Masonic Village at Burlington

Inspectors wroteComplaint # 405694Based on interviews, review of medical records, and review of other pertinent facility documents on 1/22/26 and 1/28/2026, it was determined that the facility failed to honor and communicate a cognitively intact resident's expressed preference regarding personal care providers, resulting in the resident receiving care inconsistent with their stated preferences. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1), as evidenced by the following:According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: left shoulder fracture. According to the Minimum Data Set (MDS), an assessment tool dated 5/7/2025, revealed that resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. [...]

Inspectors wroteComplaint #405694Based on interviews, review of medical records, and review of other pertinent facility documents on 1/22/26 and 1/28/2026, it was determined that the facility failed to notify the New Jersey Department of Health (NJDOH) of an injury of unknown origin, specifically an alleged unwitnessed fall resulting in a hip fracture, as required. This deficient practice was identified for 1 of 4 residents reviewed (Resident #2), as evidenced by the following:According to the admission Record (AR), Resident #2 was admitted with diagnoses that included, but were not limited to, Nontraumatic chronic subdural hematoma. According to the Minimum Data Set (MDS), an assessment tool dated 12/6/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. [...]

Inspectors wroteComplaint #: NJ 174085 Refer to F 610 Based on observation, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to protect a cognitively impaired resident from physical abuse and ensure all other residents were protected from potential abuse. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #51). A review of an abuse investigation revealed on 5/23/24 at 9:45 PM, on the Dementia Unit, a Licensed Practical Nurse (LPN #1) was informed by a Certified Nurse Aide (CNA #1) that a cognitively impaired resident (Resident #51) had a 7 centimeter (cm) left forearm skin tear that required several steri-strips (wound bandage) from the resident (Resident #51) scratching themself and had a 3 cm by 4 cm right posterior hand discoloration. [...]

Inspectors wroteComplaint #: NJ 174085 Refer to F 600 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #51). A review of an abuse investigation revealed on 5/23/24 at 9:45 PM, on the Dementia Unit, a Licensed Practical Nurse (LPN #1) was informed by a Certified Nurse Aide (CNA #1) that a cognitively impaired resident (Resident #51) had a 7 centimeter (cm) left forearm skin tear that required several steri-strips (wound bandage) from the resident (Resident #51) scratching themselves and had a 3 cm by 4 cm right posterior hand discoloration. [...]

Inspectors wroteComplaint #: NJ 174543 Repeat Deficiency Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure special dietary instructions were implemented for a cognitively impaired resident who was identified as being at risk for choking and aspiration (inhaling food into the lungs) and required nectar thick liquids (liquid thickened with an agent for a nectar-like consistency), did not receive a straw. This deficient practice was identified for 1 of 2 residents review for food (Resident #3), and it was previously cited during a complaint visit. During a breakfast observation on 3/25/25, the surveyor observed Resident #3 in the Lilac Bistro eating their meal and the resident began to forcibly cough. The surveyor observed Resident #3 had a half-filled plastic cup with a straw inserted through the lid. [...]

Inspectors wroteBased on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to identify the causal factor and implement appropriate interventions to prevent recurrence and consistently follow fall prevention interventions documented on the Care Plan. This deficient practice was identified for 1 of 2 residents (Resident # 76) reviewed for falls and accidents and was evidenced by the following: On 3/24/25 at 9:49 AM, the surveyor observed Resident #76 in bed, the head of the bed was elevated. A fall mat was observed on the left side of the bed and the call light and blanket were observed on the floor. The resident could not answer the surveyors questions. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits, and documented progress notes at least every 60 days. This deficient practice was identified for 3 of 3 residents (Resident #8 and #22, #76) reviewed for physician care and was evidenced by the following: 1. On 3/22/25 at 10:30 AM, the surveyor observed Resident #8 in bed, the resident requested to speak with the surveyor. The resident informed the surveyor that they had not seen their assigned physician for nine months. The resident stated that the Nurse Practitioner (NP) visited monthly for 5 minutes, and then charged for a 30 minute visit. The surveyor reviewed Resident #8's medical records. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to a) ensure the infection control practices for residents on transmission-based precautions (TBP) were implemented in accordance with accepted national standards, and b) ensure the facility's infection control for TBP policy reflected evidence-based standards of infection control practices. This deficient practice was identified for 3 of 3 residents reviewed on TBP (Resident #22, #8 and Resident #37 and was evidenced by the following: 1. On 3/21/25 at 10:14 AM, the surveyor observed a plastic bin with drawers outside the room for Resident #22. The drawers had personal protective equipment (PPE) including gowns and gloves. A sign affixed to the resident's door indicated the following: Contact Precaution and specified the proper Personal Protective Equipment to wear prior to entering the room. [...]

Inspectors wroteBased on observation, interviews and record review, as well as review of pertinent facility documents on 10/08/24 and 10/10/24, it was determined that the facility failed to implement a care plan dated 8/06/2024 that identified a nutritional risk. The care plan revised on 8/6/24 listed a ground texture diet with thin liquids as an intervention. On 9/29/24, Resident #2, with a diagnosis of Dysphagia (difficulty swallowing) and Cerebral Infarction (Stroke), had a Physician's Diet order for Mechanical Soft Ground texture, was served a regular consistency hot dog on a bun by the assigned Certified Nursing Assistant (CNA #2). After serving Resident #2 their lunch tray, CNA #2 left and went to assist another resident. On her way out of assisting the other resident, CNA #2 observed Resident #2's call light on. [...]

Inspectors wroteBased on observation, interviews and record review, as well as review of pertinent facility documents on 10/08/24 and 10/10/24, it was determined that the facility failed to provide a mechanically altered diet as the physician prescribed for 1 of 4 sampled resident (Resident #2), on 9/29/24, who had a Physician's Diet order for Mechanical Soft Ground texture. Resident #2, with a diagnosis of Dysphagia (difficulty swallowing) and Cerebral Infarction (Stroke), was served a regular consistency hot dog on a bun by the assigned Certified Nursing Assistant (CNA #2). After serving Resident #2 their lunch tray, CNA #2 left and went to assist another resident. On her way out of assisting the other resident, CNA #2 observed Resident #2's call light on. CNA #2 responded to Resident #2's call light and observed the resident was blue and choking. [...]

Inspectors wroteBased on observation, interviews and record review, as well as review of pertinent facility documents on 10/08/24 and 10/10/24, it was determined that the facility failed to provide a therapeutic diet for 1 of 4 sampled residents (Resident #2) on 9/29/2024, who had a Physician's Diet order for Mechanical Soft Ground texture. Resident #2, with a diagnosis of Dysphagia (difficulty swallowing) and Cerebral Infarction (Stroke), was served a regular consistency hot dog on a bun by the assigned Certified Nursing Assistant (CNA #2). After serving Resident #2 with lunch tray, CNA #2 left and went to assist another resident. On her way out of assisting the other resident, CNA #2 observed Resident #2's call light on. CNA #2 responded to Resident #2's call light and observed the resident was blue and choking. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) clarify and accurately transcribe a physician's order for an enema (a medication used to relieve constipation); b.) document the administration of the enema; c.) obtain physician's orders in accordance with professional standards of practice for tube feeding for the flushing of water before and after medication pass and checking residual to ensure accountability and consistency. The deficient practice was identified for 2 of 20 residents reviewed for professional standards of practice (Resident #43 and #778) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; [...]

Inspectors wroteBased on observations, interviews, and review of facility documentation, it was determined that the facility failed to a.) ensure respiratory equipment was kept in a clean and sanitary condition to prevent infection and ensure a portable oxygen tank was stored in accordance with facility policy and b.) develop an individualized care plan for the administration and treatment of oxygen. This deficient practice was identified for 1 of 1 residents reviewed for respiratory equipment (Resident #66), and the evidence was as follows: According to the facility's admission Record face sheet (an admission summary), Resident #66 was admitted to the facility with diagnoses that included but were not limited to heart failure (ineffective heart pumping resulting in fluid build-up in lungs), ischemic cardiomyopathy (weakened heart muscles due to heart disease), and asthma. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to appropriately label and date two Tubersol (tuberculin purified protein derivative [PPD]; a clear, colorless solution injected into the skin of the forearm that aides in the detection of tuberculosis). This deficient practice was identified in 1 of 2 medication storage rooms inspected in the facility (Magnolia nursing unit), and was evidenced by the following: On 6/21/23 at 11:30 AM, the surveyor inspected the medication storage room by the Magnolia nursing unit in the presence of the Registered Nurse (RN). At that time, the surveyor observed two opened and undated Tubersol solutions in the refrigerator. On 6/21/23 at 11:34 AM, the surveyor interviewed the RN who stated that the Tubersol was to be dated when it was opened. [...]