Mount Holly Rehabilitation & Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from chemical restraints for one of two resident (Resident (R) 108) and failed to ensure there was a stop date for an as-needed (PRN) psychotropic medication for one residents (R108 a) reviewed for psychotropic medications out of 37 sample residents. This failure had the potential to result in unnecessary medication use, adverse drug effects, and increased risk of oversedation, and had the potential to affect all residents receiving psychotropic medications in the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the resident and/or resident representative were provided complete written notice at the time of an emergency transfer, including all required elements (reason for transfer, bed-hold policy, appeal rights, and ombudsman contact information), for five of six sampled residents (Resident (R) 157, R135, R109, R6, and R150) reviewed for transfers to the hospital. This deficient practice had the potential to affect the residents' ability to make informed decisions regarding the transfer, exercise the right to appeal the transfer/discharge, and retain access to bed-hold rights, which could result in loss of the resident's bed and/or return to the facility.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure staff maintained professional standards of practice by ensuring one resident (Resident (R) 108) out of a sample of 37 residents was not administered crushed medications when there was not a clinical indication to do so. This failure had the potential to change the absorption rate of the medication and cause over-sedation and increased fall risk.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a medication error rate was below 5% with five errors out of 27 opportunities resulting in a medication error rate of 22%. This failure had the potential for residents not to receive medications following the five rights including right dose, right amount, and right time. This failure affected four out of seven sampled residents, (Resident (R) 99, R41, R98, and R63). The facility sample size was 30.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to clean the glucose testing meter in a manner approved by the manufacturer and failed to clean the insulin pen stoppers prior to insulin administration. This failure had the potential to place residents at risk for cross contamination. This failure affected six residents, (Resident (R)18, R41, R63, R98, R99, and R113). The facility identified 41 residents potentially affected by this failure.

Inspectors wroteBased on observations, record review, interviews and policy review, the facility failed to notify the physician when opioid pain medication was administered to one of one resident (Resident (R) 46) without an order. The total survey sample was 37Findings include:Review of R46's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses which included Von Willebrand disease, urinary tract infection, kidney failure, uterovaginal prolapse, rectocele, and repeated falls. Review of R46's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/26 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. [...]

Inspectors wroteBased on record review and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for two of four residents (Resident (R)108 and R67) reviewed for abuse out of 37 sampled residents. This had the potential for continued abuse to the residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the discharge tracking Minimum Data Set assessments were completed for two of nine residents (Resident (R) 48 and R114) reviewed for transfer or discharge. These failures created a potential to result in gaps in the resident's clinical record, impaired care coordination during transitions of care, and failure to ensure accurate data reporting for resident outcomes.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the discharge tracking Minimum Data Set assessments were completed for one of 37 sampled residents (Resident (R) 152. The failure created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed for one of one resident (Resident (R) 134) reviewed for PASARR out of 37 sampled residents. This failure had the potential to affect resident ability to receive needed services.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a copy of the baseline care plan for one of 36 residents (Resident (R) 46). This failure had the potential to interfere with the continuity of care and safeguard against adverse events that are more likely to occur right after admission.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that a resident who required extensive to total assistance with bathing received bathing services in accordance with physician orders, facility policy, and the resident's assessed needs for one of seven residents (Resident (R) 16) reviewed for activities of daily living. This failure placed R16 at risk for poor hygiene, compromised skin integrity (including increased risk for skin breakdown and infection), decreased dignity, and reduced quality of life.

Inspectors wroteBased on observations, record review, interviews and policy review, the facility failed to provide treatment and care in accordance with professional standards of practice, the resident's comprehensive care plan, and the resident choice when an Licensed Practical Nurse (LPN) administered narcotic pain medication without a physician order for one of one resident (Resident (R)46). This had the potential to affect the resident's physical, mental, and psychosocial well-being. The total sample was 37.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's safety after a staff member entered through a door striking the resident in the head causing a laceration for one (Resident (R) 108) of one resident reviewed for accident hazards out of a sample of 37 residents. This had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for one of three residents (Resident (R) 134) reviewed for side rails out of 37 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteComplaint # NJ 165805 Based on interview, record review, and other facility documentation, it was determined that the facility failed to ensure that Resident #29 was free from neglect and received adequate supervision when a Certified Nurse Aide (CNA #1) neglected to supervise the resident. Resident #29 was found lying on the floor complaining of severe pain and CNA #1 who refused to supervise Resident #29 was found sleeping at the nurses' desk on 5/17/23 at 3:35 AM. The resident required emergent transfer to the hospital and was diagnosed with a closed fracture of the left hip that required surgical repair (open reduction external fixation). This deficient practice was identified for 1 of 1 resident (Resident #29) reviewed for neglect. The evidence was as follows: On 2/5/25 at 10:30 AM, the surveyor reviewed Resident #29's electronic medical record. [...]

Inspectors wroteComplaint # NJ 173844 Based on observation, interview, record review, and document review it was determined that the facility failed to provide adequate monitoring and supervision to prevent falls with injury for a resident who was assessed as a high risk for falls. On 12/23/24, Resident #92 who had a fall and the nurse documented that the resident was on one staff-to-one resident (1:1) monitoring, had a second fall within one hour that required emergency services to transfer the resident to the hospital. The resident sustained from the fall: an acute comminuted fracture (breaks in three or more pieces) of the left inferior orbital rim (eye socket); an acute comminuted and mildly displaced fracture of the left lateral orbital rim; an acute comminuted and mildly displaced and depressed fracture of the left anterior maxillary sinus wall; [...]

Inspectors wroteComplaint #s NJ: 165805, 166524, 166709, 169246, 170726, 173844, 175487, 178803 Based on observation, interview and document review it was determined that the facility failed to have sufficient and competent nursing staff to consistently provide all related nursing services to ensure residents received care to ensure resident safety, and maintain the highest practical physical and mental well-being by failing to ensure staff provided a) appropriate and timely incontinence and nail care for residents dependent on staff for Activities of Daily Living (ADLs) care, b) resident supervision for safety, c) appropriate wound care per physician orders, d) a communication tool for a resident who who was known to speak a foreign language (Resident #122), and e) consistent access to the call bell (Resident #20 & #29). [...]

Inspectors wroteBased on observation, interview and review of pertinent documents it was determined that the facility failed to maintain the kitchen environment and equipment in a clean and sanitary manner to limit the potential for bacterial growth and potential food borne illness. The deficient practice was evidenced by the following: On 1/29/25 at 8:17 AM, an initial tour of the kitchen was conducted with the Regional Dining Director (RDD) and the surveyor observed the following: - The 1st walk in refrigeration unit had a soiled gasket, debris throughout the ceiling and on the fan. The RDD confirmed the observation and stated it needed attention right away. -There was various debris throughout the floor and on a shelf liner in the dry food storeroom. The RDD stated there was a new Food Service Director and he was helping to develop a cleaning schedule. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure that residents were explicitly informed of, and an understanding was assessed, prior to having the residents enter into a binding arbitration agreement (AA) which was identified as a part of the admission Agreement. This deficient practice was identified for 3 of 3 residents (Resident #71, Resident #123, and Resident #370) reviewed for arbitration agreement and was evidenced as follows: On 1/29/25 at 8:50 AM, an entrance conference was conducted with the Licensed Nursing Home Administrator (LNHA) and Regional Director of Clinical Services (RDCS). The surveyor inquired if the facility used AA and the LNHA stated that it was part of the admission Agreement, but there were no residents that entered into an AA. The facility provided the names of two staff members responsible for the AA. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to address the smell of natural gas in the kitchen. Observations conducted on 1/29/25 at 8:30 AM and 8:40 AM, with two surveyors, and interviews conducted that same day confirmed the smell of natural gas was present on 1/29/25, and the facility used a lighter to regularly light the gas stove. This deficient practice placed all 63 residents at risk and was evidenced by the following:On 1/29/25 8:17 AM, the surveyor conducted an initial tour of the kitchen in the presence of the Regional Director of Dining (RDD). At 8:30 AM, the surveyor approached the cooking area and observed the smell of natural gas was present and then observed a lighter was directly opposite of the stove on top of a metal table. [...]

Inspectors wroteComplaint #NJ 165805 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure the call bell was accessible and within reach for all residents. This deficient practice was identified for 2 of 2 residents (Resident #22 and #29) reviewed for falls and was evidenced by the following: a) On 1/30/25 at 10:00 AM, the surveyor observed Resident #29 lying in bed, and the call bell on top of the the bedside table out of Resident #29. On 1/31/28 9:10 AM, the surveyor observed Resident #29 in bed, and the call bell was again observed on top of the bedside table. On 2/5/25 at 9:00 AM, the surveyor observed Resident #29 lying in bed and the call bell was hanging over the side rail, tucked underneath the mattress, and out of the resident's reach. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a) ensure that physician orders were being consistently followed for a medication with hold parameters for 3 of 18 residents (Residents #82, #23 and #89), b) follow the physician orders for bilateral floor mats for a resident who was a fall risk for 1 of the 1 resident (Resident #19), c) administer medications according to the physician's orders for 1 of 6 residents (Resident #44) reviewed for medication administration. This deficient practice 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 wroteRepeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to provide a means of communication for a resident identified as having a language barrier. This deficient practice was identified for Resident #122, 1 of 1 resident reviewed for communication and was evidenced by the following: On 1/29/25 at 12:58 PM, the surveyor observed Resident #122 in bed. The surveyor was unable to communicate with the resident. On 1/30/25 at 8:29 AM, the surveyor observed Resident #122 eating breakfast in the bed. Resident #122 spoke in Spanish when the surveyor was in the resident's room. The surveyor was not able to understand or communicate with the resident. On 1/30/25 at 10:15 AM, the surveyor reviewed the electronic medical record for Resident #122 which revealed: [...]

Inspectors wroteComplaint #s NJ 165805, 166524, 166709, 169246, 178803 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to consistently provide appropriate incontinence care, and personal hygiene care for all residents. The deficient practice was identified for Resident #89, #100, #132, #152, #370, #123, #71, #122, #82, #35, and #77, for 2 of 3 resident units (Maple and Ridge Units) and evidenced by the following: 1. On 2/04/25 AM at 7:20 AM, the surveyor observed Resident #100 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry, the resident informed the surveyor that they were wet and needed to be changed. The surveyor asked the resident to activate the call light. The surveyor left the room and informed staff that Resident needed assistance. [...]

Inspectors wroteComplaint #s NJ 165805, 166524 Based on observation, interview, and record review, it was determined that the facility failed to: a.) ensure a treatment dressing was applied to a sacral pressure ulcer in accordance with a physician order, and b.) ensure a skin assessment was completed for a resident upon return from the hospital, and c) implement measures to prevent the development of pressure ulcers in a timely manner in accordance with professional standards of practice. This deficient practice was identified for 2 of 2 residents reviewed with pressure ulcers (Resident # 10 and #29), and was evidenced by the following: 1. On 2/04/25 at 6:05 AM, during incontinence tour, the surveyor observed Resident #10 with a deep wound to the sacral area that was not covered with a dressing. The soiled dressing was dislodged and noted in the resident's brief along with the wound packing. [...]

Inspectors wroteComplaint # NJ 178803 Based on observation, interview and document review it was determined that the facility failed to consistently serve food to resident that were at an appetizing temperature and taste. The deficient practice occurred for 5 of 5 residents who attended a resident council meeting and for 1 of 1 closed record reviewed (Resident #319) for food and was evidenced by the following: On 1/30/25 at 1:30 PM, a surveyor conducted a resident council meeting with five residents. All five residents stated the food was always cold, even in the dining room, and everything tasted bad. On 1/31/25 at 7:55 AM, the surveyor observed a breakfast meal cart delivered to the Maple Unit. At that time, the surveyor requested the kitchen staff to alert the Food Service Director that a test meal would be completed. At that time, there were 4 nursing staff present and no meal trays were removed. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure a process was followed to ensure that all concerns presented by the residents during the monthly resident council meetings (RCM) were consistently addressed. This deficient practice was identified for 5 of 5 residents who attended a resident council meeting, for 1 of 1 monthly resident council minutes reviewed (October 2024) and was evidenced by the following: This deficient practice was evidenced by the following: On 1/31/25 at 10:30 AM, the surveyor conducted RCM with 5 of the 5 residents who stated they were unaware of any follow up to their expressed concerns and were not provided with documented follow up at subsequent resident council meetings. A review of the RCM minutes that were provided by the Licensed Nursing Home Administrator (LNHA) revealed: 1. [...]

Inspectors wroteComplaint # NJ 170726, NJ 166401 Based on interview and document review, it was determined that facility failed to ensure a ensure an initial baseline care plan (CP) was developed for pain management for a resident who was admitted for rehabilitation after hip surgery. This deficient practice occurred for 1 of 1 closed record (Resident #318) reviewed for pain management and was evidenced by the following: On 2/4/25 at 9:31 AM, the surveyor reviewed the electronic medical record for Resident #318 which revealed the following: The admission Record revealed diagnoses which included, but were not limited to; unspecified fall, non-displaced intertrochanteric fracture of right femur (fracture of large leg bone) with routine healing, and Type 2 Diabetes Mellitus. [...]

Inspectors wroteComplaint # NJ 165805, 166524 Based on interview, record review and document review, it was determined the facility failed to ensure quality of care was provided in accordance with professional standards of practice for wound care by failing to monitor, identify and report changes in a wound on 2/17/23. The Resident Representative (RR) insisted the resident to be sent to the hospital and the resident was admitted to the hospital with cellulitis of the neck, chest, and infected sacral wound. This deficient practice occurred for 1 of 1 resident reviewed for wound care (Resident #10) 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 wroteComplaint # NJ 170726 Based on interview and document review, it was determined that facility failed to ensure a pain assessment was completed and documented to ensure a resident was provided with pain medication as needed. This deficient practice occurred for 1 of 1 closed record (Resident #318) reviewed for pain management and was evidenced by the following: On 2/4/25 at 9:31 AM, the surveyor reviewed the electronic medical record for Resident #318 which revealed the following: The admission Record revealed diagnoses which included, but were not limited to; unspecified fall, non-displaced intertrochanteric fracture of right femur (fracture of large leg bone) with routine healing, and Type 2 Diabetes Mellitus. The Hospital Discharge summary dated [DATE] revealed the Primary Discharge Diagnosis was Right intertrochanteric fracture proximal femur. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 1/31/25, two surveyors observed four nurses administer medications to six residents. There were 34 opportunities, and two errors were observed which calculated to a medication administration error rate of 5.8%. This deficient practice was identified for 2 of 6 residents (Resident #89 and Resident #44) that were administered medications by two of four nurses observed. The deficient practice was evidenced as follows: 1. On 1/31/24 at 8:04 AM, Surveyor #1 observed the Licensed Practical Nurse (LPN) #1 administer medications to Resident #89. LPN #4 checked the blood pressure prior to administering the medications. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #56) of 7 sampled residents reviewed for nutrition received thickened liquids per the physician's orders. During the survey, Resident #56, a resident assessed to be at risk for aspiration was ordered nectar thickened liquids. On 05/19/2023 at 1:13 PM, Resident #56 was provided a glass of regular consistency ice water. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death of residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.60 (Food and Nutrition Services) at a scope and severity of J. The IJ began on 05/17/2023 at 1:13 PM, when Resident #56 was not provided thickened liquids. [...]

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to ensure 1 (Resident #17) of 4 sampled residents reviewed for accidents was provided assistance with transfers. Specifically, on 05/01/2023, Resident #17 was found on the floor after they attempted to transfer themself due to a lack of staff available to assist the resident back to bed. Resident #17 sustained a laceration to their forehead that required two staples to close.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to provide adequate staffing to prevent falls for 1 (Resident #17) of 4 sampled residents reviewed for accidents. Specifically, on 05/01/2023, Resident #17 was found on the floor after they attempted to transfer themself due to a lack of staff available to assist the resident back to bed. Resident #17 sustained a laceration to their forehead that required two staples to close.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, it was determined that the facility failed to ensure that 1 (Resident #57) of 1 sampled resident reviewed for self-administration of medication was assessed prior to the self-administration of albuterol nebulizing treatment.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure the physician was timely notified of a change in condition for 1 (Resident #19) of 2 sampled residents reviewed for a change in condition. Specifically, the facility failed to timely notify the physician after staff noted Resident #19 experienced unexplained bleeding on 05/06/2023.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an allegation of misappropriation of resident property to the state licensing/certification agency within 24-hours for 1 (Resident #228) of 3 sampled residents reviewed for abuse.

Inspectors wroteBased on interviews, record reviews, and facility policy review it was determined that the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was updated for 2 (Resident #61 and Resident #69) of 3 sampled residents reviewed for PASARRs who had new diagnoses of serious mental disorders.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined that the facility failed to ensure Preadmission Screening and Resident Review (PASARR) was completed accurately upon admission for 1 (Resident #58) of 3 sampled residents reviewed for PASARRs.

Inspectors wroteBased on record reviews, facility policy review, and interviews, it was determined that the facility failed to have evidence quarterly care plan meetings were conducted for 3 (Residents #48, #53, and #110) of 33 sampled residents.

Inspectors wroteBased on observation, record review, facility policy review and interviews, it was determined that the facility failed to provide necessary services to ensure 1 (Resident #110) of 2 sampled residents reviewed for communication - sensory. Specifically, Resident #110 did not speak English and the facility failed to provide interpreter services and a communication board as required by the resident's care plan.

Inspectors wroteBased on observations, interviews, record review and facility policy review, it was determined the facility failed to ensure a physician's order was obtained for the use of oxygen therapy for 1 (Resident #112) of 3 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure an assessment for the use of side rails was completed and informed consent was obtained for the use of side rails for 1 (Resident #56) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, it was determined the facility failed to ensure medications were available for administration for 1 (Resident #191) of 10 residents observed for medication administration. Specifically, the facility failed to ensure glecaprevir-pibrentasvir, an antiviral medication used to treat a viral infection, and a dietary supplement, prostate health, were available for Resident #191.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to ensure ordered laboratory work was obtained for 1 (Resident #19) of 2 sampled residents reviewed for a change in condition.