Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Evesham during CMS and state inspections, most recent first.
Failure to Investigate Reported Fall Injury: A resident with impaired cognition, an unsteady gait, and fall risk had bruising around the eye initially documented as an injury of unknown origin. Later PN showed the resident reported the injury came from a fall, and staff interviews confirmed awareness of the fall report, but the event was not documented as a fall or thoroughly investigated per facility policy.
Inaccurate MDS Diagnosis Entry: A resident admitted with a stroke diagnosis had EMR orders for escitalopram and valproic acid for mood, and the care plan identified risk for mood changes related to depression. However, the admission MDS did not list an active diagnosis for depression or mood disorders in Section I, even though Section N showed the resident was taking an antidepressant. The MDS coordinator acknowledged the omission, and the DON stated the MDS must be accurate because it captures the level of care the resident needs.
A resident with a feeding tube had enteral formula hanging from a pump while in bed, but the bottle was not labeled with the resident’s name, start time, or amount to be infused. The resident had an order for Glucerna 1.5 via pump, and both the RNUM and DON stated the formula should be labeled with the resident’s name, date, time, and volume to be infused. The facility policy also required the formula label to document initials, date and time hung/administered, and verification against the order.
A resident with diagnoses including surgical aftercare and HF had orders for aspirin, Plavix, and gabapentin, but the MAR showed all three meds were given more than 3 hours after the scheduled 9:00 AM time. An LPN stated meds should be given within 1 hour before or after the scheduled time and documented right after administration, while the DON stated meds should be administered per MD orders and documented at the time of administration; facility policy required administration within 60 minutes of the scheduled time unless otherwise ordered.
The facility failed to maintain an orderly physical environment, with observations of unsanitary conditions and improper storage of personal items and linens in two units. Residents expressed dissatisfaction with the placement of unpackaged incontinence briefs and linens in their rooms. Staff interviews revealed a lack of adherence to proper storage protocols.
The facility failed to obtain physician discharge orders for three residents, did not change a central line catheter dressing as ordered for a resident, and did not follow orders to offload heels or check helmet placement for two other residents. Additionally, medication records for a resident were incomplete, lacking staff signatures for multiple medications.
The facility failed to conduct a new PASRR level 1 assessment after a resident was newly diagnosed with anxiety disorder, depression, psychotic disorder, and schizophrenia. Despite these new diagnoses, no additional PASRR was completed, and the facility lacked a policy on reevaluating PASRRs for new psychological diagnoses.
A facility failed to develop a comprehensive care plan for a resident with pain, despite the resident reporting moderate pain and having relevant medical diagnoses. The care plan was only updated after a surveyor's inquiry, indicating a lapse in proactive care planning.
A facility failed to ensure that a resident with cognitive impairment had an elopement alarm in place as required by a physician's order. The resident was observed multiple times without the alarm, and staff interviews revealed that the order was outdated and not followed.
The facility failed to document urinary output for a resident with an indwelling catheter as per physician's orders and care plan. Multiple instances of non-compliance were observed in February and March 2024, with the Director of Nursing acknowledging that documentation should not be left blank.
The facility failed to maintain respiratory equipment for three residents, including improper labeling and storage of oxygen and nebulizer tubing. Interviews revealed that the facility's practice was to change tubing weekly, but there were no physician orders for these changes, and the observed practices did not align with the facility's policy.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week. For one day during the reviewed week, the previous DON was counted as the RN on duty, which did not meet the facility's policy requirements. This was confirmed by the Licensed Nursing Home Administrator.
The facility failed to ensure proper medication storage, as evidenced by unattended medication carts with medications on top and prescribed medications found in a communal shower room cabinet. Staff confirmed these practices were against facility policies.
The facility failed to handle potentially hazardous foods and maintain sanitation in the pantry on Unit 1. Observations revealed unlabeled and improperly stored food items, including frozen meals, a burger, and a muffin tin with an exposed muffin. Staff interviews confirmed that all food should be labeled, dated, and covered, as per facility policy.
Failure to Investigate Reported Fall Injury
Penalty
Summary
The facility failed to thoroughly investigate a fall after a resident reported to staff that an injury labeled as of unknown origin was actually sustained from a fall. Resident #2 had diagnoses including discitis of the lumbar spine, cirrhosis of the liver, and difficulty walking, and the MDS showed a BIMS score of 12, indicating moderately impaired cognition. The resident had a care plan focus for fall risk due to an unsteady gait. An incident report documented bruising around the left eye with the resident unsure how it occurred, and the facility reported the event to the Department of Health as an injury of unknown origin. Subsequent progress notes documented that the resident was assessed by a physician for a recent fall causing bruising to the left eye, and later the resident told nursing staff that the bruising occurred because the resident fell. RN and ADON interviews confirmed that staff were aware of the resident’s report of a fall and expected an incident report and investigation, but no documentation was provided showing that the event was reassessed as a fall or that the fall was included on the facility’s list of March falls. The facility’s own records and interviews showed that the fall policy was not fully implemented for this event.
Inaccurate MDS Diagnosis Entry
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident. Resident #63 was admitted with a diagnosis of unspecified sequelae of cerebral infarction (stroke). The resident’s EMR showed physician orders for escitalopram oxalate 20 mg, and valproic acid 250 mg/5 mL three times a day for mood. The care plan included a focus for risk for changes in mood related to a diagnosis of depression, initiated on 07/07/2025. The admission MDS dated 07/09/2025 did not list an active diagnosis for depression or mood disorders in Section I, although Section N indicated the resident was taking an antidepressant. During interview, the MDS coordinator stated they review hospital records, care plans, lab work, x-rays, and medications when completing the MDS and acknowledged that depression should have been included, saying, "Absolutely it should be there, we missed that." The DON stated that it was important for the MDS to be accurate because it captures the level of care the resident needs. The facility policy stated that the resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessment.
Unlabeled Enteral Formula Hung on Feeding Pump
Penalty
Summary
The facility failed to ensure that nutritional formula connected to a feeding tube was accurately labeled for one resident who had a feeding tube and was receiving enteral nutrition by pump. During observation, a bottle of nutritional formula was seen hanging from a pole and connected to a feeding pump attached to the resident while he/she was in bed, and the pump was operating. The bottle was not labeled with the resident’s name, start time, or the amount to be infused. Record review showed the resident’s admission MDS documented the presence of a feeding tube, and the physician order specified Glucerna 1.5 to be infused at 65 mL per hour via pump starting at 6:00 PM until a total of 1300 mL had infused. During interview, the RNUM stated that hung nutritional formula should be labeled with the name, date, time, and volume to be infused, and said the unlabeled bottle was unacceptable. The DON also stated that hanging nutritional formula should be labeled with the date, time, and resident’s name, and explained that labeling is important to know exactly when the feeding started to ensure it has not expired or been infusing for too long. The facility policy titled, Enteral Tube Feeding via Continuous Pump, required the formula label to document initials, date and time the formula was hung/administered, and that the label was checked against the order.
Late Medication Administration and Documentation
Penalty
Summary
Resident #121, who had diagnoses including surgical aftercare following surgery on the skin and heart failure, had physician orders for aspirin 81 mg daily, Plavix 75 mg daily, and gabapentin 300 mg three times a day. The resident’s Medication Administration Audit Report for February 2025 showed that on 02/15/2025, aspirin scheduled for 9:00 AM was administered at 12:29 PM, Plavix scheduled for 9:00 AM was administered at 12:33 PM, and gabapentin scheduled for 9:00 AM was administered at 12:32 PM. During interviews, an LPN stated that medications should be administered within one hour before or after the scheduled time and documented right after they are given, and that medications should not be signed out late but should be documented if that occurred. The DON stated that medications should be administered according to physician orders and documented at the time of administration. The facility policy stated medications should be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician, and documentation of medication administration includes the date and time of administration.
Failure to Maintain Orderly Physical Environment
Penalty
Summary
The facility failed to maintain an orderly physical environment in two units, as evidenced by multiple observations of unsanitary conditions and improper storage of personal items and linens. In the 100 Unit communal shower room, a shelf adjacent to the shower stall contained an unpackaged incontinence brief, a hairbrush with hair entangled in the bristles, and various hygienic bottled toiletries, along with a foul odor. Additionally, the common area across from the nurses' station had food debris, partially consumed beverages, and a single slipper on the floor. Five PVC mobile trash bins, some containing trash, were stored in the shower room, and a scale chair was cluttered with unpacked incontinence briefs, disposable glove boxes, and plastic bags. Resident #72's room had a chair with an unpackaged incontinence brief, towels, a linen sheet, and a hospital gown, which the resident did not want there. Similar issues were observed in other rooms and common areas, including untied bags of linen on the floor and unpackaged incontinence briefs left on chairs in residents' rooms, which residents expressed they did not want there. Interviews with staff, including a housekeeper and the Director of Nursing (DON), revealed a lack of clarity and adherence to proper storage protocols for linens and personal items. The housekeeper stated he was not responsible for removing linens from rooms, while the DON confirmed that linens and incontinence briefs should be stored in closets or carts, not on chairs or in common areas. The facility's policy on laundry and linen, which mandates that clean linen should remain hygienically clean and protected from environmental contamination, was not followed. The DON and the Licensed Nursing Home Administrator confirmed that nursing staff was responsible for removing linens and incontinence briefs from resident rooms and ensuring they were stored appropriately.
Multiple Deficiencies in Physician Orders and Documentation
Penalty
Summary
The facility failed to obtain a physician's order for residents to be discharged from the facility prior to discharge. This deficiency was identified for three residents who did not have discharge orders placed in their medical records before being discharged. Interviews with the Licensed Nursing Home Administrator, Director of Nursing, and nursing staff confirmed that discharge orders were required but were not entered into the computer system due to nursing oversight. The facility policy also required a physician's order to be signed and recorded within 72 hours of discharge, which was not adhered to in these cases. The facility also failed to change a central line catheter dressing as ordered by the physician for Resident #84. The resident's dressing was dated 03/27/24, and the dressing change scheduled for 04/03/24 was not documented as completed. The resident's Treatment Administration Record showed the dressing was changed on 04/10/24, indicating a delay in following the physician's order. Interviews with nursing staff revealed that central catheter dressings should be changed weekly and documented in the Medication Administration Record or Treatment Administration Record, which was not done in this instance. Additionally, the facility did not follow physician orders to offload a resident's heels while in bed for Resident #467. The order was not documented in the Medication Administration Record or Treatment Administration Record, and there was no evidence that the task was completed by the Certified Nursing Assistant. The facility also failed to check helmet placement every two hours for Resident #468, as required by the physician's order. The Treatment Administration Record had multiple instances of missing documentation, indicating that the checks were not performed or not recorded. Furthermore, the facility did not maintain complete medication records with staff signatures for Resident #35, with multiple instances of missing documentation for various medications in the Medication Administration Record.
Failure to Conduct New PASRR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficiency was identified for a resident who had a PASRR level 1 completed in 2019, which was negative for any mental illness. However, subsequent assessments, including the Admission Minimum Data Set (MDS) and quarterly MDS, indicated diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia. Despite these new diagnoses, no additional PASRR was completed to reflect the resident's updated mental health status. During interviews, the Social Worker acknowledged that a new PASRR should have been completed following the new diagnoses but was unable to locate any updated PASRR in the electronic medical record. The Administrator confirmed that there was no policy on reevaluating PASRRs for new psychological diagnoses after admission and that audits were conducted without a requirement for annual updates. The facility's policy on Admission Criteria did not address the need for a new PASRR following a new psychological diagnosis, leading to the identified deficiency.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident experiencing pain. During an initial tour, the resident reported right hip and left foot pain, rating it as a seven on a zero to ten scale, indicating moderate pain. Despite having medical diagnoses including sciatica, fibromyalgia, depression, anxiety, and low back pain, the resident's care plan did not initially include a focus on pain management. The Medication Administration Record (MAR) showed that the resident's pain was assessed every shift, with instances of both mild and severe pain recorded. However, the care plan was only updated to include pain management after the surveyor's inquiry, indicating a lapse in proactive care planning for the resident's pain needs. Further review of the facility's policies on comprehensive person-centered care plans and pain assessment and management revealed that the facility did not adhere to its own guidelines. The policies stipulated that services should be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and that pain management interventions should be consistent with the resident's goals for treatment and documented in the care plan. The failure to include pain management in the resident's care plan until prompted by the surveyor highlights a deficiency in the facility's adherence to its policies and procedures for comprehensive care planning.
Failure to Ensure Elopement Alarm in Place
Penalty
Summary
The facility failed to ensure that a safety device used to prevent residents from elopement was in place for a resident identified as not being cognitively intact. The resident, who had diagnoses including paranoid schizophrenia and major depressive disorder, was observed multiple times without the required elopement alarm on their wrist. Despite the physician's order for the elopement alarm to be checked and in place every shift, the resident was found without it on several occasions. Staff interviews revealed that the nurses did not thoroughly check for the elopement alarm, and the Licensed Nursing Home Administrator confirmed that the physician's order was outdated and not followed by the nursing staff. The resident's care plans indicated a focus on wandering and elopement risk due to cognitive impairment, with interventions including checking the security bracelet. However, the facility's policy on wandering and elopements was not adhered to, as the resident was repeatedly observed without the elopement alarm. The failure to ensure the elopement alarm was in place and functioning as ordered led to the deficiency noted in the report.
Failure to Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate and sufficient services based on current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). This deficiency was identified for a resident diagnosed with paraplegia and neuromuscular dysfunction of the bladder, who had an indwelling urinary catheter. The physician's order required measuring and recording the catheter output every shift, but multiple instances of non-compliance were observed in both February and March 2024, where the documentation was left blank on several shifts. The Director of Nursing acknowledged that the documentation should not be left blank and suggested that staff might have forgotten to document it. A review of the facility's policy on catheter care revealed that it required following the procedure for measuring and documenting input and output. However, the Medication and Treatment Orders policy did not provide pertinent information regarding this requirement. The failure to document urinary output as ordered by the physician and outlined in the care plan indicates a lapse in adherence to the facility's policies and procedures, potentially compromising the resident's care.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain the necessary care and maintenance of respiratory equipment for three residents. During an initial tour, the surveyor observed that one resident's oxygen tubing was not labeled, and the bag holding the tubing was dated over a week prior. This resident had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a physician's order for oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath. However, there was no order to change the oxygen tubing weekly. Additionally, two other residents were observed with nebulizer tubing and masks not stored in bags, and their oxygen tubing was improperly placed. These residents had diagnoses of Interstitial Pulmonary Disease and Acute Respiratory Failure with hypoxia, respectively, and had physician orders for oxygen and nebulizer treatments, but no orders to change respiratory tubing weekly were found for one of them. Interviews with the Licensed Practical Nurse Unit Manager (LPN/UM) and the Director of Nursing (DON) revealed that the facility's practice was to change respiratory tubing weekly and store it in bags when not in use. However, there were no physician orders in place for these weekly changes, and the observed practices did not align with the facility's policy. The facility policy required changing oxygen cannulae and tubing every seven days and storing them in plastic bags when not in use. The DON confirmed that the respiratory therapist was responsible for changing the tubing weekly, but acknowledged that there were no orders for the weekly changes, and agreed that the tubing should be stored in bags when not in use.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, for the week of 04/30/2023 through 05/06/2023, the facility did not have an RN on duty for 8 consecutive hours on 05/06/2023. The Nurse Staffing Report indicated that the previous Director of Nursing was counted as the RN on duty, despite the facility's policy requiring an RN to provide services for at least 8 consecutive hours every 24 hours, 7 days a week. This deficiency was confirmed by the Licensed Nursing Home Administrator during an interview with the surveyor on 04/15/2024.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure that medications were stored appropriately, as evidenced by observations on the 100 unit. On two separate occasions, medication carts were left unattended with grey boxes containing individual medication envelopes on top of the locked carts. In one instance, an LPN left the cart in the hallway while taking a resident's vital signs, and in another instance, another LPN left the cart unattended, stating she was new to the facility. Both instances were confirmed by the Registered Nurse/Unit Manager and the Director of Nursing, who acknowledged that the medications should not have been left on top of the carts unattended. The facility's policy explicitly states that no medications should be kept on top of the cart during administration, which was not adhered to in these cases. Additionally, during a tour of the 200 Unit communal shower room, two sealed plastic bottles containing Acetic Acid Irrigation Solution were found in an open cabinet. The labels on the bottles indicated they were prescribed for an unsampled resident. The LPN/Unit Manager and the Director of Nursing confirmed that these medications should not have been stored in the shower room cabinets but rather in a medication cart or medication room. The facility's policy on medication labeling and storage requires all medications to be stored in locked compartments under proper conditions, which was not followed in this instance.
Failure to Properly Label and Store Food in Pantry
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner in the pantry on Unit 1. During observations, the surveyor found three frozen meals and a container of rice pudding in the freezer that were not labeled. Additionally, a burger in the refrigerator was not labeled or dated, and a muffin tin covered with foil had an exposed muffin. A cup with pink liquid without a lid was also found in the refrigerator, neither dated nor labeled. Interviews with the Food Service Director, an LPN, the Director of Nursing, and the Director of Environmental Services confirmed that all food should be labeled, dated, and covered, and any unlabeled food should be discarded. The facility's policy on foods brought by family/visitors also mandates that perishable foods be stored in resealable containers with tight-fitting lids and labeled with the resident's name, the item, and the use-by date. The observations and interviews indicate a failure to adhere to the facility's food handling and storage policies, which are designed to prevent foodborne illnesses. The deficiency was noted in the pantry on Unit 1, where multiple instances of improperly labeled and stored food items were found. The staff members interviewed acknowledged the importance of labeling and dating food items and confirmed that the facility's policy requires such practices to ensure food safety. However, the observed practices did not align with these standards, leading to the identified deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marlton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Mary's Center For Rehabilitation & Healthcare | 1.4 mi | ★★★★★ | 1 | 0 |
| Complete Care At Voorhees, Llc | 1.7 mi | ★★★★★ | 2 | 0 |
| Wiley Mission | 1.7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Kresson View, Llc | 1.8 mi | ★★★★★ | 0 | 0 |
| Barclays Rehabilitation And Healthcare Center | 2.9 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.