Cherry Hill for Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure arbitration agreements were signed by the resident or appropriate responsible party, and in a manner which was explained and understood by the resident or responsible party for four residents (R23, R35, R90, and R104) of reviewed for arbitration agreements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the cleanliness of the 200-hallway shower room for one (R105) and failed to maintain linen in good repair for one (R111) of three residents reviewed for the environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a low air loss mattress (LAL) was powered on for one resident (R59) of three reviewed for wound management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to float (positioning the heels to prevent sustained contact between the heels and the bed) a resident's heels per physician order for one (R19) of three resident's reviewed for pressure ulcer prevention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the behavioral health needs of one resident (R23) of one reviewed for behavioral health resulting in an assault of another resident.

Inspectors wroteBased on interview and record review, the facility failed to follow pharmacy recommendations for one resident (R77) of five reviewed for Medication Regimen Reviews (MRRs).

Inspectors wroteBased on observation, interview and record review, the facility failed to store medication not at the bedside for one resident (R50) of one resident reviewed for storage of drugs and biologicals.

Inspectors wroteThis citation pertains to MI00153028 and MI00153168. Based on observation, interview and record review, the facility failed to acknowledge and ensure the Durable Power of Attorney (DPOA) was allowed to exercise the residents' rights for one resident (R901) out of three residents reviewed for resident rights exercised by their representative.

Inspectors wroteThis citation refers to Intake MI00153374. Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff (Certified Nursing Assistant - CNA I) for one (R903) of three resident's reviewed for abuse.

Inspectors wroteThis citation pertains to Intake MI00153028. Based on observation, interview, and record review, the facility failed to develop a care plan for bladder incontinence with interventions to address resistance to toileting for one (R901) of two residents reviewed for care plans.

Inspectors wroteThis citation refers to Intake MI00153168. Based on observation, interview, and record review, the facility failed to identify 6% weight loss from 5/1/25 to 5/29/25 for one (R901) of three residents reviewed for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to answer call lights timely for eight confidential group meeting residents (C1, C2, C3, C4, C5, C6, C7, and C8) of 19 residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate space and privacy for resident counsel group meetings for 19 of 19 residents reviewed for organized group meetings.

Inspectors wroteThis citation relates to Intake #MI00146436. Based on observation, interview, and record review, the facility failed to provide palatable, appetizing meals at the proper temperature for 19 of 19 confidential group meeting residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place call light within reach and provide a closet door for two residents (R89 and R84) of four residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were labeled and dated when opened and or discarded when expired in two of four medication carts and one supply room reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store an oxygen tank in an safe manner involving one resident (R45) of four residents reviewed for environment.

Inspectors wroteThis citation pertains to Intakes M100144781 and M100145103. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for four (R701 and R703) of four residents reviewed for homelike environment.

Inspectors wroteThis citation pertains to MI00142238, MI00141119, MI00140817, MI00140327. Based on observation, interview and record review, the facility failed to ensure four residents (R904, R905, R906, R909) of four reviewed for adaptive equipment were allowed to have reachers (device about two feet long with a trigger/grip at one end that activates a jaw at the opposite end which can be used to grip and pick up items), resulting in feelings of lost independence, decreased self esteem, and fear of falls.

Inspectors wroteThis citation pertains to Intake MI00141238. Based on observation, interview, and record review the facility failed to provide safe storage of medication for three residents (R903, R907, and R908) of three residents reviewed for storage of biologicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen and ice machine in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteR52 On 8/28/23 at 9:44 AM, R52 was observed in bed and asked if they had any concerns related to the care that they have received in the facility, and explained that they would like to be shaved more often, and had questions about their dental care, specific to their dentures. A review of R52's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Heart Disease, Diabetes, and Seizures. Further review of R52's medical record including their care plan, revealed that the resident was severely cognitively impaired and required one staff participation with bathing and showers. A review of R52's medical record revealed that the resident is scheduled to receive showers on Tuesday and Fridays, and that within the last 30 days, the resident should have received nine showers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively identify an environmental hazard (metal kick plate), potentially affecting one of one resident (R4), in which created the potential for injury/skin laceration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) enter a stop date on an as-needed (PRN) anti-anxiety medication, 2) obtain informed consent for continued use of psychotropic medication, and 3) document attempts at non-pharmacological interventions prior to the administration of a PRN anti-anxiety medication, affecting one resident (R71) of five reviewed for unnecessary medications, resulting in the potential for prolonged unnecessary use of psychotropic medication without an appropriate diagnosis and consent, with the potential for adverse reactions and/or negative psychosocial outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure medications on two medication carts, for the residents that live on the 200 unit, resulting in the potential unauthorized access to residents medication.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for one sampled resident (R52) of one reviewed for medical records, resulting in untimely entry of nursing notes in the medical record and the potential for an inaccurate reflection of resident conditions/status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the survey binder was easily accessible to residents, and inform residents, families, and visitors of the location of the facility's survey results (Statement of Deficiencies -Form CMS-2567 and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent surveys) for four residents who attended a confidential group meeting, resulting in the potential for all residents, families, and visitors to be uninformed of the facility's deficient practices. Findings Include: On 8/29/23 at 11:10 AM, during the confidential group meeting, residents were asked if they knew where the facility's survey results were located. One resident stated, I think it's at the front while three other residents indicated that they did not know. [...]