Inspection Reports for Hamilton Grove Healthcare and Rehabilitation Center

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The inspection was conducted as a complaint investigation (Complaint #: NJ181916) to assess compliance with staffing requirements and other regulatory standards at Hamilton Grove Healthcare and Rehabilitation, LLC.

The facility was found not in compliance with New Jersey Administrative Code staffing standards, failing to meet required staffing ratios for 14 of 14 day shifts reviewed, with deficiencies in Certified Nurse Aide (CNA) staffing and total nursing hours. No adverse clinical outcomes were identified related to these deficiencies. The facility submitted a Plan of Correction detailing corrective actions and monitoring plans.

Complaint #: NJ181916. The complaint investigation found the facility failed to meet minimum staffing requirements as per New Jersey statutes and administrative code. The facility was not in compliance with staffing ratios for CNAs and total nursing hours during the review period. The facility was required to submit a Plan of Correction and was found in substantial compliance overall.

A Recertification/LSC survey was conducted at Hamilton Grove Healthcare and Rehabilitation from 10/18/2024 through 10/28/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.

During the survey, an Immediate Jeopardy (IJ) was identified due to failure to develop and implement an abuse policy to protect a resident and report alleged violations. The facility submitted an acceptable removal plan and implemented corrective actions. Additional deficiencies were cited related to staffing, emergency preparedness, infection control, and resident care.

Complaint # NJ 178839 triggered the survey. The complaint involved abuse allegations concerning Resident #59. The facility failed to protect the resident and report the incident to appropriate authorities. The complaint was substantiated as evidenced by interviews, observations, and record reviews.

The inspection was conducted as a complaint investigation based on multiple complaint numbers listed, to determine compliance with federal regulations for long term care facilities.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, with deficiencies related to care plan timing and revision, and failure to meet professional standards of nursing practice, including documentation and assessment of residents' needs. Deficiencies were identified for 1 of 3 residents reviewed for care plan revision and 1 of 10 residents reviewed for nursing assessment documentation.

Complaint investigation based on complaint numbers NJ00173980, NJ00175603, NJ00168117, NJ00174247, NJ00174405, NJ00175743, NJ00177768, NJ00173998, NJ00172333, NJ00172224. The facility was found not in substantial compliance with deficiencies substantiated related to care plan revisions and nursing assessments.

The inspection was conducted as a complaint survey (Complaint #: NJ00173471) to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.

The facility was found to be out of compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to failure to maintain required minimum staff-to-resident ratios on 19 of 21 day shifts. No residents were identified as having negative impact from the staffing deficiencies. A plan of correction was submitted to address staffing shortages and improve compliance.

Complaint #: NJ00173471. The complaint investigation found the facility failed to meet minimum staffing requirements on multiple day shifts, but no residents were identified as negatively impacted. The facility submitted a plan of correction to address the staffing deficiencies.

The inspection was conducted based on complaints NJ00167104 and NJ00169822 to investigate compliance with federal and state regulations regarding resident records and staffing.

The facility was found not in substantial compliance with 42 CFR Part 483 and New Jersey Administrative Code 8:39 due to deficiencies in resident-identifiable information documentation and failure to maintain required minimum staffing ratios for Certified Nursing Assistants (CNAs).

Complaint numbers NJ00167104 and NJ00169822 triggered the investigation. The facility was found deficient in documentation and staffing. The complaint was substantiated based on review of records, interviews, and staffing data.

Annual standard survey conducted to assess compliance with federal and state regulations for long term care facilities.

The facility was found not in substantial compliance with several regulatory requirements including reasonable accommodations for residents, professional standards for care plans, food safety, staffing ratios, and life safety code violations related to electrical equipment. Corrective actions were planned or implemented for all deficiencies.

The visit was a follow-up inspection to verify correction of previously cited deficiencies related to electrical equipment and power cord usage.

The facility was found to have used extension cords and power strips beyond temporary installation, which posed a potential electrical fire or shock hazard. Corrective actions were implemented including removal of improper power strips and re-education of staff. The follow-up report dated 08/31/2023 indicates the deficiency was corrected.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

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.

The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on mandatory access to care and staffing ratios.

The facility failed to maintain the required minimum direct care staff to resident ratios for day and evening shifts as mandated by New Jersey state law. Staffing reports showed consistent understaffing on 14 of 14 day shifts and 1 of 14 evening shifts reviewed. The facility implemented multiple corrective actions including recruitment incentives, staffing audits, and increased communication to address the deficiencies.

A Life Safety Code Survey was conducted by the New Jersey Department of Health on 5/18/22 and 5/19/22 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.

The facility was found to be in noncompliance with Life Safety Code requirements including exit discharge surfaces, HVAC ventilation maintenance, sprinkler system supervisory signals, and corridor door smoke resistance. Deficiencies were identified in exit discharge surfaces not being level and hard packed, malfunctioning bathroom exhaust systems, lack of tamper alarms on fire sprinkler valves, and corridor doors with gaps due to missing or torn gaskets.

The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing ratios as mandated by state law.

The facility was found not in compliance with minimum direct care staff-to-resident ratios for 14 of 14 day shifts reviewed, failing to meet the required number of Certified Nurse Aides (CNAs) for the census on multiple dates. The facility has implemented multiple corrective actions to improve staffing levels.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.

The facility was found noncompliant with life safety code requirements, specifically failing to maintain tamper alarms on fire sprinkler system valves and failing to ensure corridor doors resist the passage of smoke due to missing or torn rubber gaskets on multiple resident room doors.

The inspection was conducted as a complaint survey based on complaints NJ147161, NJ147235, and NJ146733.

The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.

Complaint numbers NJ147161, NJ147235, and NJ146733 were investigated and found to be without substantiated deficiencies.

The inspection was conducted as a complaint visit to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.

The facility failed to maintain accurate medical records for 2 of 7 residents reviewed, including errors in nursing admission assessments and incomplete documentation of activities of daily living. Re-education and new policies were implemented to address these deficiencies.

The facility was found not in substantial compliance based on a complaint visit. Deficiencies involved inaccurate medical records and documentation errors for residents #2 and #3.

A COVID-19 Focused Infection Control Survey was conducted due to concerns about infection control practices related to COVID-19 exposure and transmission in the facility.

The facility failed to isolate residents on transmission-based precautions (TBP) for unknown COVID-19 community exposure from their well and non-exposed roommates, and failed to maintain appropriate TBP for residents identified as persons under investigation (PUI) for known COVID-19 exposure. Staff were observed not changing gowns between residents, not wearing N95 masks, not donning gowns or gloves in resident rooms on TBP, and not performing hand hygiene, posing a serious and immediate threat to resident safety. Immediate Jeopardy (IJ) situations were identified and subsequently removed after the facility submitted and implemented acceptable removal plans.

The visit was complaint-related due to concerns about COVID-19 infection control practices. Immediate Jeopardy situations were identified related to failure to isolate residents and maintain proper transmission-based precautions. The facility was notified of the IJ on 1/11/21 and 1/14/21 and submitted removal plans that were accepted and verified on follow-up visits.