Inspection Reports for Complete Care At Hamilton, Llc
56 Hamilton Avenue, Passaic, NJ, 07055
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 13, 2025, found the facility in substantial compliance with all applicable standards and cited no deficiencies. Earlier inspections showed a mixed record, with a June 27, 2024, annual survey identifying multiple deficiencies related to physician visit documentation, staffing ratios, and several life safety code issues including fire safety and emergency egress. Complaint investigations from 2023 and early 2024 documented substantiated findings involving staffing shortages, failure to follow care plans resulting in resident injury, and issues with resident rights, abuse prevention, infection control, and medication management. Enforcement actions such as staff suspension and termination were noted, but fines or license suspensions were not listed in the available reports. The recent clean inspection suggests improvement following a period of cited deficiencies and complaint substantiations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
83% occupied
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
Re-Licensure Survey for their Behavioral Health Unit was conducted on 01/13/2025.
Findings
The facility is in substantial compliance with all of the standards in the New Jersey Administrative Code, Chapter 8:85-2.1-2.21 standards for Behavioral Health Nursing Facility for Long Term Care.
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
Re-Licensure Survey for their Behavioral Health Unit was conducted on 06/27/2024.
Findings
The facility is in substantial compliance with all of the standards in the New Jersey Administrative Code, Chapter 8:85-2.1-2.21 standards for Behavioral Health Nursing Facility for Long Term Care.
Inspection Report
Annual Inspection
Census: 99
Capacity: 120
Deficiencies: 10
Date: Jun 27, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint investigations were completed during this survey, including complaints NJ001173367 and NJ00165012 related to staffing and compliance with licensure standards.
Findings
Deficiencies were cited related to physician visit frequency and timeliness, staffing ratios, life safety code violations including egress door locking, exit discharge surfaces, hazardous area enclosures, fire alarm system installation, sprinkler system installation, portable fire extinguisher maintenance, smoke barrier door integrity, and essential electrical system maintenance and testing.
Deficiencies (10)
Facility failed to ensure physician visits were conducted face to face and documented at least once every 60 days for Resident #45.
Facility failed to maintain required minimum direct care staff-to-resident ratios on multiple day shifts.
One designated exit access door had a thumb turn lock on the egress side restricting emergency use.
One exit discharge door had an unstable, grassy sloped walking surface instead of a stable, hard packed all-weather travel surface.
One fire-rated door to a hazardous area (commercial laundry room) had a gap of approximately 1/2 inch between the lower meeting edges, allowing smoke and fire to pass.
Fire alarm system failed to provide audible and visible signals for the second floor outside residents smoking deck area.
Facility failed to install sprinklers in the basement stairwell lower landing area and had a plugged sprinkler pipe.
One portable fire extinguisher was not inspected monthly and one had pressure in the red discharge zone.
Smoke barrier doors on the second floor had excessive gaps (1-3/8 inch and 1-1/8 inch) along the bottom edges allowing smoke and fire to pass.
Emergency generator lacked a remote manual stop station and was not exercised under load for two months within the last year.
Report Facts
Census: 99
Total Capacity: 120
Sample Size: 28
Deficiencies cited: 10
Staffing Deficiency Days: 2
Fire Extinguishers Inspected: 15
Emergency Generator KW: 125
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Date: Jan 30, 2024
Visit Reason
The inspection was conducted based on a complaint visit (Complaint #: NJ00170690) to investigate allegations related to failure to follow required two-person assistance interventions for a resident.
Complaint Details
Complaint #NJ00170690. The facility was found not in substantial compliance based on this complaint visit. Resident #2 was injured due to failure to follow two-person assist care plan, resulting in emergency room transfer and hospital admission. CNA involved was suspended and terminated after investigation.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to provide two-person assistance as required by the resident's care plan, resulting in injury and emergency transfer of Resident #2. Additionally, the facility failed to maintain required minimum staffing ratios on one day shift.
Deficiencies (2)
Failure to use two-person assistance interventions for Resident #2 as required by the care plan, resulting in injury and emergency hospital transfer.
Failure to maintain minimum staff-to-resident ratios as mandated by the state of New Jersey for 1 of 14 day shifts.
Report Facts
Census: 102
Sample Size: 4
Deficient staffing day shifts: 1
CNA staffing on 01/14/24: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Failed to follow two-person assist care plan for Resident #2, resulting in injury and termination |
| LPN #2 | Licensed Practical Nurse | Documented nursing observations and interviewed regarding incident with Resident #2 |
| Director of Nursing | Director of Nursing | Interviewed regarding staff behavior causing injury to Resident #2 and care plan noncompliance |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
Certification Licensure Survey for their Behavioral Health Unit was conducted on 8/1/23-8/2/23.
Findings
The facility is in substantial compliance with all of the standards in the New Jersey Administrative Code, Chapter 8:85-2.1-2.21 standards for Behavioral Health Nursing Facility for Long Term Care.
Inspection Report
Complaint Investigation
Census: 106
Capacity: 112
Deficiencies: 10
Date: May 26, 2023
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of New Jersey Department of Health (NJDOH). The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation revealed incidents involving resident abuse and neglect, including failure to protect residents from harm, failure to investigate allegations timely, and failure to report to appropriate authorities within required timeframes. Specific incidents involving residents R28, R38, R63, and others were documented with interviews and record reviews confirming deficiencies.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to request, refuse, or discontinue treatment and to formulate advance directives, failure to protect residents from abuse and neglect, failure to ensure freedom from physical restraints, failure to prevent and report alleged violations of abuse and neglect, failure to ensure proper staffing ratios, failure to ensure infection prevention and control, failure to ensure proper use of bed rails, and failure to maintain compliance with psychotropic drug use and antibiotic stewardship programs. The facility was also found deficient in life safety code compliance related to fire doors.
Deficiencies (10)
Failure to ensure residents' rights to request, refuse, or discontinue treatment and to formulate advance directives.
Failure to protect residents from abuse and neglect.
Failure to ensure freedom from physical restraints.
Failure to investigate and report alleged violations of abuse, neglect, exploitation or mistreatment timely and thoroughly.
Failure to ensure adequate staffing ratios for certified nursing assistants.
Failure to ensure infection prevention and control program was effective and included antibiotic stewardship.
Failure to ensure proper use and assessment of bed rails.
Failure to ensure psychotropic drugs are used appropriately with gradual dose reductions and behavioral interventions.
Failure to ensure pneumococcal and influenza immunizations were offered and documented.
Failure to maintain fire doors inspected and tagged annually per NFPA 80 standards.
Report Facts
Survey Census: 106
Total Capacity: 112
Sample Size: 28
Staffing Deficiencies: 2
Staffing Deficiencies: 3
Staffing Deficiencies: 1
Staffing Deficiencies: 2
Staffing Deficiencies: 1
Staffing Deficiencies: 4
Staffing Deficiencies: 5
Staffing Deficiencies: 8
Staffing Deficiencies: 8
Staffing Deficiencies: 10
Staffing Deficiencies: 10
Staffing Deficiencies: 9
Staffing Deficiencies: 8
Staffing Deficiencies: 10
Staffing Deficiencies: 9
Staffing Deficiencies: 11
Staffing Deficiencies: 11
Staffing Deficiencies: 8
Staffing Deficiencies: 8
Staffing Deficiencies: 10
Staffing Deficiencies: 10
Staffing Deficiencies: 13
Staffing Deficiencies: 13
Staffing Deficiencies: 13
Staffing Deficiencies: 13
Staffing Deficiencies: 13
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
Initial licensure survey for the Behavioral Health Unit conducted on 2022-08-08.
Findings
The facility was found to be in substantial compliance with all applicable standards in the New Jersey Administrative Code for Behavioral Health Nursing Facility for Long Term Care.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
Initial state licensing survey for the Behavioral Health Unit at Complete Care at Hamilton.
Findings
A Life Safety Code Survey was conducted and the facility was found to be in substantial compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code standards for existing health care occupancies.
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 0
Date: May 3, 2021
Visit Reason
The inspection was conducted as a standard annual survey combined with a COVID-19 Focused Infection Control Survey in conjunction with the recertification survey.
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 and in compliance with infection control regulations related to COVID-19.
Report Facts
Sample Size: 21
Inspection Report
Routine
Census: 81
Deficiencies: 0
Date: Jan 5, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 5
Notice
Deficiencies: 0
Date: Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
Report Facts
Effective date: Apr 15, 2011
Response timeframe: 30
Disclosure accounting period: 6
Disclosure accounting period for electronic records: 3
Complaint filing address: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices and rights |
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