Inspection Reports for Complete Care At Voorhees, Llc

This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.

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.

A Recertification Survey was conducted from 01/02/2025 to 01/10/2025 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Deficiencies were cited in multiple areas including resident rights, safe environment, professional standards of care, medication administration, activities of daily living, food safety, and life safety code compliance. Immediate corrective actions and plans to prevent recurrence were documented.

Recertification and Complaint Survey conducted from 09/25/23 through 09/29/23 including complaint investigations and recertification compliance.

The facility was found not in substantial compliance with multiple deficiencies including infection control immediate jeopardy related to improper sanitization of glucometers, failure to maintain proper advance directives, inadequate Medicaid/Medicare liability notices, failure to protect residents from abuse, incomplete care plans, pressure ulcer care deficiencies, inadequate supervision leading to resident falls, improper use and assessment of bed rails, food quality and meal service timing issues, unsanitary kitchen and laundry conditions, failure in antibiotic stewardship program, and inadequate staffing ratios.

Complaint numbers NJ159120, NJ167234, NJ163179, NJ164052, and NJ166110 were investigated during this survey.

A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the facility's participation requirements in Medicare/Medicaid.

The facility was found to be noncompliant with several Life Safety Code requirements including missing required signage on delayed egress doors, sprinkler heads with signs of leakage or contamination, and fire extinguishers obstructed from view without proper signage. Corrective actions and education were implemented to address these deficiencies.

An onsite revisit survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a Life Safety Code Survey and other regulatory compliance checks.

The facility was found to have multiple deficiencies related to comprehensive care plans, pressure ulcer prevention, mobility, accident hazards, drug regimen review, food safety, and life safety code violations. Corrective actions were planned and some were completed by 07/11/2022. The facility census was 104 with a total capacity of 190 beds.

The document is not an inspection or regulatory report but a placeholder page for a PDF portfolio.

No inspection or regulatory findings are present in this document.

The inspection was conducted as a complaint investigation related to complaint #NJ149559.

The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.

Complaint #NJ149559 was investigated and the facility was found to be in substantial compliance.

The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ145582, NJ145092, NJ144948, NJ143963, and NJ143563) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.

The facility failed to keep residents free from misappropriation of property for two residents by spending money from their Personal Needs Allowance (PNA) accounts without obtaining consent from the residents' responsible parties. The current management acknowledged the issue inherited from prior ownership and has implemented corrective actions including staff education and auditing procedures.

The complaint investigation involved multiple complaint numbers and found substantiated issues related to misappropriation of resident property, specifically unauthorized spending from residents' PNA accounts without consent from responsible parties.

The inspection was conducted in response to complaints NJ 146260 and NJ 146468 to assess compliance with regulatory requirements.

The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.

Complaint numbers NJ 146260 and NJ 146468 were investigated and the facility was found to be in substantial compliance.

The inspection was conducted as a complaint investigation (Complaint # NJ 144742) to determine compliance with food safety requirements related to meal temperatures and food handling practices.

The facility failed to ensure that meals were served at proper temperatures, with cold foods and beverages served warmer than required and incomplete temperature monitoring documentation. The Food Service Director and Executive Chef acknowledged lapses in monitoring and temperature control, and corrective actions including staff retraining and increased audits were initiated.

Complaint # NJ 144742. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit. No residents were directly affected, and no negative outcomes were reported following the incident.

The inspection was conducted as a complaint survey based on multiple complaint intakes (NJ138322, NJ135651, NJ138914, NJ140194) to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.

The facility was found not in compliance due to a certified nursing assistant practicing outside their scope of practice by administering medication to a resident. Both the temporary CNA and the licensed practical nurse involved were suspended and terminated. The resident did not suffer any negative outcomes. Staff were re-educated on scope of practice.

Complaint Intake NJ138322. The facility failed to ensure certified nursing assistants practiced within their scope of practice when a temporary nursing assistant administered medication to a resident. Both involved staff were suspended and terminated. Resident was monitored with no negative outcome. Staff were re-educated.

The inspection was conducted in response to a complaint alleging abuse of a resident by a staff member and failure to timely report the abuse to authorities.

The facility staff failed to protect a resident from abuse by barricading the resident in bed with furniture, which was observed by multiple staff but not reported or removed for approximately 7 hours, placing the resident and others at immediate jeopardy. The facility also failed to timely report the abuse to the police as required. The facility implemented a removal plan including staff in-service and suspension, which resolved the immediate jeopardy.

Complaint # NJ 143044. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit. The abuse incident involved Resident #1 being barricaded in bed by a CNA, with multiple staff failing to report or remove the barricade for about 7 hours. The incident was not timely reported to the police as required by state law.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended practices for COVID-19.

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.