Accela Post Acute Care At Hamilton

and filed in the business office. 10.

Copies of all reports must be signed and will be made available to

NJAC 8:39 4.1 (a) (5)

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

any of her documentation.

She had nothing else to add.

President of Nursing. A review of the facility's admission Agreement revised 1/2021, revealed 3.

discharge.

A review of the facility's policy, Transfer or Discharge Notice revised 3/2021, revealed Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to transfer or discharge. 1. B. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 2.

Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 3.

Except as specified below, the resident and his or her representative are given thirty (30)-day advance written notice of impending transfer or discharge from this facility. 5.

The resident and representative are notified in writing of the following information: a. specific reason for the transfer or discharge; b. the effective date of the transfer or discharge; c. the location to which the resident is being transferred or discharged ; .8.

The reason for the transfer or discharge are documented in the resident's medical record.

NJAC 8:39-4.1(a)(31) (32)

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

President of Nursing. A review of the facility's policy, Transfer or Discharge Notice revised 3/2021,

specified below, the resident and his or her representative are given thirty (30)-day advance written

notified in writing of the following information: a. specific reason for the transfer or discharge; .6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

NJAC 8:39-5.3; 5.4

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

medications had to be scheduled to accommodate the resident being out to dialysis.

DON reflected Medications are administered within one (1) hour of their prescribed time, unless

A review of the undated facility policy End-Stage Renal Disease, Care of a Resident with provided by the DON reflected Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. In addition, the policy revealed Education and training of staff includes, specifically f. timing and administration of medications, particularly those before and after dialysis.

NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

The CP stated that a resident that goes out to dialysis had to have their medications scheduled to

addition, the CP stated that she felt the facility had improved in responding to her recommendations.

A review of the Nursing Summary Report provided by the Director of Nursing (DON), dated December 6, 2024 that was completed by the CP, revealed that a recommendation was made for Resident #21, Please be sure that the medication times are charted to accommodate resident's dialysis schedule.

The report was signed as completed by the Nursing Supervisor/Registered Nurse (NS/RN) and dated 12/8/24.

A review of the Nursing Summary Report provided by the DON, dated January 7, 2025 that was completed by the CP, revealed that a recommendation was made for Resident #21, Please be sure that the medication times are charted to accommodate resident's dialysis schedule.

Please evaluate Sevelamer scheduled 1200 on dialysis days The report was signed as completed by the NS/RN and dated 1/28/24.

On 2/7/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the evening NS/RN completed the CP recommendations.

The DON verified that the Nursing Summary Report indicated that the NS/RN had acted upon the CP recommendations.

On 2/7/25 at 10:53 AM, the surveyor attempted to contact the NS/RN via telephone.

On 2/7/24 at 10:34 AM, the surveyor interviewed the UM/LPN, who stated she was unsure why the POs for Resident #21 had not been updated to accommodate the times the resident was out to dialysis.

The UM/LPN added that usually a medication ordered for three times a day would be only ordered twice a day on dialysis days.

On 2/7/25 at 3:18 PM, the surveyor interviewed the DON, who acknowledged that medications had to be scheduled to accommodate the resident being out to dialysis.

The DON stated that she thought the CP recommendations were completed because the NS/RN had signed the reports.

The DON added that she had put a call out to the NS/RN.

A review of the facility's policy Pharmacy Services-Role of the Consultant Pharmacist dated as revised April 2019 was provided by the Licensed Nursing Home Administrator had not included a time frame for the facility's response to the CP recommendations pertaining to medication irregularities.

NJAC 8:39-29.3(a)(1)

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

otherwise specified (for example, before and after meals orders).

Further review reflected The

right medication, right dosage, right time and right method (route) of administration before giving the medication.

NJAC 8:39-11.2(b), 29.2(a)(d)

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

President of Nursing and presented the above concerns.

Accela onboarding packet. A review of the packet revealed a memorandum (memo), dated 8/27/2024.

Family.

Further review of the memo read: On behalf of the entire Healthcare team, we are thrilled to welcome you to the Accela Family .Our goal is to ensure that this transition is as seamless as possible.

The letter was signed by the Director of Recruitment and Employee Experience.

The packets were signed by the following employees: -Occupational Therapist #1, Date of Hire (DOH) 4/24/2015 -LPN/Unit Manager #1 DOH 7/22/24 -LPN #2, DOH 7/22/24 -Housekeeper, DOH 4/1/ 2018 -Registered Nurse # 1 DOH 8/24/2023 No additional information regarding the facility's name change was provided to the team.

NJAC 8:39-5.1 (a)

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

right leg.

resident had a wound, EBP were needed.

On 2/7/25 at 11:47 AM, the IP/LPN thanked the surveyor for bringing to her attention Resident # 7 had open wounds and was not on EBP.

The IP/LPN stated that she double checked, and the wounds were chronic, including a current tiny opening.

She further stated that she just put the resident on EBP.

When asked what should have been done, she stated the resident should have been on EBP all along since there were open wounds.

On 2/07/25 at 12:59 PM, the surveyor interviewed the DON and the [NAME] President of Nursing, and both confirmed that Resident #7 should have been on EBP since admission due to the presence of open wounds.

A review of facility provided policy Isolation - Categories of Transmission-Based Precautions Revised October 2018 revealed: Enhanced Barrier Precautions Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs(multi-drug resistant organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities.

Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs.

The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Examples of high-contact resident care activities requiting gown and glove use for Enhanced Barrier Precautions include: Wound care: any skin opening requiring a dressing.

N.J.A.C. 8:39-19.4 (a)

The surveyor reviewed the following for the 2023 to 2024 calendar year, corresponding with the CNA hire dates: CNA #3 was hired on 4/1/22, CNA #4 was hired on 6/15/23, and CNA #5 was hired on 1/19/23.

The facility could not provide evidence of in-service education training for the current 12-month period from hire date.

On 2/07/25 at 2:01 PM, the Licensed Nursing Home Administrator (LNHA), in presence of survey team, stated that the facility cannot find the education for CNAs # 3,4 and 5.

The LNHA stated the responsibility for ensuring the annual education on the regulatory topics, such as abuse, were completed by himself as well as with assistance from the corporate team as needed. He stated that the annual education should be reviewed when the annual evaluation was completed. He stated he was not versed on the exact topics, but he knew 12 hours were required.

The LNHA stated the CNA education was important to make sure they (the CNAs) have their skills to know what they are doing.

He further stated that the CNA in-service files were maintained by the Human Resource department.

A review of the facility policy In-service Training Program, Nurse Aide dated May 2019, included Annual in-services . are no less than 12 hours per employment year.

A review of an undated facility job description for Human Resource Director included Ensure training and in-services are provided on a regularly scheduled basis ., and Ensure that appropriate training records are maintained for staff personnel.

A review of an undated facility job description for Director of Nursing Services included Develop and participate in the planning, conducting, and scheduling of timely in-service training classes ., and assist in developing annual in-service training programs for the nursing staff and ensure these programs meet the continuing education requirements.

A review of an undated facility job description for Certified Nursing Assistant included Attend and participate in scheduled training and educational classes.

NJAC 8:39-43.17 (b)

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Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

The surveyor reviewed the medical record for Resident #21.

A review of the resident's February Order Summary Report (OSR) reflected a physician's order (PO) dated 1/21/25 for HD Dialysis Tue, Thurs, Sat @ (at) [name of dialysis facility, address and phone number redacted] P/U (pick up) time: 10 AM chair time: 11AM.

Further review revealed a PO with a start date of 1/25/25 for Sevelamer HCl (hydrochloride) Oral tablet 800 MG (Sevelamer HCl), Give 3 tablet by mouth with meals for ESRD until 2/28/25.

There was no PO found to d/c (discontinue) pending confirmation.

A review of the December 2024, January 2025 and February 2025 EMARs indicated there were medication administration times for Renvela, Calcitriol, TUMS and Heparin that occurred during the time that the resident was out of the facility at dialysis.

A review of corresponding electronic progress notes for December 2024, January 2025 and February 2025 indicated that the Renvela, Calcitriol, TUMS and Heparin were not administered because the resident was out of the facility at dialysis.

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Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 315519 B.

Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690

The surveyor reviewed the electronic medical record for Resident #21.

315519

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 315519 B.

Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Spring Hills Post Acute Hamilton 3 Hamilton Health Place Hamilton, NJ 08690