Complete Care At Hamilton, Llc

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 22 residents reviewed for accommodation of needs (Resident #96), and was evidenced by the following: On 09/04/25 at 8:07 AM, the surveyor observed Resident #96 in bed. The surveyor observed the Resident's call light pull cord (used to summon staff for assistance) affixed to the upper aspect of the right-side rail, not within his/her reach. The resident stated, There should be a string around here somewhere, but I can't seem to find it, so I can't call for help. The surveyor reviewed the medical record for Resident #96. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; diabetes mellitus (too much sugar in the blood), malignant neoplasm of the breast (cancer of the breast), and osteoarthritis (a degenerative joint disease) of the right knee. A review of Resident #96's Quarterly Minimum Data Set (MDS), an assessment tool dated 8/25/25, revealed Resident #96 had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident required maximum assistance from staff for activities of daily living care. A review of Resident #96's Individualized Care Plan (CP) initiated on 7/13/25 had a focus that indicated the resident was at risk for falls, with interventions that included but were not limited to: ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 9/4/25 at 8:18 AM, the surveyor showed the Certified Nursing Assistant (CNA) assigned to Resident #96's care the call light pull cord affixed to the upper aspect of the right-side rail, not within the resident's reach. The CNA confirmed that she should have placed the pull cord within the resident's reach.

On 9/8/25 at 12:28 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, and VP of Clinical Operations to discuss the above observations and concerns. A review of the facility's policy, Call Lights, dated 1/25, revealed:Always position the call light conveniently for use and within the reach of the resident. NJAC 8:39-27.1 (a); 31.8 (c) (9)

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Hamilton, LLC

56 Hamilton Avenue Passaic, NJ 07055

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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents had complained to her that their socks were not returned after being laundered. The housekeeping staff stated that she was very busy and had not had time to pair or deliver the residents' socks in over a month. At that time, the HKD also confirmed that the residents had complained to her several times about their missing socks. The surveyor toured the laundry room and observed five large plastic bags full of residents' personal socks, which the DHK and housekeeping staff member acknowledged was unacceptable. On 9/8/25 at 10:05 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, and the VP of Clinical Operations. The VP of Clinical Operations stated that she had observed the five large bags of residents' socks in the laundry room and that it was unacceptable. A review of the facility's policy, Laundry Delivery, reflected .Laundry is done and returned within 24-72 hours . A review of the facility's policy, Handling Clean Linen, dated 9/1/24, reflected .It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary manner . A review of the facility's policy, Safe and Homelike Environment, dated 10/1/24, reflected .In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing residents to use their personal belongings . A review of the facility's policy, Environmental Services Inspection, reflected .It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on

a regular basis. NJAC 8:39 31.4 (a)

Event ID:

Facility ID:

If continuation sheet