Masonic Village At Burlington

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor and communicate a cognitively intact resident’s expressed preference regarding personal care providers. The resident, admitted with a left shoulder fracture, had an MDS dated 5/7/2025 showing a BIMS score of 13/15, indicating intact cognition. On 5/18/2025, the resident informed an RN that they did not want any male caregivers. The RN told the resident she would ensure that no male caregivers would provide care. This interaction was documented in a Verbal Coaching/Education form dated 5/23/2025, which identified the reason for coaching as the RN being notified of the resident’s preference for no male caregivers. Despite this expressed preference, a review of the resident’s medical record showed no documentation of the preference, no corresponding entry in the care plan, and no evidence that the preference was communicated in shift-to-shift reports. As a result of this lack of documentation and communication, a male CNA provided care to the resident on 5/19/2025, contrary to the resident’s stated wishes. During an interview, the LNHA, with the DON present, stated they were unaware of the preference request until the investigation and confirmed that the nurse did not follow the resident’s preferences when notified. The LNHA acknowledged that this failure occurred at the nursing level and that the facility’s policy allows residents to choose healthcare providers consistent with their interests, values, and personal care needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required. A resident with diagnoses including nontraumatic chronic subdural hematoma and a BIMS score of 00, indicating severe cognitive impairment, was found on the floor in an unwitnessed incident in the afternoon. Progress notes documented that the resident was found on the floor at approximately 2:30 p.m. and was later sent to the hospital at approximately 9:30 p.m. for further evaluation. A subsequent progress note indicated that the resident was admitted to the hospital with a left hip fracture, and a facility QA report confirmed the fall was unwitnessed. During a telephone interview, an RN stated the resident had been experiencing leg pain, which led the physician to order pain medication and an x-ray. Facility documentation showed that an internal incident report was completed, but there was no evidence that the injury of unknown origin was reported to the NJDOH. In an interview, the DON, in the presence of the LNHA, stated that the incident was considered a fall and not abuse and therefore was not reported to the NJDOH, and the LNHA stated the fall was not suspicious in nature and did not need to be reported. This was inconsistent with the facility’s Abuse and Neglect policy, which requires that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation, be reported immediately, but not later than two hours after the allegation is made.

Penalty

Inspection fine: $86,411

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a care plan for a resident with a nutritional risk, specifically related to a diagnosis of dysphagia and cerebral infarction. The care plan, dated 8/06/2024, required a ground texture diet with thin liquids. However, on 9/29/2024, the resident was served a regular consistency hot dog on a bun, which was not in accordance with the prescribed diet. This incident occurred when a CNA served the meal and left the resident unsupervised, leading to a choking episode where the resident turned blue and required the Heimlich maneuver to dislodge the food. The resident, who had a history of cerebral vascular accident and dysphagia, was identified as needing partial/moderate assistance with eating and was on a mechanically altered diet. Despite these needs, the resident was left unsupervised with a meal that did not meet the dietary requirements. The resident's care plan was not followed, as it included interventions such as ensuring the resident was sitting upright during meals and monitoring for coughing, which were not adhered to during the incident. Interviews with staff revealed that the CNA did not verify the dietary order with a nurse or dietician before serving the meal, despite being aware of the resident's dietary needs. The CNA admitted to chopping the hot dog but acknowledged it was not the correct consistency. The incident highlighted a failure in communication and adherence to dietary protocols, as the resident was left unsupervised with an inappropriate meal, leading to a serious choking hazard.

Removal Plan

• The Director of Nursing conducted an audit to ensure all dietary orders, recommendations, and documentation were accurate in the medical record and matched the dietary department's tray card information for each resident.
• Facility policies and procedures Therapeutic Diets were reviewed/revised.
• Education was provided to the staff by the Staff Educator or designee regarding applicable facility policies and procedures titled Therapeutic Diets, diet consistency, compliance with resident-specific dietary interventions, supervision and food preparation consistent with each resident's dietary order including when a mandatory snack or alternative meal is provided.
• Mandatory in service was held. All staff who could not attend was not be permitted to work until they completed the mandatory in service. The mandatory in service was added to the new hire orientation and for all future nursing and dietary personnel.
• A member of the Interdisciplinary Team (IDT) team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. A minimum of two managers were assigned at lunch time.
• The Director of Nursing or Designee audited all new admissions to ensure the dietary orders/recommendations/documentation were accurate in the medical record and matched the dietary department's tray card information for that resident.
• The Dietary Manager or designee monitored food preparation at all three meals and compared the meal and or snacks being prepared to the physician order/documentation for each resident's dietary needs.
• Residents requiring assistance and or supervision with meals were encouraged to eat in the bistro, and residents who preferred to eat in their room were noted on the resident Kardex. A staff member was assigned to assist these residents during mealtime in the bistro and or resident rooms.
• A member of the IDT team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes.
• The Administrator implemented a Quality Assurance and Performance Improvement (QAPI) Performance Improvement Projects (PIP) in order to gather and process information from the audits/monitoring processes and findings to be reported at the monthly Quality Assessment and Assurance (QAA) meeting.

Penalty

Inspection fine: $86,411

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a mechanically altered diet as prescribed by the physician for a resident with a diagnosis of dysphagia and cerebral infarction. On a specific date, the resident was served a regular consistency hot dog on a bun by a CNA, despite having a physician's order for a mechanical soft ground texture diet. After serving the meal, the CNA left the resident unsupervised to assist another resident. The resident subsequently choked on the hot dog, turning blue, and required the Heimlich maneuver to dislodge the food. The resident's care plan, which identified a history of stroke and dysphagia, required supervision during meals. However, the resident was observed with a meal in front of them, unsupervised, on a later date. The CNA involved admitted to not verifying the resident's dietary needs with the nurse or dietician and acknowledged that the hot dog was not consistent with the prescribed diet. The CNA was aware of the resident's dietary requirements but failed to adhere to them, leading to the choking incident. Interviews with staff revealed a lack of communication and verification regarding the resident's dietary needs. The Bistro staff provided the hot dog without confirming the resident's dietary restrictions, and the CNA did not ensure the meal was appropriate for the resident's condition. The facility's policies and procedures for therapeutic diets were not followed, resulting in an immediate jeopardy situation for the resident.

Removal Plan

• The Director of Nursing conducted an audit to ensure all dietary orders, recommendations, and documentation were accurate in the medical record and matched the dietary department's tray card information for each resident.
• Facility policies and procedures Therapeutic Diets were reviewed/revised.
• Education was provided to the staff by the Staff Educator or designee regarding applicable facility policies and procedures titled Therapeutic Diets, diet consistency, compliance with resident-specific dietary interventions, supervision and food preparation consistent with each resident's dietary order including when a mandatory snack or alternative meal is provided.
• Mandatory in service was held. All staff who could not attend was not be permitted to work until they completed the mandatory in service. The mandatory in service was added to the new hire orientation and for all future nursing and dietary personnel.
• A member of the Interdisciplinary Team (IDT) team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. A minimum of two managers were assigned at lunch time.
• The Director of Nursing or Designee audited all new admissions to ensure the dietary orders/recommendations/documentation were accurate in the medical record and matched the dietary department's tray card information for that resident.
• The Dietary Manager or designee monitored food preparation at all three meals and compared the meal and or snacks being prepared to the physician order/documentation for each resident's dietary needs.
• Residents requiring assistance and or supervision with meals were encouraged to eat in the bistro, and residents who preferred to eat in their room were noted on the resident Kardex. A staff member was assigned to assist these residents during mealtime in the bistro and or resident rooms.
• A member of the IDT team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes.
• The Administrator implemented a Quality Assurance and Performance Improvement (QAPI) Performance Improvement Projects (PIP) in order to gather and process information from the audits/monitoring processes and findings to be reported at the monthly Quality Assessment and Assurance (QAA) meeting.

Penalty

Inspection fine: $86,411

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a therapeutic diet for a resident with a physician's order for a Mechanical Soft Ground texture diet. The resident, diagnosed with dysphagia and cerebral infarction, was served a regular consistency hot dog on a bun by a CNA. After being served, the resident experienced a choking incident, turning blue and requiring the Heimlich maneuver to dislodge the food. This incident created an Immediate Jeopardy situation, as it posed a risk to the health and well-being of the resident and potentially affected all residents on a therapeutic diet. The resident's care plan, which included supervision during meals, was not followed, as the resident was left unsupervised with a meal tray. The CNA responsible for serving the meal did not verify the resident's dietary needs with a nurse or dietician, despite being aware of the resident's mechanical soft ground diet order. The CNA admitted to chopping the hot dog instead of ensuring it was prepared to the correct consistency, which was a deviation from the physician's order and posed a choking hazard. Interviews with facility staff revealed a lack of communication and verification processes regarding dietary orders. The dining services staff did not verify the resident's diet before providing the meal, and the nursing staff did not ensure supervision during mealtime. The facility's policies and procedures for therapeutic diets and meal preparation were not adequately followed, leading to the resident receiving an inappropriate meal that resulted in a choking incident.

Removal Plan

• The Director of Nursing conducted an audit to ensure all dietary orders, recommendations, and documentation were accurate in the medical record and matched the dietary department's tray card information for each resident.
• Facility policies and procedures Therapeutic Diets were reviewed/revised.
• Education was provided to the staff by the Staff Educator or designee regarding applicable facility policies and procedures titled Therapeutic Diets, diet consistency, compliance with resident-specific dietary interventions, supervision and food preparation consistent with each resident's dietary order including when a mandatory snack or alternative meal is provided.
• A member of the Interdisciplinary Team (IDT) team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes.
• The Director of Nursing or Designee audited all new admissions to ensure the dietary orders/recommendations/documentation were accurate in the medical record and matched the dietary department's tray card information for that resident.
• The Dietary Manager or designee monitored food preparation at all three meals and compared the meal and or snacks being prepared to the physician order/documentation for each resident's dietary needs.
• Residents requiring assistance and or supervision with meals were encouraged to eat in the bistro, and residents who preferred to eat in their room were noted on the resident Kardex. A staff member was assigned to assist these residents during mealtime in the bistro and or resident rooms.
• The Administrator implemented a Quality Assurance and Performance Improvement (QAPI) Performance Improvement Projects (PIP) in order to gather and process information from the audits/monitoring processes and findings to be reported at the monthly Quality Assessment and Assurance (QAA) meeting.