Hamilton Grove Healthcare and Rehabilitation, LLC

In the surveyor’s words

From the most serious findings on record at Hamilton Grove Healthcare and Rehabilitation, LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Jan 19, 2021

  Based on observation, interview, review of medical records and other pertinent facility documentation, during a survey conducted on 1/11/21, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure: a.) that the facility was in compliance with all recommended infection control measures in accordance with the Centers for Disease Control (CDC) and the New Jersey Department of Health (NJDOH) guidelines and b.) the implementation of mitigation strategies to prevent the transmission of COVID-19 were appropriately followed to prevent the spread of the infection which affected residents' safety. […]

• Immediate jeopardy, widespreadF880Jan 19, 2021

  PART A Based on observation, interview, medical record review, and other facility documentation, during a survey conducted on 1/11/21, it was determined that the facility failed to isolate residents on transmission-based precautions (TBP) for unknown COVID-19 community exposure in a high risk COVID-19 positive county from their well and non-exposed roommates to prevent the transmission of COVID-19. This deficient practice was identified for 2 of 3 residents (Resident #1 and #2) reviewed for community based medical appointments. On 12/22/2020 and 1/4/2021, Resident #2 left the facility for a same day medical appointment in a high risk COVID-19 positive county (8.2%, and 10.64% respectively). […]

• Immediate jeopardy, isolatedF600Oct 28, 2024

  Complaint NJ #:178839 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement an abuse policy that addressed sexual abuse to ensure a resident was protected from staff-to-resident sexual abuse. This deficient practice was identified for one (1) of one (1) residents (Resident #59) reviewed for abuse, and was evidenced by the following: On 10/22/24 at 1:00 PM, two surveyors interviewed the Director of Nursing (DON) who stated that a Certified Nursing Assistant (CNA#1) reported that on 10/15/24, the CNA#1 observed a Licensed Practical Nurse (LPN #1) standing over Resident #59 in a compromising position. […]

• No harm, potential for more than minimal, patternF686Mar 16, 2026

  Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries and ensure that air mattresses were accurately set according to the resident's weight.This deficient practice was identified for 4 of 4 residents (Residents #6, #7, #106, and #151) reviewed for risk of pressure ulcers and was evidenced by the following:1.On 3/6/26 at 10:50 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 330 pounds.On 3/10/26 at 11:48 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 180-230 pounds.A review of the admission Record (AR) (an… […]

• No harm, potential for more than minimal, patternF609Oct 28, 2024

  Complaint # NJ 178839 Refer to F 600 Based on interviews and review of the medical record and other facility documentation, it was determined that the facility staff failed to report an allegation of sexual abuse by a staff member to a resident to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 1 resident (Resident #59) and was evidenced by the following: On 10/22/24, the surveyor reviewed Resident #59's medical record which included a quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/24, which indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition and diagnoses which included but were not limited to diabetes (high blood sugar), respiratory disease, anxiety disorder, and… […]