Preferred Care at Hamilton

Inspectors wroteBased on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to maintain complete and accurate medical records. Specifically, the facility did not have physician's orders and a care plan in place for the use of bilateral hearing aids. This deficient practice was identified for 1 of 1 resident (Resident #117) reviewed for communication and sensory needs. This deficient practice was evidenced by the following:On 5/6/2026 at 11:06 AM, the surveyor observed Resident #117 on the North Wing hallway self-propelling in his/her wheelchair and not wearing bilateral hearing aids. The bilateral hearing aids were observed on the resident's bedside dresser drawer. The surveyor said hello to the resident, and the resident did not respond to the surveyor. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to properly label and date the oxygen nasal cannula (NC) (a device used to deliver oxygen through tubing) for 1 of 1 resident (Resident #129) reviewed for respiratory care. This deficient practice was evidenced by the following: On 5/6/2026 at 11:12 AM, the surveyor observed Resident #129 in his/her bedroom lying in bed watching television, with the head of the bed elevated to approximately 90 degrees, receiving oxygen through a NC at two (2) liters per minute (LPM). The NC was not labeled or dated. [...]

Inspectors wroteComplaint #175979 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) implement interventions to prevent the development of a stage 3 (full thickness wound) facility acquired pressure injury; b.) ensure individualized comprehensive care plan interventions were implemented to prevent a facility acquired pressure injury wound from worsening; c.) ensure daily observation during wound care was documented according to professional standards of nursing practice to follow continuity of care; and d.) ensure that the physician evaluated and assessed the resident's medical issues related to skin care. This deficient practice occurred for 1 of 2 residents reviewed for pressure ulcers (Resident #167). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/28/25 at 10:00 AM, during initial tour of the kitchen, the surveyor, accompanied by the Food Service Director (FSD) and the Licensed Nursing Home Administrator (LNHA) observed the following: Upon entering the kitchen, the FSD washed her hands at the hand washing sink, and lathered with soap outside the flow of running water for 14 seconds. The LNHA then washed his hands lathering with soap prior to rinsing for a total of 13 seconds. The surveyor used a digital stopwatch to record the time. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC) site consistent with professional standards of practice. The deficient practice was identified for 1 of 24 residents reviewed for professional standard of practice (Resident #12). 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 observation, interview, and record review, it was determined that the facility failed to ensure appropriate monitoring of pain with adequate assessment prior to administration for a resident who was prescribed pain medication. This deficient practice was identified for 84 of 131 doses administered for pain management to Resident #42, and was evidenced by the following: On 1/28/25 at 11:25 AM, during initial tour of the facility, the surveyor observed Resident #42 resting in bed wearing a back brace belt and watching television. The resident told the surveyor that they were dealing with back pain. On 1/29/25 at 12:27 PM, the surveyor observed the resident as they had completed their lunch in the main dining room and were walking out of the dining room, wearing a back brace belt and using a cane. The resident stated they were being managed for pain. [...]

Inspectors wroteBased on observation, interview, review of the medical records and other facility documentation, it was determined that the facility failed to provide adequate monitoring for the use of psychoactive medication. This deficient practice was identified for 1 of 5 residents reviewed for psychoactive medication used (Resident #85), and was evidenced by the following: On 1/30/25 at 12:07 PM, the surveyor observed Resident #85 sitting up in the wheelchair reading a book. The resident was very pleasant and stated they were having a good day and had no complaints. The surveyor reviewed the medical records for Resident #85. A review of the admission Record face sheet (an admission summary) reflected that Resident #85 was admitted to the facility with the diagnoses which included but not limited to; chronic respiratory failure and diabetes mellitus (DM). [...]

Inspectors wrote3. On 1/28/25 at 10:30 AM, during the initial tour of the facility, the surveyor observed Resident #52 lying in their bed awake. The resident stated they had a suprapubic catheter (type of indwelling catheter that drains urine from the bladder into a bag). The surveyor observed the indwelling catheter drainage bag secured to the bed frame, not placed in a privacy bag exposing the contents (urine) in the bag. The surveyor was able to observe the urine in the resident's catheter drainage bag from the hallway. On 1/29/25 at 10:45 AM, the surveyor reviewed the medical record for Resident #52. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included but not limited to; [...]

Inspectors wroteComplaint # NJ 182108 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 2 nursing units (South Side) reviewed for environmental concerns, and was evidenced by the following: On 1/28/25 at 10:30 AM, the surveyor observed the South side nursing unit and identified the following concerns: In Resident room [ROOM NUMBER]-B had one bag of dirty linen on the floor near the resident's dresser. In Resident room [ROOM NUMBER]-A had a cracked trash can with no liner. In the bathroom the surveyor observed the toilet which had a brown substance splattered in the toilet and around the rim. The surveyor also observed a clear bag tied to the handrail filled with used Foley catheter leg bags. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 2 residents reviewed for PASRR (Resident #17) and was evidenced by the following: On 1/28/25 at 11:02 AM, during the initial tour the surveyor observed Resident #17 in bed with eyes closed. On 1/28/25 at 11:26 AM, the surveyor reviewed the medical Record for Resident #17. A review of the admission Record face sheet (an admission summary) reflected the resident was initially admitted to the facility in 2021, with diagnoses which included but not limited to; failure to thrive, hypertension (high blood pressure), chronic pain, and anxiety. Further review showed a new diagnosis of psychosis in 12/2022. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to revise an individual comprehensive care plan for a resident with a history of falls who used a fall mat. This deficient practice was identified in 1 of 5 residents reviewed for falls (Resident #17) and was evidenced by the following: On 1/28/25 at 11:02 AM, during the initial tour, the surveyor observed Resident #17 in bed with eyes closed. The resident had a fall mat on the floor next to the bed and the right side of the bed was pushed up against the wall. On 1/29/25 at 1:24 PM, the surveyor reviewed incidents and accidents for Resident #17. The report reflected that on 11/17/24, the resident was observed on the floor sitting with their back against the bed frame. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a) label, date, and store respiratory equipment in a manner to prevent contamination for infection control and b) develop a individualized comprehensive care plan (ICCP) for use of oxygen. This deficient practice was identified for 2 of 3 residents reviewed for respiratory care (Resident #45 and #85), and was evidenced by the following: 1. On 1/28/25 at 10:30 AM, during the initial tour of the facility, the surveyor observed Resident #45 lying in their bed watching television. The surveyor observed an oxygen concentrator (device that delivers oxygen) with nasal cannula (device that delivers additional oxygen through the nose) tubing placed on the oxygen concentrator unbagged and exposed to the air. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) provide pharmaceutical services in accordance with professional standards of practice and b) accurately document the administration of controlled medications. This deficient practice was identified on 2 of 3 medication carts reviewed for medication storage. This was evidenced by the following: On 1/30/25 at 1:03 PM, the surveyor in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM #1), reviewed the Middle Cart North medication cart. A review of the cart revealed the Individual Patient Controlled Substance Administration Record sheet (declining inventory) for Resident #21's morphine extended release (ER) 60 milligram (mg) tablets was not signed by the nurse who administered the medication on 1/30/25. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly dispose and maintain waste in garbage dumpster areas. This deficient practice was identified in 1 of 1 kitchen garbage dumpster areas, and was evidenced by the following: On 1/28/25 at 10:38 AM, during initial tour of the kitchen, the surveyor, in the presence of the Food Service Director (FSD) and the Licensed Nursing Home Administrator (LNHA) observed the kitchen's garbage dumpster area. The surveyor observed food debris including: bread slices and other unidentifiable disposed food and disposable gloves scattered on the ground. The surveyor also observed a half full garbage compactor which had the door wide open and was not actively being used by staff. At that time, the FSD stated that the dumpster area should have been maintained and cleaned; [...]

Inspectors wrote2. On 1/30/25 at 8:49 AM, the surveyor, in the presence of LPN/UM #1, toured the North Medication Storage Room. The surveyor observed; one soiled oxygen (O2) concentrator with a humidification bottle that was half-way filled with a liquid substance that was still attached and three soiled tube feeding pumps stored in the medication room. At that time LPN/UM #1 stated, the soiled equipment should have been placed in the soiled utility room so housekeeping could process the equipment. LPN/UM #1 acknowledged that the soiled equipment should not be in the medication room; it could cause cross contamination to the sterile supplies and medication preparation area. On 1/30/25 at 9:31 AM, the surveyor interviewed the IP, who stated that soiled equipment should never be placed in the medication room; there was a soiled utility room that used equipment should be placed in. [...]

Inspectors wroteBased on document review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days after completion of the MDS for six of 11 sampled residents (Resident (R) 10, R41, R57, R72, R79, and R85) reviewed for MDS transmission.