Spring Hills Hamilton: Dialysis Patient Denied Meds - NJ
Resident #21 told inspectors in February that nurses "frequently run out of their medications" and specifically complained about not receiving Renvela, a drug that removes excess phosphorus from the blood of dialysis patients. The resident had been at Spring Hills Post Acute Hamilton since late November 2024.
The resident left for dialysis at 10 AM on Tuesdays, Thursdays and Saturdays, returning around 4 PM. Yet nurses continued scheduling the noon dose of Renvela during those absences from December through February, inspection records show.
On February 5, Licensed Practical Nurse #1 told an inspector she wasn't giving the resident Renvela because the computer system showed "discontinue pending confirmation." But no discontinuation order existed in the medical record. The nurse said this meant "they were verifying orders because there may be multiple orders."
The Unit Manager found Renvela tablets labeled for the resident sitting in the medication cart. She acknowledged "there should not be a time of 12 NOON for the Renvela on Tuesdays, Thursdays and Saturdays because the resident was out to dialysis."
Records revealed the medication scheduling problem had persisted for months. In December 2024, the resident missed noon doses of Renvela on 13 different days. Electronic progress notes confirmed the resident "was at dialysis" for many of those missed doses.
The resident also missed other essential medications during dialysis appointments. Heparin injections to prevent blood clots were skipped 11 times in December when scheduled at 2 PM on dialysis days. Calcitriol capsules for low calcium levels were missed twice in late December.
January brought similar problems. The resident missed Renvela doses on 11 days, with progress notes again confirming "resident was at dialysis" for several instances. TUMS tablets for dialysis patients were missed three times when scheduled during dialysis hours.
The facility's own care plan, updated January 30, specifically stated: "Ensure medication schedule is adjusted to administer medications when I am in the facility." The resident's dialysis schedule was clearly documented, with physician orders showing appointments at the external facility on Tuesday, Thursday and Saturday with 10 AM pickup and 11 AM chair time.
When medications weren't available, nurses entered code "9" in the electronic system, meaning the drug wasn't given. Progress notes from January showed doses marked as "not available, awaiting from pharmacy" or "on order" for days at a time.
The facility's consultant pharmacist told inspectors that when medications aren't available, "the physician had to be called to get instructions on what can be done." She said nurses "cannot just document that the medication was not available or awaiting from pharmacy" without getting physician guidance.
The pharmacist confirmed that dialysis patients "had to have their medications scheduled to accommodate them being out of the facility" and that physicians should provide "specific orders as to the timing."
The Unit Manager acknowledged she was "unsure why the physician's order for Resident #21 had not been updated to accommodate the times the resident was out to dialysis." She explained that typically "a medication ordered for three times a day would only be ordered twice a day on dialysis days and scheduled for times when the resident was in the facility."
Director of Nursing acknowledged that medications "had to be scheduled to accommodate the resident being out to dialysis."
The facility's own policy on End-Stage Renal Disease care states that staff education includes "timing and administration of medications, particularly those before and after dialysis." Another policy requires medications to be given "within one hour of their prescribed time."
Resident #21 had end-stage renal disease and required mechanical filtration of blood waste three times weekly. The resident scored 15 out of 15 on a mental status assessment, indicating intact thinking ability to understand medication needs.
The medication timing failures continued even after the resident returned from a week-long hospitalization in January. Electronic records show the pattern of missed doses resumed immediately upon return to the facility.
In early February, progress notes still showed confusion about medication availability. One entry stated "pharmacy contacted awaiting from pharmacy" while another noted "pending pharm delivery as is new order" despite the Renvela order dating to January 25.
The resident had been clear about the medication problems during the inspector interview, waiting for dialysis transport that morning while explaining the recurring shortages. The scheduling conflicts had persisted for over two months without resolution despite the facility's written policies requiring accommodation for dialysis patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Hills Post Acute Hamilton from 2025-02-14 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Spring Hills Post Acute Hamilton
- Browse all NJ nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
SPRING HILLS POST ACUTE HAMILTON in HAMILTON, NJ was cited for violations during a health inspection on February 14, 2025.
The resident had been at Spring Hills Post Acute Hamilton since late November 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at SPRING HILLS POST ACUTE HAMILTON?
- The resident had been at Spring Hills Post Acute Hamilton since late November 2024.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in HAMILTON, NJ, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from SPRING HILLS POST ACUTE HAMILTON or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 315519.
- Has this facility had violations before?
- To check SPRING HILLS POST ACUTE HAMILTON's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.