Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Silver Healthcare Center during CMS and state inspections, most recent first.
A high fall-risk resident with dementia, prior fractures, muscle weakness, and a history of recent unwitnessed falls was placed on 1:1 supervision. During an evening shift change, the CNA assigned as the 1:1 monitor reported telling an LPN that the resident required continuous supervision and stated that the LPN asked another CNA to watch the resident, but no clear handoff or acceptance of responsibility was documented. The LPN later stated no one spoke with him about the resident’s care, and another CNA who arrived shortly after observed the resident in a wheelchair near the nurse’s station, then saw the resident stand and fall against the wheelchair before she could intervene, without indicating she had been assigned as the 1:1 monitor. The resident sustained a skin tear and forehead bruise, later developed new-onset aphasia, and was admitted to the hospital with a subdural hematoma. Facility leadership and policy required that a designated 1:1 monitor remain within eyesight of the resident and not discontinue supervision until another staff member confirmed taking over, but assignment records did not identify who was responsible for 1:1 monitoring on the overnight shift.
A cognitively impaired resident with a known history of exit-seeking behaviors eloped from the facility after staff failed to maintain adequate supervision and did not communicate effectively about monitoring responsibilities. The resident was able to leave the unit by accessing an elevator without a security code and exited the building undetected during a period of increased activity at the main entrance. The resident was later found outside the facility and returned without injury.
The facility failed to complete DEA 222 forms accurately for controlled medications, missing details on the number and date of receipt. The DON was unaware of the requirement to fill in Part 5, and the MD only signed the forms without verifying medication receipt. The CEO/CP confirmed the nursing department's responsibility for documentation, but the Consultant Pharmacist had not checked the forms as required.
The facility failed to follow physician's orders and nursing standards during medication administration for two residents. An LPN did not remove a Lidocaine patch as ordered, due to a transcription error, and another LPN administered blood pressure medications without rechecking a low diastolic reading or consulting a physician. Both actions were against the facility's medication administration policy.
An LPN failed to follow proper infection control practices during medication administration, including inadequate hand hygiene and not cleaning a blood pressure cuff between residents. The LPN did not sanitize her hands after turning off a faucet with bare hands and prepared medications for a resident on Enhanced Barrier Precautions without performing hand hygiene. The facility's policies on hand hygiene and equipment cleaning were not adhered to, leading to potential infection control issues.
The facility failed to properly store Alcohol Based Hand Rub (ABHR) dispensers, exceeding the five-gallon limit in a single smoke compartment. Observations in Atrium Building #1 revealed 61 cases of ABHR, totaling approximately 96 gallons, stored in Resident room #308. The dispensers contained 80% ethyl alcohol and were not stored according to safety standards, as noted during a Life Safety survey.
The facility did not maintain the required minimum direct care staff to resident ratio as mandated by New Jersey law. During a recertification survey, it was found that the facility was short of CNAs on six out of fourteen day shifts, with the number of CNAs ranging from 10 to 15, while at least 16 were required. Interviews with the Staffing Coordinator and DON confirmed awareness of the staffing requirements, yet the facility's policy was not followed.
The facility did not meet the mandatory nurse staffing requirements for one day, providing 360 actual staffing hours instead of the required 379.25 hours. The DON acknowledged occasional low staffing days but was unsure of the reasons. The facility's staffing policy emphasized adjusting staffing based on resident acuity and care needs.
The facility did not send their Emergency Preparedness Plan (EPP) to the Camden County and Local Office Emergency Management officials for review, as required. This deficiency was identified during a review of the EPP book, which showed no evidence of submission from January 2023 to December 2024. The Administrator could not provide documentation of the EPP being sent, affecting all 132 residents.
The facility failed to maintain proper food safety and sanitation standards, as observed by surveyors. Issues included exposed food in storage areas, a dirty ice machine, improper chemical storage, and inadequate dishwashing sanitization due to a lack of chemical sanitizer. The facility's cleaning schedules did not address necessary maintenance tasks, contributing to these deficiencies.
The facility failed to maintain a clean and safe environment, with surveyors observing unlined trash receptacles, improper disposal of soiled items, and unswept floors. Maintenance issues included stained ceiling tiles, missing drawers, holes in walls, and broken blinds. Staff interviews revealed a lack of timely reporting and repair, with the Executive Director acknowledging the need for increased maintenance rounds.
Two residents with ventilator dependence were admitted to the facility, but their care plans failed to document essential needs such as tracheostomy, ventilator use, and oxygen requirements. The care plans were not completed within the required timeframe, and staff interviews revealed inconsistencies in care plan responsibilities.
A resident with severe cognitive impairment and multiple medical conditions was moved to a private room with a non-functional bathroom, compromising their dignity and safety. The bathroom was bolted shut due to water damage, and repairs were delayed. Staff interviews revealed the resident had to use alternative bathrooms, and the move was attributed to an error by a former Unit Manager. Facility policies on maintaining a safe environment were not followed, as evidenced by incomplete repairs and inappropriate room transfer.
A resident with a fracture was not scheduled for a follow-up with an orthopedic surgeon, and the prescribed splint was not consistently used. The resident, who was cognitively impaired, returned from the hospital with instructions for non-weight bearing and splint use, but the facility failed to ensure compliance. The BOM and LNHA acknowledged the facility's responsibility to cover the appointment costs, but the follow-up was not pursued, and documentation of splint use was inconsistent.
A resident with a urinary catheter was observed with their drainage bag improperly managed, being in contact with the floor and not secured to the bed frame, contrary to physician orders and care plan instructions. Interviews with facility staff confirmed the risk of infection from such practices, and the facility's policy emphasized the importance of keeping catheter equipment off the floor.
Two residents in a LTC facility did not receive proper respiratory care. One resident with severe respiratory conditions was found without oxygen delivery due to an empty tank and non-functioning concentrator, with outdated tubing and an unreachable call bell. Another resident with a tracheostomy had undated respiratory equipment and lacked a physician's order for oxygen flow rate. Staff interviews confirmed these deficiencies, highlighting a failure to follow the facility's oxygen administration policy.
The facility failed to ensure proper accountability of narcotic shift count logs, as observed by a surveyor. On two medication carts, missing nursing signatures and pre-signed sections were found in the narcotic logbooks. LPNs confirmed these discrepancies, acknowledging that logs should not have pre-signed sections and that all counts should be documented at the time they are completed. The ADON confirmed that the facility's policy requires incoming and outgoing nurses to count narcotics together and sign the logs to confirm the count.
A surveyor found deficiencies in medication storage and labeling at a facility, including undated and unlabeled fluticasone nasal spray bottles and a tuberculin PPD vial. Staff confirmed that opened medications should be dated and labeled with resident information, as per facility policy.
The facility failed to adhere to infection control standards in respiratory care for two residents. A resident's suction catheter was improperly stored, uncovered in a drawer, contrary to facility policy. Another resident received tracheostomy care without proper hand hygiene between glove changes, as the respiratory therapist followed an outdated policy. The Infection Preventionist confirmed these practices did not comply with current facility policies.
A resident was not offered the pneumococcal vaccination upon admission due to confusion over consent responsibilities and lack of a Unit Manager. The resident's immunization status was not updated in the EHR, and the facility's policy requiring vaccination assessment within five days was not followed.
The facility failed to notify CMS and apply for a name change to include Doing Business As (DBA) in accordance with 42 CFR 424.516. The facility's documentation inconsistently used the names The Grove Center for Rehabilitation and Healthcare and The Grove at Cherry Hill, while the official license listed Silver Healthcare Center. The Executive Director admitted they had not completed the necessary CMS 855 B form, leading to the deficiency finding.
Failure to Maintain Continuous 1:1 Supervision for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate monitoring and supervision to prevent a fall for a resident who was assessed as high risk for falls and placed on one-to-one supervision. The resident had multiple diagnoses including rib fractures, head laceration, prior unspecified fall, muscle weakness, lack of coordination, and unspecified dementia with moderate cognitive impairment (BIMS 12/15). The resident used a wheelchair, had impaired upper extremity range of motion, and was dependent on staff for transfers. Prior to the cited event, the resident had a history of falls, including an unwitnessed fall where the resident reported bumping their head and another unwitnessed fall in the bathroom resulting in a head hematoma and laceration, after which the resident’s fall risk score increased and one-to-one supervision was initiated. On the date of the incident, the resident was on one-to-one monitoring during the 3:00 PM–11:00 PM shift. The CNA assigned as the one-to-one monitor stated that she was responsible for remaining with the resident at all times unless relieved, consistent with facility expectations. Near the end of her shift, this CNA reported informing an LPN that the resident required one-to-one monitoring and stated that the LPN then asked another CNA to watch the resident, although she could not identify that CNA. The unit manager and DON both stated that a resident on one-to-one supervision should always have a staff member with them and that supervision should not be discontinued until another staff member confirms taking responsibility, as required by the facility’s continuous 1:1 supervision policy. Around the time of shift change, documentation and staff statements showed a gap in clearly assigned supervision. The RN’s incident report and handwritten statement indicated that the resident’s one-to-one monitor had left and that the RN was unsure when the one-to-one and the resident separated or whether the resident had been placed in the care of the LPN. The LPN’s written statement indicated that no one spoke with him about the resident’s care and he denied assuming responsibility or witnessing the fall. Another CNA reported clocking in shortly after 11:00 PM, seeing the resident in a wheelchair across from the nurse’s station, and then observing the resident stand and walk, with the wheelchair spinning and the resident striking their face and arm before the CNA could reach them; this CNA did not state that she had been assigned as the one-to-one monitor. The resident sustained a skin tear to the arm and later was noted to have a forehead bruise and new-onset aphasia, and was subsequently admitted to the hospital with a subdural hematoma. The DON acknowledged that assignment sheets did not identify who was assigned as the resident’s one-to-one monitor for the 11:00 PM–7:00 AM shift, demonstrating that the facility did not ensure continuous, clearly assigned one-to-one supervision as required by its policy.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Lapses in Environmental Controls
Penalty
Summary
A cognitively impaired resident with a history of exit-seeking behaviors and prior elopement attempts was not adequately supervised, resulting in the resident eloping from the facility. The resident was on a 15-minute monitoring schedule, and staff last observed the resident pacing in the hallway before the incident. The assigned CNA was providing care to another resident and did not inform the nurse that she would be unavailable to monitor the resident at risk for elopement. The nurse was also engaged in medication pass and was not aware that the CNA was occupied, leading to a lapse in supervision. During this period, the resident was able to leave the unit, likely by following a visitor into an elevator that did not require a keypad code for operation at the time. The facility's protocol did not require a code to use the elevator, allowing residents or others to access the first floor without restriction. The receptionist, responsible for monitoring the main entrance, did not notice the resident leaving, possibly due to increased activity and the presence of a transport company at the entrance. The resident exited the building without being detected and was later found in a nearby strip mall parking lot. Facility documentation and staff interviews confirmed that the resident was identified as an elopement risk, with care plans and progress notes indicating the need for close observation and safety precautions. Despite these documented risks and interventions, the lack of communication between staff and insufficient environmental controls contributed to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #2 had head-to-toe assessment, placed on one-to-one monitoring for observation and emotional support.
- If elevator #1 is required, the visitor, vendor and/or transportation staff will be escorted by a staff member on and off elevator #1 until elevator access could be restricted.
- Restricted access to elevator #1 by installing keypad inside elevator and designating only receptionists, designees who cover receptionists, and leadership staff have the code, resulting in the elevator being inoperable to all other staff, visitors and residents.
- All codes changed and will be changed monthly, or as needed.
- All exit doors checked by maintenance for proper functioning and locking mechanism.
- Facility reviewed and updated elopement binders on each unit and by the receptionist area.
- Facility audited EMRs for presence of resident's profile pictures.
- Facility audited new admissions for presence of the elopement risk evaluation and corresponding care plan (if applicable).
- Facility conducted additional elopement drills on day, evening, and night shifts.
- Additional security measures added to include keypads inside and outside of the elevator, restricting access to elevator operation.
- Court-1 (first floor) outside Elevator #1 keypad code needed to access elevator by designated staff only.
- Elevator #1 keypad inside elevator code needed to operate first floor button (#1) to activate elevator to access first floor when on Court-2 (second floor).
- Code only given to receptionist, and designees who cover receptionists, and leadership staff.
- Receptionist and designees who cover the desk educated not to give out keypad codes.
- Added alarms to all court building stairwell exit/egress.
- Larger sign at the entrance to the elevator, redirecting visitors to the other elevator.
- Receptionist and designees who cover receptionists educated to wait to release the main entrance doors until anyone attempting to exit is identified as staff, visitors, vendors and authorized resident only.
- Elopement policy reviewed.
- ADON or designee, initiated re-education of staff members on the elopement policy and procedure.
- ADON or designee, initiated education to changes to the elevator #1 access with keypads restricting operation.
- Agency, PRN, and employees on PTO will be educated prior to their next scheduled working shift/day.
- The DON or designee audited current residents for elopement risk and implemented immediate interventions if a high elopement risk score is triggered.
- The DON or designee audited new admissions for elopement risk and implement immediate interventions if a high elopement risk score is triggered weekly.
- The DON or designee evaluated elopement risk for residents who present with new wandering/exit seeking behaviors as soon as the behavior is identified and weekly.
- The DON or designee conducted weekly observations of staff/visitors/vendors safety practices when entering and exiting secured units.
- Findings from audits and observations will be reported to the monthly QAPI Committee.
Incomplete DEA 222 Forms for Controlled Medications
Penalty
Summary
The facility failed to ensure that all DEA 222 forms were completed with sufficient detail for accurate accountability and reconciliation of controlled medications. This deficiency was identified in six out of six DEA 222 forms reviewed in the backup controlled medication storage area. The forms, dated between August and December, were missing the number of controlled medications received and the date they were received, as required in Part 5 of the form. The Director of Nursing (DON) was unaware of the requirement to fill in Part 5, as she had not read the instructions on the form and was following previous instructions given to her. Interviews with the facility's pharmacy provider and the Medical Director (MD) revealed that the process required the purchaser, or nursing home, to complete Part 5 of the DEA 222 forms. The Pharmacist and the Chief Executive Officer/Consultant Pharmacist (CEO/CP) confirmed that the nursing department was responsible for documenting the quantity and date of receipt of controlled medications. The MD stated that he only signed the forms and was not involved in the receipt of medications. The CEO/CP noted that the Consultant Pharmacist, who checked the forms quarterly, had not verified the completion of Part 5, which was a mandatory requirement according to Board of Pharmacy regulations.
Plan Of Correction
1. No resident had a negative outcome due to the deficient practice of incomplete 222 forms section 5. On 12/20/2024, US FOIA (b)(6) received 1:1 education by the Regional Director of Nursing on the importance of completing section 5 of the 222 form and attaching the packing slip when medication is received. 2. All residents on narcotic medication have the potential to be affected by the deficient practice. Section 5 of the 222 forms were reviewed to ensure completion. 3. On 12/20/2024, the Regional Director of Nursing educated the US FOIA (b)(6) on the importance of completing section 5 of the 222 forms. In addition, a new process was implemented where the pharmacy consultant will audit 222 forms on a monthly basis. 4. The Director of Nursing will audit 222 forms weekly for 4 weeks, and then monthly for 2 months. Results of these audits will be reported to the QAPI Committee monthly for 3 months.
Failure to Follow Physician's Orders and Nursing Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to a physician's order and professional standards of nursing practice during medication administration for two residents. In the first instance, an LPN was observed administering a Lidocaine 4% Patch to a resident's left knee without removing the previous patch as per the physician's order. The order specified that the patch should be removed at bedtime, but it was left on overnight due to a transcription error in the electronic health record, which scheduled the removal for the following morning instead of at night. This error was not caught by the pharmacy review or the 24-hour chart check, leading to the patch being left on longer than its effective period. In the second instance, another LPN administered blood pressure medications to a resident without rechecking a low diastolic blood pressure reading or notifying the physician. The resident's blood pressure was recorded as 108/40, which is below the recommended threshold, yet the LPN proceeded with administering amlodipine and Torsemide without confirming the accuracy of the reading or consulting the physician for guidance. The resident had a history of hypertension related to chronic kidney disease, and the care plan included monitoring for side effects and obtaining blood pressure readings under consistent conditions. The facility's policy on administering medications requires that medications be given safely and timely, as prescribed, and that any concerns about dosages or potential adverse consequences be discussed with the attending physician. In both cases, the nurses failed to follow these protocols, leading to the administration of medications without proper adherence to the physician's orders or verification of vital signs, which could potentially impact the residents' health.
Plan Of Correction
1. A. Resident #34 had [R] as a result of the deficient practice of nurses not following physician's order to remove [R] after the ordered duration (12-hour after placement). The [R] was removed and [R] assessed with no [R] noted and replaced with the ordered [R]. The order was clarified and updated to reflect correct removal time. B. Resident #49 had [R] as a result of the deficient practice of not retaking a [R] after initially getting a [R] and administering the medication without consulting the physician regarding the concern. Resident's doctor was notified and assessed Resident #49 and there were no new recommendations. 2. A. All residents with lidocaine patch orders have the potential to be affected by this deficient practice of nurses not following physician's order to remove lidocaine patch after the ordered duration (12-hour after placement). B. All residents with blood pressure medications could be affected by the deficient practice of not retaking a blood pressure after initially getting a low diastolic blood pressure and administering the medication without consulting the physician regarding the concern. 3. A. On 12/20/2024, a one-on-one in-service was completed by the Assistant Director of Nursing with LPN#1 who was responsible for resident #34's EXEC order 26,451 in question on transcription policy and removal of as ordered. Additionally, all nurses received education by the Assistant Director of Nurses on the policy and procedure for following physician orders for including removal and transcription. An audit was conducted for NJ Exec Order 26.4b1 orders to ensure proper order transcription. No further issues identified. B. On 12/20/2024, a one-on-one in-service was completed by the Assistant Director of Nursing with LPN#2 who was responsible for resident #49's medication administration on holding medication and seeking physician consultation when vital signs results show NJ Exec Order 26.4b1. Additionally, all nurses received education by the Assistant Director of Nurses on the policy to hold medication and seek physician consultation when vital signs results show NJ Exec Order 26.4b1. 4. The Director of Nurses, Assistant Director of Nurses, and Unit managers will audit new orders for lidocaine patches weekly for 4 weeks and monthly for 2 months to ensure all resident lidocaine orders are transcribed properly and followed. The Director of Nurses, Assistant Director of Nurses, and Unit Managers will audit med pass weekly for 4 weeks and monthly for two months to ensure any concerning vital sign results are communicated to the Physician for consultation prior to administration of medication. The results of these audits will be reported to the QAPI committee monthly for 3 months.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during a medication administration observation. On December 17, 2024, an LPN was observed preparing medications for a resident without following appropriate hand hygiene protocols. After taking the resident's blood pressure, the LPN washed her hands for 15 seconds but found no paper towels available to dry them. She turned off the faucet with her bare hands and used a tissue to dry her hands without sanitizing them afterward. Later, the LPN prepared medications for another resident on Enhanced Barrier Precautions without performing hand hygiene and entered the resident's room without cleaning the blood pressure cuff. The LPN admitted to the surveyor that she should have used hand sanitizer after touching the faucet and acknowledged the risk of spreading germs by not cleaning the blood pressure cuff between residents. The LPN/Unit Manager and the LPN/Infection Preventionist confirmed that the LPN should have washed her hands after touching the faucet and cleaned the blood pressure machine between residents. The Director of Nursing also stated that the failure to clean the blood pressure cuff could pose an infection control issue. The facility's policies on hand hygiene and cleaning of reusable equipment were not followed, contributing to the identified deficiencies.
Plan Of Correction
1. Resident #33 and resident #49 had [R] as a result of the deficient practice of: a. LPN #1 who failed to properly perform hand hygiene after removing gloves. b. LPN #1 who failed to clean a NEXO cuff between residents. On 12/17/2024, Assistant Director of Nursing completed 1:1 education with LPN #1 on hand hygiene and disinfecting NJ Exec Order 26.4b1 cuff between residents. 2. All residents have the potential to be affected by these deficient practices. 3. On 12/17/2024, Infection Preventionist completed one on one education with LPN #1 on hand hygiene and proper infection prevention when donning and doffing Personal Protective Equipment (PPE) and disinfecting equipment between residents. Competency on hand hygiene was completed with nurse with satisfactory return demonstration. Additionally, education was initiated for all nurses on Hand Hygiene and proper infection prevention when donning and doffing PPE and disinfecting equipment between residents. Rounds and observations were completed to ensure staff were using proper hand hygiene when donning and doffing PPE and proper disinfecting of BP cuffs between residents. 4. Infection Preventionist will complete rounds weekly for 12 weeks to ensure all staff perform hand hygiene on proper infection prevention when donning and doffing PPE and disinfecting equipment between residents. The results of these audits will be reported to the QAPI committee monthly for 3 months.
Improper Storage of ABHR Exceeding Allowable Limits
Penalty
Summary
The facility failed to ensure proper storage of Alcohol Based Hand Rub (ABHR) dispensers, exceeding the allowable limit of five gallons in a single smoke compartment. This deficiency was observed in one of the three buildings, specifically in the Atrium Building #1, Resident room #308. During the survey, it was noted that there were 61 cases, each containing six one-liter containers of ABHR, amounting to approximately 96 gallons. The label on each dispenser indicated that the active ingredient was 80% ethyl alcohol, and it included warnings about flammability and the need to keep the product away from fire or flame. The survey conducted on December 17, 2024, revealed that the facility did not comply with the requirements for storing ABHR, as outlined in the NFPA 101 and related regulations. The dispensers were not stored in a proper location, which is a violation of the safety standards. This issue was brought to the attention of the facility's representatives during the Life Safety survey exit on December 18, 2024.
Plan Of Correction
1. No residents experienced negative outcomes as a result of the deficient practice of excess storage of alcohol-based hand rub sanitizer within a single smoke compartment. On 12/18/2024, the excess supply was immediately discarded appropriately. 2. All residents have the potential to be affected by this deficient practice. Additional supply closets were audited and no issues were found. 3. On 12/18/2024, Maintenance and Housekeeping staff were educated by the regional Plant Operations Director on proper storage of Alcohol-based hand rub sanitizer. 4. Maintenance Director/Designee will audit single smoke compartments for alcohol-based hand rub sanitizer storage monthly for x3 months. Any concerning findings will be corrected immediately. The results of these audits will be reported to the monthly Quality Assurance Performance Improvement committee.
Failure to Meet Minimum Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff to resident ratio as mandated by the State of New Jersey. This deficiency was identified during a recertification survey, which revealed that for two weeks prior to the survey, the facility did not meet the staffing requirements on six out of fourteen day shifts. Specifically, the facility was short of Certified Nurse Aides (CNAs) on multiple days, with the number of CNAs ranging from 10 to 15, whereas at least 16 CNAs were required for the number of residents present. Interviews with the Staffing Coordinator and the Director of Nursing confirmed that they were aware of the New Jersey minimum staffing requirements, which stipulate one CNA for every eight residents during the day shift. Despite this knowledge, the facility's staffing policy, revised in June 2024, which stated that staffing ratios would be reviewed and adjusted based on resident acuity and care needs, was not adhered to, resulting in the deficiency.
Plan Of Correction
1. No residents were affected by not meeting the State of NJ minimum staffing requirements as determined by routine monitoring and review on those dates that no significant changes were noted. 2. All residents could be affected by not meeting State of NJ minimum staffing requirements. 3. Recruitment and retention efforts continue to include: a. Job fairs b. Daily staffing meetings and weekly Regional Labor Management reviews c. Training mentor program to support retention d. Culture committee to improve and maintain staff morale 4. Recruitment bonus and sign-on bonuses offered. 5. Competitive wage analysis. 6. Hired Elite Recruiting to support increased recruiting of nurses and aides. 7. Weekend warrior program started. 8. To monitor and maintain ongoing compliance, the Director of Nursing or designee will monitor staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement team monthly for continued review and recommendations until substantial compliance is maintained.
Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined by New Jersey regulations for one day during the period from December 1, 2024, to December 14, 2024. Specifically, on December 1, 2024, the facility provided 360 actual staffing hours, which was 19.25 hours less than the required 379.25 staffing hours. This deficiency was identified through a review of the Nurse Staffing Reports for the specified weeks. During an interview on December 20, 2024, the Director of Nursing (DON) acknowledged that the facility's staffing was based on New Jersey's minimum requirements and the residents' acuity levels. The DON admitted that there were occasional days with low staffing but was unsure of the reasons behind these occurrences. The facility's staffing policy, revised in June 2024, stated that staffing ratios would be reviewed and adjusted based on resident acuity and care needs, ensuring sufficient personnel to provide high-quality care. However, the facility did not meet these requirements on the specified date.
Plan Of Correction
1. No residents were affected by not meeting the State of NJ minimum staffing requirements as determined by routine monitoring and review on those dates that no significant changes were noted. 2. All residents could be affected by not meeting State of NJ minimum staffing requirements. 3. Recruitment and retention efforts continue to include: a. Job fairs b. Daily staffing meetings and weekly Regional Labor Management reviews c. Training mentor program to support retention d. Culture committee to improve and maintain staff morale 5. Recruitment bonus and sign-on bonuses offered. 6. Competitive wage analysis. 7. Hired Elite Recruiting to support increased recruiting of nurses and aides. 8. Weekend warrior program started. 4. To monitor and maintain ongoing compliance, the Director of Nursing or designee will monitor staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement team monthly for continued review and recommendations until substantial compliance is maintained.
Failure to Submit Emergency Preparedness Plan for Review
Penalty
Summary
The facility failed to send a copy of their Emergency Preparedness Plan (EPP) to the Camden County Office Emergency Management (CCOEM) and Local Office Emergency Management (LOEM) officials for review, as required by NJAC 8:39-31.6(h). This deficiency was identified during a review of the EPP book on December 18, 2024, at approximately 8:45 AM, which revealed no evidence of the EPP being sent to the relevant emergency management offices. During an interview, the Administrator was unable to provide evidence of the EPP being sent from January 1, 2023, through December 16, 2024. The deficiency was communicated to the Administrator and Maintenance Director during the Life Safety survey exit on December 18, 2024, at approximately 1:34 PM. This oversight had the potential to affect all 132 residents of the facility.
Plan Of Correction
1. No residents were affected by deficient practice of failing to send a copy of the facility Emergency Preparedness Plan to the County Office of Emergency Management. On 12/18/2024, an email request was sent to the County Office of Emergency Management to schedule a review of the facility's Emergency Management Plan. 2. All residents could be affected by deficient practice of failing to send a copy of the facility Emergency Preparedness Plan to the County Office of Emergency Management. 3. On 12/18/2024, a 1:1 education was completed by the Regional Plant Operations Manager with the US FOIA (b)(6) on the requirement to request an annual review of the facility's Emergency Preparedness Plan. 4. To monitor and maintain ongoing compliance, the Administrator and Regional Director of Plant Operations will review the facility's Emergency Preparedness Plan annually and ensure the Director of Maintenance requests review by the County Office of Emergency Management. The review and request to the County Office of Emergency Management will be presented to the Quality Assurance and Performance Improvement team annually to ensure compliance is maintained.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation, leading to several deficiencies observed by the surveyor. In the kitchen's dry storage area, an opened bag of rainbow pasta was found with a hole, exposing it to contamination. Similarly, in the walk-in freezer, opened boxes of frozen pancakes and French toast slices were improperly stored on milk crates, leaving them exposed. The walk-in refrigerator had an excessive amount of dust-like debris on the fan guard, which had not been cleaned despite a verbal request to maintenance. Additionally, opened boxes of frozen breaded chicken patties were found exposed in the freezer. In the Court 2 pantry, the ice machine was found to have a brown/green/black substance on the drip ledge, indicating it was dirty and needed cleaning. The maintenance department was responsible for cleaning the ice machine, but it was not scheduled for cleaning until the following month. In the Court 1 pantry, an opened bottle of Refresher Antibac Foam was stored alongside food items, which is against facility policy. A take-out container with dried food debris was also found in the same cabinet. The dishwashing process was compromised as the facility ran out of chemical sanitizer for the low-temperature dish machine. The dietary aide confirmed that dishes were being washed without sanitizer, and the interim Food Service Director was aware of the issue. The facility's policy requires a chlorine level of 50 ppm for sanitization, but the test strip indicated 0 ppm. The Regional Director later obtained liquid bleach to rectify the situation. Additionally, a quarter pan of grape jelly was found partially covered in the reach-in refrigerator, exposing it to contamination. The facility's cleaning schedules and checklists failed to address the cleaning of the fan in the walk-in refrigerator/freezer.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations across different units. On Court 1, surveyors noted that trash receptacles in residents' rooms lacked bag liners, and trash, including soiled wound care pads and incontinence briefs, was improperly disposed of. Residents reported that staff did not regularly sweep the floors, leading to food debris accumulation. Interviews with the Housekeeping Director and the Licensed Nursing Home Administrator confirmed that trash receptacles should have liners and that soiled items should not be placed in room trash cans. In addition to cleanliness issues, the facility also exhibited significant maintenance deficiencies. Surveyors observed stained ceiling tiles, missing drawers, holes in walls, and broken window blinds in various rooms. Maintenance staff acknowledged awareness of some issues but had not addressed them due to workload constraints. The Maintenance Director admitted that certain repairs, such as fixing the roof leak and replacing broken blinds, were pending despite being marked as high priority in the work orders. Further observations revealed deteriorated windowsills with exposed rusted metal and rotted wood, as well as broken wall panels and mold-like substances on windows. These conditions posed potential safety hazards to residents. Interviews with staff, including CNAs and the Maintenance Director, highlighted a lack of timely reporting and repair of these issues. The Executive Director acknowledged the environmental damage and stated efforts were being made to increase maintenance rounds and address the deficiencies.
Failure to Develop Comprehensive Care Plans for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to develop comprehensive, resident-centered care plans for two residents, both of whom were dependent on ventilators. Resident #28 was admitted with acute respiratory failure and dependence on a respirator. Despite having a tracheostomy and requiring continuous oxygen, suctioning, and trach care, the care plan did not document these needs. The care plan was not completed within the required 24 hours of admission, as confirmed by the Unit Manager/LPN, who acknowledged that the ventilator care plan was only initiated days after admission. Similarly, Resident #116, admitted with acute and chronic respiratory failure and ventilator dependence, had a care plan that failed to document the use of a tracheostomy, ventilator, and oxygen. The care plan only mentioned respiratory impairment without specifying the resident's ventilator use. The Unit Manager/LPN confirmed the absence of a specific ventilator care plan, indicating a lack of comprehensive documentation for the resident's needs. Interviews with facility staff, including the Assistant Director of Nursing, revealed inconsistencies in the understanding and execution of care plan responsibilities. The ADON stated that baseline care plans should be completed on the day of admission, but there was uncertainty about the timeline for completing comprehensive care plans. The facility's policy mandates timely, person-centered care plans, but this was not adhered to, resulting in repeated deficiencies noted in the survey.
Resident Moved to Room with Non-Functional Bathroom
Penalty
Summary
The facility failed to promote resident dignity and ensure a safe, clean, and comfortable environment when a resident was transferred into a private room without a functional bathroom or accessible handwashing sink. The deficiency was identified in one of the facility's units, affecting one resident who was observed for accommodation of needs. The resident's room had a bathroom that was bolted shut due to water damage, rendering it unsafe for use. Maintenance staff confirmed that the bathroom was closed off after the sheet rock buckled, and repairs had not yet begun due to pending materials. The resident involved had a medical history that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, chronic diastolic heart failure, and aphasia. The resident was also noted to have severe cognitive impairment and was always incontinent of bowel and bladder. Despite these conditions, the resident was moved to a room with a non-functional bathroom, which was an error attributed to a former Unit Manager. Staff interviews revealed that the resident was using a bathroom in the hallway or the tub room bathroom instead. The facility's policies on Environment of Care and Resident Rights emphasize maintaining a safe and operable environment and ensuring residents have a safe, clean, and homelike environment. However, the facility failed to adhere to these policies, as evidenced by the lack of timely repairs and the inappropriate room transfer. The Licensed Nursing Home Administrator acknowledged the error and the need for a working bathroom for the resident's privacy and dignity. Maintenance records showed high-priority work orders for the room's repairs, but there was no documented evidence of completed repairs.
Failure to Follow Physician's Orders for Resident with Fracture
Penalty
Summary
The facility failed to follow physician's orders for a resident who was readmitted with a closed fracture of the fourth metacarpal bone. The resident was supposed to have a follow-up appointment with an orthopedic surgeon and was required to wear a prescribed splint. However, the resident was observed without the splint, and there was no record of the follow-up appointment being scheduled. The resident, who was severely cognitively impaired, was readmitted with a diagnosis of unspecified fracture and dementia, and the care plan included non-weight bearing instructions and a follow-up with orthopedics. The Licensed Practical Nurse/Unit Manager (LPN/UM) and Certified Nursing Assistant (CNA) confirmed that the resident did not have the splint on, and there was no documentation of an orthopedic follow-up. The Business Office Manager (BOM) and Licensed Nursing Home Administrator (LNHA) acknowledged that the facility was responsible for ensuring the resident attended the follow-up appointment, even if the resident's Medicaid was pending. The BOM had informed the former Unit Manager that the facility should cover the cost of the appointment, but the follow-up was not pursued. The Director of Rehabilitation and Occupational Therapist noted that the resident had removed the splint, and the order for the splint was not discontinued despite the resident's non-compliance. The facility's policy required documentation of splint use and removal for skin assessment, which was not consistently done. The Director of Nursing stated that nursing should document splint use every shift, but this was not adhered to, contributing to the deficiency.
Improper Management of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, as evidenced by multiple observations of improper catheter drainage bag management. During an initial tour, a surveyor observed the resident's catheter drainage bag in contact with the floor, which was not secured to the bed frame as required. On a subsequent observation, the drainage bag was found outside of its privacy bag, exposing its contents, and the privacy bag was not positioned correctly. These observations were contrary to the physician's order and the resident's care plan, which specified that the drainage bag should be kept below the bladder and off the floor, and that a dignity bag should be used when the resident is out of bed or in a low bed. Interviews with the facility's Infection Preventionist and Director of Nursing confirmed that the catheter drainage bag should not be in contact with the floor due to the risk of infection. The facility's policy on urinary catheters, dated April 2024, explicitly stated that catheter tubing, bags, or spigots should not touch the floor, highlighting the increased risk of infection for residents with urinary catheters. Despite these guidelines, the facility did not adhere to the established standards of practice, resulting in a deficiency in the care provided to the resident.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide continuous oxygen to an oxygen-dependent resident in accordance with physician's orders, as observed during a survey. Resident #37, who was diagnosed with acute respiratory failure with hypoxia, COPD, chronic diastolic heart failure, and aphasia, was found without oxygen delivery while seated in a wheelchair. The resident's oxygen tank was empty, and the oxygen concentrator was not in use, with tubing dated from two weeks prior. The resident's call bell was also out of reach, preventing them from seeking assistance. Staff interviews revealed that the CNA was not aware of the resident's oxygen needs and had not checked the resident's room. The CNA attempted to switch the resident to an oxygen concentrator, which was not functioning properly, and informed the nurse. The LPN confirmed the oxygen tank was empty and the concentrator was not set correctly. The LPN also noted that the oxygen tubing was outdated and the call bell was misplaced, which could have posed a risk to the resident. In another instance, Resident #33, who had a tracheostomy and required oxygen therapy, was found with undated respiratory equipment and tubing that had not been changed in over a month. The facility lacked a physician's order for the oxygen flow rate, and the equipment was not maintained according to professional standards. The Infection Control Preventionist Nurse and Unit Manager acknowledged these deficiencies, indicating a failure to adhere to the facility's oxygen administration policy.
Narcotic Shift Count Log Discrepancies
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs in accordance with its policy, as observed during a survey. On two separate medication carts, the surveyor found missing nursing signatures and pre-signed sections in the narcotic logbooks. Specifically, on the Pavilion nursing unit's medication cart, there were missing signatures for certain shifts and pre-signed entries for others. Similarly, on the Vent nursing unit's medication cart, there were missing signatures for specific shifts. Licensed Practical Nurses (LPNs) confirmed these discrepancies, acknowledging that the logs should not have pre-signed sections and that all counts should be documented at the time they are completed. The Assistant Director of Nursing (ADON) confirmed that the facility's policy requires incoming and outgoing nurses to count narcotics together and sign the logs to confirm the count. The facility's Controlled Substances policy, reviewed in January 2024, mandates that controlled medications be counted at the end of each shift, with any discrepancies reported to the Director of Nursing Services. The surveyor's findings indicate a failure to adhere to this policy, as evidenced by the missing and pre-signed entries in the narcotic logbooks.
Improper Storage and Labeling of Multidose Medications
Penalty
Summary
The facility failed to properly store and label opened multidose medications, as observed by a surveyor. During an inspection of the Vent nursing unit's medication cart, three opened fluticasone propionate nasal spray bottles were found without the date of opening or resident identifying information. An LPN present during the observation confirmed that the facility's protocol requires nurses to date the medication container and label it with the resident's name to ensure proper identification and prevent mix-ups. Additionally, in the Court 1 nursing unit's medication storage room, an opened and undated vial of tuberculin purified protein derivative (PPD) was found in the medication refrigerator. The Unit Manager/LPN acknowledged that the vial should have been dated with the opened date on the vial itself, as it is used for multiple residents. The Assistant Director of Nursing reiterated the expectation that opened multidose medication containers should be dated, emphasizing that some medications have a shorter expiration date once opened. The facility's policy mandates that improperly labeled drugs be returned to the pharmacy for proper labeling before storage.
Infection Control Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to adhere to accepted standards of infection control practices in the storage of respiratory tubing and hand hygiene during respiratory care treatment. For Resident #33, the surveyor observed a suction catheter (Yankauer) improperly stored in a bedside drawer, uncovered and touching other items, over multiple days. The resident, who had a tracheostomy and required oxygen and suctioning, was at risk due to this improper storage. Interviews with the Infection Preventionist and the Respiratory Therapist confirmed that the storage did not comply with the facility's policy, which required the catheter to be stored in a plastic sleeve and bag after use. For Resident #42, the surveyor observed a respiratory therapist performing tracheostomy care without proper hand hygiene between glove changes. The resident, who was cognitively intact and dependent on a ventilator, required tracheostomy care every shift. The respiratory therapist failed to use alcohol-based hand rub after removing gloves and before donning new ones, contrary to the facility's hand hygiene policy. The Infection Preventionist confirmed that hand hygiene should be performed between glove changes and noted that the respiratory therapist was following an outdated policy. The facility's policies on suctioning and hand hygiene were not followed, leading to deficiencies in infection control practices. The Infection Preventionist acknowledged the improper storage of equipment and the outdated policy used by the respiratory therapist. The facility's hand hygiene policy required the use of alcohol-based hand rub after contact with inanimate objects and after removing gloves, which was not adhered to during the observed tracheostomy care.
Failure to Administer Pneumococcal Vaccine Upon Admission
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccination was offered to all residents upon admission, specifically for one resident who was reviewed for immunization administration. This deficiency was identified during a survey when a resident was observed with stitches and was unable to recall how the injury occurred. The resident's admission record indicated diagnoses including Alzheimer's Disease and a history of COVID-19, with no known allergies. The resident's immunization status in the Electronic Health Record (EHR) showed an undated entry for Pneumovax 20, indicating a requirement for the immunization. However, the resident's Annual Minimum Data Set (MDS) assessment revealed that the pneumonia vaccine was not up to date due to an unspecified medical contraindication. Interviews with facility staff, including an LPN and the Infection Preventionist (IP), revealed confusion and lack of clarity regarding the responsibility for obtaining consent for the vaccination. The LPN was unsure who was responsible for obtaining consent, while the IP stated that the resident should have been offered the vaccination upon admission, with consent required from a family member due to the resident's cognitive impairment. The IP acknowledged that there was no Unit Manager assigned to the nursing unit, which may have contributed to the oversight. The facility's policy required assessments of pneumococcal vaccination status within five working days of admission, but this was not adhered to in this case, leading to the delay in vaccination administration for the resident.
Failure to Notify CMS of Name Change
Penalty
Summary
The facility failed to notify the Centers for Medicare & Medicaid Services (CMS) and apply for a change in name to include Doing Business As (DBA) in accordance with 42 CFR 424.516. This deficiency was identified through interviews and a review of facility documentation. The facility's admission and arbitration agreements listed the name as The Grove Center for Rehabilitation and Healthcare, while business cards and other documents referred to it as The Grove at Cherry Hill. However, the facility's license, issued by the New Jersey Department of Health, listed the name as Silver Healthcare Center. During an interview, the Licensed Nursing Home Administrator (LNHA) and the Executive Director (ED) acknowledged that they had not applied for a CMS 855/chow (Change of Ownership) form and were using The Grove name for marketing purposes. The Executive Director stated that the facility was operating under a DBA, allowing them to use both names, but admitted that they had not completed the necessary CMS 855 B form. The surveyor pointed out the inconsistency in the facility's documentation, which included the use of The Grove name in admission agreements and arbitration agreements. The ED acknowledged that changing the documentation would be easy but had not yet taken steps to align the facility's official name with its marketing and operational practices. This failure to comply with federal regulations regarding name changes and enrollment status updates led to the deficiency finding.
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What surveyors actually found near you
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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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Barclays Rehabilitation And Healthcare Center | 1.8 mi | ★★★★★ | 7 | 0 |
| Dwellside Care And Rehab | 2.5 mi | ★★★★★ | 2 | 1 |
| St Mary's Center For Rehabilitation & Healthcare | 2.8 mi | ★★★★★ | 1 | 0 |
| Premier Cadbury Of Cherry Hill | 2.8 mi | ★★★★★ | 27 | 0 |
| Aristacare At Cherry Hill | 3.3 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.