Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Cherry Hill Manor during CMS and state inspections, most recent first.
A hospice resident with severe cognitive impairment, COPD, CHF, and a documented comfort‑focused care goal experienced unmanaged pain and terminal agitation when PRN morphine and lorazepam ordered for pain, SOB, and anxiety were not administered in a timely manner. A provider ordered sublingual morphine and lorazepam intensol early in the afternoon, and a hospice RN later documented that the resident was actively dying with severe pain, moaning, labored breathing, and terminal agitation, noting that pain management was ineffective and that the unit LPN was seeking an override for needed medications. MAR review showed morphine was not given until several hours after the order and after the hospice assessment, and lorazepam was delayed even longer, despite both drugs being available in the Omnicell and E‑Kit. In interviews, the LPN stated she did not feel the resident needed morphine and waited for a pharmacy code, and she did not consider the E‑Kit lorazepam, while the DON acknowledged the facility nurse was responsible for assessing and administering PRN medications and could not show that care met professional standards; a family member reported the resident appeared to be in agonizing pain and anxiety during this period.
A resident admitted after spinal surgery with a Hemovac drain and surgical wound did not have a baseline care plan developed within 48 hours that addressed care instructions for the wound or drain. Nursing leadership confirmed the omission when interviewed, and the resident was later hospitalized after presenting with signs of infection.
A resident with a Hemovac drain following spinal surgery did not have their drain output monitored or documented as required by facility policy. There were no physician orders for drain management, and staff could not provide evidence of required monitoring or documentation. This failure was confirmed by interviews with nursing staff, the DON, and the facility physician, as well as by the lack of documentation provided to the surgeon's office.
Two LPNs provided care to a resident with a Hemovac drain following spinal surgery without having received training or competency assessment specific to Hemovac drain care, as confirmed by staff interviews and facility records. The facility did not provide required education or competencies for this procedure, despite policy and resident needs.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound requiring dressing. Despite signage indicating the need for gown and glove use during high-contact care activities, staff were observed not adhering to these precautions. Interviews revealed a lack of understanding and adherence to the EBP policy, and the facility was unable to provide evidence of consistent EBP implementation.
Failure to Provide Timely End‑of‑Life Pain and Anxiety Management for a Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate end‑of‑life pain and symptom management for a hospice resident in accordance with physician orders and professional standards of practice. The resident was admitted with multiple chronic conditions, including COPD and CHF, and had severe cognitive impairment, requiring moderate to maximum assistance with ADLs. A provider note documented that the resident had recently presented with fever, shortness of breath, hypoxia, lethargy, and crackles throughout the lungs, and that the family’s and resident’s primary goal of care was comfort. The provider discussed hospice with the family, obtained consent for PRN morphine, lorazepam, and atropine drops for comfort, and sent a hospice referral, with the expectation that hospice would assess the resident that evening. Physician orders were entered for lorazepam intensol 0.25 mL every 4 hours PRN for anxiety/agitation and morphine 0.25 mL every 4 hours PRN for pain/shortness of breath early in the afternoon. A hospice RN assessed the resident later that day and documented that the resident was actively dying, with abnormal vital signs, severe pain (pain score 7/10), moaning, labored breathing, hyperventilation episodes, loud moaning or groaning, crying, and inability to be consoled, as well as agitation, disorientation, lethargy, and restlessness attributed to terminal agitation. The hospice RN noted that an order for sublingual morphine had been written earlier in the day but that the medication had not yet arrived from the pharmacy, and that the unit LPN was calling to obtain an override for needed medications. The hospice RN documented that current pain management was not effective and that they were awaiting morphine from the pharmacy. Medication administration records showed that morphine was not administered until 6:39 PM, approximately four and a half hours after it was ordered and about two hours after the hospice nurse’s assessment documenting severe pain. Lorazepam intensol was not administered until 10:40 PM, approximately nine hours after it was ordered and about six and a half hours after the hospice nurse’s assessment documenting anxiety and terminal agitation. Review of the Omnicell and the emergency E‑Kit showed that morphine and lorazepam intensol were available in the facility and could have been administered earlier. In interviews, the hospice nurse reported that the resident had periods of extreme anxiety and agitation and that the LPN stated she was waiting for a code from the pharmacy before administering morphine. The LPN who cared for the resident during the 3 PM–11 PM shift stated that the resident was sweaty, warm, reaching out for people’s hands, and had arthritis pain, and that she did not feel the resident needed morphine, so she waited to get a code from the pharmacy and administered it later in the evening; she also stated she did not think about the availability of lorazepam intensol in the E‑Kit. The DON acknowledged that the hospice nurse is not employed by the facility and that the facility nurse is responsible for assessing the resident and administering PRN medications, and could not provide evidence that the resident received treatment and care in accordance with professional standards of practice for end‑of‑life medications. Additionally, earlier in the resident’s course, a progress note documented that hospice services had been discussed with the family and that an informational consult in Spanish was requested, with the writer indicating an intent to contact hospice agencies to advocate for that request. Record review did not show evidence that the facility contacted a hospice agency to facilitate the requested informational consultation in Spanish at that time. The hospice agency’s director later reported that the agency did not receive a referral for the resident prior to the date the resident was ultimately admitted to hospice. A family member complainant reported that on the afternoon before the resident’s death there was a delay in providing the ordered morphine and lorazepam, that the resident appeared to be in agonizing pain and anxiety, and that the resident’s feet were hanging off the bed when the family member entered the room. The facility’s failure to use available medications from the Omnicell and E‑Kit and to administer ordered morphine and lorazepam in a timely manner, despite clear signs of severe pain and terminal agitation and the established comfort‑focused goals of care, led to unmanaged pain, terminal agitation, and psychosocial distress during the resident’s final hours of life.
Failure to Develop Baseline Care Plan for Surgical Wound and Hemovac Drain
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted following spinal fusion surgery and required orthopedic aftercare. Upon admission, documentation indicated the presence of a surgical dressing on the posterior back and a Hemovac drain with serosanguineous drainage. However, review of the baseline care plan revealed no evidence of care planning related to the surgical wound or the Hemovac drain, including necessary treatments or interventions. A complaint submitted to the state health department indicated that the resident was later found to be not alert, babbling, lethargic, and altered during a post-operative visit, with lab results showing elevated white blood cells. The resident was subsequently sent to the emergency room and admitted to the hospital for further care. During interviews, facility nursing leadership acknowledged the omission of instructions in the baseline care plan regarding the surgical wound and Hemovac drain.
Failure to Monitor and Document Hemovac Drain Output per Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in the care of a resident with a Hemovac drain following spinal surgery. Upon admission, documentation noted the presence of a surgical dressing and Hemovac drain with serosanguineous drainage, but there was no evidence that the output from the drain was measured or recorded according to facility policy, which requires emptying and measuring every 4 to 8 hours. Review of the resident's medical record revealed a lack of physician orders for monitoring, emptying, or documenting the Hemovac drain's function and output during the resident's stay. Staff interviews confirmed that there was no documentation or recollection of orders related to the drain, and the Assistant Director of Nursing and Director of Nursing were unable to provide evidence of required monitoring or orders for the drain during the relevant period. Further, during a follow-up appointment, the facility was unable to provide documentation of the Hemovac drain's output to the surgeon's physician assistant, who expected at least twice-daily monitoring and documentation. The facility physician also stated that standard practice includes having orders to monitor drainage, ensure proper function, and observe for infection. The lack of documentation and physician orders for the Hemovac drain's management, as well as the absence of output monitoring, constituted a failure to meet professional standards of quality for this resident.
Lack of Nurse Competency for Hemovac Drain Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide care for residents with specific needs, as required by the facility assessment. Record review showed that the facility's resident population may include individuals with surgical wounds, and that nurse competencies should be completed during orientation, annually, and as dictated by resident care needs. Despite this, two LPNs who cared for a resident with a Hemovac drain following spinal fusion surgery reported not receiving any training specific to Hemovac drain care prior to providing care. The facility's policy on surgical wound treatment outlines the importance of proper management of closed-wound drains, including Hemovac drains, but the required competencies were not provided to the nursing staff. Interviews with the LPNs and the Director of Nursing Services confirmed that the facility did not provide education or competencies related to Hemovac drain care for any nursing staff. Documentation showed that a resident was admitted with a surgical wound and Hemovac drain, and staff were responsible for the care of this device without having received the necessary training. This lack of training and competency assessment was identified for 2 of 5 staff reviewed, resulting in a failure to ensure resident safety and the maintenance of the highest practicable well-being as required by regulation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for a resident with a wound requiring dressing. The resident, admitted in July 2024, had a wound on the coccyx that required various treatments from October to December 2024. Despite the presence of signage indicating the need for gown and glove use during high-contact care activities, staff members were observed not adhering to these precautions. On December 10, 2024, Nursing Assistants and an LPN were seen assisting the resident without wearing the required protective gear, despite the posted instructions. Interviews with staff revealed a lack of understanding and adherence to the EBP policy. Staff acknowledged the signage but failed to comply with the requirements during care activities. The Infection Preventionist and other nursing leaders were unable to provide evidence that the facility consistently followed EBP protocols as per their policy. The deficiency was highlighted by the absence of EBP implementation for the resident, who had a wound requiring a dressing since October 29, 2024, but was not placed on EBP until December 10, 2024.
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Nursing homes near Johnston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincolnwood Rehabilitation And Healthcare Center | 2.1 mi | — | 9 | 0 |
| Golden Crest Nursing Centre | 2.2 mi | — | 8 | 0 |
| Briarcliffe Manor | 2.2 mi | — | 0 | 0 |
| Morgan Health Center | 2.4 mi | — | 2 | 1 |
| Elmhurst Rehabilitation And Healthcare Center | 2.5 mi | — | 10 | 1 |
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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 August 2026) and official state health department websites.