Careone at Moorestown

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, record review and policy review, the facility failed to thoroughly investigate an allegation of physical abuse by Certified Nursing Assistant (CNA)1 for one resident (Resident (R) 87) of two residents reviewed for abuse in a sample of 31 residents. This failure had the potential to negatively impact all residents currently residing at the facility.

Inspectors wroteBased on interview, record review, review of the facility's admission Agreement and facility policy review, the facility failed to provide information regarding a resident's right to choose an attending physician for one (Resident (R)1) of three sampled residents reviewed for facility's admissions process in a total sample of 21 residents. This had the potential R1's rights not to be upheld and honor his/her right to have a physician of his choice. Review of the facility's policy titled, admission Agreement dated 08/18, indicated, Policy statement All residents must have a signed and dated admission agreement on file. Policy Interpretation and Implementation 1. At the time of admission, the resident (or his/her representative) must sign an admission agreement (contract). 2. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide a hazard free environment for one of five residents (Resident (R) 8) reviewed for accidents out of a total sample of 21 residents. During a staff assisted transfer R8 suffered harm when the metal frame of his/her bed which had exposed openings with rough edges cut his/her leg and resulted in a large laceration which required sutures at a hospital emergency room (ER) to close the wound. Review of the facility's policy titled, Safety and Supervision of Residents dated 07/21, indicated, Policy statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Facility Oriented Approach to Safety . 2. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that medications were administered in a sanitary manner for two of five (Residents (R)18 and R20) observed during medication administration out of a total sample of 21 residents. This failure could lead to potential resident infections due to contamination. Review of the facility policy titled, Administering Medications revised April 2019 revealed . 25. Staff follows established facility infection control procedures e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.1. [...]

Inspectors wroteBased 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. Resident #302 was receiving oxygen via a nasal cannula (tubing that administers oxygen through the nose). On 9/25/24 at 11:16 AM, the surveyor reviewed the medical record for Resident #302. [...]

Inspectors wroteBased 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. The surveyor observed the nebulizer machine with attached face mask and tubing lying directly on the resident's nightstand. [...]

Inspectors wroteBased 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. On 9/25/24 at 12:10 PM, the surveyor requested from the LNHA to provide all education from 2023 and the most recent performance evaluation for five selected CNAs (CNA #1, #2, #3, #4, and #5). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by ensuring all newly hired employees were screened for potential abuse by conducting criminal background checks prior to hire. This deficient practice was identified for 1 of 10 staff (Staff #4) reviewed for newly hired employees, and was evidenced by the following: A review of the facility's Abuse Prevention Program policy with an edited date of 4/5/18, included .as part of the resident abuse prevention, administration will: 1. Protect our residents from abuse by anyone, including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 2. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to a.) initiate an investigation at the time a facility acquired pressure ulcer was discovered on 9/18/24, to rule out neglect. The deficient practice was identified for 1 of 2 residents reviewed for skin conditions and pressure ulcers (Resident #402), and was evidenced by the following: Reference: https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/ National Pressure Ulcer Staging System: Deep Tissue Injury: A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise, and they may herald the subsequent development of a Stage III-IV pressure ulcer, even with optimal treatment. Definition: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a history of falls at the facility. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #21), and was evidenced by the following: On 9/23/24 at 7:52 PM, during the initial tour of the facility, the surveyor observed Resident #21 in bed with their eyes closed. The surveyor observed a fall mat on the right side of the bed, and the left side of the bed was against the wall. The surveyor asked the Resident Representative (RR), who was present at the time, if the resident had any falls, and the RR stated that the resident didn't fall but has slid to the floor. On 9/24/24 at 11:00 AM, the surveyor reviewed the medical record for Resident #21. [...]

Inspectors wroteComplaint NJ #: 175738 Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain weekly weights as ordered; and b.) obtain a physician's order to hold a tube feeding (therapeutic nutrition) in accordance with professional standards of practices. This deficient practice was identified for 2 of 18 residents reviewed for professional standards of practice (Resident #103 and Resident #301). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure catheter care was performed and documented every shift in accordance with a physician's order. This deficient practice was identified in 1 of 2 residents reviewed for urinary catheters (Resident #44), and was evidenced by the following: On 9/23/24 at 7:05 PM, during the initial tour of the facility, Resident #44 was in the bed with their eyes closed. The surveyor did not observe a urinary catheter. On 9/24/24 at 9:00 AM, the surveyor reviewed the medical record for Resident #44. A review of the admission Record face sheet (an admission summary) reflected the resident had medical diagnoses which included but were not limited to; acute kidney failure, obstructive uropathy (structural or functional hindrance of normal urine flow), and repeated falls. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure a resident who received hemodialysis was being assessed in accordance with their hemodialysis access site and professional standards of practice every shift; and b.) complete dialysis communication forms on return to the facility from dialysis treatment. This deficient practice was identified for 1 of 1 resident reviewed for hemodialysis (Resident #48) and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff put on personal protective equipment (PPE) before they entered the room of a resident with suspected or confirmed COVID-19. This deficient affected 2 (Resident #1 and Resident #2) of 5 sampled residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure an effective infection control program was followed. Specifically, the facility failed to ensure staff properly removed (doffed) a contaminated gown and gloves for two of 21 sampled residents, (Resident (R) 200 and R202), diagnosed with COVID-19. This failure increased the risk of spreading the COVID-19 virus.