Inspection Reports for Alaris Health at Hamilton Park
525 Monmouth St, Jersey City, NJ 07302, United States, NJ, 07302
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Annual Inspection
Census: 168
Capacity: 260
Deficiencies: 6
Mar 13, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and a Life Safety Code Survey.
Findings
Deficiencies were cited related to accuracy of assessments, respiratory care, physician visits documentation, infection prevention and control, and life safety code violations including vertical openings and fire alarm system installation. Plans of correction were submitted and verified in a post-certification revisit.
Complaint Details
The survey included review of multiple complaint numbers (NJ00165501, NJ00166244, NJ00166426, NJ00168056, NJ168240, NJ00182139, NJ00183846, NJ00183944). The complaints were investigated as part of the recertification survey.
Severity Breakdown
Level D: 3
Level E: 1
Level F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to accurately code the Minimum Data Set (MDS) for resident assessments. | Level D |
| Facility failed to follow Physician's Orders for respiratory care for 2 residents. | Level D |
| Facility failed to ensure primary physician accurately dated progress notes during visits. | Level E |
| Facility failed to establish infection prevention and control practices for environmental cleaning and staff procedures. | Level D |
| Facility failed to ensure enclosed usable space within exit enclosures per Life Safety Code. | Level F |
| Facility failed to ensure low voltage wiring for sprinkler tamper switches was properly enclosed. | Level F |
Report Facts
Census: 168
Total Capacity: 260
Deficiencies cited: 6
Date of survey completion: Mar 13, 2025
Date of revisit: Apr 22, 2025
Inspection Report
Routine
Census: 150
Deficiencies: 0
Jul 1, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 154
Deficiencies: 1
Nov 16, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ165422 to investigate compliance with staffing requirements at the facility.
Findings
The facility was found not in compliance with New Jersey staffing regulations, failing to maintain the required minimum direct care staff to resident ratios on multiple day shifts. The facility submitted a plan of correction to address staffing deficiencies.
Complaint Details
Complaint #NJ165422 was investigated and the facility was found not in compliance with staffing requirements. The complaint was substantiated based on review of staffing reports and interviews.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey, evident for 2 out of 14 day shifts reviewed. |
Report Facts
Census: 154
Sample Size: 4
Deficient CNA staffing days: 14
Deficient CNA staffing days: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to reviewing nurse staffing and implementing corrective actions. |
| Staffing Coordinator | Staffing Coordinator (SC) | Named in relation to nurse staffing compliance and education on staff-to-resident ratios. |
Inspection Report
Abbreviated Survey
Census: 151
Deficiencies: 2
Aug 4, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations and failed to develop and implement a comprehensive person-centered care plan for at least one resident. Deficiencies were noted in infection prevention and control practices, including improper storage of oxygen and nebulizer equipment.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop a comprehensive person-centered care plan for Resident #7. | SS=D |
| Failure to establish and maintain an infection prevention and control program including proper storage of oxygen and nebulizer equipment. | SS=D |
Report Facts
Census: 151
Sample Size: 10
Inspection Report
Annual Inspection
Census: 135
Deficiencies: 14
Mar 14, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to comprehensive assessments after significant change, accuracy of assessments, professional standards in care plans, drug regimen review, resident records confidentiality, infection prevention and control, staffing ratios, and life safety code compliance including means of egress, fire alarm and sprinkler systems, smoking regulations, and electrical systems.
Severity Breakdown
SS=D: 6
SS=E: 5
SS=F: 3
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for Resident #63. | SS=D |
| Failed to accurately complete the Minimum Data Set (MDS) for Residents #147 and #63. | SS=D |
| Failed to follow professional standards by not administering a current Physician's Order for Resident #109. | SS=D |
| Consultant Pharmacist failed to identify and/or report medication irregularities resulting in improper medication administration for Resident #81. | SS=D |
| Failed to maintain complete and readily accessible medical records for hospice Resident #100. | SS=D |
| Failed to adhere to accepted infection control practices for proper storage of urinary catheter for Resident #116. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
| Failed to provide special signage within stairway enclosures at each floor landing for four exit stairways. | SS=F |
| One of four stairways lacked a two-hour fire resistance rating door. | SS=E |
| Two photo electric smoke detectors were installed less than 36 inches from ceiling air diffusers. | SS=E |
| Failed to complete a smoke detection sensitivity test for all 113 photo electric smoke detectors. | SS=F |
| Sprinkler coverage was not provided under two of four staircase first floor landings. | SS=E |
| Failed to provide metal containers with self-closing cover devices in smoking areas and enforce smoking regulations. | SS=E |
| Failed to ensure the 125 KW stand-by diesel generator was tested and maintained in accordance with NFPA 110 standards. | SS=F |
Report Facts
Census: 135
Deficiencies cited: 14
Minimum CNA staffing required: 18
Minimum CNA staffing actual: 11
Generator capacity: 125
Smoke detectors: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Maintenance Director | Interviewed and provided information on fire safety deficiencies and corrective actions. | |
| Maintenance Director | Interviewed and provided information on fire safety deficiencies and corrective actions. | |
| Director of Nursing | Responsible for staffing reviews and re-education related to staffing deficiencies. | |
| Licensed Nursing Home Administrator | Informed of staffing deficiencies and participated in interviews regarding medication and hospice record issues. | |
| MDS Coordinator | Interviewed regarding MDS assessment deficiencies. | |
| Consultant Pharmacist (CRPh) | Interviewed regarding medication regimen review deficiencies. |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Feb 15, 2023
Visit Reason
The inspection was conducted based on a complaint survey (Complaint #: NJ161241) to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to implement an effective discharge planning process for one resident (Resident #1) who required home health agency (HHA) services and durable medical equipment (DME) after discharge. The resident was discharged without HHA services in place and without confirmation of DME delivery, resulting in a deficient discharge plan.
Complaint Details
Complaint #: NJ161241. The complaint investigation found that the facility did not ensure that home health agency services were in place prior to discharge and failed to confirm delivery of durable medical equipment for Resident #1. The social worker did not communicate the lack of HHA services to nursing, the primary physician, Ombudsman, or Adult Protective Services. The discharge occurred without proper coordination and documentation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement an effective discharge plan for a resident requiring home health agency services and durable medical equipment after discharge. | SS=D |
Report Facts
Census: 145
Sample Size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented resident discharge and was unaware that HHA services were not in place. |
| LPN #2 | Licensed Practical Nurse | Nurse who discharged Resident #1 and was unaware that HHA services were not in place. |
| SW | Social Worker | Responsible for discharge planning; failed to communicate lack of HHA services and did not document this in the medical record. |
| DR | Director of Rehabilitation | Ordered durable medical equipment and failed to follow up on delivery status. |
Inspection Report
Abbreviated Survey
Census: 124
Deficiencies: 1
May 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to ensure staff wore appropriate Personal Protective Equipment (PPE) on non-ill units and prior to entering rooms of residents on Transmission Based Precautions. Deficiencies were observed in PPE use by Certified Nursing Assistants and Housekeeping staff on multiple units during the COVID-19 focused survey.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to wear appropriate PPE while working on non-ill units and prior to entering rooms of residents on Transmission Based Precautions. | SS=E |
Report Facts
Census: 124
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Provided information during entrance conference about facility COVID-19 status and PPE requirements | |
| Registered Nurse Infection Preventionist (RN/IP) | Provided information about PPE requirements and conducted in-service education for staff | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding PPE requirements on non-ill unit and observation area | |
| Certified Nursing Assistant (CNA) | Observed not wearing face shield in resident room; received in-service education | |
| Housekeeper | Observed wearing two surgical masks instead of N95; received in-service education | |
| Regional Nurse | Interviewed regarding PPE use and transporters' handwashing | |
| Assistant Director of Nursing (ADON) | Present during interview about resident room assignment and signage | |
| Registered Nurse (RN) on COVID-19 positive unit | Interviewed about PPE use and transporter practices |
Inspection Report
Follow-Up
Census: 129
Deficiencies: 1
Apr 13, 2021
Visit Reason
The visit was conducted as a standard survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities, specifically focusing on the facility's adherence to professional standards in care plans.
Findings
The facility was found not in substantial compliance due to failure to follow a physician's order for monitoring a resident's blood glucose, specifically administering insulin based on blood sugar readings taken after the resident had eaten, contrary to the physician's order to check before meals. Corrective actions including re-education and monitoring of nursing staff were implemented.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow a physician's order for monitoring a resident's blood glucose, administering insulin based on blood sugar readings taken after the resident ate instead of before as ordered. | SS=D |
Report Facts
Census: 129
Sample Size: 29
Deficiency correction completion date: Apr 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Nurse observed failing to follow physician's order for blood glucose monitoring on 4/8/2021 | |
| Pharmacy Consultant (PC) | Interviewed regarding proper blood glucose monitoring and insulin administration | |
| Unit Manager/Registered Nurse (UM/RN) | Interviewed about blood sugar monitoring practices | |
| Director of Nursing (DON) | Interviewed about standard practice for blood glucose monitoring and responsible for auditing and re-education | |
| Resident's Doctor | Interviewed regarding the incident and importance of following physician's orders |
Inspection Report
Life Safety
Deficiencies: 1
Apr 13, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 requirements, specifically focusing on oxygen tank storage and related safety regulations.
Findings
The facility was found not in substantial compliance with the minimum Life Safety Code requirements due to improper storage of oxygen tanks exceeding the allowed volume and proximity to combustible materials. The facility failed to comply with NFPA 99 oxygen tank storage requirements, with oxygen tanks stored too close to combustible items and exceeding maximum allowed volume.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Oxygen tanks exceeding 300 cubic feet in volume were stored within 5 feet of combustible items, with 19 oxygen cylinders stored within 1 foot of combustible cardboard boxes, exceeding the maximum allowed volume by 175 cubic feet. | SS=D |
Report Facts
Oxygen tank volume: 475
Oxygen tanks stored: 19
Maximum allowed oxygen tanks: 12
Audit frequency: 3
Audit duration: 4
Audit daily period: 30
Audit twice weekly period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observation and interview verifying the deficiency and responsible for education and audits | |
| Regional Maintenance Director | Provided education to Maintenance Director | |
| Administrator | Informed verbally of the finding during exit conference and involved in education | |
| Corporate Physical Plant Manager | Present during observation of oxygen tank storage |
Inspection Report
Routine
Census: 152
Deficiencies: 0
Jan 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
Dec 29, 2020
Visit Reason
The inspection visit was conducted in response to a complaint identified as NJ 00141996.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint number NJ 00141996 was investigated and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 173
Deficiencies: 2
Dec 18, 2020
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers related to the facility's compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found non-compliant due to failure to maintain food at safe and palatable temperatures during meal delivery, and failure to ensure proper infection prevention and control practices during the COVID-19 pandemic, including inadequate use of PPE by staff and failure of a resident in isolation to wear a mask when outside their room.
Complaint Details
The complaint investigation involved multiple complaint numbers (NJ121973, NJ123030, NJ125252, NJ125253, NJ125436, NJ130257, NJ134713, NJ134963, and NJ138162). The facility was found not in compliance based on these complaints.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure food items were stored and served under sanitary conditions and held at a palatable temperature range during meal delivery. | SS=E |
| Failure to establish and maintain an infection prevention and control program that prevents the development and transmission of communicable diseases and infections, including failure to ensure a resident in isolation wore a mask for source control and staff wore recommended PPE on the PUI unit. | SS=F |
Report Facts
Census: 173
Sample Size: 25
Food temperature measurements: 193
Food temperature measurements: 30
Food temperature measurements: 32
Food temperature measurements: 115
Food temperature measurements: 121
Food temperature measurements: 125
Food temperature measurements: 59.1
Food temperature measurements: 58.6
Food temperature measurements: 60.1
Number of residents affected: 1
Number of PUI residents: 31
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