Complete Care at Voorhees, LLC

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a cognitively impaired resident who was at risk for aspiration (accidental breathing in of fluid or food into the lungs) and had a physician's order for a ground (soft, moist, finely minced) texture diet received food that was consistent with their prescribed mechanically altered diet to prevent accidental choking (airway obstruction caused by food or small objects) and aspiration (foreign material inhaled into the airway/lungs). This deficient practice was identified for 1 of 7 residents (Resident #106) reviewed for accidents. On 3/25/26, a Hospice Liaison (HL) brought in pizza for the residents for a scheduled activity event. During this time, Resident #106, who was on a ground diet, was served regular consistency pizza by the HL. [...]

Inspectors wroteBased on interviews, medical record review, and review of other pertinent facility documents on 02/17/2026 and 02/19/2026, it was determined that the facility failed to promptly notify the Physician about a resident's abnormal urine culture result. The facility also failed to follow its policy titled Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification. This deficient practice was identified for 1 of 6 residents (Resident #6) reviewed for laboratory results. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Acute Kidney Failure (a rapid loss of kidney function), Diabetes (high blood sugar levels), and Urinary Tract Infection (bacteria infection in the bladder, kidneys). [...]

Inspectors wroteBased on interviews, medical record review, as well as review of other pertinent facility documents on 08/27/2025 and 08/29/2025, it was determined that the facility failed to administer medications in accordance with the acceptable standard of nursing practice, and to follow the facility policy on Medication Administration. This deficient practice was identified for 1 of 9 sampled residents (Resident #7) reviewed for medication administration and was evidenced by the following:According to the admission Record, Resident #7 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteComplaint # NJ 00185028 and NJ00185373 Based on interviews and record review, as well as a review of pertinent facility documents on 5/2/2025, it was determined that the facility failed to administer the medications in accordance with the acceptable standard of nursing practice and follow the facility policy on Administering Medications for 4 of 7 sampled residents (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for medication administrations. This deficient practice was evidenced by the following: According to the admission RECORD (AR), Resident #2 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 1/2/25 from 10:00 AM until 10:51 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1. There was no trash can at the handwashing sink at the entrance to the galley of the kitchen. The nearest trash can was covered with a lid and failed to contain a foot pedal. The FSD stated that the lid was normally removed during food service. 2. The oven in the galley of the kitchen was heavily soiled. The FSD stated that it was cleaned two weeks ago. 3. The lower double convection oven in the galley of the kitchen was soiled with a thick, black substance. The FSD stated that it was recently cleaned. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote dignity and respect of the residents. This deficient practice was identified in 1 of 5 units observed (the 100 unit) and was evidenced by the following: 1.) On 1/9/25 at 10:00 AM, during the surveyor-conducted resident council meeting, 4 of 4 residents (Resident #6, #60, #71 and #98) who attended the meeting stated that roommates did not get served their meal trays at the same time. 2.) On 1/7/25 at 9:27 AM, the surveyor observed the breakfast meal on the high end of the 100 unit and Resident #71 was delivered his/her breakfast tray. Resident #71 stated we don't get our meal trays delivered at the same time. [...]

Inspectors wroteComplaint #: NJ180809 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner for 3 of 35 residents (Resident #106, #107, and #126) and air temperature log for 5 of 5 units observed during environmental rounds. This deficient practice was evidenced by the following: 1.) On 1/3/2025 at 12:13 PM, the surveyor toured the 500 Unit, which was noted to be chilly in the hallway near room [ROOM NUMBER]. The hatch door leading to the attic was observed to be partially open. The Director of Maintenance (DM) took the air temperature, which registered at 65 degrees. A review of the Air Temperature audit logs from 12/1 2024 to 1/8/25 revealed the following: On 12/3/2024: The 100 Unit shower room was documented as 70 degrees. [...]

Inspectors wroteComplaint NJ #'s:168726, 168827, and 175632 Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure medications were administered within the physician's order scheduled time in accordance with professional standards of practice for 2 of 35 residents (Resident #86 and #160) reviewed for professional standards of practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteComplaint #: NJ175632 Based on observation, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to provide foot care and services for 1 of 1 resident (Resident #86) reviewed for foot care. This deficient practice was evidenced by the following: On 1/2/25 at 10:27 AM, during the initial tour the surveyor observed Resident #86 lying in bed sleeping. On 1/3/25 at 10:22 AM, the surveyor reviewed the medical record for Resident #86. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, Diabetes Mellitus (DM- high blood glucose), abnormalities of gait (a person's manner in walking) and mobility, and Alzheimer's disease. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 11/10/23, that the resident had DM. Interventions included: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adjust medication administration times to accommodate for scheduled dialysis times. This deficient practice was identified for 1 of 1 resident (Resident # 33) reviewed for dialysis and was evidenced by the following: On 1/2/24 at 10:15 AM, the surveyor observed that Resident #33 was not in his/her room. Per the staff, Resident #33 was at dialysis. On 1/7/24 at 10:18 AM, the surveyor interviewed Resident #33 who stated that his/her Midodrine medication (used to treat low blood pressure) was ordered three (3) times a day and he/she did not receive the medication at noon on his/her dialysis days. [...]

Inspectors wroteComplaint #: NJ175632, 176860 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to ensure appetizing and palatable temperature of food for 1 of 1 lunch meal on 1 of 5 nursing units (300 Unit). This deficient practice was evidenced by the following: 1. On 1/3/25 at 9:21 AM, the surveyor conducted a Resident Council meeting which included four residents (Resident #6, #60, #71 and #98). All four residents informed the surveyor that the food was served cold and was not appetizing or recognizable. On 1/7/25 at 11:17 AM, the surveyor informed the Food Service Director (FSD) and the District Food Service Manager (DFSM) that they wanted to observe a lunch meal service for the day including food temperatures. The DFSM stated that all hot foods should be above 135 F on the food service line. [...]

Inspectors wroteComplaint #: NJ00174162 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) provide nail care to a resident who required assistance with the activities of daily living (ADL) and b.) implement the comprehensive care plan. This deficient practice was identified for 1 of 8 residents (Resident #118) reviewed for activities of daily living. This deficient practice was evidenced as follows: 1.) On 1/7/25 at 11:07 AM, during an incontinence tour, while accompanied by Licensed Practical Nurse/Unit Manager (LPN) #1 and Certified Nurse Assistant (CNA) #2, the surveyor observed Resident #118 bilateral (b/l) lower legs with multiple blister-like areas containing some dried blood. The LPN/UM#1 stated that the resident scratches themselves. [...]

Inspectors wroteComplaint #: NJ172440 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that resident dietary preferences were accurately identified and implemented for 4 of 21 residents (Resident #20, #39, #107, and #275) reviewed for dining and was evidenced by the following: On 1/3/25 at 10:00 AM, during a surveyor-conducted resident council meeting, 4 out of 4 residents (Residents #6, #60, #71 and #98) stated that condiments such as cream, sugar, mustard, and mayonnaise would not be on the meal trays and that the facility did not honor food preferences on their meal tickets. The residents also stated that when they ask for a substitute food item than what was on their meal ticket, it can take a long time for another meal tray, or they don't get it at all. 1. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure the proper sanitization of a glucometer used to obtain blood glucose results for two (Residents (R) R61 and R81) of seven residents reviewed during medication administration observations. This failure had the potential to lead to serious illness and death for R61 and R81 related to the transmission of blood borne pathogens from resident to resident via the un-sanitized glucometer. In addition, the facility failed to ensure all areas in the laundry room were cleaned. The facility's Administrator was informed on 09/27/23 at 5:10 PM, that Immediate Jeopardy existed related to the failure to ensure that two of seven residents identified as receiving blood glucose checks received glucometers properly sanitized in between resident use. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a fully completed Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to include the cost of continued services for three of three residents (Resident (R) 388, R389, and R57) reviewed for liability notices out of a total sample of 41 residents. This failure prevents the resident or responsible party the ability to make an informed decision related to the cost of continued services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food was palatable for nine out of 41 sampled residents (Residents (R)28, R102, R40, R60, R119, R189, R89, R188, R97), for 27 residents residing on the 200 unit, and for six residents who attended the resident council interview out of 146 total residents who resided in the facility.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure meals were served at regular times comparable to those in the community, failed to ensure there was not more than a 14-hour lapse between dinner and breakfast the next morning, and failed to ensure a substantial evening snack was offered to residents. In addition, the greater than 14-hour timeframe between dinner and breakfast the next day, had not been approved by the resident group. These failures had the potential to affect 142 out of 146 residents (four residents received nutrition via tube feeding.)

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to ensure the kitchen dish room, floor, countertops, and wall behind the dish machine was maintained in a sanitary condition creating the potential for the spread of foodborne illness for 142 out of 146 residents who resided in the facility (four received nutrition via tube feeding). In addition, the facility failed to adhere to proper hand hygiene when serving meals to residents on the secured unit during food delivery to the adjoining dining rooms and the resident's individual rooms.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the antibiotic screening documentation was completed for the use of antibiotics including identifying trends and implementing protocols to monitor the antibiotic use, measure the effectiveness of the antibiotics, and create an action plan to lower the use of antibiotics that did not meet the screening criteria for R91 and all residents receiving antibiotics with the potential to affect any residents who have taken antibiotics.

Inspectors wroteBased on observations, record review, staff interview, and facility policy review, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four (Resident (R) 288, R41, R72, and R240) of seven residents reviewed for bed rail use of 41 sample residents. These failures had the potential to cause risk of entrapment or injury due to use of bed rails for these four residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to maintain the proper Advance Directive after one (Resident (R) 112) out of five residents reviewed for advance directives in a total sample of 41 residents. The facility's failure had the potential to prevent the residents from having their wishes granted for advance directives.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to protect the rights of one (Resident (R) 121) of five residents reviewed for abuse of 41 sample residents to be free from physical abuse by another resident (R44). This failure had the potential to cause physical injury and/or psychological harm to R121.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to develop policies and procedures that identified abuse, including resident-to-resident abuse, in order to prohibit and prevent abuse for one (Resident (R) 121 of five residents reviewed for abuse of 41 sample residents. This failure had the potential to cause physical injury and/or psychological harm to R121.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure the comprehensive Care Plan was revised to reflect resident-specific information regarding behavioral symptoms and activities of daily living (ADL) assistance for two (Resident (R) 119 and R288) of 41 sample residents. These failures had the potential to lead to unmet behavioral and/or ADL needs for these two residents due to a lack of care-planned interventions.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure a newly identified area of skin breakdown was assessed and treated in a timely manner for one (Resident (R) 121) of five residents reviewed for pressure ulcers of 41 sample residents. This failure had the potential to cause further deterioration or infection of R121's wound.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one out of six residents (Resident (R)62) reviewed for falls out of a total sample of 41 residents was adequately supervised resulting in a fall out of bed while the Certified Nursing Assistant (CNA) went to the bathroom to get supplies.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of two residents (Resident (R)62), reviewed for tube feeding out of a total sample of 41 residents, had head of bed elevated high enough while the tube feeding was being administered, which placed the resident at risk for aspiration (when something such as food or liquid enters the airway or lungs).

Inspectors wroteBased on observation, record review, interviews, and facility policy review the facility failed to ensure appropriate use of side rails through routine assessments for three (Residents (R) R72, R240, and R288) of 16 residents reviewed for accidents of 41 sample residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure dates of newly identified wound and bed rail assessments were accurately reflected for two (Resident (R) 121 and R238) of 41 sample residents. This failure had the potential to cause further deterioration or infection of R121's wound or risk of entrapment or injury from side rail use for R238.