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🔎 Complete Care At Voorhees Llc

Inspection Results


Inspection Overview

Complete Care At Voorhees Llc has been cited for a total of 54 deficiencies since we began saving each survey.

In New Jersey, the average facility has **22.80 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide appropriate foot care.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2025-01-13
Correction Date: 2025-02-21
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: J

Provide and implement an infection prevention and control program.

Survey Date: 2023-09-29
Correction Date: 2023-11-30
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2023-09-29
Correction Date: 2023-10-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2022-06-07
Correction Date: 2022-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-06-07
Correction Date: 2022-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2022-06-07
Correction Date: 2022-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-06-07
Correction Date: 2022-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-06-07
Correction Date: 2022-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2022-06-07
Correction Date: 2022-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-06-07
Correction Date: 2022-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2022-01-04
Correction Date: 2022-01-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2021-08-31
Correction Date: 2021-09-27
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-06-10
Correction Date: 2021-06-22
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2021-05-31
Correction Date: 2021-07-02
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2021-02-24
Correction Date: 2021-02-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-02-24
Correction Date: 2021-03-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2020-01-10
Correction Date: 2020-01-27
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2020-01-10
Correction Date: 2020-01-27
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-01-10
Correction Date: 2020-01-27
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-02-08
Correction Date: 2019-03-19
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**