Cherry Hill for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Cherry Hill for Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 28, 2021

  This citation pertains to intake number M 322 Based on observation, interview, and record review the facility failed to ensure appropriate monitoring and supervision of one sampled resident (R500) of four residents reviewed for elopement, allowing R500 to exit the building unbeknownst to staff, resulting in Immediate Jeopardy due to the likelihood of serious injury or death from being outside near a heavily trafficked congested road, for an extended period of time. Findings include: On 7/27/21 at 10:36 AM R500's Electronic Health Record (EHR) was reviewed and revealed the following, 5/22/2021 15:14 (3:14 PM) Alert Note Text: Staff found the resident outside on the same side of street of facility, Resident was out on her W/C (wheelchair) going towards the [convenience store] close to the… […]

• Actual harm, isolatedF600Apr 14, 2022

  This citation pertains to M 7524 Based on observation, interview and record review, the facility 1) Failed to operationalize policies and procedures to ensure the provision and implementation of adequate and necessary supervision and monitoring and 2) Failed to provide an environment free from physical sexual inappropriateness of two Residents (R901 and R902) of three Residents reviewed for abuse, resulting in R901 being found in the room of R902 with their hand in R902's pants, and from a reasonable persons perspective potential feelings of violation and anxiety. […]

• Actual harm, isolatedF684Nov 17, 2021

  This citation pertains to intake MI 041 and pertains in part to intake MI 405. Based on interview and record review, the facility failed to document follow-up after R701's noted change in condition and notification of Physician, and failed to adequately recognize and address a change in condition in R705 as exhibited by significant weight gain, shortness of breath, and need for supplemental oxygen, affecting two (R701 and R705) sampled residents of six reviewed, resulting in delay in treatment, decline in health status, and the discharge of a resident to the community after noted onset of a new health diagnosis ([CONDITION(S)]). […]

• Actual harm, isolatedF600Jul 28, 2021

  This citation is pertains to intake MI 094 Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse by other residents for two sampled Residents (R503 and R507) of six residents reviewed for abuse, resulting in R503 and R507 being struck by another resident. Findings include: A review of a facility reported incident revealed On 6/11/21, at approximately 8:50 am, (certified nursing assistant) [CNA L] witnessed (R502) come out into the hallway agitated and with (their) right hand made contact with the left side of (R503's) face. […]

• Actual harm, isolatedF600Mar 18, 2021

  This citation pertains to intake: MI 593 and MI 425. Based on observation, interview, and record review, the facility failed to prevent physical abuse from Resident #18 (R18) and failed to separate the residents after the incident, for one unsampled Resident (R76) of three sampled residents reviewed for abuse, resulting in physical abuse and psychosocial distress using the reasonable person concept. Findings include: On 3/18/21 at 12:00 PM, R76 was observed sitting on the unit in their wheelchair next to the door of R18. R18 was observed sitting in their doorway near R76. R76 appeared to have a cognitive impairment as observed to make incoherent verbal sounds and clapping of their hands. While R76 was sitting in front of R18's door, R18 was observed to smack R76 on top of their head. […]