Inspection Reports for
Complete Care At Hamilton, Llc

Complaint #NJ 401472 involved failure to maintain a clean, safe, and homelike environment and failure to return personal clothing items (socks) after laundering. The complaint was substantiated based on observations, interviews, and documentation.

The facility failed to maintain call bells within reach for residents, specifically Resident #96, and failed to maintain a clean and safe environment in multiple resident rooms with issues such as broken furniture, soiled floors, and insect infestations. Additionally, several residents reported missing socks that were not returned after laundering, with large bags of residents' socks found in the laundry room.

Complaint #NJ 401472 involved failure to maintain a clean, safe, and homelike environment in resident rooms and failure to return personal clothing items (socks) after laundering to residents, including Resident #96 and 5 residents attending the resident council meeting. The complaint was substantiated based on observations and interviews.

The facility was found deficient in maintaining call bells within residents' reach, ensuring a clean and homelike environment, returning residents' personal clothing after laundry, monitoring resident weights per physician orders, obtaining physician orders for oxygen therapy and proper respiratory equipment storage, and maintaining proper kitchen sanitation practices.

The complaint investigation substantiated incidents of resident-to-resident abuse. The investigation revealed that R7 pulled R8's sweater and R8 swung at R7's face. Another incident involved R13 hitting R14 in the head after R14 ran over R13's foot with a wheelchair. Interviews with staff and residents confirmed these events.

The facility failed to protect residents from physical abuse by other residents, with substantiated incidents involving four of five residents reviewed. Interventions included separating residents, body assessments, police notification, and psychological evaluations.

The complaint investigation was substantiated, identifying that the facility failed to provide the prescribed diet consistency to Resident #1, leading to choking and subsequent cardiac and respiratory arrest. Immediate Jeopardy was identified and later abated after staff education and corrective actions.

The facility failed to provide the prescribed diet consistency to Resident #1, resulting in choking, cardiac arrest, and respiratory arrest. The deficient practice created an Immediate Jeopardy to resident health. The facility implemented a Plan of Correction including staff suspension, education on diet identification, and updated procedures to ensure diet compliance. At the time of the survey, the facility was in substantial compliance.

The complaint was substantiated as the facility did not provide documentation of physician visits or progress notes for Resident #45 for the months of March, April, and May 2024.

The facility failed to ensure that the physician visited and documented progress notes for Resident #45 at least every 60 days from March through May 2024, resulting in a deficiency with minimal harm or potential for actual harm affecting a few residents.

Complaint investigations were completed during this survey, including complaints NJ001173367 and NJ00165012 related to staffing and compliance with licensure standards.

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.

The complaint investigation substantiated that the CNA failed to follow the care plan requiring two-person assistance for Resident #2, resulting in a fracture of the resident's right upper extremity. The CNA was suspended pending investigation and subsequently terminated.

The facility failed to use two-person assistance for Resident #2 as required by the care plan, resulting in the resident sustaining a right humeral fracture during care. The CNA provided care alone despite the resident's documented need for two-person assistance, leading to actual harm and transfer to an acute care hospital.

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.

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.

The facility was found deficient in multiple areas including failure to ensure proper documentation and implementation of advance directives and code status, failure to protect residents from abuse, failure to prevent inappropriate use of physical restraints, failure to timely report and investigate abuse allegations, failure to provide written transfer and bed hold notices, failure to conduct PASARR Level II evaluations when indicated, failure to invite residents or representatives to care plan meetings, failure to ensure safe bed mattress fit, failure to monitor psychotropic medication use including gradual dose reductions, failure to maintain an effective infection prevention and control program including antibiotic stewardship, and failure to offer pneumococcal vaccinations according to current standards.

The facility was found deficient in multiple areas including failure to ensure proper documentation and implementation of advance directives, failure to protect residents from abuse, failure to prevent inappropriate use of physical restraints, failure to timely report and investigate abuse allegations, failure to provide written transfer and bed hold notices, failure to conduct PASARR Level II evaluations when indicated, failure to invite residents or representatives to care plan meetings, failure to ensure safe bed and mattress fitting, failure to document side rail use properly, failure to monitor psychotropic medication efficacy and implement gradual dose reductions, failure to maintain an effective infection prevention and control program including antibiotic stewardship, and failure to offer pneumococcal vaccinations according to current standards.

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.

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.