the admission Record (AR) for Resident #2, revealed that the resident was admitted with diagnoses including but not limited to: [...]

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 2) sampled for medication errors, was free from significant medication errors of 11 sample residents. Specifically, R2 was administered another resident's medications. This continued practice fails to protect residents from receiving the wrong medications that could result in significant harm.

Inspectors wroteComplaint NJ #:178839 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement an abuse policy that addressed sexual abuse to ensure a resident was protected from staff-to-resident sexual abuse. This deficient practice was identified for one (1) of one (1) residents (Resident #59) reviewed for abuse, and was evidenced by the following: On 10/22/24 at 1:00 PM, two surveyors interviewed the Director of Nursing (DON) who stated that a Certified Nursing Assistant (CNA#1) reported that on 10/15/24, the CNA#1 observed a Licensed Practical Nurse (LPN #1) standing over Resident #59 in a compromising position. A review of the investigation revealed the Social Worker (SW) interviewed Resident#59, who stated, I gave him oral sex. [...]

Inspectors wroteComplaint # NJ 178839 Refer to F 600 Based on interviews and review of the medical record and other facility documentation, it was determined that the facility staff failed to report an allegation of sexual abuse by a staff member to a resident to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 1 resident (Resident #59) and was evidenced by the following: On 10/22/24, the surveyor reviewed Resident #59's medical record which included a quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/24, which indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition and diagnoses which included but were not limited to diabetes (high blood sugar), respiratory disease, anxiety disorder, and depression. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide services in a manner consistent with standards of practice to maintain a urinary catheter from 8/28/24 until surveyor inquiry. The deficient practice was identified for one (1) of three (3) residents, (Resident #55), reviewed for urinary catheter care. The deficient practice was evidenced by the following: On 10/22/24 at 10:42 AM, the surveyor observed Resident #55 in a wheelchair in their room. The resident stated that they had just returned from physical therapy and was exhausted. The surveyor had not observed a urinary catheter drainage bag (a device inserted to collect urine from the bladder into a drainage bag). [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that a.) all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required for 5 of 5 CNAs and b.) abuse prevention training was completed for 2 of the 5 CNA files reviewed for in-service training. This deficient practice was evidenced by the following: On 10/24/24, 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 #1 was hired on 8/17/18, with a total of 6 hours (hrs.) of in-service training for the current 12-month period. CNA #2 was hired on 8/25/15, with a total of 5.5 hrs. of in-service training for the current 12-month period. [...]

Inspectors wroteComplaint # NJ 178839 Refer to F 600 Based on interviews, review of the medical record and other facility documentation, it was determined that the facility failed to thoroughly investigate an alleged incident of sexual abuse between a staff member and a resident. This deficient practice was identified for 1 of 1 resident (Resident #59) reviewed for abuse and was evidenced by the following: On 10/22/23, the surveyor reviewed Resident #59's medical record which included a quarterly Minimum Data Set (MDS), an assessment tool dated 08/21/24, which indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition and diagnoses which included but were not limited to diabetes (high blood sugar), respiratory disease, anxiety disorder, and depression. [...]

Inspectors wroteBased on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to ensure heel booties were consistently applied to prevent skin breakdown. This deficient practice was identified for Resident #72, 1 of 2 residents reviewed for position and mobility. This deficient practice was evidenced by the following: On 10/18/24 at12:18 PM, during initial tour, the surveyor observed Resident #72 sitting in a reclining chair in the main activity area. The resident was wearing white socks with their heels resting on the footrest. A review of the electronic medical record (EMR) for Resident #72 revealed the following: A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents it was determined that the facility failed to ensure that the resident's care plan and smoking evaluation were followed to ensure the resident's ability to safely smoke cigarettes in accordance with their facility policy. The deficient practice occurred for 1 of 2 residents reviewed for smoking (Resident #74) and was evidenced by the following: On 10/18/24 at 12:45 PM, the surveyor observed Resident #74 in a wheelchair in the dining room waiting on lunch. On 10/23/24 at 1:34 PM, the surveyor observed Resident #74 outside smoking with supervision provided by the Director of Activity (DOA). The surveyor observed that the DOA lit the resident's cigarette. The surveyor did not observe a smoking apron in use for Resident # 74. Two other residents had smoking aprons applied before their cigarettes were lit. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission and b.) were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 2 of 9 residents (Resident #28 and #167) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 10/18/24 at 12:10 PM, during the initial tour, the surveyor observed Resident #28 wearing a gray sweatshirt. The resident was walking around the unit. The surveyor reviewed the electronic medical record (EMR) for Resident # 28. [...]

Inspectors wroteBased on interviews, medical records (MR) review, and review of pertinent facility documentation's, it was determined that the facility failed to update and revise a resident care plan (CP), add interventions as deemed necessary, for 1 of 3 (Resident #3) residents reviewed for CP revision. The deficient practice was evidenced by the following: A review of Resident #3's admission Record (AR) indicated the Resident was admitted with the following diagnoses which included but not limited to: Acute Embolism and Thrombosis, Atherosclerotic Heart Disease, Hypertension, Metabolic Encephalopathy, Dementia, Anxiety Disorder, Osteoarthritis, Mood Disorder, and Depression. [...]

Inspectors wroteCOMPLAINT #: NJ00173980 Based on observation, interview, review of medical records and other pertinent facility documentation on 10/08/24 and 10/09/24 it was determined that the facility failed to follow acceptable standards of nursing practice by not documenting a registered nurse's (RN) assessment of a reported injury of unknown origin. This deficient practice was identified for 1 of 10 residents reviewed (Resident #10) and was evidenced by the following: On 10/09/24, at 10:12 A.M., the surveyor observed the resident lying in bed asleep. On 10/9/24, at 10:26 A.M., the surveyor interviewed the resident's assigned RN #1 for the day, who stated that the resident was receiving hospice services. She further stated that the resident was declining and although the resident would occasionally call out a family member's name, the resident was no longer verbal. [...]

Inspectors wroteC #: NJ00167104 Based on interviews, medical record review, and review of other pertinent facility documents on 12/21/23, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 1 of 3 residents (Resident #3) reviewed for documentation. This deficient practice was evidenced by the following: According to the facility admission Record (AR), Resident #3 was admitted with diagnoses that included but were not limited to: Dementia, End Stage Renal Disease, Dependence on Renal Dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a physically impaired resident clear access to the handrails equipped in the hallways. This deficient practice was identified for Resident #27, 1 of 35 residents reviewed and was evidenced by the following: During an interview with Resident #27 on 07/06/2023 at 11:29 AM, the resident stated the handrails were blocked daily with carts and he/she did not have clear access to use the handrails along the hallways. The surveyor observed in the hallway directly outside Resident #27's room, there were three carts along both sides of the hallway. A linen cart, a medical cart, and a cart used by the CNAs. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to reweigh a Resident with a significant weight gain in one week. This deficient practice was identified in Resident #86, 1 of 1 resident reviewed for tube feeding and was evidenced by the following: On 06/27/23 at 09:35 AM, the surveyor observed the resident in the bed awake. The resident was a tube feeding resident and the surveyor observed a syringe/container in a closed plastic container with a date of 06/27/23. The resident could not be interviewed due to cognitive status. Review of Resident #86 admission record revealed the resident was admitted to the facility in 2019. Medical diagnoses included, but not limited to diabetes (high blood sugar), dysphagia (inability to swallow), heart disease, and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 06/26/2023 at 9:58 AM, the surveyor accompanied by the Food service Director (FSD) observed the following in the kitchen: The surveyor observed a number of unlabeled and undated items located throughout the kitchen in the refrigerators and freezers which included seven bags of shredded cheese, two roasts, one crate of milk, two bags of frozen French fries, two bags of frozen tater tots, and one bag of frozen broccoli. [...]