Mount Holly Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Mount Holly Rehabilitation & Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF908Feb 7, 2025

  Based on observation, interview and document review, it was determined that the facility failed to immediately 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. The facility's failure to address the natural gas smell, while utilizing a lighter to light the stove top burners, placed all residents at risk from an explosion or fire and resulted in an Immediate Jeopardy (IJ) Situation. The IJ began on 1/29/25 at 8:30 AM, and the Licensed Nursing Home Administrator (LNHA) was provided the IJ template on 1/29/25 at 11:20 AM. […]

• Immediate jeopardy, isolatedF808May 20, 2023

  Based 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 [DATE] 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. […]

• Actual harm, isolatedF600Feb 7, 2025

  Complaint # 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). […]

• Actual harm, isolatedF689Feb 7, 2025

  Complaint # 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. […]

• Actual harm, isolatedF689May 20, 2023

  Based 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. Findings included: Review of an undated facility policy titled, Falls and Fall Risk, Managing, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from… […]