Masonic Village at Burlington

In the surveyor’s words

From the most serious findings on record at Masonic Village at Burlington, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 28, 2025

  Complaint #: 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… […]

• Immediate jeopardy, patternF610Mar 28, 2025

  Complaint #: 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. […]

• Immediate jeopardy, patternF808Mar 28, 2025

  Complaint #: 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. […]

• Immediate jeopardy, isolatedF656Oct 15, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 15, 2024

  Based 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. […]