Inspection Reports for
Care One At Moorestown
895 Westfield Road, Moorestown, NJ, 08057
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Capacity: 65
Deficiencies: 3
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, and infection control in the nursing home.
Findings
The facility was found deficient in honoring a resident's right to choose an attending physician, maintaining a hazard-free environment leading to a resident's leg laceration from an exposed bed frame, and ensuring sanitary medication administration practices.
Deficiencies (3)
Failed to provide information regarding a resident's right to choose an attending physician for one resident.
Failed to provide a hazard-free environment resulting in a resident sustaining a large laceration from exposed rough edges on a metal bed frame.
Failed to ensure medications were administered in a sanitary manner; medications dropped on medication cart were still administered to residents.
Report Facts
Total beds: 65
Missing bed frame caps: 267
Residents sampled: 21
Residents reviewed for accidents: 5
Residents observed for medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Prepared incident report and notified physician and family regarding resident's leg laceration |
| LPN2 | Licensed Practical Nurse | Observed administering medication that was dropped on medication cart |
| LPN3 | Licensed Practical Nurse | Observed administering medications dropped on medication cart |
| Admissions Director | Admissions Director | Interviewed regarding admission agreement and resident rights information |
| Administrator | Administrator | Interviewed regarding expectations for admission agreement and facility safety |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding bed frame inspection and maintenance |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policy |
| CNA1 | Certified Nursing Assistant | Notified nurse of resident's leg bleeding during transfer |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 27, 2024
Visit Reason
The inspection was conducted based on a complaint (NJ #: 175738) regarding failure to obtain weekly weights as ordered and failure to obtain a physician's order to hold a tube feeding in accordance with professional standards of practice.
Complaint Details
Complaint NJ #: 175738. The complaint was substantiated with findings that the facility failed to obtain weekly weights as ordered and failed to obtain a physician's order to hold tube feeding for residents, violating professional standards of practice.
Findings
The facility failed to obtain weekly weights as ordered for Resident #103 and failed to obtain a physician's order to hold tube feeding for Resident #301, resulting in minimal harm or potential for actual harm to a few residents.
Deficiencies (3)
Failure to obtain weekly weights as ordered for Resident #103.
Failure to obtain a physician's order to hold tube feeding for Resident #301.
Failure to document services, progress, or changes in resident condition in the medical record as required.
Report Facts
Residents reviewed for professional standards of practice: 18
Weekly weights missing: 2
Tube feeding volume: 800
Tube feeding water flush volume: 150
BIMS score: 12
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist/Registered Nurse (IP/RN) | Interviewed regarding weight obtaining and documentation process. | |
| Registered Dietitian (RD) | Interviewed about orders for weekly weights and documentation. | |
| Licensed Nursing Home Administrator (LNHA) | Acknowledged failure to obtain weekly weights as ordered. | |
| Licensed Practical Nurse (LPN) | Interviewed regarding tube feeding administration and lack of physician order to hold feeding. | |
| Charge Nurse (CN) | Acknowledged that physician's order should have been obtained prior to holding tube feeding. |
Inspection Report
Routine
Deficiencies: 13
Date: Sep 27, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including review of staff hiring practices, resident care, medication management, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to conduct timely criminal background checks for newly hired staff, inadequate investigation of a pressure ulcer, failure to revise care plans after resident falls, incomplete weekly and daily weight monitoring, failure to hold tube feeding orders properly, lack of incentive spirometer use and documentation, improper catheter care documentation, improper storage of nebulizer equipment, incomplete dialysis site assessments and documentation, missing annual CNA performance evaluations, and medication storage and narcotic count deficiencies.
Deficiencies (13)
Failure to conduct criminal background checks prior to hire for newly hired employees.
Failure to initiate investigation of facility-acquired pressure ulcer to rule out neglect.
Failure to revise individual comprehensive care plan after resident falls.
Failure to obtain weekly weights as ordered for residents.
Failure to obtain daily weights as ordered for a resident with congestive heart failure.
Failure to hold tube feeding with a physician's order during scheduled imaging.
Failure to provide and document use of incentive spirometry as ordered for multiple residents.
Failure to perform and document catheter care every shift as ordered.
Improper storage of nebulizer equipment exposed to air and contamination.
Failure to assess dialysis access site for bruit and thrill and incomplete dialysis communication forms.
Failure to conduct yearly performance evaluations for Certified Nursing Aides.
Failure to complete narcotic shift count logs and controlled medication administration documentation accurately.
Presence of loose pills in medication cart, contrary to policy.
Report Facts
Missing narcotic count shifts: 5
Missing narcotic count shifts: 11
Missing narcotic count shifts: 5
Missing narcotic count shifts: 4
Missing narcotic count shifts: 5
Missing narcotic count shifts: 3
Blood pressure checks: 50
Blood pressure checks on AV fistula arm: 18
Missed catheter care documentation: 11
Missed daily weights: 7
Missed weekly weights: 2
Missed dialysis communication forms: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Licensed Practical Nurse | Named in finding for failure to conduct criminal background check prior to hire |
| LPN #1 | Licensed Practical Nurse | Acknowledged missing narcotic documentation and loose pills in medication cart |
| LPN #2 | Licensed Practical Nurse | Acknowledged missing narcotic documentation on Maple Shade nursing unit |
| Licensed Nursing Home Administrator | Provided information and acknowledged deficiencies during survey | |
| Infection Preventionist/Registered Nurse | Provided information and acknowledged deficiencies during survey | |
| President of Operations Bridge Care | Present during interviews and acknowledged deficiencies | |
| Unit Manager/Licensed Practical Nurse | Interviewed regarding incentive spirometry and care plan revisions | |
| Charge Nurse | Interviewed regarding dialysis communication and tube feeding orders | |
| Registered Nurse | Interviewed regarding dialysis blood pressure documentation | |
| Director of Nursing | Interviewed regarding narcotic count and medication cart policies |
Inspection Report
Routine
Deficiencies: 1
Date: Jun 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding staff adherence to personal protective equipment (PPE) protocols for residents with suspected or confirmed COVID-19.
Findings
The facility failed to ensure staff properly donned PPE before entering the rooms of two residents with suspected or confirmed COVID-19, resulting in minimal harm or potential for actual harm to a few residents. The per diem Nurse Practitioner did not perform hand hygiene or wear full PPE as required.
Deficiencies (1)
Failure to ensure staff put on personal protective equipment (PPE) before entering the room of residents with suspected or confirmed COVID-19.
Report Facts
Residents affected: 2
Sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| per diem Nurse Practitioner | Entered rooms without proper PPE and hand hygiene | |
| interim Administrator | Provided statements on proper PPE and hand hygiene procedures |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 22, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding staff compliance with COVID-19 transmission-based precautions.
Findings
The facility failed to ensure staff properly removed contaminated gowns and gloves when exiting the rooms of two COVID-19 positive residents, increasing the risk of virus spread. Interviews and policy reviews confirmed staff noncompliance despite training and clear expectations.
Deficiencies (1)
Failure to ensure staff properly removed contaminated gown and gloves for two COVID-19 positive residents, increasing risk of virus spread.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA#1) | Named in infection control deficiency for improper PPE removal | |
| Director of Nursing (DON) | Provided expectations regarding PPE removal | |
| Infection Prevention Nurse | Provided expectations and confirmed CNA#1 PPE training |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 8, 2022
Visit Reason
The inspection was conducted due to a complaint investigation focusing on the facility's failure to adequately monitor a high fall risk resident and implement fall prevention interventions, as well as concerns related to medication security, food safety, infection control, and COVID-19 outbreak management.
Complaint Details
The complaint investigation focused on Resident #34's multiple falls and injuries due to inadequate supervision and fall prevention. Additional concerns included medication security, food safety, infection control breaches during medication administration and wound care, and incomplete COVID-19 contact tracing leading to potential exposure risks.
Findings
The facility failed to adequately monitor Resident #34, a high fall risk resident, resulting in multiple falls and injuries. Medication was left unsecured on a medication cart. Food safety violations included unlabeled and undated food items and improper sanitizer concentration. Infection control breaches were observed during medication administration and wound care, including improper hand hygiene and PPE use. The facility also failed to conduct thorough contact tracing for a COVID-19 positive resident, missing staff contacts and risking further spread.
Deficiencies (5)
Failure to adequately monitor a high fall risk resident and implement fall prevention interventions, resulting in multiple falls and injuries.
Failure to secure medications in a locked compartment; medication left unattended on medication cart.
Failure to properly handle and store potentially hazardous foods, maintain kitchen sanitation, and prevent microbial growth and cross-contamination.
Failure to perform proper hand hygiene and infection control during medication administration and wound care treatment.
Failure to complete thorough contact tracing for COVID-19 positive resident, resulting in missed staff contacts and potential spread of infection.
Report Facts
Fall Risk Assessment Score: 17
Number of fall investigations reviewed: 7
Number of medication carts observed: 4
Sanitizer concentration: 0
Number of staff listed as contacts in COVID-19 contact tracing: 7
Handwashing duration: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed leaving medication unattended on medication cart. |
| LPN #3 | Licensed Practical Nurse | Observed failing to perform hand hygiene before medication preparation and administration. |
| LPN #4 | Licensed Practical Nurse | Observed failing to perform hand hygiene and improper handling of resident mask during medication pass. |
| LPN #5 | Licensed Practical Nurse | Observed performing wound care with multiple hand hygiene and glove use violations. |
| DON | Director of Nursing | Provided fall investigations, confirmed infection control breaches, and contact tracing procedures. |
| IPRN | Infection Preventionist Registered Nurse | Reported COVID-19 outbreak and contact tracing initiation. |
| CNA #1 | Certified Nursing Assistant | Provided care to COVID-19 positive resident but was not listed on contact tracing. |
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