Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Dwellside Care And Rehab during CMS and state inspections, most recent first.
A resident with chronic pain and intact cognition, receiving scheduled extended-release morphine for moderate pain, experienced a period when the facility ran out of the ordered narcotic and it was not refilled in a timely manner. The MAR showed multiple scheduled doses marked with chart codes indicating "other" or "hold" and references to nurse notes, but corresponding progress notes were missing or incomplete, with only some entries noting that the medication was out of stock or awaiting pharmacy delivery. There was no documented evidence that the provider was contacted promptly for a refill, despite later verbal reports that multiple attempts had been made, and an RN confirmed entering a code for a missed dose without documenting follow-up. Pharmacy records showed delays related to obtaining a correct script, while facility policies required complete, accurate documentation of all services and physician communications in the medical record, which was not met in this case.
A severely cognitively impaired resident with a known history of wandering and elopement risk was able to leave the facility undetected after the alarm systems on the elevator and employee entrance failed to activate. Staff did not recognize or intervene as the resident exited, and previous reports of alarm malfunctions were not effectively addressed, resulting in the resident being missing for several hours before being found by police.
A resident with dementia and behavioral issues repeatedly physically assaulted other residents and staff, resulting in injuries such as bruising, swelling, and a head hematoma. The facility failed to consistently implement effective supervision or interventions, did not always maintain required 1:1 monitoring, and did not complete recommended staff training or interviews after incidents. Affected residents reported feeling unsafe and traumatized.
A resident with dementia and diabetes returned from the hospital with a cast after a wrist fracture. Facility staff failed to monitor or assess the skin around the cast for nearly two months. When necrotic skin and an opening were eventually found, there was a delay in notifying the physician. The resident later developed a foul odor, was diagnosed with a wrist infection, and was found to have a maggot infestation under the cast after hospital admission.
Multiple residents with intact cognition reported that the only shower room on their unit was used for storage of equipment, clothing, and soiled incontinence briefs, resulting in odors and an unclean environment. Observations confirmed sticky spills and debris on common area floors, clutter and garbage in the shower room, and food carts with partially eaten meals left in hallways. Staff acknowledged that cleaning and storage practices were not followed, and that cleanliness concerns had been raised by residents.
Multiple residents reported that meals were served without necessary condiments and were often bland, cold, or unappetizing, with staff and committee meeting minutes confirming ongoing issues with food quality, temperature, and missing items. Observations showed that condiments were not consistently provided in the dining room, and staff interviews revealed frequent resident complaints about food and condiment availability.
The facility did not conduct thorough abuse investigations or maintain complete documentation in multiple incidents involving resident altercations. Key actions such as interviewing all involved parties, obtaining signed witness statements, and documenting resident assessments were not completed, despite facility policy requiring these steps. The DON confirmed missing documentation and incomplete investigation records.
A medication cart was left unlocked and unattended in front of the nurse's station, with the computer screen displaying resident names. An LPN acknowledged not securing the cart during the overnight shift due to the absence of visitors or residents, despite facility policy requiring carts to be locked when not attended. The DON confirmed that the cart should have been secured and resident information kept private.
Failure to Maintain Complete and Accurate Documentation for Narcotic Pain Medication Refill
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record in accordance with professional standards for one resident receiving chronic pain management. The resident was admitted with diagnoses including osteoarthritis of the knee, spinal stenosis, abnormalities of gait, major depressive disorder, and anxiety, and had a comprehensive MDS showing a BIMS score of 15/15, indicating intact cognition, and frequent pain. The resident had an active order for Morphine Sulfate Oral Tablet Extended Release 15 mg to be given every 12 hours for moderate pain. In an interview, the resident reported that in August there was a time when the facility ran out of morphine, it was not refilled timely, and that oxycodone and Percocet were given as substitutes during the period when morphine was unavailable. Review of the August MAR showed multiple scheduled morphine doses on specific dates and times marked with chart codes "#9" (Other/See Nurse Notes) and "#5" (Hold/See Nurse Notes). However, corresponding progress notes for those dates did not consistently document the reasons for these codes or the actions taken. Progress notes that were present included a physician note on one date ordering a lidocaine patch after a report of left knee pain, and several EMAR notes on later dates indicating "awaiting pharmacy delivery," "waiting on pharmacy delivery," and "med [out of stock] awaiting order." There was no documented evidence in the medical record that the facility contacted the resident’s medical provider to request a refill for the morphine from the time the medication first became unavailable until two days later. Interviews and external documentation further highlighted gaps in charting. The contracted pharmacy provided a timeline showing that an electronic refill request was received, a fax was sent to the physician for a needed script, a script with missing information was received, clarification was requested from facility staff, and the correct script was eventually received and the medication delivered. An RN stated that nurses were responsible for monitoring narcotic counts, that narcotics required a written script rather than electronic re-ordering, and that all related actions should be documented. The RN confirmed entering a "#9" code for a missed morphine dose without a corresponding progress note and could not recall calling the physician, acknowledging that such a call and its documentation should have occurred. The DON reported that an LPN had verbally stated multiple attempts were made to reach the physician, but these efforts were not documented in the medical record, contrary to the facility’s policies requiring complete, accurate documentation of services and all communication with physicians and supervisory staff in the resident’s record.
Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Alarm Systems
Penalty
Summary
A severely cognitively impaired resident with a history of exit-seeking and previous elopement attempts was able to elope from the facility. The resident, who had diagnoses including dementia and Alzheimer's disease and a BIMS score indicating severe cognitive impairment, was known to require supervision for locomotion off the unit and was identified as an elopement risk on their care plan. The resident was equipped with a Wander Guard (WG) device intended to prevent unauthorized exit by triggering alarms and disabling elevator and door access. On the day of the incident, the resident exited the facility through an employee entrance after using an elevator, both of which were supposed to be secured and alarmed for residents with a WG. The alarm system failed to activate when the resident used the elevator and exited through the employee door. A CNA observed the resident leaving but did not intervene, mistaking the resident for a visitor due to their appearance and the absence of an alarm. Multiple staff interviews revealed that the elevator and alarm system had a history of malfunctioning, with several staff members reporting prior incidents where the resident accessed the elevator and left the unit, as well as reporting these issues to management. However, there was no evidence that these concerns were effectively addressed or escalated to facility administration. The facility's policies required adequate supervision and a systemic approach to monitoring residents at risk for elopement, but staff practices and system failures allowed the resident to leave the building undetected. The resident was missing for several hours before being located by police and returned to the facility. Staff interviews indicated a lack of clear responsibility for supervising residents not assigned to them and inconsistent communication regarding malfunctioning safety systems. The failure to provide adequate supervision and maintain functional safety systems resulted in a situation of Immediate Jeopardy.
Removal Plan
- Resident was sent to the hospital for evaluation, returned to the facility, and immediately placed on 1:1 supervision that was maintained.
- Resident had a skin and pain assessment with no injury.
- The physician and family were notified.
- Resident's Wander Guard (WG) was checked every shift for placement and function.
- The facility's vendor serviced the WG system.
- Staff were stationed at employee entrance/exit until the system was repaired and the WG vendor increased the system's sensitivity.
- All residents with WG were checked.
- Updated resident photos for residents with WGs were posted in both elevators and employee entrance.
- All receptionists were educated on the process of buzzing employees in and out of the facility.
- All staff were educated on the facility's elopement policy, wandering binders and identification process.
- Elopement drills were conducted.
Failure to Protect Residents from Physical Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect three residents from physical abuse by another resident, who had a history of Alzheimer's disease, dementia, and behavioral disturbances. The resident in question exhibited escalating aggressive behaviors, including multiple incidents of physical altercations with both residents and staff. These incidents included hitting, punching, and choking, resulting in injuries such as bruising, swelling, and a hematoma. Despite these events, the facility did not consistently implement or maintain effective supervision or interventions to prevent further abuse. The aggressive resident was involved in several documented incidents over a period of months, including unprovoked attacks on other residents and staff members. In one instance, a resident was found with significant injuries after being attacked, including facial bruising, scratches, and swelling, and required hospital evaluation. Another resident reported being pushed and falling, resulting in a head injury and subsequent trauma. Staff members were also physically assaulted while attempting to redirect the aggressive resident, with one LPN sustaining a cut to the nose and another being punched and placed in a chokehold. The facility's response to these incidents was inconsistent and, at times, inadequate. There were lapses in supervision, such as the removal of increased monitoring after serious incidents and failure to provide 1:1 observation as ordered. Staff were not always interviewed or provided statements following incidents, and recommended staff training on managing resident aggression was not completed. Additionally, some staff and the medical director were unaware of the full extent of the incidents, and residents affected by the abuse reported feeling unsafe and traumatized, with one resident keeping their door closed out of fear.
Failure to Monitor and Timely Notify Physician of Cast-Related Skin Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to monitor and assess a resident's skin condition around a cast and did not notify the physician in a timely manner after necrotic skin was discovered. The resident, who had dementia, diabetes mellitus, and severe cognitive impairment, had sustained a right wrist fracture and returned to the facility with a cast following surgery. There was no documentation of any assessments or monitoring of the resident's arm, wrist, or skin around the cast for nearly two months after the cast was applied. On one occasion, the resident complained of arm pain, and necrotic skin with an opening was found under the cast, but there was no immediate physician notification or further assessment documented for two days. Subsequent documentation noted a foul odor from the cast, at which point the physician was notified and an antibiotic was ordered. Two days later, the resident was sent to the emergency room and admitted with a wrist infection. Upon return to the facility, the resident was diagnosed with a right wrist infection, status post hardware removal, and maggot infestation. Attempts to interview the nursing staff involved were unsuccessful, and the DON declined to comment on expectations for care at the time of the incident.
Failure to Maintain Clean, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for residents on the second floor, as evidenced by multiple observations and resident interviews. Several residents with intact cognition reported that the only shower room on their unit was used as a storage area for equipment, discharged residents' clothing, and soiled incontinence briefs, resulting in unpleasant odors and an unclean environment. Residents also described the shower room as cluttered and dirty, with unclean shower pads and chairs, and reported that the common area floors had not been mopped for several days, leaving them sticky and covered in debris. Direct observations confirmed these concerns, with surveyors noting sticky food and beverage spills, white particles, and large spills in the hallways and dining areas. The shower room contained soiled pads, garbage, missing floor drains, and piles of clothing and equipment, all of which were verified by staff as inappropriate. Housekeeping and nursing staff acknowledged that the shower room and common areas were not being cleaned as required, and that extra equipment and residents' clothing should not be stored in the shower room. The Housekeeping/Laundry Supervisor and DON both stated that cleanliness issues had been raised by residents in council meetings. Additionally, food carts with partially eaten meals from the previous day were left in the hallway outside the dining room on the first floor, accessible to residents. Staff interviews revealed that the carts should have been stored in a locked area and not left in the hallway. The DON confirmed that staff should be rounding every hour to prevent such occurrences and acknowledged that leaving the carts in the hallway was a hazard and put residents at risk.
Failure to Provide Palatable Food and Appropriate Condiments
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately tempered food and drink to eight out of 32 sampled residents. Multiple residents with intact cognition reported that meals were served without necessary condiments, such as sweetener, salt, pepper, ketchup, or mustard, and described the food as bland, overcooked, dry, or unappetizing. Specific complaints included dry noodles, overcooked vegetables, inedible fish sticks, and soup with minimal ingredients. Several residents also reported that their meals were served cold or at an unappetizing temperature, and that condiments were inconsistently provided or missing entirely, despite being indicated on tray cards for certain diets. Resident Council and Menu Committee meeting minutes documented ongoing concerns from residents regarding the taste, temperature, and appearance of food, as well as the lack of condiments and missing menu items. These concerns were raised repeatedly over several months, with some meeting minutes lacking any documented response or action. Observations during meal service confirmed that while food temperatures on the tray line were within acceptable ranges, by the time meals reached residents, some items were cold, dry, or bland, and condiments were not provided in the dining room as required. Staff interviews corroborated these findings, with LPNs and CNAs reporting frequent resident complaints about food quality and the inconsistent availability of condiments. The Dietary Manager acknowledged issues with staffing and the failure to prepare condiment containers for the dining room, as well as ongoing problems with food temperatures and menu satisfaction. The Regional Dietitian was unaware of the extent of resident complaints. The facility's own Food Preparation Guidelines policy requires food to be prepared in a manner that preserves or enhances nutrition, flavor, and appearance, and to be served at safe and appetizing temperatures, but these standards were not met as evidenced by resident reports, staff interviews, and direct observations.
Failure to Conduct Thorough Abuse Investigations and Maintain Complete Documentation
Penalty
Summary
The facility failed to ensure that abuse investigations were thoroughly conducted for three out of five reviewed cases, affecting four residents. Specifically, the facility did not interview all involved parties, including alleged victims, perpetrators, and witnesses, nor did it determine whether abuse occurred, its extent, or cause. Documentation of the investigations was incomplete, with missing or undated witness statements, lack of resident interviews, and absent or incomplete skin assessments following incidents. In one incident, a resident with Alzheimer's disease and moderate cognitive impairment attempted to enter another resident's room, resulting in a physical altercation. Staff statements were present but lacked proper identification and signatures, and there was no documentation of interviews with the residents involved or complete skin assessments. In another event, a resident was observed with hands on another resident's neck, resulting in visible injuries and hospitalization, but only one unsigned witness statement was present, and no statements from the residents or other staff were included. The investigation summary did not indicate whether abuse was substantiated. A third incident involved a resident entering another's room, leading to a physical altercation and injury. Only one staff statement was present, with no documentation from the involved CNA or the resident who was cognitively intact. The DON confirmed that no additional documentation or statements were available for these incidents. These failures in investigation and documentation were contrary to the facility's own abuse policy, which requires thorough interviews and complete records.
Unsecured Medication Cart and Exposed Resident Information
Penalty
Summary
A medication cart on A Hall was observed unsecured and unattended in front of the nurse's station, with the computer screen open and displaying the names of 14 residents. At the time of observation, only a certified nurse's aide was present in the hallway, and no licensed nursing staff were at the cart. During an interview, an LPN admitted to knowingly leaving the cart unlocked during the overnight shift, citing the absence of families and residents as the reason for not being as careful with securing the cart. The facility's policy requires medication carts to be secured during medication pass to prevent unauthorized access, and the Director of Nursing confirmed that the cart should have been locked unless a nurse was present. The incident was found to be in violation of the facility's policy and regulatory requirements for medication security and resident information privacy.
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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 |
| Barclays Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Palace Rehabilitation And Care Center, The | 1.2 mi | ★★★★★ | 27 | 0 |
| Laurel Brook Rehabilitation And Healthcare Center | 1.4 mi | ★★★★★ | 9 | 0 |
| Aristacare At Cherry Hill | 2 mi | ★★★★★ | 21 | 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.