Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Aristacare At Cherry Hill during CMS and state inspections, most recent first.
A resident with Type 2 DM and other serious conditions experienced multiple hypoglycemic events for which an LPN administered glucagon without obtaining a provider order or having the order transcribed into the medical record. Review of the MAR and OSR showed no glucagon orders, and the DON acknowledged that the LPN did not contact the provider after the events. The DON also documented insulin refusals on the MAR using her own electronic signature based on information from the remote LPN, rather than having the LPN enter the documentation, contrary to facility policies requiring that licensed personnel providing care record verbal orders and clinical entries themselves.
Kitchen Equipment and Dumpster Area Not Kept Clean and Sanitary: Surveyors observed a can-opener blade with a metal chip and brown sticky food debris on the blade, screw connection, and holder insert, and the FSD could not provide a cleaning log or maintenance log. Surveyors also observed loose debris around the dumpster and open dumpster lids. The FSD acknowledged the equipment and dumpster area were not cleaned or maintained according to facility policy, and the LNHA reviewed the findings and acknowledged the concerns.
An LPN failed to perform hand hygiene at multiple points during a medication pass, including after glove removal, before medication preparation, and before resident care, and also handled a scored tablet with bare hands. Surveyors also found PPE carts on multiple units stocked with gloves and masks but lacking gowns, including for residents on EBP, and the COO confirmed the facility was out of gowns.
The facility failed to send written notices when residents’ PNA balances approached the limit that could affect Medicaid or SSI eligibility, and failed to return a discharged resident’s remaining funds with a final accounting within the required timeframe. Surveyors found three residents with balances above or near the spend-down threshold, and the BOM and LNHA confirmed the notices were not sent and the discharge funds were not conveyed as required.
Unsafe and Unsanitary Resident Environment: Surveyors found multiple resident rooms, bathrooms, and common food areas in dirty and poorly maintained condition, including flies on linens and in bathrooms, brown liquid and stained bedding, feces on a toilet seat, overflowing trash, sticky and foul-smelling bathroom floors, exposed and dirty PTAC components, and debris and unlabeled food in a resident refrigerator and pantry. Staff and leadership acknowledged that several areas were not cleaned or maintained according to policy, and one resident said the bed had not been slept in because of the flies.
Medication administration was not timely for one resident, with the MAAR showing numerous late doses and no documented provider notification or rationale. Narcotic accountability was also incomplete, with missing shift signatures and discrepancies in controlled substance counts on the low cart and in the AMS. In addition, an LPN failed to offer a scheduled lidocaine patch to one resident, and another resident’s lidocaine patches were removed before the new patches were applied, contrary to the PO and MAR instructions.
A resident with dementia and severely impaired cognition received a PRN lorazepam order for anxiety that did not include the required 14-day stop date. The eMAR showed the medication was continued beyond that initial period, and the CP, an LPN unit manager, and the DON all confirmed the order should have been limited to 14 days unless the prescriber documented a rationale for extension.
Failure to Timely Report Allegation of Misappropriation: A cognitively intact resident with multiple chronic diagnoses reported missing money and implicated a CNA in taking it. The facility investigated and could not substantiate the allegation, but the LNHA later acknowledged that the allegation and the investigation summary were not reported to the NJDOH within the required time frames. The abuse policy named the NJ Dept. of Health and the Ombudsman for notification, but did not include the required reporting deadlines.
A resident with dementia, encephalopathy, and Type 2 DM had a BIMS score of 5 and was receiving Lorazepam PRN for anxiety and Metformin for diabetes, but the ICCP did not include care plan entries for either the antianxiety medication or the diabetes diagnosis. An LPN/UM and the DON stated these items should have been included in the comprehensive care plan and updated as part of the resident’s ongoing care.
A resident’s ICCP was not revised after the resident’s tracheostomy had been removed years earlier. The admission record listed tracheostomy, vocal cord and larynx paralysis, and dysphagia, but the most recent MDS showed no trach care. The care plan still included trach-related interventions, and both an LPN and the DON acknowledged that the plan should have been updated when the trach was discontinued.
A resident with stroke-related hemiplegia and hemiparesis had an order for a left resting hand splint to be applied in the AM and removed in the PM, with skin checks and contracture care. Surveyors observed the resident without the splint, with the left hand clenched and the splint found misplaced in the room, while the resident said it had not been offered and had not been used for months. The TAR showed daily administration, but staff stated refusal should have been documented if the splint was not used.
A resident with a suprapubic catheter and intact cognition was repeatedly observed with the catheter drainage bag secured to the bed frame and not placed in a privacy bag, allowing the urine contents to be visible from the hallway. The resident stated this bothered them and said the facility had previously used a privacy screen. CNA, LPN, and DON interviews confirmed that catheter drainage bags should be placed in a privacy bag for resident dignity.
Oxygen and humidification orders were not followed for two residents with respiratory diagnoses. One resident ordered for 4 L O2 via NC was observed receiving 3 to 3.5 L, and another resident ordered for 30% O2 via trach collar with humidification had an empty humidification bottle during repeated observations. An LPN and the DON confirmed the settings and empty bottle did not match the physician orders, and the facility policy required staff to verify oxygen equipment and water levels.
A resident with multiple medical conditions and intact cognition reported being handled roughly by a CNA during bed mobility assistance. Despite the incident being documented and investigated, the care plan was not updated with new interventions related to the abuse allegation, as confirmed by the DON, which was inconsistent with facility policy.
A resident with Huntington's Disease and moderate cognitive impairment did not receive PT/OT assessments after falls, despite IDT recommendations. The facility's care plan intervention for PT was not implemented, and interviews with staff confirmed that expected referrals were not made.
A facility failed to ensure a physician conducted an initial comprehensive visit for a resident with Huntington's Disease and other conditions. Despite NP assessments, no physician assessments were documented. The Medical Director observed the resident but did not document assessments, and the facility's policy lacked clarity on responsibility for initial visits.
A facility failed to maintain accurate medical records for a resident with multiple diagnoses, including seizures and COPD. The resident's MAR showed a blank entry for a scheduled Clonazepam dose, despite it being signed out in the Controlled Drug Administration Record. A grievance was filed by the resident, claiming the medication was not received. The DQE considered the grievance resolved, but the DON noted that the UM should have followed up with the LPN to address the unsigned MAR. Attempts to contact the LPN were unsuccessful, contributing to the deficiency.
The facility failed to report to the DOH within two hours for allegations of exploitation, misappropriation of resident property, and verbal abuse involving a resident. The facility did not investigate the matters as abuse or report them to the DOH, despite the resident's alert and oriented status and the facility's own abuse policy requiring such actions.
The facility failed to investigate allegations of exploitation and verbal abuse involving a resident and two CNAs. The facility did not follow its abuse policy, leading to deficiencies in handling the reported incidents.
The facility failed to administer medications on time for two residents, complete the dialysis communication book for a resident on dialysis, and follow a physician's order to monitor a resident for urinary retention. These deficiencies were confirmed by the Director of Nursing, Unit Manager, and Licensed Nursing Home Administrator.
The facility failed to ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, for 5 of the 16 weekends reviewed. Despite efforts to reach out to agency staff, the facility had difficulty scheduling RNs, particularly from the beginning of 2023 until May 2023. The LNHA and DON confirmed the staffing issues during the surveyor's entrance conference and subsequent interviews.
The facility failed to properly label and date medications and did not maintain a medication refrigerator temperature log. Multiple medications were found opened and undated, and the refrigerator temperature log was incomplete. The LPN and UM/LPN acknowledged these deficiencies, and the RDON confirmed that all medications should be dated and refrigerator temperatures monitored daily.
The facility failed to meet residents' nutritional needs and preferences, including serving inadequate protein portions, not following the menu, and not providing requested coffee. Additionally, a resident was served pork despite their preference for non-pork meals.
The facility failed to provide nourishing bedtime snacks to residents when there was more than a fourteen-hour span between dinner and breakfast. Residents reported that snacks were not offered every night and had to be requested, often limited to chips, pretzels, or cookies. The RD and DD acknowledged the extended time between meals and the lack of automatic provision of nutritious snacks.
The facility failed to store, label, and date potentially hazardous foods properly, leading to several observed issues such as improperly dated sour cream and cottage cheese, missing vinyl strip curtains in the freezer, dusty cans in dry storage, and a malfunctioning milk box latch. The facility's policies on labeling, dating, and food storage were not followed, and senior staff acknowledged these concerns during the survey.
The facility failed to maintain the required minimum direct care staff-to-resident ratios for 75 out of 105 day shifts reviewed. The deficiency was identified through interviews and a review of facility documents, revealing a consistent pattern of understaffing during day shifts. The LNHA and DON acknowledged the issue, and the Staffing Coordinator confirmed that the facility fell short of the required ratios at times.
The facility failed to follow infection control practices, including the use of PPE, maintaining sanitary medical supplies, and performing proper hand hygiene. Staff did not wear isolation gowns or sanitize equipment as required, and medical supplies were found on the floor. These deficiencies were confirmed by the Infection Preventionist and other staff.
The facility failed to implement an adequate antibiotic stewardship program, as evidenced by the lack of proper surveillance documentation for antibiotic use. The Infection Preventionist (IP) could not provide the requested forms, and the Chief Clinical Officer Licensed Nursing Home Administrator (CCO/LNHA) acknowledged that no tracking sheets were available after October 2023.
The facility failed to maintain a resident bathroom sink in working condition and to keep resident rooms and common areas safe and sanitary. The Maintenance Director was unaware of the sink issue, and the electronic work order system did not contain a report of the malfunction. Additionally, several deficiencies were observed in the Second-Floor nursing unit, including peeling wallpaper and holes in the walls. Senior staff acknowledged these issues.
The facility failed to serve meals in a dignified manner on the Second-Floor nursing unit. Observations revealed that residents were not served by tables, leading to some watching their tablemates eat while waiting for their own meals. Staff publicly discussed a resident's feeding status in a raised voice, and meal trays were delivered inconsistently. The facility's policies on serving food and resident rights were not adhered to.
The facility failed to provide a wheelchair for a resident, maintain a call bell within reach for another resident, and accommodate a resident's preference to smoke without getting wet during inclement weather. Staff confirmed these deficiencies, and the residents' medical records indicated severe cognitive impairments and dependence on staff for daily activities.
A resident reported that a CNA borrowed money and failed to repay it, but the facility did not investigate the incident as abuse. The resident, who was alert and oriented, felt pressured to give money to receive better care. The facility's policy requiring prompt investigation of abuse and misappropriation was not followed.
The facility failed to develop an abuse policy in accordance with regulatory guidelines and did not implement their abuse policy for an allegation of misappropriation of resident property. A resident reported that a CNA borrowed money and failed to repay it. The facility did not investigate the incident as abuse or report it to state agencies, and the CNA was terminated for refusing to provide a statement.
A facility failed to accurately complete the MDS assessment for a resident with multiple diagnoses, including PTSD, which was omitted from the most recent MDS. The MDS Coordinator and LNHA acknowledged the oversight, and the facility's policy lacked a clear process for MDS completion.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident's care plan lacked interventions for urinary retention and wound care, while another's did not address a PTSD diagnosis. Staff acknowledged these oversights, which were contrary to facility policies.
The facility failed to revise comprehensive care plans for two residents, leading to deficiencies in their care. One resident's care plan was not updated to address developed pressure ulcers, and another resident's care plan did not reflect financial interactions with a staff member. The facility's policy requires care plans to be updated to reflect changes in care needs, but this was not done.
The facility failed to assist a resident out of bed daily with a hoyer lift as ordered by the physician. The resident, who had not been out of bed for over a week, expressed a desire to be moved. Staff interviews revealed inconsistencies and a lack of communication regarding the resident's care and the condition of the geri chair.
A resident with a right-hand contracture did not receive appropriate services to prevent further decrease in range of motion. The resident reported pain from a prescribed brace, but no action was taken by the nursing staff. The brace order was not documented in the MAR/TAR, and the care plan was not updated. Staff interviews revealed a lack of awareness and responsibility regarding the brace application and monitoring.
The facility failed to update a resident's care plan with necessary safety interventions post-fall. The resident, with a history of falls, was observed without footrests on their wheelchair, leading to a fall and subsequent fracture. Staff interviews confirmed the care plan was not updated to include footrests, which was identified as the root cause of the fall.
The facility failed to accurately document the administration of a controlled medication for a resident. An LPN admitted to forgetting to sign the declining inventory sheet after administering tramadol, leading to a discrepancy in the medication count. The Unit Manager and Regional Director of Nursing confirmed the proper procedure was not followed.
The facility failed to ensure safe and appetizing food temperatures during a lunch meal observation. Residents reported that meals were often cold, and the surveyor confirmed that food temperatures were below the required 135 degrees Fahrenheit. The Director of Dietary and the LNHA acknowledged the issue.
The facility failed to complete discharge MDS assessments for two residents within the required 14-day period post-discharge. The oversight was confirmed by the MDS/RN, MDS Coordinator, and senior staff during the survey.
Failure to Maintain Accurate and Complete MAR Documentation for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with professional standards, specifically related to a resident with Type 2 Diabetes Mellitus and other serious diagnoses. Surveyors reviewed this resident’s December Medication Administration Record (MAR) and Order Summary Report (OSR) and found no provider orders for glucagon, despite the DON’s statement that an LPN had administered glucagon three times over two days for hypoglycemic events. The DON acknowledged that the LPN gave glucagon without a provider order, describing the situation as emergent, and further admitted that the LPN did not subsequently contact the provider or have an order transcribed into the record, contrary to facility policy requiring verbal orders to be recorded immediately in the resident’s chart. The survey also identified inaccurate MAR documentation when the DON entered medication administration information on behalf of the LPN. The DON stated that the LPN had reported the resident refused insulin on two dates, and because the LPN was remote and did not have access to the MAR, the DON entered the information using her own electronic signature instead of the LPN’s. This practice conflicted with the facility’s charting and documentation policy, which states that entries in the clinical record must be made by the licensed personnel providing the care, in accordance with state law and facility policy. The LPN did not return the surveyor’s call for an interview, and the DON reported that the LPN declined to speak with the surveyor.
Kitchen Equipment and Dumpster Area Not Kept Clean and Sanitary
Penalty
Summary
Kitchen equipment was not maintained in a clean, safe, and sanitary manner. On 8/21/25 at 10:36 AM, in the presence of the Food Service Director (FSD), the surveyor observed a can-opener blade with a metal chip on the right side and brown sticky food debris on the blade and screw connection. The FSD acknowledged that the blade had not been changed since she started working at the facility and that the can-opener was not cleaned according to facility policy. The can-opener holder attached to the counter also had a blue insert covered with brown sticky debris, and a cleaning log for the can-opener could not be provided. The FSD acknowledged that it was not cleaned according to facility policy. The garbage dumpster area was also not maintained in a clean, safe manner and was not free from pests. The surveyor observed loose debris on the ground around the dumpster and the dumpster lids left open. The FSD acknowledged that the area should have been cleaned and the lids closed according to facility policy. During later interviews, the FSD stated the can-opener blades should be checked and changed when needed, and the dumpster lids should have been closed with fallen debris picked up and the surrounding area cleaned to prevent the attraction of flies, rodents, or other vermin. The LNHA reviewed the pictures and acknowledged the concerns, stating the equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury.
Infection Control Lapses During Medication Pass and PPE Shortages
Penalty
Summary
The facility failed to follow infection control protocol during a medication pass observation when an LPN did not perform hand hygiene at required points and handled resident care items and medications after glove use without cleaning her hands. During the observation, the LPN cleaned a blood pressure machine, cuff, and pulse oximeter probe while wearing gloves, removed the gloves, and then did not perform hand hygiene before donning a face mask and entering a resident’s room to obtain vital signs. Later, after again cleaning the equipment with gloves, she removed the gloves and did not perform hand hygiene before accessing the computer, pouring water for the resident, and preparing medications. The same LPN was observed caring for another resident and again removed gloves without performing hand hygiene before preparing medications. She stated that a scored Keppra tablet could be broken in half and then used her bare hands to split the tablet before crushing medications and administering them. She was also observed washing her hands in the pantry and using the same paper towel that dried her hands to turn off the faucet. Later, after cleaning the blood pressure machine with gloves, she placed the cuff on another resident’s arm without first doffing the gloves and performing hand hygiene, then removed the gloves and accessed the computer and medication cart without cleaning her hands. The facility also failed to ensure that essential PPE was readily available for staff and visitors on multiple nursing units. Surveyors observed yellow PPE carts on the first and second floors that contained gloves and masks but no gowns, including for residents identified with Enhanced Barrier Precautions. Staff stated that gowns were kept in the carts or stored downstairs, but the carts were observed empty of gowns on several occasions. The COO later confirmed that the facility was out of gowns and had ordered more, and the LNHA was made aware of the infection control concerns.
Failure to Notify Residents of PNA Limits and Return Funds After Discharge
Penalty
Summary
The facility failed to ensure that residents with Personal Needs Accounts (PNA) received written notification when their balances approached the limit that could affect Medicaid or SSI eligibility. During review of the facility’s Trial Balance, surveyors found three residents with PNA balances ranging from $1,901.47 to $6,917.52. The Business Office Manager stated that written notification should be sent when a resident’s balance reached $1,800.00 so the money could be spent down, and acknowledged that Resident #50 had a balance of $2,112 and should have been notified, Resident #55 had a balance of $1,901.47 with no way to know whether notices were sent, and Resident #143 had a balance of $6,917.52. The facility also failed to ensure that funds and a final accounting were conveyed within 30 days after discharge. The Business Office Manager stated that Resident #143 was discharged on 7/9/24 and that the remaining funds should have been returned to the resident directly if requested or sent back to Social Security, but acknowledged the money should have been returned within 30 days. The Licensed Nursing Home Administrator later confirmed that the notifications were not sent and that the funds should have been sent back within 30 days of discharge. The facility’s Resident Funds policy stated that upon discharge the facility would convey the resident’s funds and a final accounting of those funds within 30 days.
Unsafe and Unsanitary Resident Environment
Penalty
Summary
The facility failed to maintain resident rooms, bathrooms, common areas, and food storage areas in a safe, sanitary, and homelike condition across the 100, 200, and 300 units. During observations, surveyors found brown liquid on the floor near a tube feeding pole, black flies on resident linens, a stained unoccupied bed with multiple flies on the linens and air mattress pump, a laundry basket with a brown substance smeared inside, crumbs on a floor mat, and repeated sightings of black flies on beds and linens in resident rooms. A CNA acknowledged that flies had been seen on resident beds before and stated they were mostly residents who were incontinent. Housekeeping and administration staff stated rooms were cleaned daily, but also stated that some rooms were only deep cleaned after discharge or on a periodic schedule, and the LNHA acknowledged that one room had been a problem and was placed on a more frequent deep cleaning schedule. In another area, the Life Safety Code surveyor observed rotted, crumbling sheetrock behind loose cove base in a resident room, a shared hall bathroom with feces smeared across the toilet seat, a used adult brief laid on the toilet seat, an overflowing trash can, and bags and boxes piled in the shower room. In a resident room bathroom, the surveyor observed five flies on the toilet seat, flies flying in the bathroom, and what appeared to be drain flies hovering over a bed. A resident stated the assigned bed had not been slept in since arriving at the facility because of the flies surrounding it. The AMT confirmed these observations. The surveyor also found a PTAC unit in a resident room with all vent covers removed, exposed internal components, and dried food inside the unit. In the same room, the bathroom had a strong foul odor, sticky flooring, and thick gray buildup at the baseboards and miter joints. Staff stated the floor was dirty if it was sticky and that the baseboards needed cleaning. In addition, the resident lounge refrigerator and freezer area had debris in the door seal gasket, no working thermometer, no temperature log, and unlabeled or undated food items. The First Floor Unit pantry also had debris in the freezer seal gasket, debris in cabinets, a missing drawer, and warped, broken, cracked flooring and wall under the sink. Staff and leadership acknowledged the conditions and stated the areas were not cleaned or maintained according to facility policy.
Late Medication Administration, Narcotic Count Discrepancies, and Lidocaine Patch Order Errors
Penalty
Summary
Medication administration was not carried out in a timely manner for one resident with diagnoses including generalized anxiety disorder, hypothyroidism, and asthma, whose BIMS score was 15/15. The resident stated that medications were being given late. Review of the August 2025 MAR and MAAR showed that although the MAR appeared to show scheduled administration times, the MAAR documented 255 late administrations out of 420 opportunities on day shift and 127 late administrations out of 189 opportunities on evening shift. The record did not contain documentation that the physician was notified when scheduled medications were given late, and there was no documented rationale in the EHR for the delays. Facility staff stated medications should be given within one hour before or after the ordered time and that the provider should be notified if a medication was not given on time. Narcotic accountability was not maintained on the second floor low cart and in the AMS medication room. On review of the RNBDC log, multiple shift signatures were missing, including signatures for outgoing and incoming nurses on several shifts. The resident-specific declining inventory logs also showed discrepancies between the expected and actual counts for multiple controlled medications, including oxycodone IR, oxycontin ER, lyrica, tramadol, methadone, and others. Staff stated that the narcotics should have been counted between incoming and outgoing nurses and signed on the shift-to-shift log, and that the resident-specific inventory log should have been signed when the medication was removed and administered. The AMS narcotic logbook did not contain a shift-to-shift accountability log for August 2025. Medication administration observations also showed failure to follow physician orders for lidocaine pain patches. For one resident with intact cognition and diagnoses including muscle wasting and atrophy, a lidocaine pain relief patch ordered for daily application to the back was not offered during the medication pass observation, and the EMAR entry was left blank at the scheduled time. The nurse stated she normally gave medications first and then treatments, and that she would have applied the patch later because she had gotten behind in her work. For another resident with muscle weakness, rheumatoid arthritis, and chronic pain syndrome, two lidocaine pain patches ordered for the knees were observed being removed before the new patches were applied. The resident’s MAR showed the patches were scheduled to be removed at 9:00 PM, and staff stated the patches should remain on for 12 hours and be removed as scheduled.
PRN Lorazepam Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure that a physician’s order for a PRN psychotropic medication was limited to 14 days for one resident. Resident #5 had diagnoses including dementia and encephalopathy, and the most current MDS dated 7/8/25 showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The MDS also reflected that the resident received antianxiety medications, but the resident’s comprehensive care plan did not include an entry for an antianxiety medication. The order summary report showed a physician’s order dated 7/2/25 for lorazepam 1 mg by mouth every 8 hours as needed for anxiety, and the order did not include a 14-day stop date. The August 2025 eMAR showed the lorazepam order started on 7/3/25 and was discontinued on 8/4/25, and the resident received lorazepam as needed after the 14-day period. The consultant pharmacist stated the initial PRN psychotropic order should have had a 14-day stop date, and both the LPN unit manager and DON stated the initial lorazepam order needed a 14-day stop date. The facility policy stated PRN psychotropic medications are limited to 14 days unless the prescriber documents a rationale and duration for extension.
Failure to Timely Report Allegation of Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the NJDOH within the required time frames and failed to submit the outcome of the investigation within five working days. The deficiency involved one resident who was cognitively intact with a BIMS score of 15 out of 15 and had diagnoses including lumbar spine fusion, pathological dislocation of the right knee, heart failure, bipolar disorder, and anxiety disorder. The resident’s care plan included a focus area for missing money and use of a lock box for valuables. The resident reported that money was missing and implicated a CNA in taking it, although the resident did not see the CNA take the money and later stated being upset at the aide and having no further concerns about money being taken. The incident report documented that the allegation was made and that the CNA was removed from the schedule, statements were gathered, the care plan was updated, and the Ombudsman was notified. The investigation summary stated that the facility immediately initiated an investigation, suspended the CNA, interviewed cognitively intact residents, and concluded that the allegation could not be substantiated. During surveyor interviews, the LNHA stated that the allegation of abuse with no harm was required to be phoned in within 24 hours and that the completed investigation had to be submitted within five days. He later stated he was unsure whether the summary and conclusion were sent to the NJDOH, and then acknowledged that the investigation and related summary and conclusion were not reported within the required time frames. The facility abuse prevention policy stated that the Administrator/designee would notify the NJ Dept. of Health & Senior Services and the Ombudsman when an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, but it did not include the required reporting time frames.
Incomplete Care Plan for Antianxiety Medication and Diabetes
Penalty
Summary
The facility failed to develop an individual comprehensive care plan for a resident with diagnoses including dementia, encephalopathy, and Type 2 diabetes mellitus. The resident’s most recent MDS, dated 7/8/25, showed a BIMS score of 5 out of 15, indicating severely impaired cognition, and also reflected that the resident received antianxiety and hypoglycemic medications. The medical record included an order dated 7/2/25 for Lorazepam 1 mg by mouth every 8 hours as needed for anxiety and an order dated 7/3/25 for Metformin 500 mg by mouth two times a day for diabetes, administered with meals. Review of the resident’s ICCP showed no care plan entry for the antianxiety medication or for the diagnosis of diabetes mellitus, including Metformin. An LPN/UM stated that residents receiving antianxiety and diabetic medications should have a care plan and that these items should have been included in the comprehensive care plan completed 14 days after admission. The DON stated the resident should have had a care plan for receiving antianxiety and diabetic medications and that care plans should be updated by the nurse on the cart, the unit manager, and the DON.
Care Plan Not Updated After Tracheostomy Removal
Penalty
Summary
The facility failed to revise an individualized comprehensive care plan for a resident whose admission record listed tracheostomy, paralysis of the vocal cords and larynx, and dysphagia. During the survey, the resident was observed seated in a wheelchair in the room, and the resident stated that the tracheostomy had been removed a couple of years earlier. The most recent MDS dated 6/26/25 showed a BIMS score of 14 out of 15 and indicated no tracheostomy care in section O for respiratory treatments. The resident’s individualized comprehensive care plan still contained a focus area with a revision date of 10/16/20 stating that the resident had a tracheostomy related to impaired breathing mechanics, with interventions for trach ties to be secured at all times, suction as necessary, and universal precautions as appropriate. An LPN confirmed that care plans should be updated when changes occur and acknowledged that the resident’s care plan should have been updated when the tracheostomy was discontinued. The DON also confirmed that the care plan should have been updated when the resident no longer had a tracheostomy and stated that care plans are updated when there is any change in the resident’s care.
Splint Care Not Provided as Documented
Penalty
Summary
The facility failed to ensure that a resident with a history of stroke, hemiplegia, and hemiparesis received the prescribed left resting hand splint and related range of motion/contracture care. The resident was cognitively intact and had a care plan goal to tolerate appropriate splint and ROM for mobility, with physician orders to apply the left resting hand splint in the morning and remove it in the evening, along with skin checks before and after use. The resident told the surveyor that the splint was in a drawer but had not been put on for a long time. During observation, the resident was seen lying in bed with the left upper extremity covered by a blanket, and later with the left hand lightly clenched in a fist and no splint on. The resident stated the splint had not been offered that day and had not been applied for months. The resident’s nails were noted to be long bilaterally. A CNA stated the resident did not have contractures and skin was intact, while an LPN later found the blue resting hand splint on top of a hamper between the bed and nightstand. The TAR showed the splint order as administered daily from 8/1/25 through 8/25/25, but the resident was observed without the splint despite those entries. The LPN/UM stated the resident was supposed to have the splint on and that if the resident refused, nursing should document the refusal. The DON stated that refusal would need to be documented in a progress note so therapy could address it appropriately, and later stated that nursing staff’s falsification of documentation on the TAR regarding splint application was addressed.
Suprapubic Catheter Drainage Bag Left Exposed
Penalty
Summary
The facility failed to place Resident #90’s suprapubic catheter drainage bag inside a privacy bag to maintain the resident’s dignity. During multiple observations, the resident was seen lying in bed with the indwelling catheter drainage bag secured to the bed frame and not covered, with the urine contents visible from the hallway. The resident stated that the facility used to place the catheter drainage bag in a privacy screen but had not recently, and said it bothered them when the bag was not placed in a privacy bag. Resident #90’s record showed diagnoses including urinary tract infection and neuromuscular dysfunction of the bladder, with a BIMS score of 15 indicating intact cognition. The resident had an order for an 18 Fr suprapubic catheter with monthly and as-needed changes, and the care plan addressed the suprapubic catheter and monitoring for patency. Staff interviews confirmed that catheter drainage bags should be placed in a privacy bag for resident privacy and dignity, and the DON acknowledged that the catheter drainage bag should always be maintained in a privacy bag for dignity reasons.
Oxygen and Humidification Orders Not Followed
Penalty
Summary
The facility failed to ensure that oxygen was administered in accordance with physician orders for 2 residents reviewed for respiratory care. One resident had diagnoses including acute and chronic respiratory failure with hypoxia and dependence on supplemental oxygen, and the record showed an order for 4 L oxygen via nasal cannula with humidification every shift for COPD. Survey observations found the resident wearing oxygen at 3 L, and later the oxygen concentrator was set at 3 1/2 L. The resident stated the oxygen level had not been changed and believed it was set too high. An LPN confirmed the order should have been set at 4 L and stated staff should check the concentrator each shift to ensure the correct liters were being delivered. A second resident had diagnoses including acute respiratory failure with hypoxia and COPD, with a care plan directing oxygen as ordered and a physician order for oxygen humidification bottle changes when empty, with sterile water to be used. Survey observations showed the resident on a tracheostomy collar at 30% oxygen with the humidification bottle empty, and the bottle remained empty on repeated observations later that day. The resident was also noted to be non-verbal during one observation. The TAR showed the humidification bottle change order was signed out as administered, but the bottle was still empty when observed by the surveyor. During interviews, the LPN/UM confirmed the humidification bottle was empty and should have contained sterile water for humidification. The DON stated nursing was responsible for carrying out respiratory orders and should have assessed the humidification bottle according to the physician's order, and also confirmed that the empty bottle shown in photographs did not meet the order. The facility policy for oxygen administration required staff to verify provider orders, check the humidifier or refillable oxygen humidifier bottle, ensure sterile or distilled water was present, and periodically re-check the water level.
Failure to Update Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update the care plan with appropriate interventions following an allegation of staff-to-resident abuse involving a resident admitted with diagnoses including diabetes, major depressive disorder, and hypertension. The resident, who had intact cognition as indicated by a BIMS score of 14 out of 15, reported to the social worker that a CNA was rough while assisting with bed mobility, describing being shoved into bed without being given the opportunity to move independently. The incident was documented in the facility's investigation summary, which noted the resident's desire for increased independence and the CNA's intent to prevent a fall. A review of the resident's care plan revealed that no updates or new interventions were added in response to the abuse allegation. The DON confirmed during an interview that the care plan was not revised after the incident, despite facility policy requiring care plans to be revised as changes in the resident's condition or circumstances dictate. The lack of care plan update was identified during a survey and was found to be inconsistent with both facility policy and regulatory requirements.
Failure to Implement PT/OT Consults After Falls
Penalty
Summary
The facility failed to implement a care plan intervention for a physical therapy (PT) consult and did not provide a resident with a PT/OT assessment after a fall, as recommended by the Interdisciplinary Team (IDT). This deficiency was identified for one resident who was admitted with diagnoses including Huntington's Disease, severe protein-calorie malnutrition, and adult failure to thrive. The resident had a moderately impaired cognition with a BIMS score of 9 out of 15. The care plan included a PT consult for strength and mobility initiated on a specific date, but the medical record did not indicate that the consult was completed. Incident reports revealed that the IDT recommended PT/OT assessments after two unwitnessed falls, but the medical record showed no evidence of these assessments being completed. Interviews with the Director of Rehabilitation Services and the Director of Nursing confirmed that referrals for PT/OT assessments were expected but not made. The facility's care plans policy emphasized the importance of revising care plans to prevent or reduce declines in functional status and enhance optimal functioning, but this was not adhered to in the case of the resident.
Failure to Conduct Initial Comprehensive Physician Visit
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit for a resident. This deficiency was identified during a survey conducted on specific dates, where it was found that a resident, who was no longer at the facility, did not have any documented physician assessments. The resident had been admitted with diagnoses including Huntington's Disease, severe protein-calorie malnutrition, and adult failure to thrive, and had a moderately impaired cognitive status as indicated by a BIMS score of 9 out of 15. Despite the presence of Nurse Practitioner assessments in the resident's medical record, there were no documented physician assessments. The Medical Director, who was also the resident's attending physician, stated that he observed the resident and discussed their care in meetings but did not provide documented assessments. The facility's policy did not clearly identify who was responsible for conducting initial comprehensive visits, contributing to the oversight in ensuring the resident received the necessary physician services.
Deficiency in Medication Documentation and Grievance Handling
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies in the documentation of medication administration. The resident, who had diagnoses including seizures, severe protein-calorie malnutrition, and COPD, was prescribed Clonazepam for anxiety. However, a review of the Medication Administration Record (MAR) revealed a blank box for the medication on a specific date, despite the Controlled Drug Administration Record indicating that the medication was signed out. This discrepancy was further highlighted by a grievance filed by the resident, stating that they did not receive the scheduled medication. The grievance was reviewed by the Director of Quality Experience (DQE), who considered it resolved after the Unit Manager (UM) found no discrepancies upon reviewing the MAR. However, the Director of Nursing (DON) noted that the UM should have followed up with the assigned nurse to address why the MAR was not signed. The surveyor's attempt to contact the Licensed Practical Nurse (LPN) responsible for the resident's care on the date in question was unsuccessful, as the provided contact number was not in service. This lack of follow-up and incomplete documentation contributed to the deficiency in maintaining accurate medical records.
Failure to Report Abuse and Misappropriation of Resident Property
Penalty
Summary
The facility failed to report to the New Jersey Department of Health within two hours for an allegation of exploitation and misappropriation of resident property and an allegation of verbal abuse. This deficiency was identified for two incidents involving Resident #47. The first incident involved a Certified Nursing Aide (CNA #1) who borrowed money from the resident and failed to repay it. Despite the resident's alert and oriented status, the facility did not investigate the matter as abuse or report it to the DOH. The grievance form did not include witness statements or a completed Resident Abuse Form as per facility policy. The second incident involved verbal abuse by another CNA (CNA #2) who allegedly yelled at the resident and made derogatory comments. The resident reported feeling disrespected and upset by the interaction. The facility did not investigate or report this incident to the DOH, as the Licensed Nursing Home Administrator (LNHA) believed the CNA was simply loud and that abuse was ruled out. The facility's abuse policy requires notification to the DOH within one business day, which was not followed in either case. The facility's failure to report these incidents to the DOH within the required timeframe and to conduct thorough investigations as per their policy constitutes a significant deficiency. The LNHA confirmed that the incidents were not reported to the DOH or any other authority, and the facility did not follow its own procedures for handling allegations of abuse and misappropriation of funds.
Failure to Investigate Allegations of Exploitation and Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of exploitation and misappropriation of resident property and an allegation of verbal abuse. In the first incident, a resident reported that a CNA, who no longer worked at the facility, had borrowed money from them and failed to repay approximately $330. The resident had informed the Director of Quality Experience and the Licensed Nursing Home Administrator, who took pictures of the transactions but did not conduct a thorough investigation as required by the facility's abuse policy. The grievance form did not include witness statements or a completed Resident Abuse Form, and the incident was not reported to the Department of Health (DOH). In the second incident, the same resident reported that another CNA had verbally abused them by yelling and making derogatory comments. The resident stated that the CNA had refused to provide ice water and made the resident feel uncomfortable by leaving the light on and the door open. The facility's investigation was limited to removing the employee from the schedule and providing education, without reporting the incident to the DOH or conducting a thorough investigation as per the facility's policy. The facility's failure to investigate these allegations properly and report them to the DOH is a violation of their abuse policy. The facility's undated Abuse Policy & Procedure requires immediate notification and a thorough investigation of any reported incidents or suspected incidents of abuse, neglect, or misappropriation of resident property. The facility did not follow these procedures, leading to deficiencies in handling the reported incidents.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to administer medications within scheduled parameters for two residents. Resident #38 had multiple instances where medications were administered late, particularly during weekend shifts. The April 2023 Medication Administration Record (MAR) showed numerous dates where medications were given hours past the scheduled time. The Director of Nursing (DON) acknowledged these discrepancies, confirming that medications should be administered within an hour of the scheduled time, and if delayed, the physician should be contacted. Similarly, Resident #42's 9:00 AM medications were administered late on 2/29/24, as observed by the surveyor and confirmed by the Licensed Practical Nurse (LPN) and Unit Manager (UM). The LPN admitted to administering treatments and medications simultaneously, which led to the delay. The facility also failed to complete the dialysis communication book for Resident #37, who was on dialysis. The dialysis communication book had multiple instances of missing documentation, including missing staff signatures and vital signs. The Unit Manager (UM) acknowledged these gaps, stating that the dialysis center staff were responsible for post-dialysis vital signs, but the facility staff should have ensured the book was filled out completely. The Licensed Nursing Home Administrator (LNHA) and other senior staff confirmed the missing documentation during a review. Additionally, the facility did not follow a physician's order to monitor Resident #45 for urinary retention. The order required monitoring urine output every shift and documenting the number of wet briefs per shift. However, the Progress Notes showed no entries from 1/25/24 to 3/1/24, indicating a lack of documentation. Interviews with Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) confirmed that urinary retention should be reported and documented, but this was not done for Resident #45. The UM and LNHA acknowledged the missing documentation and confirmed that the physician's order was not fully completed.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, for 5 of the 16 weekends reviewed. This deficiency was identified through interviews, review of Nurse Staffing Report sheets, and other pertinent facility documents. Specifically, there were no RNs scheduled for eight consecutive hours on 1/7/23, 2/18/23, 2/25/23, 3/18/23, and 5/27/23 through 5/28/23. The facility's staffing coordinator acknowledged the difficulty in scheduling RNs, particularly from the beginning of 2023 until May 2023, despite efforts to reach out to agency staff for coverage. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) confirmed the staffing issues during the surveyor's entrance conference and subsequent interviews. The facility's undated staffing policy states that adequate staffing should be maintained on each shift to meet residents' needs and services. However, the review of the Nurse Staffing Reports revealed gaps in RN coverage, with the last RN scheduled on the 3:00 PM to 11:00 PM shift on the day before the deficiency dates. The LNHA, in the presence of the Regional DON, Chief Clinical Officer, and survey team, acknowledged the facility's failure to schedule RNs for the required hours on the specified dates. This failure was in violation of NJAC 8:39-25.2(h).
Failure to Properly Label Medications and Maintain Refrigerator Temperature Log
Penalty
Summary
The facility failed to properly label and date medications in accordance with manufacturer recommendations and did not maintain a medication refrigerator temperature log to ensure safe medication storage. During an inspection of the Second-Floor nursing unit's low cart, multiple multi-dose medications, including inhalers and insulin vials, were found opened and undated. The LPN acknowledged that these medications should have been dated when opened. Additionally, an opened and undated bottle of lorazepam was found in the medication refrigerator, and the refrigerator temperature log had not been completed for one of the days inspected. The UM/LPN confirmed that all medications should be dated when opened and that refrigerator temperatures should be monitored and recorded daily. The facility's policies on medication storage and refrigerator maintenance were reviewed and found to be undated. The policies indicated that all drugs and biologicals should be stored in a safe, secure, and orderly manner, and that refrigerator temperatures should be tracked monthly. The RDON stated that all medications should be dated when opened and discarded per manufacturer's instructions, and that nurses should monitor refrigerator temperatures to ensure they are within a safe range for medication storage.
Nutritional and Dietary Preference Deficiencies
Penalty
Summary
The facility failed to ensure that residents received meals that met their nutritional needs and preferences. During the survey, it was observed that the dietary staff did not follow the menu, serving only one fish cake instead of the required two, and cutting sweet potatoes in half instead of serving whole ones. The Registered Dietitian (RD) confirmed that the protein portion served was inadequate and that the menu had not been reviewed for nutritional adequacy. Additionally, residents were not informed of menu changes, and the facility used outdated nutrition guidelines from 2000 instead of the current 2020-2025 recommendations. Several residents reported not receiving their requested coffee with meals. The surveyor observed that Resident #21 and Resident #6 did not receive coffee as indicated on their dietary slips. Staff interviews revealed that the kitchen did not have enough coffee cups, leading to residents frequently missing their coffee. The RD and Director of Dietary (DD) confirmed that the kitchen was responsible for ensuring tray accuracy, but the issue persisted due to a lack of resources. Resident #99, who had a preference for non-pork meals, was served ham despite their dietary slip indicating otherwise. The resident had to request sandwiches instead, and the RD confirmed that the resident's preferences were not updated in the system. The facility's policy required that food preferences be honored, but this was not followed, leading to the resident being served food they did not eat. The Licensed Nursing Home Administrator (LNHA) acknowledged these concerns during the survey review.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficiency was identified for five residents who reported that bedtime snacks were not offered every night and that they had to request snacks, which were often limited to chips, pretzels, or cookies. The residents confirmed that dinner was served between 4:30-5:00 PM and breakfast between 8:00-8:45 AM, resulting in a fifteen-hour and twenty-five-minute period between meals. The Registered Dietitian (RD) and the Director of Dietary (DD) were interviewed and acknowledged the extended time between meals and the lack of automatic provision of nutritious snacks to residents. The surveyor reviewed the facility's mealtime schedule and found that the first dinner cart was served at 4:15 PM and the first breakfast cart at 7:40 AM. The RD stated that she did not oversee the snacks and was unsure of the delivery times and the definition of a nourishing snack. The DD confirmed that snacks were available only upon request and acknowledged the need for providing nutritious snacks due to the extended time between dinner and breakfast. The Licensed Nursing Home Administrator (LNHA) confirmed that all residents should have been provided nutritious snacks and acknowledged that a nourishing snack should contain protein. The facility's Serving of Food policy did not include procedures for providing nourishing bedtime snacks when the period between dinner and breakfast exceeded fourteen hours.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to store, label, and date potentially hazardous foods properly, which could lead to food-borne illness. During a kitchen tour, the surveyor observed several issues: a five-pound container of sour cream opened on 2/1/24 with an unclear usage period, a five-pound container of cottage cheese opened on 2/13/24 with an expiration date of 2/24/24, and an opened gallon of mayonnaise without an opened date or use-by date. Additionally, the walk-in freezer had missing vinyl strip curtains, dry storage had cans with visible white particles and dust, a forty-pound bucket of chicken-flavored base had a heavily soiled lid, and the reach-in milk box #2 had a latch that did not close properly. The ice cream freezer also had a built-up accumulation of ice. The facility's policies on labeling, dating, and food storage were not followed, as evidenced by the undated facility-provided Labeling and Dating System Protocol and Food Storage policy. These policies required following the manufacturer's expiration dates and maintaining clean and sanitary food storage areas. The Licensed Nursing Home Administrator, along with other senior staff, acknowledged these concerns during the survey. The failure to adhere to these protocols and maintain sanitary conditions in food storage areas was a significant deficiency observed by the surveyor.
Failure to Maintain Required Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 75 out of 105 day shifts reviewed. This deficiency was identified through interviews and a review of pertinent facility documents. The New Jersey Department of Health memo dated 01/28/2021, which established minimum staffing requirements in nursing homes, was referenced. The facility was found to be non-compliant with the required staffing ratios for multiple weeks between November 2022 and February 2024. For example, on 11/20/22, the facility had only 8 CNAs for 121 residents on the day shift, whereas at least 15 CNAs were required. Similar deficiencies were noted on various other dates, indicating a consistent pattern of understaffing during the day shifts. During the entrance conference on 2/27/24, the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged that the facility primarily utilized agency staff for certified nursing aides (CNAs) and had callouts. The surveyor requested the Nurse Staffing Report for several weeks, which revealed multiple instances of non-compliance with the required staffing ratios. The Staffing Coordinator confirmed that she scheduled staff according to state and federal regulations but admitted that the facility fell short at times. The facility used two agency staff companies to cover callouts or lack of facility staff, and the Staffing Coordinator, who was also a CNA, had to work on the floor when the facility was short-staffed. On 3/7/24, the LNHA, in the presence of the Regional DON, Chief Clinical Officer, and survey team, acknowledged that the facility had days where the staffing requirements did not meet state ratios. A review of the facility's undated Staffing policy indicated that the facility aimed to maintain adequate staffing on each shift to ensure that residents' needs and services were met. However, the facility's staffing levels frequently fell below the required ratios, leading to the identified deficiency.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that infection control practices were followed, particularly in the use of personal protective equipment (PPE) for residents on enhanced barrier precautions. Observations revealed that staff did not wear isolation gowns or perform hand hygiene as required when providing care to residents. For instance, a Licensed Practical Nurse (LPN) repositioned a resident and administered nutrition via a gastrostomy tube without wearing an isolation gown. Additionally, the Unit Manager entered the resident's room without performing hand hygiene. The Infection Preventionist confirmed that PPE was not readily accessible, and staff were not adhering to the required precautions. Medical supplies and equipment were not maintained in a sanitary manner, contributing to the risk of infection. The surveyor observed corrugated oxygen tubing and urinary catheter drainage bags on the floor, which were not discarded or replaced as needed. Soiled medical equipment, such as suction machines and feeding pumps, were also noted. The Infection Preventionist and other staff acknowledged that these items should have been cleaned or replaced to prevent infection. Proper hand hygiene was not performed prior to dining, and infection control practices were not followed during medication administration. Certified Nursing Aides (CNAs) did not perform hand hygiene between assisting different residents with hand wipes. During medication pass observations, LPNs failed to sanitize blood pressure cuffs and other equipment between uses, and one LPN used a clipboard as a tray without sanitizing it. The Director of Nursing and other staff confirmed that these practices were not in line with infection control protocols.
Failure to Implement Adequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an adequate antibiotic stewardship program, as evidenced by the lack of proper surveillance documentation for antibiotic use. During a review of the last three months of antibiotic use and conducted surveillance from November 2023 through February 2024, the Infection Preventionist (IP) was unable to provide the requested surveillance documentation. The IP mentioned that nurses filled out blue forms on the units for antibiotic use, which she reviewed during morning meetings and documented in a spreadsheet for the Director of Nursing (DON). However, the IP could not provide these forms when requested. The Chief Clinical Officer Licensed Nursing Home Administrator (CCO/LNHA) later provided antibiotic tracking sheets from April 2023 through October 2023 but acknowledged that no further tracking sheets were available after October 2023. The facility's Infection Control Program Overview indicated that the IP should monitor and document infections, but this was not adequately done.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a resident bathroom sink in a sanitary working condition and to maintain resident rooms and common areas in a safe, sanitary, and comfortable environment. During a water temperature tour, the surveyor observed that the sink in a resident's bathroom did not operate properly, with water only dripping out. The Maintenance Director (MD) was unaware of the issue, and the electronic work order system did not contain any report of the malfunction. Interviews with Certified Nursing Aides (CNAs) revealed that they were aware of the issue but believed it had been reported to the MD or entered into the electronic work order system. The MD later confirmed that the faucet had to be replaced and acknowledged that no work order had been entered into the system. Additionally, during a tour of the Second-Floor nursing unit, the surveyor observed several deficiencies, including a hole in the wall behind a door handle, peeling wallpaper, missing wallpaper panels, and paint peeling from the walls in the day room. The MD acknowledged these issues and stated that repairs were needed throughout the floor. The Licensed Nursing Home Administrator (LNHA) and other senior staff acknowledged that these conditions should not exist and that the facility's policy required a safe, clean, and comfortable environment for residents.
Failure to Serve Meals in a Dignified Manner
Penalty
Summary
The facility failed to ensure residents were served their meals in a dignified manner during meal services on the Second-Floor nursing unit. During meal observations, it was noted that a CNA placed a tray in front of a resident and walked away, leading to another resident taking the tray and being addressed in a raised voice by another CNA. Additionally, residents were not served by tables, resulting in some residents watching their tablemates eat while waiting for their own meals. The staff also publicly discussed a resident's feeding status in a raised voice, which was acknowledged as a dignity issue by the CNA involved. The surveyor observed that meal trays were delivered inconsistently, with some residents receiving their meals much later than others. The Unit Manager and other staff members acknowledged that residents should be served by tables, and those dependent on staff for feeding should be seated separately from those who could feed themselves. The facility's policies on serving food and resident rights were reviewed and found to include provisions for feeding residents with attention to safety, comfort, and dignity, which were not adhered to in this instance.
Deficiencies in Resident Accommodation and Safety
Penalty
Summary
The facility failed to provide a wheelchair for a resident who required one for mobility. The resident was observed in bed without a wheelchair on multiple occasions, and staff confirmed that the resident had been without a wheelchair for about a month. The resident's primary CNA had to borrow wheelchairs from other residents to get the resident out of bed. The resident was eventually provided with a reclining wheelchair after being evaluated for therapy services for sitting tolerance. The resident's medical record indicated severe cognitive impairment and functional limitations in mobility, necessitating the use of a wheelchair for getting out of bed. Another deficiency was observed when a resident's call bell was found wrapped around a circadian alert system, making it inaccessible to the resident. The call bell was observed in this state on multiple occasions, and staff acknowledged that it should not have been tied around the alert system. The resident's medical record indicated severe cognitive impairment and dependence on staff for all activities of daily living, highlighting the importance of having the call bell within reach for summoning assistance. The facility also failed to accommodate a resident's preference to smoke without getting wet during inclement weather. The designated smoking area did not provide adequate shelter for residents to smoke without getting wet when it rained. The Director of Activities and the LNHA acknowledged that the smoking area was insufficient for the number of residents who smoked, leading to complaints from residents about getting wet during inclement weather. The facility's policies on resident rights and smoking practices emphasized the need for reasonable accommodations and safe smoking environments, which were not met in this case.
Failure to Protect Resident from Exploitation and Misappropriation of Property
Penalty
Summary
The facility failed to ensure a resident was free of exploitation and misappropriation of property. A resident reported that a CNA, who no longer worked at the facility, had borrowed money from them multiple times and failed to repay around $330. The resident had informed the Director of Quality Experience (DQE) and the Licensed Nursing Home Administrator (LNHA), but no further action was taken. The facility's investigation did not include the abuse allegation made by the resident, and the grievance form lacked witness statements and a completed Resident Abuse Form as per facility policy. The resident, who had diagnoses including multiple sclerosis, major depressive disorder, insomnia, and anxiety, was alert and oriented with a fully intact cognition score. The resident's care plan did not include the issue of giving money to staff, and there was no documentation of the incident in the progress notes. The resident stated that the CNA would take their personal items and borrow money, promising to repay but failing to do so. The resident felt pressured to give money to the CNA to receive better care. Interviews with the Director of Nursing (DON), LNHA, Director of Social Services (DSS), and DQE revealed that the facility did not investigate the incident as abuse because the resident was alert and oriented. The LNHA confirmed that it was against facility policy for staff to accept money from residents. The CNA was terminated for refusing to provide a statement on the incident. The facility's undated Abuse Policy and Procedure required prompt and thorough investigation of all reports of resident abuse, neglect, and misappropriation of property, which was not followed in this case.
Failure to Develop and Implement Abuse Policy
Penalty
Summary
The facility failed to develop an abuse policy in accordance with regulatory guidelines and did not implement their abuse policy for an allegation of misappropriation of resident property. The surveyor found that the facility's abuse policy did not include necessary components such as screening, training, prevention, identification, and protection. Additionally, the policy incorrectly stated that the facility had one business day to report suspected abuse to the New Jersey State Department of Health, instead of the required two hours. The Licensed Nursing Home Administrator (LNHA) confirmed these deficiencies during the surveyor's review and interviews. A resident reported that a Certified Nursing Aide (CNA) had borrowed money from them multiple times and failed to repay approximately $330. The facility's Director of Quality Experience (DQE) and LNHA were aware of the situation but did not take further action beyond completing a grievance form. The grievance form lacked witness statements and did not follow the facility's abuse policy, which required a thorough investigation and completion of a Resident Abuse Form. The LNHA confirmed that the incident was not investigated as abuse and was not reported to any state agencies. The LNHA stated that the facility did not consider the incident as misappropriation of funds because the resident was alert and oriented and had willingly given the money to the CNA. However, the LNHA acknowledged that it was against facility policy for staff to accept money from residents. The CNA was terminated for refusing to provide a statement, not for accepting the resident's money. The LNHA, along with the Regional DON and Chief Clinical Officer, confirmed that the incident was never investigated or reported to state agencies.
Failure to Accurately Complete MDS Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident reviewed for unnecessary medications. The resident, who was observed self-propelling in a wheelchair, had diagnoses including schizophrenia, bipolar disorder, and cerebral infarction. A psychiatric progress note also indicated diagnoses of schizoaffective disorder, insomnia, and PTSD. However, the most recent comprehensive MDS did not include PTSD as an active diagnosis, despite the resident having a fully intact cognition as indicated by a BIMS score of 15 out of 15. The MDS Coordinator acknowledged that the PTSD diagnosis should have been included in the MDS and needed to modify it accordingly. The Licensed Nursing Home Administrator confirmed that the MDS had been updated to include PTSD but should have originally included it. Additionally, the facility's MDS submission Timeframes policy did not outline the process for completing an MDS assessment, contributing to the oversight.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #45 was admitted with osteomyelitis, a stage 4 pressure ulcer, and heart failure. Despite having physician's orders to monitor urine output and document wet briefs, these interventions were not included in the resident's care plan. Additionally, the care plan did not address the resident's wound care orders. Interviews with LPN #2 and the Unit Manager confirmed that these interventions should have been included in the care plan, and the Licensed Nursing Home Administrator acknowledged the oversight. Resident #80, who was diagnosed with schizophrenia, bipolar disorder, and PTSD, also had deficiencies in their care plan. The resident's most recent comprehensive MDS did not reflect the PTSD diagnosis, and the care plan lacked focuses, goals, or interventions related to PTSD. The MDS Coordinator admitted that the MDS should have included the PTSD diagnosis, and the Regional Director of Nursing confirmed that the care plan should have addressed the PTSD diagnosis. The Licensed Nursing Home Administrator also acknowledged this deficiency. The facility's policies and job descriptions for LPNs and Unit Managers emphasize the importance of updating care plans to reflect residents' current health statuses and physician's orders. However, these policies were not followed, leading to incomplete care plans for the residents. The facility's failure to update and implement comprehensive care plans compromised the residents' physical, mental, and psychosocial well-being.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise a comprehensive care plan for two residents, leading to deficiencies in their care. For Resident #79, the facility did not update the care plan to address two developed pressure ulcers, despite the resident having a stage III pressure ulcer and an unstageable pressure wound. The Unit Manager confirmed that the care plan should have been updated to reflect these wounds and include appropriate interventions, but this was not done. The resident's medical records and progress notes indicated the presence of these wounds and the need for new treatments, but the care plan remained outdated. For Resident #47, the facility did not update the care plan to reflect that the resident had given money to a staff member. The resident reported multiple financial transactions with a CNA who no longer worked at the facility, and the CNA had stopped repaying the borrowed money. Despite the resident being alert and oriented, and the facility's administration being aware of the situation, the care plan was not revised to include this issue. The Director of Nursing and the Licensed Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's financial interactions with the staff member. The facility's policy on Baseline Care Plan Completion and Ongoing Care Plan Updates requires that care plans be updated by nursing staff to reflect changes in care needs and physician's orders. However, in both cases, the care plans were not revised as required, leading to deficiencies in the residents' care. The facility's failure to update the care plans as needed was confirmed by multiple staff members, including the Unit Managers and the Licensed Nursing Home Administrator.
Failure to Assist Resident Out of Bed Daily as Ordered
Penalty
Summary
The facility failed to assist a resident out of bed daily with the use of a hoyer lift as ordered by the physician. This deficiency was identified for one resident who had not been assisted out of bed for over a week, despite expressing a desire to be moved. The resident's medical record indicated a physician's order for daily transfer to a geri chair at 11:00 AM, which was not followed. Observations by the surveyor confirmed that the resident remained in bed during multiple visits, and the resident confirmed the lack of assistance. The resident's diagnoses included peripheral vascular disease, obstructive uropathy, and muscle weakness, and the resident had a fully intact cognition as per the most recent assessment. Interviews with staff revealed inconsistencies and a lack of communication regarding the resident's care. The Certified Nursing Aide (CNA) responsible for the resident stated that the resident was only transferred out of bed three times a week, contrary to the physician's order. The geri chair was found in the shower room, and there was confusion among staff about whether the chair was broken. The Director of Rehabilitation was not informed about the chair's condition and stated that a temporary replacement could have been arranged if notified. The facility's Licensed Nursing Home Administrator and Regional Director of Nursing acknowledged the failure to follow the physician's order and the lack of communication regarding the geri chair.
Failure to Ensure Proper Use of Brace for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion of the right hand received appropriate services to prevent further decrease in range of motion. This deficiency was identified for one resident who had a contracture in the right hand and was supposed to wear a brace. The resident reported that the brace caused pain, and despite informing the nursing staff, no action was taken. The resident was observed multiple times without the brace, and the order for the brace was not documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The resident's care plan also did not include the contracture or the physician's order for the splint. Interviews with staff revealed a lack of awareness and responsibility regarding the application and monitoring of the brace. Certified Nursing Aides (CNAs) and Licensed Practical Nurses (LPNs) were not aware of the resident's need for the brace, and there was no documentation of the resident's refusal to wear the brace or the pain it caused. The Unit Manager and Director of Rehabilitation confirmed that the care plan should have been updated to include the contracture and the brace, and that any issues with the brace should have been reported to Physical Therapy (PT) or Occupational Therapy (OT) for further evaluation. The Licensed Nursing Home Administrator (LNHA) acknowledged the deficiencies, including the lack of documentation regarding the resident's refusal to wear the brace, the absence of the order in the MAR/TAR, and the failure to update the care plan. The facility's policies and job descriptions for CNAs, LPNs, and Unit Managers emphasized the importance of accurate documentation, updating care plans, and ensuring that physician's orders are followed, but these were not adhered to in this case.
Failure to Update Care Plan Post-Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed and the comprehensive care plan was updated post-fall with safety interventions for a resident with a history of falls. This deficiency was identified for one resident who was observed seated in a high-back wheelchair without footrests in the dining area. The resident had a history of falls and was admitted with diagnoses including anemia, a fracture of the right femur, and hypertension. The resident experienced a fall on 11/26/23, resulting in an acute right femoral neck fracture and was subsequently sent to the hospital. The incident report indicated that the resident fell from the wheelchair while attending activities, and the post-fall huddle revealed that footrests should have been used as a safety intervention, but this was not updated in the care plan at that time. Interviews with staff, including the CNA, Director of Rehabilitation, Physical Therapist, Recreation Aid, and Director of Nursing, revealed that the resident was not provided with the necessary footrests on the wheelchair, which was identified as the root cause of the fall. The Recreation Aid admitted to lifting the resident off the floor after the fall, which was against the facility's policy. The Director of Nursing confirmed that unit managers were responsible for completing and summarizing conclusions on interdisciplinary team notes after a fall, and that all activity staff were educated not to move a resident after a fall. The Licensed Nursing Home Administrator and Unit Manager/LPN confirmed that the care plan should have been updated to reflect the need for footrests on the wheelchair to prevent further falls. The facility's policy on assessing falls and their causes included evaluating for possible injuries before moving the resident and applying new interventions post-fall. However, the care plan for the resident was not updated with the necessary intervention of using footrests, leading to the deficiency identified in the report.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of a controlled medication for one resident. During an inspection of the Second-Floor nursing unit's medication cart, it was found that the number of tramadol tablets in the blister pack did not match the declining inventory sheet. The Licensed Practical Nurse (LPN) admitted to administering the medication earlier and forgetting to sign the inventory sheet, which is required to ensure accurate inventory of controlled medications. The Unit Manager and the Regional Director of Nursing both confirmed that the LPN should have signed the declining inventory sheet immediately after removing the medication from the packaging. A review of the facility's Controlled Substance policy indicated compliance with laws and regulations related to controlled medications, but the Administering Medications policy did not include the process for documenting administration using a declining inventory sheet.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure safe and appetizing temperatures of food for residents during a lunch meal observation. During a Resident Council meeting, four out of five residents reported that meals served at the facility were often cold or at room temperature. The surveyor observed the lunch meal service and noted that the food temperatures were not maintained at the required minimum of 135 degrees Fahrenheit for hot foods. The temperatures of the regular texture meal and the alternate regular texture meal were significantly below the required temperature when tested by the Director of Dietary (DD) and the surveyor. Residents on the Second-Floor nursing unit confirmed that their meals were not served hot, with several residents expressing dissatisfaction with the temperature of their food and beverages. The surveyor's observations included the calibration of the facility's digital thin probe thermometer, which was found to be accurate. Despite the use of a plate warmer and insulated domes and bases, the food temperatures dropped below the required levels by the time the meals were served to the residents. The DD acknowledged that the hot food should be at 135 degrees Fahrenheit and confirmed that the food on the test trays did not meet this standard. The Licensed Nursing Home Administrator (LNHA) and other facility leaders acknowledged the issue of cold food temperatures during a meeting with the survey team.
Failure to Complete Discharge MDS Assessments
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments as required for two residents. Resident #13 was discharged on November 4, 2023, and Resident #111 was discharged on October 30, 2023. Both residents' discharge MDS assessments were not completed within the required 14-day period post-discharge. The MDS/Registered Nurse (RN) and the MDS Coordinator confirmed that the assessments were not completed, citing that the MDS Coordinator should have completed the assessments despite assistance with quarterly assessments at the time. The Licensed Nursing Home Administrator (LNHA) and other senior staff confirmed the oversight during an interview with the survey team. The facility's policy and the Centers for Medicare & Medicaid Services' (CMS) Resident Assessment Instrument (RAI) Manual were reviewed, both of which mandate that discharge assessments be completed within 14 days of discharge and submitted within an additional 14 days. The failure to complete these assessments was acknowledged by the facility's staff during the survey process.
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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 Cherry Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Premier Cadbury Of Cherry Hill | 1 mi | ★★★★★ | 27 | 0 |
| River Front Rehabilitation And Healthcare Center | 1.8 mi | ★★★★★ | 23 | 0 |
| Palace Rehabilitation And Care Center, The | 1.9 mi | ★★★★★ | 27 | 0 |
| Dwellside Care And Rehab | 2 mi | ★★★★★ | 2 | 1 |
| Sterling Manor | 2.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.