Inspection Reports for Careone At Moorestown
895 Westfield Road, Moorestown, NJ, 08057
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025, did not identify any deficiencies and served primarily to inform about privacy practices. Earlier inspections showed a pattern of deficiencies mainly related to staffing ratios, infection control, and life safety code compliance. Several complaint investigations substantiated issues with maintaining required nursing staff levels and infection prevention practices, though no fines or enforcement actions were listed in the available reports. The facility implemented corrective actions such as staff re-education, wage adjustments, and use of agency staff to address these concerns. The inspection history suggests some improvement in compliance with staffing and regulatory requirements over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
57 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and related offices, and describing their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Mar 24, 2025
Visit Reason
The inspection was conducted based on complaint NJ182004 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint #: NJ182004. The facility was found deficient in staffing ratios and total nursing staff hours based on complaint investigation. The facility was not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long-Term Care Facilities.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 for staffing ratios, failing to meet minimum certified nurse aide and total nursing staff requirements on multiple shifts during December 2024 and March 2025. No residents were adversely affected, but all residents had the potential to be affected. The facility implemented corrective actions including re-education, wage reassessment, incentives, and use of employment agencies.
Deficiencies (2)
Failure to ensure staffing ratios were met for 2 of 7-day shifts and 1 of 7 evening shifts for the week of 12/22/2024 to 12/28/2024; and 5 of 14 day shifts for the weeks of 03/09/2024 to 03/22/2024.
Deficient in total nursing staffing hours for 2 of 14 days during 03/09/2025 to 03/22/2025.
Report Facts
Census: 57
Staffing Deficiencies: 2
Staffing Deficiencies: 1
Staffing Deficiencies: 5
Required CNA staffing: 7
Actual CNA staffing: 6
Required CNA staffing: 7
Actual CNA staffing: 6
Required CNA staffing: 6
Actual CNA staffing: 5
Required CNA staffing: 8
Actual CNA staffing: 7
Required CNA staffing: 8
Actual CNA staffing: 7
Required CNA staffing: 7
Actual CNA staffing: 6
Required CNA staffing: 7
Actual CNA staffing: 6
Required CNA staffing: 7
Actual CNA staffing: 6
Required Staffing Hours: 210.5
Actual Staffing Hours: 208
Required Staffing Hours: 206.5
Actual Staffing Hours: 192
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to review and corrective actions for staffing deficiencies | |
| Director of Nursing | Named in relation to review and corrective actions for staffing deficiencies and re-education |
Inspection Report
Annual Inspection
Census: 51
Capacity: 65
Deficiencies: 14
Date: Sep 27, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations and a Life Safety Code Survey.
Complaint Details
Complaint numbers NJ169497, NJ171563, NJ174482, NJ175738 were investigated. The facility failed to maintain minimum direct care staff-to-resident ratios on multiple shifts and failed to investigate and prevent abuse as required. The complaint was substantiated with multiple deficiencies cited.
Findings
The facility was found deficient in multiple areas including abuse prevention policies, investigation of alleged violations, care plan timing and revision, quality of care, bowel/bladder incontinence care, pharmacy services, and life safety code compliance. Deficiencies were cited related to failure to maintain minimum staffing ratios, failure to conduct required audits and education, failure to maintain fire alarm and sprinkler systems, and failure to ensure proper medication administration and documentation.
Deficiencies (14)
Failed to implement abuse policy by ensuring all newly hired employees were screened for potential abuse by conducting criminal background checks prior to hire.
Failed to initiate an investigation at the time a facility acquired a resident with a pressure ulcer and failed to ensure proper care and documentation.
Failed to maintain minimum direct care staff-to-resident ratios as mandated by the state for 26 out of 35 day shifts reviewed.
Failed to develop and revise comprehensive care plans timely for residents.
Failed to ensure services provided met professional standards of practice.
Failed to ensure bowel/bladder incontinence care and catheter care met professional standards.
Failed to maintain pharmacy services including medication storage, labeling, and controlled substance accountability.
Failed to maintain quality of care including assessment, monitoring, and documentation of residents' weights and vital signs.
Failed to ensure dialysis care met professional standards including assessment, monitoring, and documentation.
Failed to ensure respiratory/tracheostomy care and suctioning met professional standards.
Failed to conduct regular in-service education for nurse aides annually.
Failed to maintain accurate fire alarm system and sprinkler system inspections and maintenance.
Failed to conduct required fire drills quarterly on each shift.
Failed to maintain emergency preparedness communication plan with accurate contact information.
Report Facts
Census: 51
Total Capacity: 65
Staff-to-Resident Ratios Deficient Shifts: 26
Deficiency Severity Counts: 7
Deficiency Severity Counts: 4
Deficiency Severity Counts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Named in abuse policy deficiency related to failure to conduct criminal background check prior to hire. | |
| Licensed Practical Nurse #1 | LPN | Named in medication storage and administration deficiencies. |
| Licensed Practical Nurse #2 | LPN | Named in medication storage and narcotic count deficiencies. |
| Administrator | Named in staffing ratio deficiency and in review of staffing reports. | |
| Director of Nursing | Named in multiple deficiencies including abuse prevention, staffing, education, medication administration, and audits. | |
| Regional Employment Coordinator | Named in audits of employee performance evaluations. | |
| Environmental Service Director | Named in fire alarm and sprinkler system deficiencies. | |
| Registered Dietician | RD | Named in deficiencies related to weight monitoring and nutrition. |
| Licensed Nursing Home Administrator | LNHA | Named in employee performance review deficiencies. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Apr 22, 2024
Visit Reason
The inspection was conducted based on complaint NJ173002 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint #: NJ173002. The facility was found to be in substantial compliance overall but had deficiencies related to staffing ratios. The complaint was substantiated based on interviews and document review.
Findings
The facility was found deficient in meeting mandatory staffing ratios for certified nursing assistants on 4 of 14 day shifts reviewed, potentially affecting all residents. The facility was not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long-Term Care Facilities.
Deficiencies (1)
Failed to ensure staffing ratios were met for 4 of 14-day shifts reviewed, specifically CNA staffing was below required minimums on multiple days.
Report Facts
Census: 54
Deficient shifts: 4
CNA staffing on deficient days: 6
Residents on deficient days: 55
Residents on deficient day: 60
Residents on deficient day: 58
Required CNAs: 7
Inspection Report
Complaint Investigation
Census: 49
Capacity: 65
Deficiencies: 5
Date: Sep 22, 2023
Visit Reason
A recertification and complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health due to complaints NJ157753, NJ163728, NJ164320, and NJ167210. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The survey was complaint-related with complaint numbers NJ157753, NJ163728, NJ164320, and NJ167210. The facility was found not to be in substantial compliance with infection prevention and control requirements.
Findings
The facility failed to ensure an effective infection control program, specifically staff did not properly remove contaminated gowns and gloves increasing infection risk. Additionally, the facility failed to maintain required minimum staffing ratios for certified nurse aides (CNAs) on multiple shifts and dates. Life safety code deficiencies were also identified including unprotected vertical openings, unsecured hazardous area doors, and fire alarm system issues.
Deficiencies (5)
Failure to ensure staff properly removed contaminated gowns and gloves increasing risk of infection transmission.
Failure to maintain required minimum staffing ratios for CNAs on multiple shifts and dates.
Failure to ensure unprotected vertical openings between floors were properly enclosed with fire resistance rating.
Failure to ensure hazardous area doors were self-closing or automatic closing and secured in the closed position.
Failure to ensure photo electric smoke detector was installed at proper distance from ceiling air diffusers.
Report Facts
Survey Census: 49
Sample Size: 27
Supplemental Residents: 0
Certified Beds: 65
CNA Staffing Deficiencies: 4.5
CNA Staffing Deficiencies: 4
CNA Staffing Deficiencies: 5
CNA Staffing Deficiencies: 4.5
Residents Potentially Affected: 14
Residents Potentially Affected: 30
Residents in Facility: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in infection control deficiency for failing to properly doff contaminated gown and gloves. |
| Director of Nursing | Director of Nursing (DON) | Stated expectation that staff should remove gown and gloves prior to exiting resident rooms. |
| Infection Prevention Nurse | Infection Prevention Nurse | Confirmed PPE competency training and expectations for gown and glove removal. |
| Maintenance Director | Maintenance Director | Observed and confirmed unprotected vertical openings and door deficiencies. |
Inspection Report
Annual Inspection
Census: 51
Capacity: 65
Deficiencies: 13
Date: Jul 8, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to accident hazards and supervision, medication labeling and storage, food safety and sanitation, infection prevention and control, staffing ratios, and multiple life safety code violations including building construction, egress doors, number of exits, vertical openings, fire alarm system, corridor doors, utilities, electrical systems, and power cords.
Deficiencies (13)
Facility failed to adequately monitor a resident at high risk for falls and implement prevention interventions.
Facility failed to secure medications in a locked compartment by leaving unattended medication in a plastic cup on top of a medication cart.
Facility failed to properly handle and store potentially hazardous foods, maintain equipment and kitchen sanitation to prevent foodborne illnesses.
Facility failed to establish and maintain an infection prevention and control program including proper hand hygiene and PPE use.
Facility failed to maintain required minimum direct care staff-to-resident ratios for day and evening shifts as mandated by New Jersey.
Facility failed to provide acceptable construction type and fire resistance rating of building structural elements per NFPA 101.
Facility failed to provide exit doors in the means of egress readily accessible and free of obstructions or impediments for emergency use.
Facility failed to provide at least two acceptable exits remote from each other for each floor or fire section; second egress led to an open stairway not permitted as a required means of egress.
Facility failed to maintain fire alarm manual pull stations accessible at all times; one pull station was blocked by furniture.
Facility failed to ensure corridor doors resist passage of smoke; six resident room doors did not fit properly and left gaps.
Facility failed to install and maintain gas piping in compliance with NFPA 54; yellow flexline gas pipe was improperly supported with zip ties.
Facility failed to ensure remote manual stop station was installed for emergency generator to prevent inadvertent operation.
Facility failed to prohibit use of extension cords and power cords beyond temporary installation; microwave plugged into power strip plugged into quad outlet.
Report Facts
Census: 51
Total Capacity: 65
Deficiencies cited: 13
Staffing ratios: 4
Staffing ratios: 6
Dead-end corridor length: 44
Gap in door: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| 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 wearing surgical mask improperly |
| LPN #5 | Licensed Practical Nurse | Observed failing to perform hand hygiene and improper glove use during resident care |
| DON | Director of Nursing | Interviewed regarding staffing and infection control practices |
| Maintenance Director | Interviewed and observed regarding building construction, fire safety, gas piping, and fire alarm issues | |
| Regional Plant Operations Director | Interviewed and observed regarding building construction, fire safety, gas piping, and fire alarm issues | |
| Administrator | Interviewed and informed of all findings and deficiencies |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Dec 4, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ149621 and NJ149608. The facility was reviewed for compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Complaint Details
Complaint #: NJ149621, NJ149608. The facility was found deficient in meeting minimum staffing requirements as per NJDOH memo dated 01/28/2021 and P.L. 2020 c 112. The deficient practice had the potential to affect all residents.
Findings
The facility was found not in substantial compliance due to failure to meet minimum staffing ratios for certified nurse aides (CNAs) on multiple shifts. Staffing deficiencies were identified for 34 of 56 shifts reviewed, potentially affecting all residents. The facility faced challenges hiring staff post-pandemic and implemented corrective actions including increased pay, bonuses, job fairs, and use of agency staff.
Deficiencies (1)
Failure to ensure minimum staffing ratios for certified nurse aides on 34 of 56 shifts reviewed.
Report Facts
Shifts reviewed: 56
Shifts deficient: 34
Census: 56
Sample size: 3
Date of correction: Jan 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding staffing challenges and corrective actions | |
| Director of Nursing (DON) | Interviewed regarding staffing challenges, scheduling, and corrective actions |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Sep 21, 2021
Visit Reason
The inspection was conducted based on complaints NJ144002 and NJ145039 to determine compliance with regulatory requirements.
Complaint Details
Complaint #: NJ144002 and NJ145039. The facility is in compliance based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Jun 14, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ140303, NJ142940, and NJ143255.
Complaint Details
Complaint numbers NJ140303, NJ142940, and NJ143255 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 9
Inspection Report
Routine
Census: 49
Deficiencies: 0
Date: Jan 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 9
Viewing
Loading inspection reports...
