CareOne At Moorestown

In the surveyor’s words

From the most serious findings on record at CareOne At Moorestown, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Feb 11, 2026

  Based on document review, interview and policy review, the facility failed to ensure that a Registered Nurse (RN) was working at least eight consecutive hours for two days in 2025. This has the potential to affect all 61 residents that are currently in the facility. Findings include: Review of the facility provided Nurse Staffing Report dated 09/07/25, indicated no evidence of an RN working on any shift for this day. Review of the facility provided Nurse Staffing Report dated 12/26/25, indicated no evidence of an RN working on any shift for this day. Interview on 02/10/26 at 4:45 PM, the Administrator confirmed that there were no RNs for these two days. He/she said that he/she has been working with the staffing coordinator to ensure that there is an RN scheduled daily. […]

• No harm, potential for more than minimal, patternF684Sep 27, 2024

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to obtain daily weights for 7 out of 20 daily weights ordered for a resident with congestive heart failure that required daily weights to monitor fluid retention. This deficient practice was identified for 1 of 1 resident reviewed for respiratory care (Resident #302), and was evidenced by the following: On 9/23/24 at 7:39 PM, during initial tour of the facility, the surveyor observed Resident #302 in their bedroom lying in bed watching television. […]

• No harm, potential for more than minimal, patternF695Sep 27, 2024

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) store nebulizer equipment in a manner to prevent the spread of infection for 1 of 1 residents reviewed for respiratory care (Resident #302); and b.) administer and accurately document breathing exercises using an incentive spirometer tool as ordered by the physician for 3 of 4 residents reviewed for incentive spirometry therapy (Resident #5, Resident #401, and Resident #402). This deficient practice was evidenced by the following: 1. On 9/23/24 at 7:39 PM, during initial tour of the facility, the surveyor observed Resident #302 in their bedroom lying in bed watching television. […]

• No harm, potential for more than minimal, patternF730Sep 27, 2024

  Based on interview and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of Certified Nursing Aides (CNA) to provide specific education based on the outcomes of the reviews. This deficient practice was identified for 4 of 5 CNAs reviewed for education (CNA #1, #2, #3, and #4), and was evidenced by the following: During entrance conference on 9/23/24 at 6:55 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to provide a list of all the facility's CNAs with their date of hire. […]

• No harm, potential for more than minimal, patternF755Sep 27, 2024

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the accountability of the narcotic shift count logs were completed; b.) accurately account for and document the administration of controlled medications; and c.) ensure medications were stored appropriately in accordance with professional standards of practice. This deficient practice was identified on 2 of 2 medication carts reviewed for medication storage, and was evidenced by the following: 1. […]