Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Premier Cadbury Of Cherry Hill during CMS and state inspections, most recent first.
Food served during lunch on one nursing unit was found at unsafe temperatures during a test tray observation. A turkey burger measured 95 degrees Fahrenheit and a 4-ounce milk carton measured 46 degrees Fahrenheit after the tray cart arrived on the unit in an open, not enclosed cart. The FSD stated the turkey burger temperature was not adequate and that the plates did not have metal plate warmers underneath them.
Kitchen sanitation and resident pantry food labeling deficiencies: Surveyors observed wet nesting in stacked stainless-steel pans, a pan with a dried yellow substance, and paper stored inside a nonworking pellet warmer. In resident pantries, opened ice cream and bagged food items were found in refrigerators and freezers without required labels or dates, and the LNHA acknowledged the wet nesting and unlabeled items.
Failure to Carry Out Ophthalmology Recommendations: A resident with bilateral cataracts and intact cognition had cataract surgeries and an ophthalmology consult that recommended eyeglasses and a follow-up visit for intermittent diplopia. The record showed the prescription was communicated, but there was no documentation that the glasses were ordered or received and no follow-up eye appointment was scheduled; the resident reported continued double vision.
Delayed Resident Mail Delivery: A resident council meeting and staff interviews showed that resident mail was not consistently delivered during a staffing gap in Activities. One resident reported not receiving mail for an extended period, and an activities aide later found a box of undelivered mail. The ACD, DON, and facility records confirmed that mail delivery was assigned to Activities, but staffing was limited and the facility policy required mail to be delivered within 24 hours of arrival.
Survey results were not readily accessible to residents and notice of their location was not posted in prominent areas. Residents on two units said they did not know where to find the State survey results, staff on the units could not direct the surveyor to them, and one binder was kept behind a nurses' station while the other was in a locked lobby that residents could not enter without staff assistance. The DON and LNHA confirmed the results were not accessible on the units and that signage was missing.
Unclean and Damaged Resident Room Environment: A resident’s room had an unlabeled open food container and debris inside a personal refrigerator, ice in the freezer with no thermometer, debris on the bedroom floor, and damaged walls and bathroom trim with visible residue. The DOM, D of Housekeeping and Laundry, IP, and DON gave differing accounts of responsibility for cleaning the refrigerator and maintaining the room, while the facility policy required a clean, sanitary, and orderly environment and labeled refrigerated foods.
A resident with influenza, dysphagia, seizures, heart disease, and dementia was transferred to the hospital for respiratory distress, increased lethargy, and low O2 levels. The facility did not notify the Ombudsman of the emergency transfer and did not provide the bed hold policy to the resident or representative, despite policies requiring written bed-hold information at transfer or within 24 hours and documentation of Ombudsman notification.
MDS assessments were not accurately completed for three residents because BIMS was not assessed in Section C. Two residents did not speak English, and one resident was alert and oriented and able to converse with the surveyor. Records showed diagnoses including osteomyelitis, subarachnoid hemorrhage with dysphagia and aphasia, and acute pulmonary edema with anxiety and depression. The MDS consultant stated every resident should have a completed BIMS, with staff interview or translator use when needed.
A resident with influenza, dysphagia, seizures, heart disease, and dementia had refused meds and meals and later developed abnormal vital signs, including low BP, low temperature, lethargy, and low SpO2. The nurse informed the supervisor and monitored the resident, but there was no evidence the physician was notified of the abnormal findings before the resident was transferred to the hospital with respiratory distress.
A resident with right hemiplegia and a contracted right hand was observed without the ordered right-hand orthosis/hand splint in place, despite the care plan and MD order requiring it to be worn at all times except during care. The TAR showed an LPN documented the device as being worn when it was not, and no progress note explained why it was absent; interviews with the LPN, LPN/IUM, DON, and DPT confirmed the documentation was inaccurate and that the device should have been reported to PT when not in use.
Ordered Nutritional Supplement Not Served With Meals: A resident with dysphagia, aphasia, and recent weight loss was prescribed a fortified nutritional supplement with meals, but surveyors observed the supplement missing from both lunch and breakfast trays even though the meal tickets listed it. An LPN and RN/UM confirmed it was not on the trays, and the RD, FSD, and DON stated it should have been served as ordered.
Oxygen Therapy Not Provided as Ordered: A resident receiving O2 therapy was observed with a portable cylinder in the room, with the regulator set above the ordered flow rate and the tank gauge in the red. The chart showed an order for O2 at 2 LPM via NC PRN, while the care plan identified O2 therapy. An LPN and the DON stated the resident should have had an O2 concentrator in the room, and the portable cylinder was intended for emergencies, transport, or use outside the bedroom.
Incorrect Medication Dispensed During Medication Pass: An LPN dispensed the wrong calcium carbonate medication for a resident during a med pass after removing it from an OTC bottle. The LPN later confirmed the physician’s order called for a different calcium carbonate product, and the DON and LPN/UM stated staff should verify the medication against the MAR and prescriber order before administration.
The facility failed to timely act on pharmacy consultant recommendations for two residents. One resident had incomplete PRN bowel medication orders and was receiving cetirizine 10 mg daily despite a lower recommended dose for older adults, while staff could not explain the MRR follow-up process and the DON was unsure of the required timing. Another resident with hypothyroidism had a levothyroxine administration time that remained inconsistent with the consultant’s recommendation for months, and the DON acknowledged the recommendation should have been addressed sooner.
Uncovered Dumpster and Debris in Dumpster Area: The surveyor observed 1 of 1 dumpsters without a lid and found mattresses, wood pallets, and a reclining chair on the ground in the enclosed dumpster area. The FSD said the dumpster was delivered without a lid and identified housekeeping as responsible for the surrounding trash. The LNHA stated dumpsters should be closed and the area kept clear to avoid rodent issues.
An LPN administered medications to three residents during a med pass but did not document them immediately after administration, instead moving on to the next resident. The MARs were signed later, and the LPN, LPN/UM, and DON all stated medications should be signed off right after they are given to keep the record accurate.
A resident's oxygen NC tubing was observed lying directly on a bare mattress instead of being stored when not in use. The resident had oxygen therapy orders at 2 LPM via NC, and the IP and DON stated the tubing should be kept in a plastic bag to maintain infection control.
Kitchen floor tiles were missing and broken in multiple areas, including near the three-basin sink and in front of the steam table, creating an uneven floor surface. The FSD acknowledged the condition and stated mats are sometimes placed over the area, and the LNHA later stated the facility would initiate tile repairs after surveyor inquiry. The facility policy required maintenance service to keep all areas safe and operable at all times.
A resident with a full-code status was found unresponsive, and the facility failed to activate the emergency response system. A CNA reported the situation to an LPN, who began CPR but did not call 911 or notify an RN until over an hour later. The RN, upon arrival, did not perform CPR or call 911, and the resident was pronounced deceased. The facility's failure to follow protocol for a code blue situation posed a risk of serious harm.
A resident with multiple health conditions, including Alzheimer's and diabetes, experienced a 23-day delay in treatment for a right shin tear, leading to necrotic tissue and infection. The facility failed to document and implement the correct treatment order, and weekly skin assessments were not completed. The resident was on hospice care, and the facility's reliance on hospice contributed to the oversight.
A New Jersey LTC facility failed to meet the state's minimum staffing requirements, with deficiencies in CNA and RN staffing levels. The facility was unable to maintain the required staff-to-resident ratios on multiple shifts, despite having a staffing policy in place. Interviews revealed awareness of the staffing issues, particularly due to weekend callouts, but efforts such as offering bonuses and full-time schedules for agency staff were insufficient to address the shortfalls.
The facility failed to maintain proper sanitation and food safety standards, with issues including a malfunctioning dish machine, unsanitary kitchen conditions, and improper food storage and labeling. Staff did not follow hand hygiene and hair restraint protocols, leading to potential contamination risks. The LPN/IP and LNHA acknowledged the deficiencies and the need for corrective actions.
The facility's LNHA failed to ensure staff followed protocols, leading to deficiencies in care. A resident was found unresponsive, and staff did not follow proper resuscitation procedures. Another resident's skin tear was not documented or treated timely. Additional issues included inadequate staffing, improper documentation of hand splints, and food service problems. The LNHA acknowledged these concerns but did not provide evidence of corrective actions.
A resident with spastic quadriplegic cerebral palsy was not provided with prescribed carrot hand splints, as observed multiple times with clenched fists and the splints lying unused. The facility failed to transcribe the physician's order for the splints into the EMR and TAR, leading to a lack of documentation and application. Staff interviews revealed a lack of training and awareness regarding the splints, and the facility's policies on splints and physician orders were not followed.
The facility failed to adjust medication administration times for two residents to accommodate their dialysis schedules and did not obtain physician's orders to monitor dialysis fistula sites for bruit and thrill. Medications were scheduled during dialysis times, and there was no documentation of fistula monitoring, violating facility policies.
The facility failed to serve food at the required temperature during a lunch meal, as observed by a surveyor. Residents reported that the food was not hot, and the Assistant Dining Director recorded food temperatures below the required 135 degrees Fahrenheit. The facility's Hot Foods policy was not followed, as staff did not document temperatures prior to service.
The facility failed to provide nourishing snacks to residents when there was a 14-hour gap between dinner and breakfast. Residents reported that snacks were not accessible during the evening shift, leaving them hungry if they did not like their dinner. Staff interviews revealed inconsistencies in snack distribution, with no documentation of snack delivery and no snacks found in the pantry during inspection.
The facility failed to serve meals in a manner that respects residents' dignity, as observed when some residents were served before others, causing delays and discomfort. An LPN noted the issue of dignity when moving residents who had not been served away from those who were eating. The facility's protocol, which states that no resident should eat until all have their trays, was not followed.
The facility did not adhere to its new hire policy requiring reference checks for new employees. Four staff members, including an LPN, two CNAs, and an RN, were hired without completed reference checks. The HRD acknowledged that while two references were typically obtained, employment was not delayed if references were pending, contrary to the facility's protocol requiring three references before the start date.
A resident with severe cognitive impairment and psychiatric conditions engaged in a verbal and physical altercation with another resident, requiring staff intervention. The facility failed to report the incident to the NJDOH as required by their policy, and staff interviews revealed uncertainty about reporting obligations.
The facility failed to investigate a resident-to-resident altercation and an injury of unknown origin. A resident with severe cognitive impairment was involved in an altercation, but no incident report or investigation was conducted. Another resident was found with a hip fracture 15 days after falls, but the facility did not investigate the injury's origin. Staff interviews confirmed that incident reports and investigations were necessary but not completed.
A facility failed to notify the State Long-Term Care Ombudsman about a resident's hospitalization for pneumonia. The resident, who had COPD and acute respiratory failure, was their own responsible party. Despite having a protocol to notify the Ombudsman, the facility did not have a record of sending the required notification, resulting in a deficiency.
The facility failed to update the care plans for two residents after they experienced falls, despite having severe cognitive impairments and being at high risk for falls. The individualized comprehensive care plans (ICCP) for both residents were not revised with new interventions following their falls, contrary to the facility's policies. Interviews with staff and the Director of Nursing (DON) confirmed that the care plans should have been updated promptly to prevent further incidents.
A resident with severe cognitive impairment and a history of falls fell in the physical therapy gym, sustaining an injury. The facility failed to complete an incident report or conduct a thorough investigation to determine the cause of the fall or develop preventive interventions. Staff interviews confirmed that the facility's protocol required such documentation and investigation, which was not followed.
A resident with a history of anemia, dysphagia, and other conditions experienced significant weight fluctuations that were not consistently documented or addressed by the facility. Despite having a care plan to monitor for malnutrition, the facility failed to record weights and conduct reweighs as required. The RD noted the resident's meal intake was not documented unless a calorie count was ordered, and the resident often skipped meals for smoking breaks. Staff interviews revealed inconsistencies in smoking break scheduling and food consumption documentation, contributing to the deficiency.
A facility failed to ensure a PRN psychotropic medication was prescribed with a 14-day duration and re-evaluated for continued use for a resident with dementia and anxiety. The resident was on Ativan without a stop date, contrary to the psychiatric APN's recommendation. The LPN and DON acknowledged the oversight, which was against the facility's policy requiring time-limited PRN orders.
Food Served at Unsafe Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was maintained at safe and appetizing temperatures during lunchtime meal service on the 600 nursing unit. During a test tray observation with a calibrated thermometer, the meal tray cart arrived on the unit at 12:20 PM as an open, not enclosed, cart, and when trays were delivered at 12:25 PM, the regular consistency meal temperatures were measured at 95 degrees Fahrenheit for a turkey burger and 46 degrees Fahrenheit for a 4-ounce milk carton. The Food Service Director acknowledged that the turkey burger temperature was not adequate and stated that the plates did not have metal plate warmers underneath them because the facility had no bottoms, meaning no plate warmers. The facility policy reviewed by the surveyor identified the danger zone for food temperatures as between 41 degrees Fahrenheit and 135 degrees Fahrenheit and listed meat, poultry, and seafood as hazardous foods.
Kitchen sanitation and resident pantry food labeling deficiencies
Penalty
Summary
The facility failed to maintain clean kitchen equipment and to store foods in a manner intended to prevent the spread of food borne illness in resident pantries. During a kitchen tour, the surveyor observed eight stainless-steel pans stacked on an open shelf with wet nesting between each pan, and one pan had a dried yellow substance on the inside. The Food Service Director stated the pans were clean but said he would rewash them, and he acknowledged the wet nesting and removed the pans from the shelf. The surveyor also observed paper stored inside a pellet warmer that the FSD said had not worked for close to a year. In two resident pantries, the surveyor observed food storage issues. In the 500 unit pantry, there were no paper towels at the sink, and the resident refrigerator and freezer contained two opened half-gallons of ice cream that were not labeled or dated. In the 600 unit pantry, the freezer contained one opened gallon container of ice cream that was not labeled or dated, and the refrigerator contained two clear plastic bags of food items with resident names but no dates. During a meeting with the LNHA and DON, the LNHA acknowledged the wet nesting and the unlabeled items in the resident pantries. Facility policy required ready-to-eat, time/temperature control for food safety items to be clearly marked with the day or date by which they are to be consumed or discarded, and another policy stated supervisors were responsible for ensuring food items in pantries, refrigerators, and freezers were not expired or past perish dates.
Failure to Carry Out Ophthalmology Recommendations
Penalty
Summary
The facility failed to follow a consultant physician’s recommendations in a timely manner for a resident who had bilateral age-related cataracts and intact cognition with a BIMS score of 13 out of 15. After left eye cataract surgery and right eye cataract surgery, the resident was seen by an ophthalmology consultant who documented that the resident was stable after surgery but had intermittent diplopia. The consultant recommended a prescription for eyeglasses, a follow-up visit in 2 months, and consideration of PRISM glasses if diplopia continued. The resident later told the surveyor that they had been told eyeglasses were ordered but never received them, and that they still had double vision. Review of the record showed the prescription was given to the ophthalmologist and the resident and doctor were made aware, but there was no documentation that the eyeglasses were ordered or received and no documentation that a follow-up eye appointment was scheduled. The resident’s comprehensive care plan did not include a focus area for cataracts or eyeglasses. Staff interviews indicated that when a resident returned from an outside physician visit, the nurse was expected to contact the attending physician for orders and notify the unit secretary to schedule follow-up, but the LPN and DON stated they did not know what happened to the eyeglass prescription or follow-up appointment. The DON and LNHA later acknowledged that the eyeglass prescription should have been completed and a follow-up visit with the eye doctor should have been scheduled.
Delayed Resident Mail Delivery
Penalty
Summary
The facility failed to consistently provide residents with mail delivery between December 2025 and late February 2026. During a resident council group meeting, five alert and oriented residents stated that the Activities Director coordinated mail delivery, but the facility had no ACD during that period. One resident reported not receiving mail during that time and stated that an activities aide later found a box of undelivered mail. Interviews with facility staff confirmed that the previous ACD left in December 2025 and that the current ACD did not begin until February 2026. The ACD stated that mail was supposed to be distributed daily and that only one activities aide worked part time on Mondays, Wednesdays, and Fridays during the staffing gap. The DON stated activities staff were responsible for delivering resident mail but could not say how often it should be delivered. Facility records and timecards showed there was only one activities aide working between late December 2025 and February 2026, and the facility's policy required mail and packages to be delivered to residents within 24 hours of arrival, including Saturday deliveries.
Survey Results Not Readily Accessible or Posted
Penalty
Summary
The facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to residents and failed to post notice of where those results could be found in prominent areas. During a resident council meeting, five alert and oriented residents stated they were not aware of the location of the State Survey results. On tour of the [NAME] 5 unit, the surveyor could not locate the most recent State Survey results and found no signage directing residents to them; the LPN/UM on the unit was unable to identify their location and had to get the LNHA, who stated the results were in the lobby. On tour of the [NAME] 6 unit, the surveyor again could not locate the survey results and found no signage on the unit. An LPN retrieved a binder from behind the nurses' station, which was not accessible to residents, and it contained the most recent recertification survey results. The surveyor then found that the lobby doors were locked, with a sign instructing people to knock and a keypad present; the receptionist stated residents had to ask staff for permission to enter the lobby because elopement risk residents were not allowed there. The LPN/UM later stated the survey results were kept in the lobby, that there were no survey results available on the unit, and that residents had to ask staff to find out where the results were located. The DON and LNHA confirmed the lobby location was not readily accessible to residents and that the binder behind the [NAME] 6 nurses' station was not readily accessible, while the facility policy required survey reports and related information to be readily accessible and posted on resident bulletin boards and at each nurses' station.
Unclean and Damaged Resident Room Environment
Penalty
Summary
The facility failed to maintain a homelike environment that was clean, safe, and sanitary in room [ROOM NUMBER]B on the [NAME] 6 Unit. During observation, a personal refrigerator contained an unlabeled, open container of food inside the door, with debris on the bottom of the refrigerator and a loose blue paper label. The freezer compartment did not have a thermometer and had ice covering the floor. Debris was also visible on the bedroom floor. In the same room, the wall had areas of missing white paint exposing the drywall paper layer, and the bathroom walls had black scuff marks with wall trim hanging loose adjacent to the toilet and black residue visible behind it. During interviews, the DOM stated maintenance was not responsible for cleaning residents’ personal refrigerators and was unsure why the freezer lacked a thermometer, though he said one should be present to ensure proper freezer temperature. He also stated the wall damage and loose trim should not have been present and noted a private contractor had been hired for repairs, though he did not know when they would begin. The D of Housekeeping and Laundry stated rooms were cleaned daily and as needed, but personal refrigerators were not routinely cleaned unless requested, while also stating bedroom floors and personal refrigerators should be kept clean. The IP stated residents’ personal refrigerators were cleaned daily by housekeeping and should not contain open, unlabeled, or undated food, debris, or loose trash. The DON stated the refrigerator and freezer should have been cleaned and defrosted by housekeeping and that maintenance should have ensured a thermometer was present in the freezer compartment.
Failure to Notify Ombudsman and Provide Bed Hold Information
Penalty
Summary
The facility failed to notify the representative of the Office of the State of Long-Term Care Ombudsman about a resident’s emergency discharge to the hospital and failed to provide the bed hold policy for one resident reviewed for hospitalization. Resident #99 had a facility-initiated discharge and was no longer in the facility. The resident’s admission record listed diagnoses including influenza, dysphagia, seizures, heart disease, and dementia. Progress notes showed the resident was transferred to the hospital with respiratory distress, and the NJ Universal Transfer Form documented transfer on 1/5/26 at 11:45 AM for increased lethargy and low oxygen levels. Review of the hybrid medical record found no evidence that the Ombudsman representative was notified of the emergency discharge or that the bed hold policy was provided to the resident or the resident’s representative. The LNHA stated he could locate notifications for November and December 2025 but not January 2026, and later confirmed the January 2026 emergency transfer notification had not been sent before surveyor inquiry. The AD stated she was not sure whether the bed hold notification had been sent for Resident #99 and later confirmed it was not sent. Facility policy required written bed-hold information to be provided at transfer or within 24 hours for an emergency transfer, and the Ombudsman notification policy required the administrator or designee to ensure notification was completed and documented.
MDS Assessments Not Completed for Cognitive Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for 3 of 20 residents reviewed. For Resident #1, the surveyor observed the resident awake and alert in a wheelchair in the room and the resident stated he/she did not speak English. The medical record showed diagnoses including osteomyelitis. The comprehensive MDS dated 1/19/26 showed that in Section C for cognitive patterns, the Brief Interview for Mental Status (BIMS) was not assessed, and the omission did not reflect the resident's true physical, mental, and psychosocial status. For Resident #5, the surveyor observed the resident awake and alert in a wheelchair by the nurse's station, and a staff member stated the resident did not speak English. The medical record showed diagnoses including nontraumatic subarachnoid hemorrhage from the left middle cerebral artery, dysphagia, and aphasia. The resident's comprehensive MDS also showed that BIMS was not assessed in Section C. For Resident #61, the surveyor observed the resident alert and oriented and conversing with the surveyor regarding care, but the comprehensive MDS dated 2/2/26 showed that BIMS was not assessed in Section C. The MDS consultant stated every resident should have a completed BIMS assessment, and if non-interviewable, a staff interview should be completed; if the resident did not speak English, a translator would be used. The LNHA and DON acknowledged that the three residents should have been assessed for mental status as required by RAI guidelines.
Failure to Notify Physician of Resident’s Abnormal Vital Signs and Decline
Penalty
Summary
The facility failed to notify the physician of a resident’s change in condition for 1 of 23 sampled residents. The resident had diagnoses including influenza, dysphagia, seizures, heart disease, and dementia, and the care plan directed staff to monitor vital signs as ordered and notify the physician of significant abnormalities. On 1/4/26, the resident refused medications and refused to eat breakfast and lunch, and vital signs showed a blood pressure of 85/55 and a temperature of 94.2 degrees. The progress note documented that the nurse informed the supervisor, the supervisor monitored the resident, and a speech therapy evaluation was scheduled, but there was no evidence that the physician was notified of the low blood pressure and low temperature. On 1/5/26, the resident was noted to be increasingly lethargic and required a sternal rub for arousal. Vital signs showed an SpO2 of 67% and a blood pressure of 64/50, and the resident was transferred to the hospital and admitted with respiratory distress. The NJ Universal Transfer Form indicated the transfer occurred because of increased lethargy and low oxygen levels. During interviews, the LPN stated she would notify the physician for any change in condition, and the DON and MD stated the physician should have been notified on 1/4/26 when the resident’s vital signs were abnormal. Facility policy required notifying the physician of significant changes in condition, refusal of treatment or medication two or more consecutive times, and abnormal vital signs.
Failure to Provide Ordered ROM Support Device
Penalty
Summary
The facility failed to ensure that therapy services and treatment for range of motion limitations were provided for a resident with right hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident had a right hand contracture and, during observation, was seated in a wheelchair in the bedroom and later self-propelling in the hallway without the ordered right-hand orthosis/hand splint (right-hand roll/carrot) in place. The resident stated he/she had difficulty using the right side of the body, and no orthosis or hand splint was observed on either occasion. The resident’s care plan directed that the right-hand device be worn at all times except during care, with pre- and post-skin checks, and the physician order required the device to be worn at all times except during care for comfort and proper positioning. However, the TAR showed the LPN documented the resident as wearing the device on both days when it was not in place, and no progress note explained why it was absent. Interviews with the LPN, LPN/IUM, DON, and DPT confirmed that staff should not document the device as being worn when it was not in place and that the reason for nonuse should be documented and reported to PT.
Ordered Nutritional Supplement Not Provided With Meals
Penalty
Summary
The facility failed to provide a physician-ordered nutritional supplement for Resident #5, who had diagnoses including nontraumatic subarachnoid hemorrhage from the left middle cerebral artery, dysphagia, and aphasia. The resident’s MDS indicated the resident needed supervision for eating, had lost 5% or more of body weight in the last month, was not on a prescribed weight loss program, and had dysphagia. The care plan identified the resident as at risk for nutrition alteration and included supplements as ordered. The physician ordered the [name redacted] supplement with meals, with instructions not to substitute due to thickened liquids, along with a regular diet with mechanical soft/ground texture and nectar/level 2 consistency. During observation, the surveyor saw the resident’s lunch tray on the overbed table with the meal ticket indicating the supplement, but the supplement was not on the tray; an LPN confirmed it was missing. The next day, the surveyor again observed the breakfast tray with the supplement listed on the meal ticket, but it was not on the tray; an RN/UM confirmed it was missing. The RD stated the supplement should have been on the meal trays as ordered, and the FSD confirmed it should have been on each meal tray and must have been missed. The DON also stated the supplement should have been on the meal trays as ordered.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for Resident #14 by not administering oxygen at the prescribed flow rate and by not providing the appropriate oxygen delivery system. On 3/11/26, the surveyor observed the resident in the bedroom receiving oxygen by nasal cannula connected to a portable oxygen cylinder in a cart. The regulator was set at 3 LPM, and the pressure gauge was in the red, indicating the tank required refilling. The resident was first observed lying in a lateral position with the head of the bed flat, and later sitting in a wheelchair adjacent to the bed while still receiving oxygen from the portable cylinder. The resident’s record showed diagnoses including metabolic acidosis, a quarterly MDS with a BIMS score of 15 out of 15, and an ICCP that identified oxygen therapy with interventions for oxygen at 2 LPM via NC. The OSR included a physician order for oxygen at 2 LPM via NC PRN for shortness of breath or hypoxia, and another order for weekly tubing and humidifier bottle changes. During interview, the LPN/IUM stated the resident should have an oxygen concentrator in the bedroom when oxygen is prescribed, and that the portable cylinder was for emergencies, transport, or use outside the bedroom; she also stated the regulator should have been set at 2 LPM, not 3 LPM, and that the cylinder should not have been empty if used for shortness of breath or hypoxia. The DON also stated that if the resident was prescribed oxygen, an oxygen concentrator should be present in the room at all times.
Incorrect Medication Dispensed During Medication Pass
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when an LPN dispensed the wrong calcium carbonate medication for a resident during the medication pass. The surveyor observed the LPN remove six medications for the resident, including an OTC pill bottle labeled calcium carbonate 600 mg - vitamin D 10 mcg, and then dispense one pill from that bottle into the medicine cup. After the medications were prepared and before entering the resident’s room, the surveyor asked the LPN to review the medications, and the LPN verified that the physician’s order was for calcium carbonate 600 mg, one tablet by mouth in the morning for supplement. The LPN then acknowledged that the medication dispensed was incorrect and destroyed it using a drug buster. During interviews, the LPN stated she should have checked the physician’s order multiple times against the medication bottle. The LPN/UM stated nurses should compare the medication dispensed against the physician’s order in the MAR and call the physician if the correct medication was not available. The DON also stated nurses should check the medication against the physician’s order in the MAR to ensure the correct medication is administered and should call the physician for instructions if the correct medication was not in stock. The facility policy stated medications are to be administered in accordance with prescriber orders and the label is to be checked three times to verify the right resident, medication, dosage, time, and route.
Delayed Follow-Up on Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the pharmacy consultant were acted upon in a timely manner for 2 of 5 residents reviewed for unnecessary medications. For one resident, the pharmacy consultant’s February 2026 review identified incomplete PRN orders for Dulcolax suppository, Fleet enema, and Milk of Magnesia because the orders lacked frequency, and also noted that the resident was receiving cetirizine 10 mg daily even though the manufacturer recommends a maximum dose of 5 mg per day for older adults. The resident was alert and oriented, and the record showed diagnoses including acute pulmonary edema, anxiety, and depression. During the survey, an LPN/UM was unable to immediately explain the process for following up on the pharmacy consultant’s recommendations and later stated that a call had just been made to the physician for a response. The LPN/UM could not explain why the physician had not been notified earlier or describe the facility’s MRR process or follow-up procedure. When the DON was questioned in the presence of the LNHA and survey team, she was also unable to explain the process, timing, or steps for the MRR and stated she would need to check because she was not sure. The facility policy on Pharmacy Services-Role of the Consultant included timing of responses. For another resident, the pharmacy consultant recommended on 11/12/25 that levothyroxine be administered on an empty stomach, preferably before breakfast. The resident had hypothyroidism, intact cognition, and a care plan addressing thyroid replacement therapy. The MAR showed levothyroxine was scheduled for 4:30 PM daily through 3/11/26, and on 3/12/26 the administration time was changed to 6:00 AM while the physician order still instructed evening administration. The DON later stated that a new physician order had been obtained to change the administration time and acknowledged that the 11/12/25 recommendation should have been addressed sooner than 3/11/26. The facility’s Medication Regimen Reviews policy stated that if the physician does not provide a timely or adequate response, or if no action has been taken, the consultant pharmacist contacts the medical director or administrator, but the policy did not include a timeframe for addressing recommendations.
Uncovered Dumpster and Debris in Dumpster Area
Penalty
Summary
The facility failed to provide a sanitary environment by not keeping the garbage container area free of debris and by failing to cover 1 of 1 dumpsters. During an initial tour of the kitchen with the Food Service Director, the surveyor observed that the large green dumpster had no lid, and the FSD stated it had been delivered without one. In the same enclosed area beyond the dumpster, the surveyor observed two mattresses, four wood pallets, and a reclining chair on the ground. When asked who was responsible for maintaining the trash surrounding the dumpster, the FSD stated it was the housekeeping department. During an interview with the LNHA, he stated dumpsters should be closed to prevent pest and rodent issues and that trash should not be on the ground in the dumpster area to avoid rodents. The facility policy titled, Disposal of Garbage and Refusal, dated 12/2025, stated that refuse containers and dumpsters kept outside the facility shall have tightly fitting lids, doors, or covers and that garbage should not accumulate or be left outside of the dumpster.
Delayed Medication Documentation
Penalty
Summary
The facility failed to maintain accurate medication administration records for three residents by not signing off medications immediately after they were administered. During a medication pass on 3/12/26, an LPN administered six medications to Resident #52 at 8:13 AM, five medications to Resident #77 at 8:22 AM, and two medications to Resident #24 at 8:48 AM, but did not document the administrations when returning to the medication cart and instead moved on to the next resident. At 8:52 AM, the LPN stated she was preparing the next resident's medications when the surveyor stopped the medication pass. When asked what should be done immediately after administering medications, the LPN stated nurses should sign off medications as administered because if it is not documented, it is not done, and acknowledged she had not signed off the three residents' medications after administration. A review of the Medication Admin Audit Reports dated 3/12/26 showed Resident #24's medications were signed off at 9:02 AM and 9:03 AM, Resident #77's medications were signed off at 9:03 AM and 9:04 AM, and Resident #52's medications were signed off at 9:04 AM. The LPN/UM stated nurses should sign medications off immediately after the resident takes them so the facility knows the time the medications were taken. The DON, in the presence of the LNHA and survey team, stated nurses should sign off medications immediately after they are given and should not delay because the facility needed to ensure the resident got the medication at the correct time. The facility's policies stated that the individual administering the medication records the date and time the medication was administered and that medications administered are documented in the resident medical record.
Oxygen Tubing Left Exposed on Bare Mattress
Penalty
Summary
The facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections when Resident #14's oxygen nasal cannula tubing was left exposed on a bare mattress. On 3/12/26 at 9:20 AM, the surveyor observed the resident's oxygen NC tubing lying directly on the resident's bare mattress instead of being stored appropriately when not in use. Resident #14 had diagnoses including metabolic acidosis and had a quarterly MDS dated 2/20/26 with a BIMS score of 15 out of 15, indicating intact cognition. The resident's care plan included oxygen therapy at 2 LPM via NC, and the order summary included physician orders to change the oxygen tubing and humidifier bottle weekly and every night shift on Wednesday, as well as oxygen at 2 LPM via NC PRN for shortness of breath or hypoxia. During interviews, the IP stated the oxygen tubing should be kept in a plastic bag when not in use, and the DON stated the tubing should have been stored in a bag and not placed on a bare mattress to maintain infection control.
Kitchen Floor Tiles Missing and Broken
Penalty
Summary
The facility failed to provide a safe environment for facility staff in the kitchen. During a surveyor tour of the kitchen with the Food Service Director, the floor was observed to have four-inch by four-inch tiles throughout the area, with 18 ceramic tiles missing near the three-basin sink, creating an uneven floor surface. The Food Service Director acknowledged the missing tiles and stated that mats are sometimes placed over the area to make it safer. The surveyor also observed the steam table area, where 14 broken tiles were present in front of the steam table, with some loose pieces and some missing pieces, also creating an uneven floor surface. During an interview, the Licensed Nursing Home Administrator stated that the facility was going to initiate repair of the floor tiles following surveyor inquiry. A review of the facility policy titled Maintenance Service stated that maintenance service shall be provided to all areas of the building, grounds, and equipment in a safe and operable manner at all times.
Failure to Activate Emergency Response for Full-Code Resident
Penalty
Summary
The facility failed to activate their emergency response system for a resident who was found unresponsive and was a full-code status, meaning all resuscitation procedures should have been provided. On the specified date, a Certified Nursing Assistant (CNA) found the resident unresponsive and reported it to a Licensed Practical Nurse (LPN), who began performing cardiopulmonary resuscitation (CPR). However, the LPN stopped CPR, did not call 911, and did not notify the Registered Nurse (RN) until one hour and ten minutes later. The RN also did not perform CPR or call 911 and pronounced the resident deceased shortly after. The resident involved had a medical history that included essential hypertension, hemiplegia, hemiparesis, dysphagia, cognitive communication deficit, and a personal history of nicotine dependence. The resident's records indicated a full-code status, meaning they desired full resuscitation efforts, including CPR and intubation if necessary. Despite this, the facility staff failed to follow the established protocol for a code blue situation, which required immediate CPR and activation of emergency services. Interviews with facility staff revealed a breakdown in protocol adherence. The LPN did not document calling 911, and the RN, upon arrival, did not initiate emergency procedures despite being CPR certified. The Director of Nursing (DON) confirmed that 911 should have been called and acknowledged the lack of documentation and protocol adherence. The Medical Director also stated that 911 should have been notified in such a situation. This failure to activate the emergency response system posed a likelihood of serious harm to residents who were full-code.
Removal Plan
- The facility's Code Blue/CPR policy was updated to reflect staff are to call 911 during emergency response.
- LPN #1 and RN #1 will be educated by the DON on the facility's Code Blue/CPR policy.
- All licensed nurses will be educated on the facility's Code Blue/CPR policy.
- The Staffing Coordinator will ensure at least 50% of all licensed nurses in the building are CPR certified.
Delayed Treatment of Shin Wound Leads to Infection
Penalty
Summary
The facility failed to implement a treatment order for a right shin tear for a resident, resulting in a 23-day delay. This delay led to the wound worsening, developing necrotic tissue and an infection that required a seven-day antibiotic treatment. The resident, who had Alzheimer's disease, dementia, heart failure, diabetes mellitus, and muscle weakness, was on hospice care and had severely impaired cognition. The resident was dependent on assistance for most activities of daily living and had existing pressure ulcers. On April 23, 2024, a nurse was notified by the resident's Hospice Nurse about a new wound on the right shin. The nurse assessed the wound, notified the doctor, and documented the necessary information. However, the physician's order entered into the electronic medical record was incorrectly documented for a sacral wound instead of the right shin wound. This error was not corrected until May 16, 2024, when the wound had worsened significantly. During this period, there was no documented evidence of weekly skin assessments being completed, and the resident's individual comprehensive care plan did not include interventions for the new wound. Interviews with facility staff, including the Director of Nursing, Licensed Practical Nurse/Unit Manager, and the Attending Medical Doctor, confirmed the oversight in documentation and the lack of timely treatment. The facility's policies required immediate assessment, documentation, and treatment of new wounds, but these were not followed. The staff relied heavily on hospice care for the resident, which contributed to the oversight in the facility's responsibilities for wound care management.
Deficient Staffing Levels in New Jersey LTC Facility
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports for a standard survey conducted on 11/20/2024. The facility was found to be deficient in Certified Nurse Aide (CNA) staffing for residents on 15 of 21 day shifts and in total staff for residents on 1 of 21 evening shifts during the period from 01/21/2024 to 02/10/2024. Additionally, for the two weeks prior to the survey, from 10/20/2024 to 11/02/2024, the facility was deficient in CNA staffing for residents on 10 of 14 day shifts and in total staff for residents on 1 of 14 overnight shifts. The facility's staffing policy, revised in September 2023, stated that the facility would develop and implement a written staffing plan to provide an adequate number of qualified direct-care staff to meet the residents' needs. However, interviews with the Staffing Coordinator and the Licensed Nursing Home Administrator revealed that the facility was aware of the staffing ratios but faced challenges, particularly with callouts on weekends. Despite offering bonuses to in-house staff and full-time schedules for agency staff, the facility was unable to consistently meet the required staffing levels. Furthermore, the facility was also deficient in Registered Nurse staffing for the two weeks of AAS-12 staffing from 10/20/2024 to 11/02/2024. The required total staffing hours were not met on several days, with significant shortfalls in actual staffing hours. The facility's staffing policy indicated that qualified employees would be scheduled to meet operational requirements and the needs of the residents, but the facility failed to adhere to this policy, resulting in the noted deficiencies.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by the surveyor. The high-temperature dish machine was not functioning properly, with gauges that did not move to reflect the correct temperatures during the wash, rinse, and final rinse cycles. The Dining Director (DD) and Dietary Manager (DM) were unable to confirm that the dish machine was sanitizing dishes effectively, as the test strips used to measure sanitizer levels were expired. Additionally, the dish machine temperature/sanitizer log was not accurately maintained, with pre-filled entries and missing documentation for certain meals. The kitchen environment was found to be unsanitary, with wet nesting of dishes on drying racks, heavily soiled floors, and unclean equipment such as ovens, grills, and deep fryers. The DD admitted that there was no cleaning schedule in place, and cleaning tasks were communicated verbally among staff. The walk-in refrigerator and freezer also had issues, including exposed food, lack of proper labeling and dating, and a missing light bulb in the freezer. Expired food items were found in storage, and the ice machine had not been serviced as scheduled. In the nourishment rooms, there were further sanitation issues, such as undated opened containers, improperly labeled frozen dinners, and ice scoops stored in non-self-draining mounts with pooled water. Staff members were observed not following proper hand hygiene and hair restraint protocols, which could lead to contamination. The Licensed Practical Nurse/Infection Preventionist (LPN/IP) and Licensed Nursing Home Administrator (LNHA) acknowledged the deficiencies and the need for immediate corrective actions to address the sanitation and food safety issues.
Deficiencies in Care and Protocols at LTC Facility
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that staff implemented facility policies and procedures, resulting in several deficiencies across different areas of care. In one instance, a resident who was a full code was found unresponsive, and the staff failed to follow proper protocol for resuscitation. The Certified Nursing Assistant (CNA) reported the situation to the Licensed Practical Nurse (LPN), who began CPR but did not call 911 or notify the Registered Nurse (RN) until much later. The RN did not perform CPR or call 911 and pronounced the resident deceased. The Director of Nursing (DON) did not investigate the time lapse or question the actions taken by the staff. Another deficiency involved a resident with a right shin skin tear that was not properly documented or treated in a timely manner. The Physician's Order (PO) for the treatment was delayed by 23 days, and the Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed that the order was incorrectly entered in the electronic medical record (EMR). The LNHA was made aware of the wound infection by the Hospice Nurse and the local ombudsman but could not recall the exact date of notification. Additional issues included the failure to document the application of hand splints for a resident, inadequate staffing levels, and problems with food service. The facility was found to be deficient in Certified Nursing Assistant (CNA) staffing on multiple shifts, and residents reported that food was not served hot. The facility also failed to maintain proper sanitation in the kitchen, as the dish machine was out of service, and meals were served on paper products. The LNHA acknowledged these concerns but did not provide evidence of corrective actions taken to address them.
Failure to Apply and Document Carrot Hand Splints
Penalty
Summary
The facility failed to properly manage and document the use of carrot hand splints for a resident with spastic quadriplegic cerebral palsy, muscle wasting, and epilepsy. The resident was observed multiple times with clenched fists and without the prescribed carrot hand splints, which were instead found lying on the overbed table. The resident's care plan and physician's orders required the use of these splints at all times, except during routine care and skin checks, to manage contractures and maintain skin integrity. The deficiency was further evidenced by the lack of documentation in the Treatment Administration Record (TAR) regarding the application of the hand splints. The physician's order for the splints was not correctly transcribed into the electronic medical record (EMR) and was not transferred to the TAR, leading to a failure in following the prescribed treatment. Interviews with staff, including a CNA, RN, and the Director of Rehabilitation, revealed a lack of awareness and training regarding the application of the splints, as well as an incorrect entry of the physician's order in the EMR. The facility's policies on splints and physician orders were not adhered to, as the splints were not documented in the TAR, and the physician's order was incomplete and inaccurate. The Director of Nursing and other staff acknowledged the importance of the splints for preventing contractures and maintaining skin integrity, but the failure to properly document and apply the splints as ordered resulted in a deficiency in the resident's care.
Failure to Adjust Medication Times and Monitor Dialysis Fistula
Penalty
Summary
The facility failed to adjust medication administration times to accommodate scheduled dialysis times and did not obtain a physician's order to monitor dialysis fistula sites for bruit and thrill. This deficiency was identified for two residents who required dialysis services. For one resident, the medical record review revealed that medications were scheduled to be administered at 6:00 AM, which conflicted with the resident's dialysis schedule, as the resident was picked up for dialysis at 4:50 AM. The facility's staff, including an LPN and the Director of Nursing (DON), confirmed that there was no physician's order to monitor the resident's dialysis fistula site for bruit and thrill, which is necessary to ensure the site is functioning properly. For the second resident, the facility failed to have a physician's order for the resident to attend hemodialysis and to monitor the dialysis fistula site for function both prior to and after dialysis treatments. The resident's medical record lacked documentation of the resident's care and assessment before and after dialysis treatments. The facility also did not maintain the required Communication Sheets that should have documented the resident's vital signs, medications received, and condition before leaving for dialysis. The DON confirmed that these documents were missing from the resident's closed record. The facility's policies on medication administration and dialysis care were not followed, as medications were not administered in a timely manner in accordance with physician's orders, and the dialysis access site was not checked for bruit and thrill as required. The facility's failure to adhere to these policies resulted in the identified deficiencies, impacting the care provided to the residents requiring dialysis services.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature during a lunch meal on one of its units. During a meeting with the Resident Council, four out of five residents reported that the food was not served hot and was described as cool. The surveyor observed that the facility's staff did not document food temperatures after obtaining them from the steam table. Additionally, the Assistant Dining Director (ADD) recorded food temperatures from both pureed and regular trays that were below the required 135 degrees Fahrenheit, with temperatures ranging from 113 to 132 degrees Fahrenheit. The ADD acknowledged that the timing of meal distribution could have been improved and noted that the facility was not using plate warmers because meals were being served on paper products due to a dish machine being out of service. The Licensed Nursing Home Administrator (LNHA) confirmed that there had been complaints about cold food, which had been addressed with the residents. The facility's Hot Foods policy requires that hot foods be held and served at 135 degrees Fahrenheit or above, and that dietary staff record temperatures immediately prior to service, which was not adhered to in this instance.
Failure to Provide Nourishing Snacks Between Meals
Penalty
Summary
The facility failed to provide nourishing snacks to residents when there was more than a 14-hour gap between dinner and breakfast, as evidenced by observations and interviews. During a resident council meeting, five residents reported that snacks were not accessible during the evening shift, and if they did not like their dinner, they were left hungry. The Assistant Dining Director could not provide documentation of snack delivery, and the Cart Delivery Log showed a gap of 14 hours and fifty-three minutes between dinner and breakfast. Interviews with staff revealed inconsistencies in snack distribution. The LPN/UM stated that snacks were available during the day and were labeled for specific residents, but there was no book identifying which residents received snacks. An inspection of the pantry showed no snacks available, contradicting the LPN/UM's statement. A CNA mentioned that snacks were delivered in the evening but were not usually labeled, and residents had to ask for them. The LNHA confirmed that snacks should be available in the pantry, but the surveyor found none during the inspection.
Failure to Serve Meals Respectfully and Timely
Penalty
Summary
The facility failed to ensure that residents were served their meals in a manner that promotes respect and dignity during lunch. This deficiency was observed when six out of ten unsampled residents were not served their meals at the same time, and one resident experienced a significant delay in meal service delivery in the dining room. On the day of observation, the surveyor noted that residents were seated and awaiting meal service, but the food cart was delayed. Some residents began eating while others, including one specific resident, waited for their meals. The delay in meal service led to a situation where some residents were moved away from tables where others were already eating, as noted by the LPN/Infection Preventionist, who acknowledged the dignity issue of having residents eat in front of others who had not yet been served. The specific resident in question was the last to receive their meal, despite being seated with others who were already eating. The facility's Resident Dining-Protocol states that no resident should be eating until all residents at the specific location have their trays, which was not adhered to in this instance.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to implement its new hire policy to ensure reference checks were completed for new employees. This deficiency was identified in the files of four employees, including an LPN, two CNAs, and an RN, all of whom did not have reference checks on file. The Human Resource Director (HRD) stated that while two references were typically obtained for each employee, the facility did not delay employment if references were not received, instead continuing to contact references and requesting additional ones if necessary. The facility's protocol required three references to be requested and contacted before the employee's start date, which was not adhered to in these cases.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the New Jersey Department of Health (NJDOH) as required. The incident involved a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's Disease, dementia, and PTSD. The resident exhibited verbal behavioral symptoms and had a history of verbal aggression. On the day of the incident, the resident was observed cursing at another resident and charged at them, prompting a nurse to intervene physically to prevent harm. The resident was subsequently sent to a hospital for crisis intervention. Despite the altercation, the facility did not provide a Facility Reportable Event (FRE) for the incident when requested by the surveyor. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed a lack of clarity regarding the reporting requirements for such incidents. The facility's policy on abuse investigation and reporting mandates that all alleged violations involving abuse or mistreatment be reported to the state licensing agency, but this procedure was not followed in this case.
Failure to Investigate Resident Incidents
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident-to-resident altercation involving Resident #310. The resident, who had severe cognitive impairment and a history of verbal aggression, was involved in an incident where they cursed at and charged another resident. Although the nurse intervened before physical contact was made and the resident was sent to crisis, the facility did not complete an incident report or conduct an investigation into the altercation. Interviews with staff, including the LPN, LPN/UM, and DON, confirmed that an incident report should have been completed and that a thorough investigation was necessary to prevent future occurrences. In another case, the facility failed to investigate an injury of unknown origin for Resident #6. The resident, who had severe cognitive impairment and a history of falls, was found to have a left hip fracture 15 days after two falls were documented. Despite the resident's complaints of pain and subsequent x-ray revealing the fracture, the facility did not complete an incident report for the injury of unknown origin or obtain statements from staff for the shifts leading up to the discovery of the fracture. Interviews with staff, including the LPN, LPN/UM, and DON, indicated that a full investigation should have been conducted to rule out abuse and determine the cause of the injury. The facility's policies on Management and Reporting of Resident Incidents and Abuse Investigation and Reporting require thorough investigations of incidents and injuries of unknown origin, including obtaining statements from staff who had contact with the resident. However, these procedures were not followed in the cases of Resident #310 and Resident #6, leading to deficiencies in the facility's handling of these incidents.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman about a resident's hospitalization, which was identified during a survey. The deficiency involved a resident who was admitted to the hospital for pneumonia. The resident had a history of chronic obstructive pulmonary disease (COPD) and acute respiratory failure, with a comprehensive care plan in place to monitor for signs of respiratory insufficiency. Despite the resident being their own responsible party, the facility did not follow through with the required notification to the Ombudsman. Interviews with facility staff revealed that the Director of Social Services was responsible for sending out Bed Hold Notices, while the Licensed Nursing Home Administrator was tasked with notifying the Ombudsman. However, there was no record of a facsimile confirmation to verify that the notification was sent. The facility's protocol required a monthly list of hospital transfers to be faxed to the Ombudsman, but this procedure was not followed, leading to the deficiency.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents after they experienced falls, as required by their policies. Resident #87, who had severe cognitive impairment and a history of falls, fell on 6/11/24 and sustained injuries. Despite this incident, the resident's individualized comprehensive care plan (ICCP) was not updated with new interventions to prevent future falls. The incident report and the Supervisor Fall Incident Investigation also lacked documentation of new interventions, and interviews with staff confirmed that the ICCP should have been revised promptly. Similarly, Resident #309, who also had severe cognitive impairment and was at high risk for falls, experienced a fall on 1/26/24. The resident's ICCP, which initially included interventions dated 1/23/24, was not updated following the fall. The incident report did not indicate any new interventions, and interviews with staff revealed inconsistencies in the process of updating care plans after falls. The current Director of Nursing (DON) confirmed that interventions should have been implemented after each fall to prevent further incidents. The facility's policies, including the Falls - Clinical Protocol and Care Planning - Interdisciplinary Team policy, require that care plans be updated with pertinent interventions to prevent subsequent falls. However, the facility did not adhere to these protocols, as evidenced by the lack of updated interventions in the care plans of Residents #87 and #309 after their falls. Interviews with staff and the Licensed Nursing Home Administrator (LNHA) highlighted issues with the previous DON's approach to care plan updates, which contributed to the deficiency.
Failure to Document and Investigate Resident Fall
Penalty
Summary
The facility failed to complete an incident report and thoroughly investigate a resident's fall, which was identified during a survey. The incident involved a resident with severe cognitive impairment and a history of falls, who fell in the physical therapy gym and sustained an injury. Despite the resident's known risk factors for falls, such as cognitive impairment and poor safety awareness, the facility did not document an incident report or conduct a thorough investigation to determine the cause of the fall or develop interventions to prevent future occurrences. The fall packet provided by the facility lacked essential components, including an incident report and a detailed investigation reviewed by the interdisciplinary team. Interviews with staff, including an LPN, LPN/Unit Manager, and the DON, confirmed that the facility's protocol required the completion of an incident report and investigation following a fall. The facility's policies on falls and incident management emphasized the need for thorough documentation and evaluation of falls, which was not adhered to in this case.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to adhere to its standard operational procedures for monitoring and addressing significant weight loss in a resident. The resident, who had a history of anemia, dysphagia, major depressive disorder, generalized anxiety disorder, muscle wasting, and tobacco use, experienced fluctuations in weight that were not consistently documented or addressed. Despite having a comprehensive care plan that included monitoring for signs of malnutrition and significant weight loss, the facility did not consistently record the resident's weight or conduct reweighs as required by their policy. The Registered Dietician (RD) acknowledged that the resident's weight dropped significantly in February, but no reweigh was conducted to confirm a 6.3-pound weight gain in March. Additionally, there was no recorded weight for April, which the RD attributed to a possible issue with the scale. The RD also noted that the resident's meal intake was not documented unless a calorie count was ordered, and the resident often skipped meals to attend smoking breaks. Despite these issues, the RD did not consider the weight loss significant due to the lack of a recorded weight in April and did not make any changes to the resident's care plan. Interviews with facility staff revealed inconsistencies in the scheduling of smoking breaks and the documentation of food consumption. The Certified Nursing Assistant (CNA) and Licensed Practical Nurse/Unit Manager (LPN/UM) stated that smoking breaks were scheduled after meals, but the resident reportedly skipped meals to smoke. The Director of Nursing (DON) confirmed that there were complaints about non-functioning scales and acknowledged that weights were not obtained at one point. The facility's policy required monthly weights and reweights for significant changes, but these procedures were not consistently followed, leading to a deficiency in the resident's nutritional care.
Failure to Implement 14-Day Limit for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was prescribed with a 14-day duration and re-evaluated for continued use for a resident reviewed for unnecessary medications. The resident, who was admitted with diagnoses including dementia, cerebral infarct, generalized anxiety disorder, and major depressive disorder, was observed to be on Ativan without a stop date. The psychiatric APN had recommended a 14-day duration for the PRN Ativan, but this was not reflected in the resident's medication orders. The Licensed Practical Nurse Unit Manager acknowledged that the Ativan should have had a 14-day stop date and that a rationale and duration should have been documented for continued use. The Director of Nursing confirmed that the medication should have been time-limited and documented according to the facility's policy. The facility's policies required PRN psychotropic medications to be time-limited and reviewed by the consultant pharmacist, but these procedures were not followed, leading to the deficiency.
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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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Illustrative
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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) |
|---|---|---|---|---|
| Aristacare At Cherry Hill | 1 mi | ★★★★★ | 21 | 0 |
| Dwellside Care And Rehab | 1 mi | ★★★★★ | 2 | 1 |
| Palace Rehabilitation And Care Center, The | 1.2 mi | ★★★★★ | 27 | 0 |
| Barclays Rehabilitation And Healthcare Center | 2.1 mi | ★★★★★ | 7 | 0 |
| Laurel Brook Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 9 | 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.