Atrium Post Acute Care Of Hamilton

F-F698

Based on observation, interview and record review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from December 2024 until surveyor inquiry for one (1) of six (6) residents, (Resident #21), reviewed for medication management.

The deficient practice was evidenced by the following:

On 2/4/25 at 10:09 AM, the surveyor interviewed Resident #21, who stated that they had been here (in the facility) since late November but had gone to the hospital for a week in January and returned. The resident also stated that they (the nurses) frequently run out of their medications. The resident added specifically I don't get my Renvela (Sevelamer) (a medication used to lower the amount of phosphorous in the blood when receiving dialysis). The resident also stated that they went out of the facility for dialysis on Tuesdays, Thursdays and Saturdays at approximately 10 AM. The resident added they were waiting to be picked up

this morning.

On 2/5/25 at 8:32 AM, during the morning medication administration observation, the surveyor with Licensed Practical Nurse (LPN#1) reviewed the electronic administration record (EMAR) for Resident #21. LPN#1 stated that she was not administering the resident's Sevelamer (Renvela) because the EMAR computer screen indicated d/c (discontinue) pending confirmation. LPN#1 explained that meant they were verifying orders because there may be multiple orders.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 On 2/5/25 at 11:02 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN), who stated that she was unaware that there was an issue with Renvela or any medications for Resident #21. The UM/LPN was aware Level of Harm - Minimal harm or that the medications had to be scheduled for when the resident was in the facility because they went out of potential for actual harm the facility for dialysis.

Residents Affected - Some On 2/7/25 at 8:58 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that a resident that goes out to dialysis had to have their medications scheduled to accommodate them being out of the facility and she has made the recommendation. The CP added that the physician would be contacted, and specific orders would be given as to the timing. In 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 34033 potential for actual harm Based on observations, interviews, and record review, it was determined that the facility failed to ensure that Residents Affected - Few all medications were administered without error of 5% or more. During the morning medication administration

observation on 2/5/25, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. The deficient practice was identified for two (2) of five (5) residents, (Resident #21 and #82), that were administered medications by two (2) of three (3) nurses that were observed.

The deficient practices were evidenced by the following:

1. On 2/5/25 at 8:36 AM, during the morning medication administration pass, the surveyor observed Licensed Practical Nurse (LPN#1) administering medications to Resident #21. The resident stated that they would like their pain medication and their cough medicine.

On 2/5/25 at 8:37 AM, the surveyor observed LPN#1 preparing to administer the resident's pain medication and cough medication. LPN#1 reviewed the electronic medication administration record (EMAR) which revealed a physician's order (PO) for Guaifenesin Oral Liquid 100 MG/ML (Guaifenesin), Give 10 ML by mouth every 6 hours as needed (PRN) for cough 10 ML=200 MG. LPN#1 removed a bottle of Tussin DM (Guaifenesin with Dextromethorphan) 100 milligrams(MG)/5 milliliter (ML) from the medication cart and stated that the Tussin DM was an over-the-counter/house stock (OTC/HS) medication, meaning that the bottle was not labeled for a specific resident because the facility purchased the medication, and it could be administered to any resident that had a PO. LPN#1 stated that Tussin DM was the OTC/HS cough medicine.

On 2/5/25 at 8:41 AM, the surveyor observed LPN#1 administer 10 ML of Tussin DM to Resident #21.

On 2/5/25 at 8:44 AM, upon returning to the medication cart, the surveyor with LPN#1 reviewed the electronic medication administration record (EMAR) for the PRN cough medication. The surveyor asked LPN #1 why the EMAR indicated Guaifenesin but had not indicated Dextromethorphan (DM). The LPN#1 stated that the DM did not matter and that was the OTC/HS that was in the medication cart. (ERROR #1)

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

A review of the Admission Record revealed diagnoses that included but not limited to; chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and Diabetes Mellitus (high blood sugar).

A review of the comprehensive admission Minimum Data Set (MDS), an assessment tool used to facilitate

the management of care, with an assessment reference date of 12/7/2024, reflected the resident had a brief

interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 A review of the Order Summary Report (OSR) revealed an active physician's orders (PO) with a start date of 1/21/25 for Guaifenesin Oral Liquid 100 MG/5 ML (Guaifenesin), Give 10 ML by mouth every 6 hours as Level of Harm - Minimal harm or needed for cough 10 ML=200 MG. potential for actual harm

On 2/5/25 at 1:30 PM, the surveyor interviewed the Director of Nursing (DON), who stated that she was Residents Affected - Few responsible for educating the staff and that medication administration observations were performed by the Consultant Pharmacist (CP). The DON added that medications were administered as per PO.

A review of the facility OTC/HS list provided by the Director of Nursing (DON) indicated that the facility supplied Robitussin (Guaifenesin). There was no Tussin-DM listed.

On 2/5/25 at 11:02 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN), who stated that Tussin DM cannot be substituted for Guaifenesin (Robitussin). The surveyor, with the UM/LPN, observed the Tussin DM in medication cart #1. The UM/LPN stated there was no Robitussin in medication cart #1 and would have to look into it.

On 2/5/25 at 11:13 AM, the UM/LPN returned to the surveyor and stated that medication cart #2 had the OTC/HS Robitussin and showed the surveyor a bottle labeled Guaifenesin 100 MG/5 ML and stated that should have been administered to Resident #21. The UM/LPN explained that the assignment of residents was split between the nurses and depending on the census, the room Resident #21 was in could have their medications kept in either medication cart #1 or #2.

On 2/7/25 at 8:58 AM, the surveyor interviewed the CP via the telephone. The CP stated that she completed medication administration observations as requested by the facility and had not completed a medication administration inservice for the nurses. The CP stated that she was not familiar with LPN#1 and thought she may have been an agency nurse. The CP also stated that the PO must match the medication being administered and that Tussin DM could not be substituted for Guaifenisen.

On 2/7/25 at 3:18 PM, the surveyor interviewed the DON who stated that LPN#1 had no medication administration observation completed. The DON added LPN#1 was an agency nurse and had reached out to

the agency but had not received documentation of a medication administration observation.

There was no facility medication administration inservice provided to the surveyor.

2. On 2/5/25 at 8:49 AM, during the morning medication administration pass (med pass), the surveyor observed LPN #2 preparing to administer five (5) medications to Resident #82. LPN#2 removed an OTC/HS Lidocaine 4% patch from the medication cart and then stated that the PO on the EMAR indicated Lidocaine 5% for Resident #82. LPN #2 returned the Lidocaine 4% patch to the medication cart and stated the Lidocaine 5% patch had to come from the provider pharmacy and there was none in the medication cart for Resident #82.

On 2/5/25 at 8:37 AM, the surveyor observed LPN#2 administer four (4) medications to Resident #82. The Lidocaine 5% patch was not administered.

On 2/5/25 at 9:31 AM, the surveyor interviewed LPN#2 who stated Resident #82 was alert and oriented to person, place and time. LPN #2 also stated that she would have to call the provider pharmacy to obtain the Lidocaine 5% patch for Resident #82.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 On 2/5/25 at 12:54 PM, the surveyor interviewed Resident #82, who stated that they had not received any pain patch today, but they were not in pain at the moment and knew that they could ask the nurse for a pain Level of Harm - Minimal harm or pill if needed. The resident also stated that they thought the physician had said the patch would help and potential for actual harm thought the physician would have to order the patch and the nurses would have to get it delivered but wasn't sure if that had happened. Residents Affected - Few

On 2/5/25 at 12:57 PM, the surveyor interviewed LPN #2, who stated that she had sent a message to the provider pharmacy via an app on her phone but had not heard back yet. LPN#2 also stated that the process when a medication was not available was to call the pharmacy and wait until the medication came in. LPN #2 then added that maybe she could call the physician to see if the 4% patch could be used. (ERROR #2)

The surveyor reviewed the medical record for Resident #82.

A review of the Admission Record revealed diagnoses that included but not limited to; rhabdomyolysis (a breakdown of muscle tissue).

A review of the OSR revealed an active PO with a start date of 2/4/25 for Lidoderm Patch 5% (Lidocaine), Apply to per additional directions topically one time a day for lower back pain for 14 days.

A review of the resident's electronic progress notes (EPN) indicated on 2/5/25 at 9:04 AM, LPN #2 had entered a Note Text: Lidoderm Patch 5% (Lidocaine), Apply to per additional directions topically one time a day for lower back pain for 14 days, awaiting from pharmacy. Sending followup.

In addition, the EPN revealed at 1:16 PM, after surveyor inquiry, LPN#2 indicated Called MD (physician) calling service to speak with MD to see if lidocaine patch order can be changed to house stock 4%. Awaiting call back. Then, at 1:33 PM, LPN#2 indicated Spoke with Dr. [name redacted] received new order for 4% lidocaine patch daily. Order placed.

On 2/5/25 at 1:30 PM, the surveyor interviewed the DON, who stated that she was responsible for educating

the staff and that medication administration observations were performed by the CP. The DON also stated that if a medication was not available to be administered then the physician was to be contacted for follow up as to what to do and that the physician can order an alternative medication. The DON added that she would solicit help to follow up as soon as possible in order to provide the medication in a timely manner.

A review of a Medication Pass Observation dated 11/12/24 provided by the DON and was completed by the CP for LPN#2 indicated that the percent error rate was 14.6%. The form indicated that one of the errors that occurred was a medication that was not administered within one hour of prescribed time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 On 2/7/25 at 8:58 AM, the surveyor interviewed the CP via the telephone. The CP stated that she completed medication administration observations as requested by the facility and had not completed a medication Level of Harm - Minimal harm or administration inservice for the nurses. The CP added that she will do an inservice after completing a med potential for actual harm pass with that specific nurse. The CP also stated that she tells the nurses that if a medication was not available then to enter Code 9 in the EMAR but then the physician had to be called to get instructions on Residents Affected - Few what can be done about not having the medication. The CP added that the nurses cannot just document that

the medication was not available or awaiting from pharmacy. The CP also stated that the nurses needed to get instructions from the physician fairly quickly when a medication was not available.

On 2/7/25 at 3:18 PM, the surveyor interviewed the DON, who stated that the medication observation completed by the CP was followed up with an inservice with that nurse by the CP after the observation. The DON added that there was no further follow-up.

A review of a facility policy Administering Medications dated as revised April 2019 provided by the DON reflected Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals orders). Further review reflected The individual administering

the medication checks the label THREE (3) times to verify the right resident, 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted Level of Harm - Minimal harm or professional standards. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41858 Residents Affected - Many Repeat Deficiency

Based on observations, interviews, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516.

This deficient practice was evidenced by the following:

According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:

(a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements:

(1) Compliance with title XVIII of the Act and applicable Medicare regulations.

(2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare.

(3) Not employing or contracting with individuals or entities that meet either of the following conditions:

(i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act.

(ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76

(d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes:

(1) Within 30 days -

(i) A change of ownership;

(ii) Any adverse legal action; or

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 (iii) A change in practice location.

Level of Harm - Minimal harm or (2) All other changes in enrollment must be reported within 90 days. potential for actual harm Prior to the survey, the surveyor accessed the facility's website which listed the facility's name as Accela Residents Affected - Many Post Acute Care at [NAME] at the address listed for the registered name Spring Hills Post Acute [NAME].

On 2/4/25 at 7:30 AM, upon arrival to the facility, the surveyors observed signage on the building which read, Accela Post Acute Care [NAME]. That name did not correspond with the CMS licensed, approved name and provider registered name Spring Hills Post Acute [NAME].

On 2/4/25 at 7:35 AM, upon entering the facility, the surveyors observed signage on the wall which read Spring Hills Post Acute [NAME]. The surveyor observed a sign on the receptionist desk in the front lobby which read Accela Post Acute Care [NAME]-All Visitors, please SIGN IN . At that time, License Practical Nurse/Supervisor (LPN/S) #1 greeted the surveyors wearing a black jacket with the logo Accela.

On 2/4/25 at 10:23 AM, during entrance conference with the surveyor, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA stated Accela was managing the facility as of 9/1/24 and they (Accela) are in the process of buying it. At that time, the surveyor requested the NJ approved license and the application, form 855B, for the name change to CMS from the LNHA.

A review of the facility provided license revealed the New Jersey Department of Health Division of Certificate of Need & Licensing issued a license to [NAME] AMOP, LLC (Limited Liability Company) was licensed to operate Spring Hills Post Acute [NAME], effective 5/1/2024, Expires: 4/31/2025, Issued: 4/19/2024.

On 2/4/25 at 3:15 PM, the surveyor interviewed the LNHA and the Regional LNHA, who stated the signage

on the building was changed on 1/3/25. At that time, the LNHA provided a letter dated 9/10/24, to the Department of Health Certificate of Need and Healthcare Facility Licensure.

A review of the letter dated September 10, 2024, revealed .effective September 4, 2024, [NAME] AMOP LLC, the licensed operator of the skilled nursing facility formerly doing business as Spring Hills Post Acute [NAME] has changed its trade name to Accela Post Acute Care at [NAME] .The change is limited to the doing business as name only.

On 2/7/25 at 10:00 AM, during a follow up interview with the surveyor, the LNHA confirmed no approval for name change could be provided. He stated he spoke to his corporate office and 2 lawyers who stated they (the facility) only needed to do the notification. The LNHA also confirmed at that time the 855B notification to CMS was not completed.

On 2/7/25 at 12:59 PM, the survey team met with the LNHA, DON, Regional LNHA, and the [NAME] President of Nursing and presented the above concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 On 2/07/25 at 03:04 PM, a review of 10 employee files revealed 5 of those employees signed an Accela onboarding packet. A review of the packet revealed a memorandum (memo), dated 8/27/2024. The memo Level of Harm - Minimal harm or was on Accela Healthcare letter head with the Subject Line: Welcome to the Accela Family. Further review of potential for actual harm 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 Residents Affected - Many 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 48964 potential for actual harm Based on observation, record review, interview, and facility policy review, the facility failed to prevent the Residents Affected - Few potential for cross contamination by placing a resident with open wounds on Enhanced Barrier Precautions (EBP), meaning a gown and gloves be worn when performing high contact care, for one of two residents (Resident #7) with open wounds.

The deficient practice was evidenced by the following:

On 2/4/25 at 10:21 AM, the surveyor observed Resident #7 self-propelling their wheelchair in the hallway.

The resident stated they can wheel the chair but can not stand. The surveyor observed a dressing on the right leg.

The surveyor reviewed the electronic medical record (EMR) for Resident #7.

A review of the Order Summary Report revealed a physician order (PO) dated 1/24/25 for Collagen-Antimicrobial External Sheet (Collagen-Antimicrobial) to the Right Lateral Ankle topically one time a day. There was also a PO dated 1/10/25 for Weekly Skin Checks every day shift every Friday.

A review of the comprehensive admission Minimum Data Set (MDS), (an assessment tool) dated 1/10/25, revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating an intact cognition. In addition,

the MDS reflected diagnoses that included but not limited to; hypertension (elevated blood pressure), diabetes (elevated blood sugar), and a pressure ulcer of the right ankle stage 4, and the presence of a diabetic foot ulcer.

The Individual Comprehensive Care Plan (ICCP), initiated 1/16/25, included a focus area of impaired skin integrity. Interventions included diets and supplements as ordered and monitoring for signs of infection.

On 2/5/25 at 9:30 AM, the surveyor observed Resident #7, lying in bed. The resident stated therapy is going well but slow. The resident also stated their leg dressing gets changed every day, and that it was not done yet today. The surveyor asked Resident #7 if the surveyor could observe the dressing change. The resident stated yes, that was fine.

On 2/5/25 at 10:38 AM, the surveyor observed the treatment to the right leg by Licensed Practical Nurse (LPN) #1. LPN #1 pre-medicated Resident #7 for pain and then performed the treatments to the right calf and ankle as ordered with only gloves on.

The surveyor had not observed EBP signage or personal protective equipment (PPE) supply bin at the resident's doorway or in the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/05/25 at 12:43 PM, the surveyor interviewed the Infection Preventionist/LPN (IP/LPN) who stated that EBP, meaning a gown and gloves should be worn when performing high contact care, and were needed for Level of Harm - Minimal harm or the presence of wounds. When asked about Resident #7, she stated that the resident's wound was a potential for actual harm diabetic ulcer which was resolved today. When reminded that EBP was not in place prior to today, she further stated that prior to today, the wound physician classified the resident's wounds as diabetic, and that Residents Affected - Few her understanding was that since the wounds were classified as diabetic and not pressure ulcers then EBP was not needed.

On 2/7/25 at 09:33 AM, the surveyor observed the resident lying in bed, with a dressing noted to the right leg.

On 2/7/25 at 11:07 AM, the surveyor interviewed the Director of Nursing (DON), who stated that if a 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 40042

Residents Affected - Some Based on interview and review of facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required for 3 of 5 randomly selected CNA (CNA # 3, #4, #5) files reviewed for in-service training.

This deficient practice was evidenced by the following:

On 2/07/25 at 9:17 AM, the surveyor reviewed in-service education hours for five randomly selected CNA files which were provided by the Director of Nursing (DON). 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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 315519

F-F756 Residents Affected - Some Based on observation, interviews and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times from December 2024 until surveyor inquiry February 2025.

Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for

the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.

Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for

the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under

the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.

The deficient practice was identified for one (1) of one (1) resident, (Resident #21), reviewed for dialysis services and was evidenced by the following:

On 2/4/25 at 10:09 AM, the surveyor interviewed Resident #21, who stated that they had been here (in the facility) since late November but had gone to the hospital for a week in January and returned. The resident also stated that they (the nurses) frequently run out of their medications. The resident added specifically I don't get my Renvela (Sevelamer) (a medication used to lower the amount of phosphorous in the blood when receiving dialysis). The resident also stated that they went out of the facility for dialysis on Tuesdays, Thursdays and Saturdays at approximately 10 AM and returned from dialysis approximately 4 PM. The resident added that they were waiting to be picked up this morning.

On 2/5/25 at 8:32 AM, during the morning medication administration (med pass) observation, the surveyor with Licensed Practical Nurse (LPN #1) reviewed the electronic administration record (EMAR) for Resident #21. LPN #1 stated that she was not administering the resident's Sevelamer (Renvela) because the EMAR computer screen indicated d/c (discontinue) pending confirmation. LPN# 1 explained that meant they were verifying orders because there may be multiple orders.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 A review of the Admission Record revealed diagnoses that included, but not limited to, chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), Level of Harm - Minimal harm or dependence on renal dialysis (a mechanical process used to filter waste from the blood) and essential potential for actual harm (primary) hypertension (high blood pressure).

Residents Affected - Some A review of a comprehensive admission Minimum Data Set, an assessment tool used to facilitate the management of care, with an assessment reference date of 12/7/2024, reflected the resident had a brief

interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition.

A review of the resident's individualized interdisciplinary care plan revealed a focus area, with an initiated date of 1/30/25, Resident has end stage renal disease and is on HD (hemodialysis) at [name and place redacted] on T (Tuesday)-TH (Thursday)-SAT (Saturday) chair time 11 AM. An intervention/task included, but not limited to, Ensure medication schedule is adjusted to administer medications when I am in the facility.

A review of the resident's February 2025 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 February 2025 electronic medication administration record (EMAR) indicated a medication administration time of 12 NOON that occurred during the time that the resident was out of the facility at dialysis. Further review of the EMAR revealed the following:

-on 2/1/25 at 8:00 AM, 12 NOON and 5 PM, on 2/2/25 at 8 AM and 12 NOON and on 2/4/25 at 8 AM and 5 PM, all had a code number 9 entered for administration which corresponded to Other/see progress notes.

A review of the corresponding electronic progress notes (EPN) had the following:

-on 2/1/25 and 2/2/25 had no Note Text with an explanation.

-on 2/4/25 at 8:02 AM had a Note Text: pharmacy contacted awaiting from pharmacy.

-on 2/4/25 at 4:41 PM had a Note text: pending pharm delivery as is new order , 0 [name of electronic back up medication supply machine redacted].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 On 2/5/25 at 11:02 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated that she was unaware that there was an issue with Renvela or any medications for Resident #21. The UM/LPN was aware Level of Harm - Minimal harm or that the medications had to be scheduled for when the resident was in the facility because they went out of potential for actual harm the facility for dialysis. The surveyor, with the UM/LPN reviewed the February EMAR. The UM/LPN was unable to explain why there was a code number 9 entered for administration. The UM/LPN verified that 9 Residents Affected - Some meant the medication was not administered and there should be a progress note explaining. The surveyor with the UM/LPN went to the medication cart and the UM/LPN stated that there was Renvela tablets labeled for Resident #21 available in the medication cart. The UM/LPN was unable to speak to why there was an issue with the Renvela. The UM/LPN added that there should not be a time of 12 NOON for the Renvela on Tuesdays, Thursdays and Saturdays because the resident was out to dialysis.

Further review of the resident's December 2024 and January 2025 EMAR and EPN revealed the following:

-on 12/3/24, 12/5, 12/7, 12/10, 12/12, 12/14, 12/17, 12/19, 12/21, 12/23, 12/26, 12/28 and 12/30 the 12:00 PM doses of Renvela indicated that the medication was not administered. The EMAR indicated on 12/3/24, 12/5, 12/7, 12/12, 12/14 that the resident was Absent from home without meds. There was a corresponding EPN for 12/10/24, 12/21, 12/23, 12/26, 12/28 and 12/30 that indicated the resident was at dialysis.

-on 12/27/24 and 12/30/24 the 9 AM doses of Calcitriol (medication used to treat low calcium levels caused by kidney disease) Oral capsule 0.25 micrograms (MCG) Give 0.25 MCG by mouth one time a day every Mon, Wed, Fri for supplement indicated that the medication was not administered. There was a corresponding EPN on 12/27/24 n/a (not available) and on 12/30/24 awaiting.

-on 12/3/24, 12/5, 12/10, 12/12, 12/17, 12/19, 12/21, 12/23, 12/26, 12/28 and 12/30 the 2:00 PM doses of Heparin (medication used to prevent blood clots) Sodium (Porcine) injection solution 5000 Unit/milliliter (ML), Inject 1 ML subcutaneously every 8 hours for blood clot prevention indicated that the medication was not administered. The EMAR indicated on 12/3/24, 12/5 and 12/28 that the resident was Absent from home without meds. In addition, on 12/12 the EMAR indicated Absent from home with meds. There was a corresponding EPN for 12/10/24, 12/19, 12/21, 12/23, 12/26 and 12/30 that indicated the resident was at dialysis.

-on 1/9/25, 1/11 and 1/13 the 12:00 PM doses of TUMS oral tablet chewable (Calcium Carbonate) (Antacid) Give 2 tablet by mouth with meals for dialysis indicated that the medication was not administered. There was

a corresponding EPN for 1/11 and 1/13 that indicated the resident was at dialysis.

-on 1/2/25, 1/4, 1/6, 1/7, 1/8, 1/13, 1/14, 1/15, 1/25, 1/28 and 1/30 the 12:00 PM doses of Renvela indicated that the medication was not administered. The EMAR indicated on 1/4/25 that the resident was Absent from home without meds. There was a corresponding EPN for 1/25, 1/28 and 1/30 that indicated the resident was at dialysis. In addition, the corresponding EPN for 1/6/25, 1/7, 1/8, 1/13, 1/14 and 1/15 indicated that for the 8 AM, 12 NOON and 5 PM doses of Renvela were not available, awaiting from pharmacy or on order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 On 2/7/25 at 8:58 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that she completed medication administration observations as requested by the facility and had not Level of Harm - Minimal harm or completed a medication administration inservice for the nurses. The CP added that she will do an inservice potential for actual harm after completing a med pass with that specific nurse. The CP also stated that she tells the nurses that if a medication was not available then to enter the code number 9 in the EMAR but then the physician had to be Residents Affected - Some called to get instructions on what can be done about not having the medication. The CP added that the nurses cannot just document that the medication was not available or awaiting from pharmacy. The CP also stated that the nurses needed to get instructions from the physician fairly quickly when a medication was not available. The CP then stated that a resident that goes out to dialysis had to have their medications scheduled to accommodate them being out of the facility. The CP added that the physician would be contacted, and specific orders would be given as to the timing.

On 2/7/24 at 10:34 AM, the surveyor interviewed the UM/LPN, who stated that she was unsure why the PO 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 only be ordered twice a day on dialysis days and scheduled for times when the resident was in the facility.

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

A review of a facility policy Administering Medications dated as revised April 2019 provided by the DON reflected Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals orders).

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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 21 315519 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 34033

Residents Affected - Some REFER to