St Mary's Center For Rehabilitation & Healthcare
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
that a provider was notified that the aforementioned medication doses were not administered or of the resident's refusals. A telephone interview was conducted with a Unit Manager (UM #2) on 09/08/2025 at 2:27 P.M. UM #2 stated that when ordered medications or treatments were not available follow up should have been conducted with the pharmacy and a provider. UM #2 further stated that documentation of the follow up should have been made in the PNs. An interview was conducted with the Director of Nursing (DON) on 09/08/2025 at 3:29 P.M. The DON stated that the only documentation of provider notification that Resident #1 did not receive the aforementioned phenobarbital doses was on 02/17/2025. The DON reviewed the MAR and PNs for Resident #3 and stated that she did not see documentation that a provider was notified that the resident was not administered Clinimax and Clinolipid on the aforementioned dates.
During the same interview the DON stated that providers may have been made aware that the medications were not administered, and the notifications were not documented. The DON stated that it was her expectation that if a provider notification was made that a PN would be made to reflect the notification. The DON further stated that a resident's medical record should reflect the care that was given and that failure to document provider notification was not in keeping with the facility's policy. An interview was conducted with NP #1 on 09/12/2025 at 1:20 P.M. NP #1 stated that she did not recall if she was notified of the aforementioned unadministered and refused medications for residents #1 and #3. The surveyor attempted to reach the Medical Doctor (MD #2) for an interview on 09/16/2025 at 10:23 AM, and was informed that
she was on leave of absence. An interview was conducted with the Medical Doctor (MD #1) on 09/19/2025 at 1:25 P.M. MD #1 stated that he did not recall if he was notified of unadministered phenobarbital doses for Resident #1. MD #1 further stated that facility staff made him aware of several times that Resident #3 did not receive Clinimax and Clinolipid but did not recall the dates. The facility policy Change in Condition with
an effective date of 12/2018 and a revised date of 02/2023, was reviewed. Under Policy Interpretation and Implementation the policy revealed, The nurse will notify the resident's Attending Physician, or physician/NP of a change in condition if a concern warrants medical intervention. NJAC 8:39-13.1(d)
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ST MARY'S CENTER FOR REHABILITATION & HEALTHCARE in CHERRY HILL, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHERRY HILL, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ST MARY'S CENTER FOR REHABILITATION & HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.