Inspection Reports for Hamilton Grove Healthcare and Rehabilitation Center

The complaint investigation found that Resident 2 was administered medication intended for another resident by an agency nurse, resulting in adverse effects and hospitalization. The nurse did not report the error to the supervisor or primary care physician, and the medication error was not documented. The facility was unaware of the incident until three days later when notified by the hospital.

The facility failed to ensure one of three sampled residents was free from significant medication errors. Specifically, one resident was administered another resident's medications, resulting in nausea, vomiting, and hospitalization for an upper gastrointestinal bleed. The medication error was not documented, and the nurse involved did not report the error immediately.

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.

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 # 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.

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 regarding staff-to-resident sexual abuse involving Resident #59 and LPN #1. The complaint was substantiated with findings of immediate jeopardy.

The facility failed to protect Resident #59 from sexual abuse by LPN #1, did not report the incident timely to authorities, and did not thoroughly investigate or notify the resident's physician. The facility also failed to ensure proper care in other areas including catheter care, physician visits, smoking supervision, heel booties application, and CNA training.

Complaint NJ #: 178839. The complaint alleged sexual abuse of Resident #59 by LPN #1 on 10/15/24. The facility initially failed to report the incident to the NJDOH and police, citing the resident's claim of consensual contact and desire for confidentiality. The investigation was incomplete at the time of survey. The resident was cognitively intact and confirmed the incident occurred. The facility later submitted a removal plan and reported the incident after surveyor intervention.

The facility failed to protect a resident from staff-to-resident sexual abuse, failed to fully investigate and report the incident timely to the state and law enforcement, and did not notify the resident's physician promptly. The incident involved a Licensed Practical Nurse engaging in sexual contact with Resident #59 on 10/15/24, which was witnessed by a Certified Nursing Assistant. The facility initially did not report the incident due to the resident's claim of consensual contact but later submitted a removal plan and reported the incident after surveyor intervention.

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 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 #: NJ00173980. The complaint involved failure to document a registered nurse's assessment of a reported injury of unknown origin for Resident #10. The investigation found the facility did not follow acceptable nursing standards by failing to document the RN assessment and investigation of the injury.

The facility failed to update and revise the care plan for Resident #3 to include new interventions for pressure injuries and failed to document a nursing assessment for a reported injury of unknown origin for Resident #10. Interviews and record reviews confirmed these deficiencies.

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 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 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.

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).

The complaint investigation found that documentation of ADL care for Resident #3 was incomplete or missing on multiple shifts and dates, with substantiation based on interviews and record reviews.

The facility staff failed to consistently document ADL care, specifically toileting care, for Resident #3 on multiple dates and shifts in August and September 2023. Interviews with staff confirmed documentation lapses in the Documentation Survey Report (DSR).

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 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.

The facility was found deficient in providing clear access to handrails for a physically impaired resident, failing to reweigh a resident after a significant weight gain, and not maintaining proper food labeling, dating, and sanitation in the kitchen.

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.

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 complaint investigation focused on two residents with enteral tube feedings who were improperly cared for, including feeding while lying flat and improper bolus feeding techniques. Additionally, multiple residents complained about cold food temperatures during meals, and the facility's pellet warmer was found to be broken and inconsistently repaired.

The facility failed to follow standards of practice for enteral tube feeding administration, including improper positioning of residents during feeding, lack of proper staff education, and unsafe feeding techniques. Additionally, meals were often served at unacceptable temperatures, with residents frequently receiving cold or lukewarm food, and the facility's pellet warmer used to keep food hot was malfunctioning.

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.

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 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.

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 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.

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.