Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Moorestown during CMS and state inspections, most recent first.
A resident with a history of CVA, hallucinations, and moderately impaired cognition reported that a CNA placed both hands firmly on the resident’s shoulders while repositioning a wheelchair, describing the motion as a “hit” but denying pain or intent to harm and expressing not wanting further care from that CNA. Therapy staff and an OT documented the resident’s account, including that the resident felt startled and upset. The CNA denied any inappropriate touching or hitting. The facility’s investigation was limited to statements from the resident, the CNA, and the reporting therapy staff, with no interviews of other residents, additional staff on other shifts, roommates, family, or visitors, despite facility policy requiring a thorough investigation that includes these interviews.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
Two residents were administered medications that had been dropped onto the medication cart by LPNs, who then placed the dropped pills into administration cups and gave them to the residents. Both LPNs later acknowledged that they should have replaced the dropped medications, in accordance with facility policy and infection control procedures. The DON confirmed that administering dropped medications is not permitted by facility policy.
A facility failed to obtain daily weights for a resident with CHF, as ordered by the physician. Despite the resident's need for daily weight monitoring due to their condition, weights were not recorded on seven occasions. This deficiency was confirmed through medical record reviews and staff interviews, highlighting a lapse in following the facility's protocols for weight monitoring.
A facility failed to properly store nebulizer equipment, exposing it to contamination, and did not administer or document incentive spirometry therapy for three residents as ordered. A resident with respiratory issues had their nebulizer mask improperly stored, while three residents requiring IS therapy reported not receiving the device or training, despite records indicating otherwise. Staff acknowledged these discrepancies, confirming the residents' claims.
The facility failed to conduct annual performance evaluations for CNAs, as required for staff improvement and education. During a survey, it was found that four CNAs did not have up-to-date evaluations, and the facility could not provide documentation for the re-hiring of two CNAs. The LNHA and President of Operations confirmed the requirement for annual evaluations, but no additional documentation or policies were provided.
The facility failed to maintain accurate narcotic shift count logs and properly document the administration of controlled medications. Missing signatures and incomplete records were found across multiple shifts, and doses of controlled medications were not signed out on inventory sheets. Additionally, loose pills were found in a medication cart, violating storage policies. LPNs and the DON acknowledged these deficiencies.
The facility failed to obtain weekly weights for a resident as ordered and did not secure a physician's order to hold a tube feeding for another resident. The first resident's weights were not documented on the MAR as required, while the second resident's tube feeding was held without a physician's order due to a scheduled X-ray. Staff acknowledged these oversights, which were contrary to facility policies.
The facility failed to conduct a criminal background check on an LPN before their employment, contrary to its abuse prevention policy. The background check was completed seven weeks after the LPN started working, as confirmed by the LNHA and other officials. No allegations of abuse were reported against the LPN, who no longer works at the facility.
A facility failed to investigate a pressure ulcer on a resident's heel. Despite a physician's order for skin prep and heel elevation, a nurse incorrectly documented no skin breakdown. The resident reported heel pain, but the LPN administered Tylenol without assessing the heel. Later, non-blanchable erythema was observed, indicating a pressure ulcer. The facility's policies on incident reporting and pressure ulcer management were not followed, and an investigation was only initiated after surveyor inquiry.
A resident with a history of falls did not have their comprehensive care plan updated after multiple incidents, despite assessments being conducted. The facility staff showed confusion over who was responsible for revising the care plan, and the facility's policy lacked guidance on care plan revisions.
A facility failed to document catheter care every shift for a resident with an indwelling urinary catheter, as per physician's orders. The resident, with diagnoses including acute kidney failure and obstructive uropathy, had missing documentation for catheter care eleven times in the Treatment Administration Record. Facility policies required documentation of all services, but the Licensed Nursing Home Administrator and President of Operations acknowledged that if care was not documented, it was considered not done.
A resident with end-stage renal disease receiving hemodialysis was not properly assessed or documented according to professional standards. The facility failed to complete dialysis communication forms and incorrectly took blood pressure from the arm with the dialysis access site. Staff acknowledged these oversights, citing rushed procedures.
A facility failed to ensure staff donned PPE before entering the rooms of two residents on COVID-19 isolation. A per diem NP entered without performing hand hygiene or wearing the required PPE, assuming the residents were off isolation due to the absence of visible droplet precaution signage. The interim Administrator confirmed the need for proper PPE use and hand hygiene.
Failure to Thoroughly Investigate Allegation of Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse by a CNA toward one resident. The resident, who had a history of cerebrovascular accident (CVA), hallucinations, and a BIMS score of 9 indicating moderately impaired cognition, was re-admitted shortly before the incident. The admission MDS indicated the resident had no documented behaviors. On the date of the incident, the resident completed an Individual Statement Form describing that while standing beside the bed to get into the wheelchair, the CNA moved the wheelchair to face the door and placed both hands firmly on the resident’s shoulders. The resident stated the CNA did not punch, slap, or shove, denied pain or discomfort, and did not believe the CNA intentionally tried to cause harm, but did not want to work with that CNA. The facility’s Reportable Event Record/Report documented that the resident told therapy staff that the CNA “hit” the resident while attempting to move back into the wheelchair, then clarified that the CNA put hands on the shoulders in a strong manner and denied being struck. The DON assessed the resident with no untoward findings, and statements were obtained from the resident and the CNA. The COTA/L and PT documented that the resident reported being in the room trying to scoot back in the chair when the CNA “hit” the resident, later clarifying that the resident was not used to being touched like that and did not want to return to the current room if that caregiver would be there. An OT email further recorded that the resident used the word “hit” to describe the motion, stated it was not hard and did not cause pain, but that the resident was startled, upset, and unwilling to go back to the room if that caregiver was present. The CNA’s written and verbal statements denied any inappropriate touching or hitting and indicated that after repositioning the wheelchair, the resident made no comments or complaints. During the surveyors’ review of the facility’s investigation, there was no evidence that other residents or additional staff beyond the reporting staff and the CNA involved were interviewed. The Administrator confirmed that only residents and staff directly involved or around the area of the incident were interviewed and acknowledged there were no other resident or staff interviews. This practice did not follow the facility’s Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, which requires that all allegations be thoroughly investigated, including interviews with the person reporting, any witnesses, the resident, staff on all shifts who had contact with the resident during the period of the alleged incident, the resident’s roommate, family members, visitors, and other residents to whom the accused employee provides care or services.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
During medication administration, two residents were given medications that had been dropped onto the top of the medication cart by two different LPNs. In the first instance, a furosemide tablet was dropped and then placed into the administration cup and given to the resident. The LPN involved acknowledged during an interview that she should have discarded the dropped pill and obtained a new one, as per her training. In the second instance, both a clopidogrel tablet and a sertraline tablet were dropped onto the medication cart and subsequently administered to another resident. The LPN in this case also stated in an interview that she should have replaced the dropped medications. Review of the facility's medication administration policy confirmed that staff are required to follow infection control procedures, including not administering medications that have been dropped. The DON confirmed that it is not facility policy to administer dropped medications.
Failure to Obtain Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to obtain daily weights for a resident with congestive heart failure (CHF) as ordered by the physician. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure, asthma, chronic kidney disease, and acute on chronic diastolic heart failure, required daily weight monitoring to manage fluid retention. Despite a physician's order dated 9/5/24 for daily morning weights, the facility did not record weights on seven occasions between 9/5/24 and 9/25/24. This oversight was confirmed through a review of the resident's medical records and interviews with facility staff, including a Licensed Practical Nurse and a Charge Nurse, who acknowledged the importance of daily weights in monitoring the resident's condition. The deficiency was further corroborated by the Infection Preventionist/Registered Nurse and the Licensed Nursing Home Administrator, who confirmed the lack of daily weight records. The facility's job descriptions for Licensed Practical Nurses and Certified Nursing Assistants, as well as the Weight Assessment and Intervention policy, emphasize the importance of monitoring resident weight and notifying practitioners of significant changes. However, the facility failed to adhere to these protocols, resulting in missed weight recordings for the resident with CHF, which is critical for preventing fluid overload.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to properly store nebulizer equipment for a resident, leading to potential contamination. During an initial tour, a surveyor observed a nebulizer machine with an attached face mask and tubing lying directly on a resident's nightstand, exposed to air and contamination. The resident, who had a history of acute and chronic respiratory failure, asthma, and other conditions, confirmed receiving a nebulizer treatment that morning. The Licensed Practical Nurse (LPN) and Charge Nurse acknowledged that the nebulizer mask should have been stored in a plastic bag to prevent infection, as per facility policy. Additionally, the facility did not administer or accurately document the use of incentive spirometry for three residents as ordered by their physicians. One resident, who had a displaced fracture and an artificial hip, reported never receiving an incentive spirometer (IS) or being taught how to use one, despite medical records indicating otherwise. The Infection Preventionist/Registered Nurse (IP/RN) confirmed the absence of the IS and acknowledged that the nurses should not have signed off on its use. The Unit Manager/LPN also confirmed the resident's claim and stated that staff should have trained the resident on IS use. Similarly, two other residents with medical conditions requiring IS therapy reported not receiving the device or training. Despite this, their medical records showed that nurses had signed off on the use of IS multiple times a day. The IP/RN and Unit Manager/LPN confirmed the discrepancies, acknowledging that the residents were cognitively intact and would have known if they had received the IS. The Licensed Nursing Home Administrator (LNHA) expected staff to follow facility policies, which were not adhered to in these cases.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct yearly performance reviews for Certified Nursing Aides (CNAs), which is a requirement for staff improvement and education. This deficiency was identified during a survey when the surveyor requested performance evaluations for five selected CNAs. It was found that four out of the five CNAs did not have up-to-date performance evaluations. Specifically, CNA #1's last evaluation was in 2022, CNA #2's was in September 2021, and no evaluations were provided for CNA #3 and CNA #4. The facility was unable to provide documentation for the re-hiring of CNA #3 and CNA #4, which was claimed by the Licensed Nursing Home Administrator (LNHA). During the survey, the LNHA and the President of Operations confirmed that performance evaluations should be completed annually. Despite this acknowledgment, the facility did not provide any additional information or policies to support their compliance with this requirement. The lack of documentation and failure to conduct annual evaluations for CNAs #1, #2, #3, and #4 led to the identification of this deficiency.
Deficiencies in Narcotic Accountability and Medication Storage
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs, accurately account for and document the administration of controlled medications, and store medications appropriately according to professional standards. During a review of the medication carts on two nursing units, it was found that the narcotic count logs were incomplete, with missing signatures from both incoming and outgoing nurses across multiple shifts. This lack of documentation was observed for both the day and night shifts, indicating a systemic issue in maintaining accurate records for controlled substances. Additionally, the surveyor identified discrepancies in the documentation of controlled medication administration. Specifically, doses of clonazepam and alprazolam for two residents were not signed out on the declining inventory sheets, although they were recorded as administered in the electronic Medication Administration Record. The LPNs acknowledged the missing documentation and confirmed that the narcotic counts should be conducted and signed by both incoming and outgoing nurses to ensure accuracy and accountability. Furthermore, the surveyor observed loose, unidentifiable pills in the medication cart, which is against the facility's policy for medication storage. The Director of Nursing and LPNs confirmed that there should be no loose pills in the medication carts and that it is the responsibility of the nursing staff to maintain a clean and organized medication storage area. The facility's policies on controlled substances and medication storage emphasize the importance of accurate documentation and proper storage practices to prevent loss or diversion of medications.
Failure to Obtain Weekly Weights and Physician's Order for Tube Feeding
Penalty
Summary
The facility failed to obtain weekly weights for Resident #103 as ordered by the physician. The resident was admitted with several diagnoses, including a fracture of the left femur, osteoarthritis, muscle weakness, and anemia. The physician's order dated 5/21/24 required weekly weights every Tuesday, but the Medication Administration Records (MAR) for May and June 2024 showed blanks for 5/28/24 and 6/6/24. The facility's Infection Preventionist/Registered Nurse and Registered Dietitian confirmed that the weights were not obtained or documented as required, acknowledging the oversight. For Resident #301, the facility did not obtain a physician's order to hold a tube feeding, which was necessary due to a scheduled KUB X-ray. The resident, who had severe cognitive impairment, was observed with a feeding tube that was not connected, and the feeding pump was turned off. The Licensed Practical Nurse (LPN) confirmed that the tube feeding was not being administered and acknowledged the absence of a physician's order to hold the feeding. The LPN later contacted the Nurse Practitioner, who was aware of the situation and intended to issue an order to hold the feeding. The facility's policies and job descriptions require proper documentation and obtaining physician orders for changes in resident care, such as holding tube feedings. The Charge Nurse and Infection Preventionist/Registered Nurse acknowledged that a physician's order should have been obtained before holding the tube feeding. The lack of adherence to these protocols resulted in the deficiencies identified during the survey.
Failure to Conduct Timely Background Checks on New Hires
Penalty
Summary
The facility failed to implement its abuse prevention policy by not conducting criminal background checks on all newly hired employees before their employment commenced. This deficiency was identified during a survey when it was discovered that a Licensed Practical Nurse (LPN), referred to as Staff #4, was hired and began working without a completed background check. The background check for Staff #4 was only initiated seven weeks after their employment start date, which was contrary to the facility's policy that mandates background checks be completed prior to hiring. The surveyor's review of personnel files revealed that Staff #4 began working on December 7, 2023, but the background check was not completed until January 26, 2024. Despite the facility's policy to protect residents from abuse by ensuring thorough screening of potential employees, this lapse in procedure was confirmed by the Licensed Nursing Home Administrator (LNHA) and other facility officials. They acknowledged that Staff #4 did not have a background check prior to hire, although there were no allegations of abuse against this staff member, who no longer worked at the facility.
Failure to Investigate Pressure Ulcer
Penalty
Summary
The facility failed to initiate an investigation when a facility-acquired pressure ulcer was discovered on a resident's heel. The resident, who had a fully intact cognition, was admitted with several medical diagnoses, including a unilateral inguinal hernia. On a specific date, a physician's order was made for skin prep wipes and to float the resident's heels on a pillow due to a red and boggy right heel. However, the Treatment Administration Record indicated that a nurse signed off as having observed no skin breakdown, despite the presence of a pressure-related injury. The surveyor observed the resident in bed with their foot elevated on a pillow, and the resident reported heel pain. The Licensed Practical Nurse (LPN) administered Tylenol for the pain but did not assess the heel before doing so. Upon later assessment in the presence of the surveyor, the LPN noted non-blanchable erythema and swelling on the right heel, indicating the beginning of a pressure ulcer. The resident's feet were not properly offloaded from the pillow, which could contribute to pressure injury. The Unit Manager/LPN stated that the nurse should have reported the pressure injury to the Charge Nurse or Supervisor for an incident report to be completed. The facility's policies on abuse prevention, accidents and incidents, and pressure ulcer management were not followed, as the nurse did not document or report the pressure injury appropriately. An investigation was only initiated after the surveyor's inquiry, revealing a lack of awareness among nurses regarding proper wound staging.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls, which was identified during a survey. The resident, who had diagnoses including cancer, infection following a procedure, and dementia, was observed with a fall mat beside their bed. Despite having a Brief Interview of Mental Status (BIMS) score indicating intact cognition, the resident experienced multiple falls within a short period. These incidents included sitting on the floor, kneeling at the foot of the bed, and being found on the floor near the closet. Although fall evaluations and pain assessments were conducted after each fall, the individualized comprehensive care plan (ICCP) was not updated with specific interventions following each incident. Interviews with facility staff revealed a lack of clarity regarding the responsibility for revising the ICCP. The Charge Nurse indicated that the ICCP should be updated after each fall, but the Infection Preventionist/Registered Nurse and the MDS Coordinator provided conflicting information about who was responsible for these revisions. The facility's policy on comprehensive person-centered care plans did not include guidelines for care plan revisions, contributing to the oversight. Ultimately, it was acknowledged that the ICCP was only revised after the first two falls, leaving the third and fourth falls unaddressed in the care plan.
Failure to Document Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that catheter care was performed and documented every shift as per the physician's order for a resident with an indwelling urinary catheter. The resident, who had medical diagnoses including acute kidney failure and obstructive uropathy, was observed by the surveyor without a visible urinary catheter during the initial tour. However, later observations confirmed the presence of a urinary drainage bag. The resident's medical record indicated a physician's order for catheter care every shift, but the Treatment Administration Record (TAR) showed that catheter care was not documented as rendered eleven times from the beginning of the month through the 23rd. The facility's policies on charting and urinary catheter care required documentation of all services provided to residents. Despite this, the surveyor found missing documentation for catheter care in the TAR, which was acknowledged by the Licensed Nursing Home Administrator and the President of Operations. They stated that if the care was not documented, it was considered not done. This deficiency was identified during a review of the resident's comprehensive care plan and the facility's policies, highlighting a lapse in adherence to the physician's orders and facility protocols.
Deficient Hemodialysis Care and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation for a resident receiving hemodialysis. The resident, who had end-stage renal disease and required dialysis three times a week, was not assessed according to professional standards. The facility's policy required regular monitoring of dialysis treatment sites for complications, including pre and post-dialysis assessments. However, the facility did not complete the necessary dialysis communication forms upon the resident's return from treatment on multiple occasions. Additionally, there were no physician orders related to checking the dialysis access site for a bruit or thrill, which are essential assessments to ensure the functioning of the arteriovenous graft. The surveyor's review revealed that the resident's blood pressure was incorrectly taken from the arm with the dialysis access site 18 times out of 50, despite the known risk of clotting. The Charge Nurse and Registered Nurse acknowledged the oversight, confirming that the dialysis communication forms were not completed and that blood pressures were mistakenly documented from the left arm. The Infection Preventionist and the Licensed Nursing Home Administrator confirmed these deficiencies, noting that staff sometimes rushed, leading to these errors.
Failure to Adhere to PPE Protocols for COVID-19 Isolation
Penalty
Summary
The facility failed to ensure that staff adhered to the infection prevention and control program by not donning personal protective equipment (PPE) before entering the rooms of residents with suspected or confirmed COVID-19. This deficiency was observed during a survey where a per diem Nurse Practitioner (NP) entered the room of two residents who were on isolation for COVID-19 without performing hand hygiene or wearing the required PPE. The NP only wore an N95 face mask and did not use goggles or a face shield, as required by the facility's policy for droplet precautions. The incident involved two residents, one of whom had a medical history that included a diagnosis of COVID-19, and the other had moderate cognitive impairment. The NP assumed the residents were off isolation because the droplet precaution signage was not visible, which led to the oversight. The interim Administrator confirmed that staff should perform hand hygiene and don the appropriate PPE when entering the room of a resident on transmission-based precautions.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Moorestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court Skilled Care At Evergreens | 0.6 mi | ★★★★★ | 5 | 0 |
| Cambridge Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Total Rehab Moorestown | 1.6 mi | ★★★★★ | 1 | 0 |
| Wynwood Rehabilitation And Healthcare Center | 2.8 mi | ★★★★★ | 13 | 0 |
| Sterling Manor | 4.2 mi | — | 0 | 0 |
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