Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
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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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 | — | 1 | 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 | — | 0 | 0 |
| Laurel Brook Rehabilitation And Healthcare Center | 2.2 mi | — | 9 | 0 |
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