Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cherry Hill For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to ensure arbitration agreements were properly signed and understood for multiple residents. One agreement was signed by someone other than the resident, one resident’s agreement was in English despite documented non-English speaking status, and two residents denied signing such an agreement when asked to explain it. The NHA acknowledged the concern, and the facility did not provide its arbitration policy during survey.
A resident with DM, mild cognitive impairment, and wounds was observed in a LAL specialty bed whose power unit had no active lights or display, indicating it was not powered on. The resident said they felt like they were lying on the frame and did not get out of bed often. Staff later confirmed they were unaware the mattress was not working, and the record showed the resident was dependent on staff for care and had care plan interventions for pressure ulcer risk and skin impairment, including use of a special mattress.
Failure to Float Heels per Physician Order: A resident with Type-II DM, CKD, a history of facility-acquired pressure ulcers, and moderate cognitive impairment had an active order to float heels while in bed. On multiple observations, the resident’s heels were laying directly on the mattress without heel float boots or pillow support under the lower legs, despite staff stating that heels should be floated using either method when ordered.
A resident with PTSD, hemiplegia/hemiparesis, and HTN had repeated aggressive and confused behaviors documented, including striking staff and throwing items, but the record did not show additional behavioral interventions or monitoring of triggers after these incidents. The resident later assaulted a roommate with a hand weight, and afterward stated they had struck the roommate and would do so again; SW reported the resident declined behavioral health services, though the record did not show any refusals.
Failure to Document Review of Pharmacy-Identified Lab Irregularities: A resident with DM, heart disease, HTN, and CKD had repeated pharmacist-identified irregularities during monthly MRRs for missing CMP, CBC, fasting lipid panel, and HgbA1c results ordered by the physician. The irregularity reports did not show physician review, action taken, or a rationale for no action, and the record contained only one lab refusal note despite the DON stating the resident had declined labs.
Medication Storage and Self-Administration Deficiency: A resident with COPD, anxiety disorder, and acute cough had cough drops and inhalers kept at the bedside on multiple observations, including OTC and prescription inhalers. The resident had intact cognition, but there were no active MD orders for self-medication and no self-administration assessments were found. The DON stated residents are assessed for self-administration, and the facility did not provide a policy on self-administration by the end of the survey.
A resident reported avoiding a shower room because of visible mold, and surveyors observed a black substance along the wall-floor seam, broken tile with exposed drywall, and debris that appeared to be feces and hair. In a separate finding, another resident with HF and chronic respiratory failure was observed with sheets containing multiple holes, and the resident stated the linens were unacceptable; staff said worn or torn sheets should be removed from rotation.
Facility staff did not recognize or activate a valid Durable Power of Attorney (DPOA) for a resident with severe cognitive impairment, resulting in the DPOA being denied access to information and involvement in care decisions. The DPOA documentation was rejected due to lack of notarization, and there was no evidence of timely capacity evaluation or proper documentation, despite the resident's significant cognitive and functional deficits.
A resident with cognitive impairment requested help at the nurses' station and, after receiving assistance from an LPN, threw a sweetener packet toward a CNA. The CNA responded with profanity and engaged in a physical altercation by grabbing the resident's wrists, requiring staff intervention. The incident violated the facility's abuse policy, which prohibits staff from engaging in verbal or physical abuse toward residents.
A resident with severe cognitive impairment and a history of bladder incontinence did not have a care plan addressing incontinence or resistance to toileting, despite repeated episodes of urinating in inappropriate places and staff reports of resistance to care. Staff and the resident's DPOA confirmed ongoing issues, and review of the medical record showed no care plan was developed as required by facility policy.
A resident with severe cognitive impairment and dependent on a PEG feeding tube experienced significant unplanned weight loss over a month. Despite documented behaviors of pulling and disconnecting the tube, and staff discussions about the weight loss, the facility did not identify or address the issue according to policy, nor did they document interventions or reassess the necessity of the feeding tube.
The facility failed to provide adequate space and privacy for resident council meetings, affecting 19 residents. Meetings were held in a cramped activity room, leading to frustration and privacy concerns. Residents preferred the larger dining room, but it was also subject to frequent staff interruptions. The DON acknowledged the issue and agreed that residents should meet without interruptions, highlighting a deficiency in providing a homelike environment.
The facility failed to answer call lights promptly, causing frustration and helplessness among residents. Specific incidents included a resident waiting 45 minutes after a fall, resulting in a shoulder injury, and another waiting an hour and a half to use the bathroom, leading to incontinence. The Activity Director confirmed these issues, and resident council minutes documented multiple complaints about extended wait times, with inadequate follow-up on most concern forms.
The facility failed to provide palatable and properly tempered meals for 19 residents, as meals were often served cold due to delays, lacked variety, and were sometimes wet from condensation. Residents expressed dissatisfaction with specific food items and the absence of a food committee. Observations and interviews revealed that food was not maintained at required temperatures, and dietary staff did not attend resident council meetings to address concerns.
The facility failed to accommodate the needs of two residents. One resident's call light was repeatedly out of reach, hindering their ability to request assistance, while another resident's grievance about a missing closet door was not addressed, leaving their personal items exposed. Both residents were cognitively intact and had expressed their needs, but the facility did not ensure these needs were met.
An oxygen tank was improperly stored in a resident's room who was not receiving oxygen therapy. The tank was found without a holder, placed behind the bed against the wall. Staff confirmed there was no order for oxygen, and the facility's policy requires unused tanks to be stored in a designated storage room in approved holders.
The facility failed to ensure proper labeling and disposal of expired medications in two medication carts and a supply room. Observations revealed undated and expired medications, including insulin vials and eye drops, as well as expired protein shakes. The DON acknowledged the oversight, and the facility's policy requires proper labeling and disposal of medications.
The facility failed to provide a clean and homelike environment for two residents. One resident reported a "nasty" shower room with feces and debris, while another experienced a persistent urine odor in their room. Despite claims of regular cleaning, these issues persisted, affecting the residents' living conditions. Both residents had intact cognition and specific medical diagnoses.
The facility failed to ensure that residents were allowed to have reachers, resulting in lost independence, decreased self-esteem, and fear of falls. The decision to remove reachers followed an incident where a resident used one as a weapon. Residents reported long wait times for assistance and increased dependence on staff, negatively impacting their quality of life.
The facility failed to ensure safe storage of medications for three residents, leading to a deficiency. Medications were left at the bedside without proper assessment or supervision, contrary to facility policies and care plans.
Improper Completion of Arbitration Agreements
Penalty
Summary
The facility failed to ensure arbitration agreements were signed by the resident or an appropriate responsible party and were explained and understood by the resident or responsible party for four residents. A review of the arbitration agreement list showed 77 residents had entered into arbitration agreements. For one resident, the agreement was signed on admission by someone other than the resident, and the resident’s record identified the resident as their own responsible party while listing a significant other as an emergency contact; guardianship documentation requested by surveyors was not provided by the end of the survey. For another resident, the signed arbitration agreement was in English even though the medical record documented that English was not the resident’s primary language and that the resident was non-English speaking, creating communication challenges and the need for alternative communication methods. Two additional residents told surveyors they would not have signed an arbitration agreement upon admission when asked to explain what it was, yet both were listed as residents who had entered into arbitration agreements. The Nursing Home Administrator acknowledged this was a new concern identified, and the facility’s arbitration agreement policy was requested but not provided by the end of the survey.
LAL Mattress Left Powered Off for Resident With Wounds
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was powered on for one resident who was reviewed for wound management. On 01/13/2026, the resident was observed in a LAL specialty bed with side bolsters, sunk low between the bolsters, and a green wedge behind the torso; the mattress power unit showed no active lights or display screen. Later that day, the power unit still was not powered on, and the resident stated they felt like they were laying on the frame and adjusted their position slightly. The resident also reported they did not get out of bed often. On 01/14/2026, the resident was again observed in bed with the mattress power unit still not powered on. That afternoon, an LPN checked the mattress and stated they were not aware it was not working, confirming there were no lights or active display. On 01/15/2026, the mattress power unit was observed with green lights and an active display, and an LPN reported they were not aware the mattress had been off and locked the power screen to prevent it from being turned off inadvertently. The resident’s record showed diagnoses of diabetes and mild cognitive impairment, a BIMS score of 6/15, dependence on staff for rolling, dressing, and toileting hygiene, and care plan interventions for potential pressure ulcer development and actual skin integrity impairment, including use of a special mattress. The MAR/TAR review for December 2025 and January 2026 showed no documentation of monitoring the LAL mattress.
Failure to Float Heels per Physician Order
Penalty
Summary
The facility failed to float a resident’s heels per physician order. R19 was admitted with diagnoses including Type-Two Diabetes Mellitus and Chronic Kidney Disease, had a history of facility-acquired pressure ulcers, and had a BIMS score of 8/15 indicating moderate cognitive impairment. The resident’s current physician orders included skin prep to bilateral heels and to float heels while in bed. A Braden Assessment dated 01/04/26 indicated the resident had moderate risk for pressure sores. During multiple observations, R19 was found in bed with both feet laying directly on the mattress without support to float the heels and without heel float boots in place. On 01/13/2026, 01/14/2026, and 01/15/2026, the resident’s heels were observed not floated. When interviewed, CNA F stated that heels are floated by using heel float boots or placing a pillow under the lower legs to elevate the heels off the bed surface. RN G and the DON both stated that when a resident has an order to float heels in bed, the heels should be floated by pillow support under the lower legs or by heel float boots.
Failure to Address Behavioral Health Needs Led to Resident Assault
Penalty
Summary
The facility failed to address the behavioral health needs of one resident, who had diagnoses including Post-Traumatic Stress Disorder, hemiplegia and hemiparesis, and hypertension, and was documented as cognitively intact and requiring one-person assistance with ADLs. The resident was observed and documented over time as confused, aggressive, throwing items, and physically striking staff, yet the record did not reveal additional behavioral interventions or monitoring of triggers and behaviors after these incidents. The care plan included interventions such as maintaining routine, avoiding invasion of personal space, using a calm voice, and initiating a behavior management consult, but the record did not show further behavioral follow-up after the resident’s behaviors continued. The resident later assaulted a roommate by throwing the roommate’s items and striking the roommate with a hand weight, causing injury to the roommate’s forehead and under the left eyelid. After the incident, the resident stated they struck the roommate and would do so again, and was dismissive when redirected. During interview, Social Worker E stated the resident declined behavioral health services and was unfamiliar with the resident’s care plan and OBRA assessment, but the medical record did not show any refusals for behavioral health services. The Nursing Home Administrator stated he had no prior knowledge of behaviors that may have predicted the incident between the two residents.
Failure to Document Review of Pharmacy-Identified Lab Irregularities
Penalty
Summary
The facility failed to follow pharmacy recommendations for one resident during monthly medication regimen reviews. The pharmacist identified irregularities on 5/19/25, 6/24/25, and 7/21/25 related to missing lab results that had been ordered on 4/14/25 and 4/21/25, including CMP, CBC, fasting lipid panel, and HgbA1c levels. The irregularity reports stated the results could not be located in the resident’s chart at the time of review, and the reports did not show that the attending physician reviewed the irregularities, what action was taken, or a rationale for not taking action. The resident involved was admitted on 9/30/22 with diagnoses including diabetes, heart disease, hypertension, and chronic kidney disease. The resident was cognitively intact and required limited assistance with activities of daily living. On 1/15/26, the DON stated the resident had declined lab draws, but only one progress note dated 7/30/25 was provided documenting a refusal. The record review did not identify prior refusals of lab draws.
Medication Storage and Self-Administration Deficiency
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when medication was found at the bedside of one resident, R50, instead of being secured. On 1/13/26, R50 was observed in bed with a bag of cough drops, an over-the-counter inhaler, and two prescription inhalers at the bedside, and R50 stated the nurse gave them to them. On 1/14/26, three inhalers were again observed at the bedside while R50 was sitting on the side of the bed. Record review showed R50 was admitted on 2/25/23 with diagnoses including COPD, anxiety disorder, and acute cough, and the most recent BIMS score was 15/15, indicating intact cognition. There were no active physician orders for R50 to self-medicate, and the DON stated residents are assessed for self-administration, but no self-administration assessments for R50 prior to 1/14/26 were found. A facility policy on self-administration of medications was requested but not received by the end of the survey.
Unclean shower room and torn bed linens
Penalty
Summary
The facility failed to maintain the cleanliness of the 200-hallway shower room for one resident who reported not wanting to use the room because they believed mold was visible along the lower rear wall seam between the wall and floor. On observation, the shower room had a black substance along the seam of the back wall and floor where there was a two- to three-inch gap in the tile leaving only grout exposed, and the black substance could be wiped onto a napkin. The room also had two areas of broken tile on wall corners with exposed drywall measuring approximately four to six inches wide, along with a clump of brown substance that appeared to be feces and a large clump of hair. The Administrator observed the room with the surveyor and acknowledged the areas of concern. The facility also failed to maintain linen in good repair for another resident who was observed lying in bed with two golf ball-sized holes in the sheets near the pillow and several smaller pea-sized holes on the side of the sheets. The resident stated the holes bothered them and were unacceptable, and said they would not use sheets with holes if they were in their own home. The resident had diagnoses of Heart Failure and Chronic Respiratory Failure with Hypoxia/Hypercapnia, and a Brief Inventory for Mental Status score of 15/15 indicating intact cognition. Facility staff stated that nursing assistants change beds at least once a week and as needed, and that worn or torn sheets are to be sent back to laundry to be taken out of rotation.
Failure to Recognize and Activate DPOA for Severely Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to acknowledge and allow a resident's Durable Power of Attorney (DPOA) to exercise the resident's rights, despite being presented with valid DPOA documentation. The DPOA, prepared by a law firm and signed by the resident, two witnesses, and the DPOA, was rejected by staff because it was not notarized. The DPOA was instructed to provide the paperwork to the Social Worker, and was told that the document had not been activated. There was no documentation in the Electronic Medical Record (EMR) regarding the activation process or attempts to obtain a capacity evaluation for the resident. The resident in question had diagnoses of vascular dementia and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment, was minimally verbal, and dependent for activities of daily living. Despite these conditions, the DPOA was not listed as a contact and was denied information about the resident's care. The Social Worker confirmed that the DPOA process was explained, but there was no documentation of this or of any capacity evaluation. The Nursing Home Administrator and Director of Nursing acknowledged that the DPOA activation should have been addressed soon after admission, as per facility policy.
Staff-to-Resident Verbal and Physical Abuse Incident
Penalty
Summary
A resident with diagnoses including aphasia, memory deficit, dementia, and stroke, who was assessed as having moderately impaired cognition, approached the nurses' station and requested assistance to open a packet of sweetener. An LPN assisted the resident, after which the resident threw the opened packet toward a CNA seated at the station. In response, the CNA began to swear at the resident. The situation escalated when both the resident and the CNA grabbed each other by the wrists over the nurses' station, requiring intervention from other staff to separate them. The facility's abuse policy prohibits verbal and physical abuse by staff toward residents. Despite this, the CNA engaged in both verbal (profanity) and physical (grabbing wrists) abuse toward the resident. The incident was witnessed by staff, and subsequent interviews and documentation confirmed the sequence of events. The resident was later observed to be interacting appropriately with staff and other residents, and a wellness check indicated the resident felt safe at the facility.
Failure to Develop Care Plan for Bladder Incontinence and Resistance to Toileting
Penalty
Summary
The facility failed to develop a care plan addressing bladder incontinence and resistance to toileting for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including vascular dementia and a cognitive communication deficit, was dependent on staff for activities of daily living and required prompting and assistance for toileting. Despite being incontinent of urine and exhibiting resistance to toileting and brief changes, no care plan was in place to address these needs. Multiple staff interviews confirmed the resident's behaviors, such as urinating in inappropriate places and resisting care by refusing to go to the bathroom or stiffening their body during care attempts. Observations included the resident being found in a room with a puddle of urine and staff cleaning up after incontinence episodes. The resident's Durable Power of Attorney and staff members reported ongoing issues with resistance to toileting and incontinence. A review of the electronic medical record confirmed the absence of a care plan for these issues, and facility policy requires a baseline care plan within 48 hours of admission, updated as needed until a comprehensive plan is developed. The Director of Nursing acknowledged that a care plan should have been in place for the resident's bladder incontinence and resistance to toileting.
Failure to Identify and Address Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
A resident with vascular dementia and severe cognitive impairment, who was dependent on a PEG feeding tube for nutrition and hydration, experienced a 6.03% weight loss over a 28-day period. The resident was noted to be minimally verbal, dependent for activities of daily living, and exhibited behaviors such as pulling on and disconnecting the feeding tube, as documented in multiple progress notes. The resident's Durable Power of Attorney (DPOA) was aware of the resident's agitation and attempts to pull on the tube but was not informed if the tube had ever been fully removed. There was no documentation in the medical record indicating that the feeding tube was pulled out or required replacement during this period. The facility's Registered Dietician (RD) and Director of Nursing (DON) acknowledged the significant weight loss and discussed it during a team meeting, with the RD suspecting a possible error in the weight measurement and requesting a re-weigh. However, the facility failed to identify and address the significant weight loss in accordance with their policies, which require monitoring, reassessment, and individualized care planning for significant unplanned weight changes. Additionally, there was no documentation of interventions or reassessment of the appropriateness and necessity of the feeding tube, as required by facility policy.
Inadequate Space and Privacy for Resident Council Meetings
Penalty
Summary
The facility failed to provide adequate space and privacy for resident council group meetings, affecting 19 residents. During an observation, 19 residents were crowded into a small activity room, with some seated only one to three feet apart. The meeting was frequently interrupted by knocks on the door from staff or other residents. Some residents had difficulty entering or exiting the room due to the cramped space, especially those in wheelchairs. Residents expressed frustration and privacy concerns about meeting in the activity room and preferred the larger dining room, which also had issues with interruptions by staff. The Director of Nursing (DON) acknowledged the limited space in the activity room and agreed that the residents should be able to meet in the dining room without interruptions. The facility's policy on providing a homelike environment was reviewed, which emphasized a safe, clean, comfortable, and homelike setting for residents. Despite this policy, the residents' need for a larger, private meeting space was not met, leading to their dissatisfaction and the deficiency noted in the report.
Failure to Timely Answer Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for eight residents, leading to feelings of frustration and helplessness among them. These residents reported waiting more than 30 minutes for assistance, with specific incidents including a resident waiting 45 minutes after a fall, resulting in a shoulder injury, and another resident waiting an hour and a half to use the bathroom, leading to incontinence. The Activity Director confirmed these extended wait times and noted that staff were sometimes difficult to locate, particularly in the evenings. The resident council minutes and concern forms from July and September 2024 documented multiple complaints about extended call light wait times, with one resident being left soiled. Despite these documented concerns, follow-up was only noted on one of the six concern forms from September, with the rest lacking any documented resolution. The facility's policy on Quality of Life and Dignity emphasized treating residents with dignity and respect, but no specific policy on call light answering was provided by the survey exit date.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable, appetizing meals at the proper temperature for 19 residents, as revealed through observations, interviews, and record reviews. Residents expressed concerns during a confidential group meeting, highlighting issues such as meals being served cold due to delays of 15 to 45 minutes, bland and repetitive menu options, and dissatisfaction with specific food items like Tilapia fish and sandwiches. Additionally, residents reported that their food was often wet and soggy due to condensation from the trays and older food covers, and they expressed a desire for a food committee to address these issues. Observations on a lunch meal tray showed that the chicken appeared wet from condensation, and the hard plastic plate cover was worn, preventing a proper seal. The resident council minutes from July to September 2024 indicated that no kitchen or dietary staff attended the meetings, despite residents' requests for their presence to discuss food concerns. The minutes also documented residents' complaints about receiving wet food, dirty utensils, and a lack of menu variety. Interviews with staff revealed that the Dietary Manager acknowledged the discontinuation of a food committee due to lack of attendance and mentioned that fresh fruit was only provided when in season. The Director of Nursing acknowledged the residents' concerns, and the Administrator stated that food should be served at the appropriate temperature and in a timely manner. However, temperature checks on a lunch tray showed that the food was not maintained at the required temperatures, with hot food at 109 degrees Fahrenheit and cold food at 51 degrees Fahrenheit, contrary to the facility's policy requirements.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents, R89 and R84, as observed during a survey. R89 was found in their bed with their call light out of reach on two separate occasions, despite being cognitively intact and requiring assistance for pain management and other needs. The call light was placed on the dresser, making it inaccessible for R89, who relied on it to request pain medication and other assistance. Both a CNA and an LPN confirmed that the call light should have been within R89's reach, indicating a lapse in ensuring the resident's needs were met. Additionally, R84's accommodation needs were not met as their closet lacked a door or curtain, leaving their clothing and personal items exposed. R84, who was also cognitively intact, had previously filed a grievance regarding the lack of a closet door, expressing dissatisfaction with the appearance of their room. The grievance, dated several months prior, had not been adequately addressed, as evidenced by the absence of a response or corrective action. The DON acknowledged the environmental concerns but had not provided a policy related to accommodation of needs and call lights by the time of the survey exit.
Improper Storage of Oxygen Tank in Resident's Room
Penalty
Summary
The facility failed to store an oxygen tank safely in the room of a resident who was not receiving oxygen therapy. During an observation, an oxygen tank was found without a holder, placed behind the bed against the wall in the resident's room. The resident, who had been admitted with diagnoses including paroxysmal atrial fibrillation and alcohol abuse, confirmed that they had not been receiving oxygen therapy. A review of the resident's electronic medical record corroborated that there was no order for oxygen therapy. Interviews with facility staff, including an LPN and the Maintenance Director, confirmed that the resident did not have an order for oxygen and that the oxygen tank should not have been in the room. The Maintenance Director indicated that all unused oxygen tanks should be stored in the facility's designated oxygen storage room in a holder. The facility's policy on the storage of small compressed oxygen cylinders, dated 2006, requires that oxygen cylinders be stored in approved carts or holders, which was not adhered to in this instance.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated when opened, and expired medications were not discarded in two of four medication carts and one supply room. During an inspection of medication cart three with an LPN, it was observed that a Breo Ellipta inhaler was not dated on the actual inhaler, a Humalog insulin vial was expired, and several eye drop vials, including Lantanoprost and Dorzolomide, were not dated when opened. Similarly, a review of medication cart four revealed that glucose strips were not dated when opened, and two vials of Novolog insulin were expired. Additionally, in the supply room, six max protein shakes were found to be expired. The Director of Nursing acknowledged that nurses should check the medication carts they are responsible for. The facility's policy on the storage of medications requires that all drugs and biologicals be stored safely and securely, with proper labeling and disposal of expired items. The policy also states that drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling. The prescribing information for Breo Ellipta and Novolog insulin indicates specific time frames for safe usage after opening, which were not adhered to in this case.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents R701 and R703. R701 expressed concerns about the cleanliness of the shower room, describing it as "nasty" and unfit for use. An observation confirmed the presence of a dried brown stain on the floor, a pile of feces in the shower room drain, and trash and debris in the corners. Despite the Director of Nursing's (DON) assertion that the shower room is cleaned daily, the conditions observed contradicted this claim. R701 was admitted with medical diagnoses including Morbid Obesity, Bipolar Disorder, and Raynaud's syndrome with Gangrene, and had intact cognition as indicated by a BIMS score of 15. R703's living environment was compromised by a persistent strong odor of urine in their room. Despite the resident expressing no general care concerns, the odor was noted throughout the day. CNA A, responsible for R703, acknowledged the odor and suggested it might originate from a liquid puddle across the hall, which was later cleaned. However, the odor persisted in R703's room. The DON and the facility Administrator both indicated that housekeeping and cleanliness protocols should be followed to address such issues, yet the odor remained unresolved. R703 was admitted with a diagnosis of cerebral infarction with right hemiplegia and also had intact cognitive function with a BIMS score of 15.
Facility's Removal of Reachers Leads to Resident Complaints and Increased Falls
Penalty
Summary
The facility failed to ensure that four residents were allowed to have reachers, resulting in feelings of lost independence, decreased self-esteem, and fear of falls. The decision to remove reachers from all residents was made following an incident where a resident used a reacher as a weapon. This policy change led to numerous complaints from residents and their families, highlighting the negative impact on residents' autonomy and dignity. Residents reported that the removal of reachers affected their ability to be self-sufficient and increased their risk of falls and injuries. Despite being instructed to use call lights for assistance, residents experienced long wait times for help, further exacerbating their frustration and sense of helplessness. One resident, admitted with diagnoses including paralysis of one side and heart failure, experienced a fall while trying to reach something on the floor after their reacher was taken away. Another resident, bedridden and diagnosed with multiple sclerosis and diabetes, reported that the reacher allowed them to perform tasks independently, such as picking up items and adjusting blankets. The removal of the reacher made them feel more dependent and negatively impacted their self-esteem. A third resident, also bedridden, used the reacher to retrieve items from their drawer and the end of the bed. The loss of the reacher decreased their quality of life and increased their dependence on staff, leading to feelings of debility and depression. The Director of Nursing (DON) and the Occupational Therapist (OT) acknowledged that the removal of reachers was a safety measure but did not involve residents in the decision-making process. The OT revealed that therapy was instructed not to provide reachers, and residents were not assessed for their need for reachers. The Rehab Manager confirmed that around 20 reachers were removed from residents, and no alternative interventions were put in place. The facility's policy on personal property and person-centered care plans emphasized the importance of residents' rights to retain personal possessions and participate in their care planning, which was not upheld in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to provide safe storage of medication for three residents, leading to a deficiency in medication management. Resident R903 was observed with a medicine cup containing multiple tablets on their bedside table, and the resident did not attempt to consume the tablets. The resident's care plan did not indicate that they had been assessed to self-administer medications, and the resident had moderate cognitive impairment. When queried, the resident did not provide information on how the medications got there, and the nurse admitted to leaving medications for residents who would not take them in front of the nurse. Resident R907 was found with two medication tablets and a cup of light-yellow liquid on their overbed table. The resident consumed one pill in the presence of the surveyor and identified the remaining pill as Xanax. The resident's care plan also did not indicate an assessment for self-administration of medications, despite the resident having intact cognition. The nurse confirmed that they leave medications for residents they believe will take them without supervision. Resident R908 was observed with an empty medicine cup on their overbed table and stated that the nurse leaves the room while they take their medication. The resident's care plan did not include an assessment for self-administration of medications. The Director of Nursing confirmed that nurses should observe residents taking their medications and that any resident assessed to self-administer medications would have a care plan. The facility's policies on bedside medication storage and administering medications were reviewed, revealing that bedside storage is only permitted with a written order and proper assessment, which was not followed in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Westland | 0.9 mi | ★★★★★ | 10 | 0 |
| Westland, A Villa Center | 2.2 mi | ★★★★★ | 5 | 0 |
| Optalis Health And Rehabilitation Of Canton | 2.8 mi | ★★★★★ | 41 | 1 |
| Four Seasons Nursing Center Of Westland | 2.9 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Haggerty Road | 3.3 mi | ★★★★★ | 0 | 0 |
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