Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Cambridge Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments, totally dependent on staff for care, sustained a head injury after falling from bed during incontinence care. The CNA providing care did not review the care plan or receive a shift report, and attempted to turn the resident without the required two-person assist, contrary to documented interventions. The facility's investigation did not align with the care plan and assessment documentation, and staff interviews confirmed the resident's inability to assist with turning.
A resident with severe cognitive impairment and total dependence on staff for care suffered a fall resulting in head injuries after being found on the floor. The care plan required two-person assistance, but the CNA involved was unaware of this requirement and did not check the plan before providing care. The facility failed to conduct a thorough investigation and did not ensure staff followed the documented care plan, leading to the deficiency.
A resident with severe cognitive impairment and a history of fractures experienced significant shoulder pain due to a non-displaced humerus fracture. Despite documented complaints of pain and assessment findings, there was no evidence in the MAR or nursing notes that pain medication or interventions were administered. Staff interviews confirmed that pain management steps, including physician notification and documentation, were not followed according to facility policy.
Expired food was found in the kitchen, including a frozen lasagna in the walk-in freezer and chicken noodle soup in the walk-in refrigerator, both past their use-by dates. In unit pantries, plastic cups were observed stacked or stored open to the air rather than contained in a sleeve or container, and an LPN discarded the exposed cups. The LNHA stated cups should be contained when not in use and outdated food should not be kept in the refrigerator or freezer.
Personal refrigerator temperature logs were not maintained for several residents with room refrigerators. Surveyors observed missing or incomplete log entries for multiple refrigerators, and an RN was unsure how often temperatures were to be checked, while the LNHA stated they should be checked daily. The facility policy required designated employees to check and record refrigerator and freezer temperatures daily.
Two residents with lower extremity impairment did not consistently receive or have documentation of required ADL support, including scheduled turning to prevent skin breakdown and assistance with bathing. Gaps in the medical record and ADL documentation, along with lack of evidence for care provision or resident refusal, led to deficiencies in maintaining residents' functional abilities.
Surveyors found that two residents had their handheld call devices on the floor and out of reach while in bed, despite facility policy and staff statements requiring the call system to be accessible. Staff interviews confirmed the expectation that the call device should be attached to bedding and within reach, but this was not consistently implemented.
A resident with HF and PVD had an order for apixaban 5 mg every 12 hours, and the MDS indicated an anticoagulant was ordered, but the current care plan did not include a focus area or interventions for anticoagulant use. The UMRN acknowledged the resident should have been care planned for oxygen but it was not included, and the DON stated there should be a focus or intervention for anticoagulant use on the care plan.
Pain medication was not administered according to physician-ordered pain scale parameters for two residents. One resident with a fractured ankle and another resident with a rib fracture and opioid dependence both received multiple oxycodone doses when documented pain scores were below the ordered severe-pain range. The MARs showed repeated doses given outside the prescribed parameters, and an LPN stated that pain outside the ordered range would require contacting the physician for a different order.
Failure to Follow and Communicate Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's plan of care was followed and properly communicated to all staff, resulting in a fall that caused head trauma and a laceration requiring hospital transfer. The resident involved had significant medical conditions, including Parkinson's disease, hemiplegia, muscle wasting, and dementia, and was assessed as having severe cognitive impairment and total dependence on staff for care. The care plan specified that the resident required two-person assistance for all activities of daily living, including turning and repositioning, due to impaired upper and lower extremities and inability to roll independently. On the day of the incident, a CNA was providing incontinence care and attempted to turn the resident without a second staff member present, contrary to the care plan requirements. The CNA did not review the plan of care or receive a report from the previous shift regarding the resident's assistance needs. During the care, the resident rolled out of bed and sustained a head injury. The incident report and staff interviews confirmed that the resident was found on the floor with active bleeding and was transferred to the hospital for further evaluation and treatment. Further review revealed discrepancies between the facility's investigation and the documented care plan. While the investigation concluded that the CNA followed protocol, the care plan and MDS assessment clearly indicated the resident was unable to assist with turning and required two-person assistance. The CNA later acknowledged not reviewing the care plan prior to providing care. The facility was unable to provide a bedrail assessment, and staff interviews confirmed the resident's total dependence and immobility. The failure to follow and communicate the care plan interventions directly led to the resident's fall and injury.
Failure to Investigate and Follow Care Plan for Dependent Resident After Fall
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation to identify the causal factors of a fall involving a severely cognitively impaired resident. The resident, who was totally dependent on staff for care due to conditions including Parkinson's disease, hemiplegia, muscle wasting, and dementia, was found lying on the floor in a pool of blood with a hematoma and laceration to the head, requiring emergent transfer to the hospital. The resident's care plan and MDS assessment indicated a need for two-person physical assistance with all care and transfers, and that the resident was unable to turn or roll independently. Despite these documented care requirements, the investigation concluded that the resident rolled out of bed during an incontinent and linen change. Interviews with staff revealed inconsistencies and a lack of awareness regarding the resident's care plan. The CNA involved in the incident did not check the care plan prior to providing care and was unaware that two-person assistance was required. Additionally, the CNA did not receive a report from the previous shift about the resident's care needs. The DON was unable to comment on the plan of care at the time of the survey and had not reviewed the MDS coding related to the resident's needs. Documentation and interviews further showed that the facility did not provide statements from all involved staff and could not produce evidence of in-service education for the CNA involved in the fall. The investigation was closed without a clear identification of the root cause, and the facility was unable to comment on the plan of care required for the resident, despite the assessment indicating the need for two-person assistance. This lack of thorough investigation and failure to ensure staff followed the resident's care plan led to the deficiency.
Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, COPD, and osteoporosis was admitted to the facility and later reported right shoulder pain, which was confirmed by x-ray to be a non-displaced humerus fracture. The resident had a history of pathological fractures and required maximum assistance with all activities of daily living. Documentation showed that the resident complained of significant pain, rated as high as 8 out of 10, with noted tenderness and limited range of motion. Despite these findings, there was no documentation that pain medication or any intervention was administered at the time of the initial complaint or during subsequent pain assessments. Further review of the Medication Administration Record (MAR) and nursing progress notes revealed no evidence that pain medication was given, even though pain was monitored and the resident continued to report discomfort. Interviews with facility staff, including the ADON and an LPN, confirmed that pain management interventions were not documented or possibly not provided, and that the physician was not notified as required. The facility's policy required staff to assess, intervene, and document pain management, but these steps were not followed, resulting in a failure to manage the resident's pain according to professional standards of practice.
Expired Food and Open Cup Storage in Kitchen and Pantries
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. On 7/25/2025, during observation of the kitchen with the Food Service Director (FSD), a frozen lasagna in the walk-in freezer was found wrapped in plastic wrap with a use-by date of 7/25/25, and a container of chicken noodle soup in the walk-in refrigerator was found wrapped in plastic wrap with a use-by date of 7/28/25. When asked about the lasagna, the FSD stated it should not be used and removed it from the freezer; the expired soup was also removed by the FSD. On 7/30/2025, in the [NAME] unit pantry, 11 plastic cups labeled for 7/30 7-3 were observed stacked facing up and exposed to the air. An LPN stated she did not know what the cups were for and said they should not be out and should be in a container for infection control reasons, then discarded them. On 7/31/2025, in the Laurel Creek unit pantry, a sleeve of plastic cups was observed laying on its side open to the air, and one cup in the cabinet was facing upward and open to the air. On 8/01/2025, the LNHA stated cups should be contained in a sleeve when not in use to prevent food borne illness, and that outdated food should not be in the refrigerator or freezer to prevent food borne illness. The facility policy also stated that food is to be dated for proper rotation by expiration dates and that supervisors are responsible for ensuring pantry, refrigerator, and freezer items are not past use-by or expiration dates.
Personal Refrigerator Temperature Logs Not Maintained
Penalty
Summary
The facility failed to ensure that food brought to residents by family and other visitors was stored, handled, and consumed in a safe and sanitary manner for 4 of 6 residents with personal refrigerators in their bedrooms. On 07/31/2025, the surveyor observed that Resident #26's personal refrigerator temperature log had not been filled out since July 18, Resident #9's refrigerator was missing temperature log entries for the entire month of July, Resident #51's refrigerator had no temperature log on the refrigerator for the month of July, and Resident #13's temperature log had not been filled out since July 18. During interview, the RN stated that nursing staff were responsible for cleaning, checking, and documenting the personal refrigerators in residents' rooms, but was unsure how often the temperatures needed to be checked and said the 11-7 shift was responsible. The LNHA stated that personal refrigerator temperatures should be checked daily to prevent food borne illnesses. A review of the facility policy dated September 2022, titled "Refrigerators and Freezers-Resident Personal," stated that designated employees will check and record refrigerator and freezer temperatures daily, consistent with NJAC 8:39-17.2(g).
Failure to Ensure Consistent ADL Support and Documentation
Penalty
Summary
The facility failed to provide necessary care and services to ensure that residents did not lose the ability to perform activities of daily living (ADLs) unless medically unavoidable. For one resident with bilateral lower extremity impairment and at risk for pressure ulcers, the care plan and physician's orders required turning and repositioning every two hours. However, documentation in the Treatment Administration Record (TAR) showed multiple blanks where turning was not recorded, and there were no progress notes to indicate the care was provided. The Director of Nursing acknowledged the importance of turning for skin integrity but could not confirm the care was completed in the absence of documentation. Another resident, also with bilateral lower extremity impairment and requiring substantial assistance with showering, had a care plan intervention for staff-assisted bathing. The ADL record documentation sheet revealed several blanks for scheduled showers on the evening shift, and the resident had previously filed a grievance regarding the shower schedule. Facility policy required that refusals or provision of showers be documented, but there was no documentation to indicate whether the showers were provided or refused. These findings demonstrate a failure to ensure that residents received the necessary care and services to maintain their ADL abilities as required by facility policy and regulation.
Failure to Ensure Call System Accessibility for Residents in Bed
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of access to the call system for residents while in bed. During multiple observations over several days, two residents were found in bed with the handheld call device on the floor adjacent to their beds, rather than within their reach. These observations occurred both when the residents were asleep and awake. Interviews with facility staff, including a CNA, the Registered Nurse Unit Manager, and the Director of Nursing, confirmed that the call device should be attached to the resident's sheet or blanket and within easy reach when residents are in bed, and that it should not be on the floor. A review of the facility's policy on answering call lights, dated April 2016, also indicated that the call light must be within easy reach of residents who are in bed or confined to a chair. The repeated observations of the call device being on the floor and out of reach for two residents demonstrate a failure to follow both facility policy and regulatory requirements regarding resident access to the call system.
Missing Care Plan Focus for Anticoagulant Use
Penalty
Summary
Resident #14 was admitted with diagnoses including Heart Failure and Peripheral Vascular Disease. The resident's admission MDS dated 06/27/2025 indicated that an anticoagulant was ordered, and the electronic medical record showed a physician's order dated 05/26/2025 for apixaban 5 milligrams every 12 hours. However, the current care plan did not include a care plan focus area or interventions for the anticoagulant. During surveyor interviews, the Unit Manger RN stated that care plans include focus areas for falls, wounds, catheters, certain medications, and diagnoses, and acknowledged that the resident should have been care planned for oxygen but it was not included. The DON stated that there should be a focus or intervention on the resident's care plan for use of an anticoagulant. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Pain medication given outside ordered pain parameters
Penalty
Summary
The facility failed to ensure residents received pain medications according to physician-ordered pain level parameters for 2 of 4 residents reviewed for pain. Resident #7 was admitted with diagnoses including a lower extremity fracture, diabetes, and depressive disorder, and the admission MDS indicated the resident was cognitively intact and receiving a pain management regimen. The physician ordered oxycodone 15 mg every 4 hours as needed for severe pain rated 7-10 and acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain. The MAR showed 92 doses of oxycodone were given in July, with 9 doses administered outside the ordered pain parameter, including doses when the documented pain level was 0, 2, 3, 5, or 6. The resident told the surveyor they had a fractured ankle, had surgery, and were receiving pain medication with relief. Resident #49 was admitted with diagnoses including asthma, opioid dependence, hypertension, and a rib fracture, and the admission MDS indicated the resident was cognitively intact and receiving a pain management regimen. The physician ordered oxycodone extended release 40 mg every 12 hours and oxycodone 20 mg every 4 hours as needed for severe pain rated 8-10. The MAR showed 93 doses of oxycodone were given in July, with 12 doses administered outside the ordered pain parameter, including doses when the documented pain level was 5, 6, or 7. The care plan for pain directed staff to administer pain medication as ordered and evaluate effectiveness, and the LPN stated that if pain was outside the ordered parameters, the physician would need to be called for a one-time dose or a lower-severity medication order.
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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.
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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) |
|---|---|---|---|---|
| Total Rehab Moorestown | 0.8 mi | ★★★★★ | 1 | 0 |
| Willowbrooke Court Skilled Care At Evergreens | 1.3 mi | ★★★★★ | 5 | 0 |
| Careone At Moorestown | 1.5 mi | ★★★★★ | 1 | 0 |
| Laurel Brook Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 9 | 0 |
| Wynwood Rehabilitation And Healthcare Center | 3.6 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.