Inspection Reports for Complete Care At Voorhees, Llc
3001 Evesham Road, Voorhees, NJ, 08043
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025, did not identify any deficiencies and focused on informing individuals about privacy practices. Earlier inspections showed a pattern of multiple deficiencies in areas such as resident care, medication administration, food safety, life safety code compliance, and staffing ratios. Complaint investigations revealed some substantiated issues, including a resident abuse case involving barricading a resident in bed and unauthorized spending from residents’ personal accounts, with corrective actions taken in response. Enforcement actions included suspensions and terminations related to medication administration outside scope of practice, but fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with care and safety standards, though the absence of deficiencies in the most recent report suggests some improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
94% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
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.
Findings
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.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 179
Capacity: 190
Deficiencies: 8
Date: Jan 13, 2025
Visit Reason
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.
Findings
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.
Deficiencies (8)
Facility failed to ensure residents' dining experience was provided in a manner to promote dignity and respect.
Facility failed to maintain a safe, clean, comfortable, and homelike environment, including temperature and housekeeping.
Facility failed to ensure medications were administered within the physician's ordered time frame for 2 of 35 residents.
Facility failed to provide adequate assistance with activities of daily living for one resident.
Facility failed to provide proper foot care for one resident.
Facility failed to ensure food was served at proper temperatures and palatability for one lunch meal.
Facility failed to ensure food safety requirements including proper storage, preparation, and sanitation.
Facility failed to maintain adequate life safety code compliance including exit signage and hazardous area separation.
Report Facts
Census: 179
Total Capacity: 190
Deficiencies cited: 8
Medication administration errors: 47
Medication administration errors: 34
Certified Nurse Aide staffing: 19
Certified Nurse Aide staffing: 17
Certified Nurse Aide staffing: 16
Certified Nurse Aide staffing: 18
Certified Nurse Aide staffing: 14
Certified Nurse Aide staffing: 13
Certified Nurse Aide staffing: 18
Certified Nurse Aide staffing: 19
Certified Nurse Aide staffing: 19
Certified Nurse Aide staffing: 19
Certified Nurse Aide staffing: 20
Inspection Report
Annual Inspection
Census: 145
Capacity: 146
Deficiencies: 14
Date: Sep 29, 2023
Visit Reason
Recertification and Complaint Survey conducted from 09/25/23 through 09/29/23 including complaint investigations and recertification compliance.
Complaint Details
Complaint numbers NJ159120, NJ167234, NJ163179, NJ164052, and NJ166110 were investigated during this survey.
Findings
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.
Deficiencies (14)
Improper sanitization of glucometer between resident use leading to immediate jeopardy for infection control.
Failure to maintain proper advance directives for residents.
Failure to provide fully completed Skilled Nursing Facility Advance Beneficiary Notices including estimated costs.
Failure to protect resident from abuse by another resident and inadequate abuse prevention policies.
Failure to revise comprehensive care plans to reflect resident-specific behavioral symptoms and ADL assistance.
Failure to timely assess and treat newly identified pressure ulcers.
Inadequate supervision resulting in resident fall when CNA left resident unattended.
Failure to ensure resident receiving tube feeding had adequate positioning to prevent aspiration.
Food served was not palatable, not always hot, and resident council feedback was not adequately solicited or documented.
Meals were served at irregular times with greater than 14-hour lapse between dinner and breakfast without resident group approval and inadequate bedtime snacks.
Unsanitary kitchen dish room and laundry room conditions including black residue, deteriorated floors, and poor hand hygiene during meal service.
Failure to complete antibiotic stewardship screening tools timely and monitor antibiotic use effectively.
Failure to conduct regular inspection of bed frames, mattresses, and bed rails to identify entrapment risks.
Failure to meet minimum staffing ratios for Certified Nursing Assistants on multiple day shifts.
Report Facts
Survey Census: 145
Total Capacity: 146
Deficiencies cited: 14
CNA staffing shortfall: 10
Wet time for disinfectant: 3
Meal delivery time span: 15
Bedside snack count: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in infection control deficiency related to improper sanitization of glucometer. |
| Director of Nursing | Provided multiple interviews regarding infection control, antibiotic stewardship, and bed rail assessments. | |
| Dietary Director | Interviewed regarding food quality, meal timing, and snack availability. | |
| Infection Preventionist | Interviewed regarding infection control practices and antibiotic stewardship. | |
| Maintenance Director | Interviewed regarding bed rail assessments and laundry room conditions. | |
| CNA7 | Certified Nursing Assistant | Named in supervision deficiency related to resident fall. |
Inspection Report
Life Safety
Census: 145
Capacity: 190
Deficiencies: 3
Date: Sep 26, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the facility's participation requirements in Medicare/Medicaid.
Findings
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.
Deficiencies (3)
Exit doors lacked required signage stating 'PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS'.
Sprinkler heads showed signs of leakage, were painted improperly, corroded, damaged, or loaded and were not replaced as required.
Fire extinguishers were obstructed from view and lacked means to indicate their location.
Report Facts
Residents affected: 11
Residents affected: 145
Current occupied beds: 145
Total licensed capacity: 190
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed missing signage on delayed egress doors and fire extinguisher location issues; received education on sprinkler and fire extinguisher maintenance requirements. |
Inspection Report
Routine
Census: 104
Capacity: 190
Deficiencies: 11
Date: Jun 7, 2022
Visit Reason
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.
Findings
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.
Deficiencies (11)
Failure to obtain a physician's order for the use of bed side rails for Resident #14.
Failure to prevent and treat pressure ulcers for Resident #6.
Failure to increase/prevent decrease in range of motion/mobility for Resident #9.
Failure to maintain mandatory access to care staffing ratios on 5 of 14 day shifts.
Failure to follow physician's orders to prevent accidents for Resident #100.
Failure to conduct monthly drug regimen review and respond to medication irregularities for Resident #55.
Failure to accurately transcribe and administer medications for Resident #87.
Failure to maintain food safety and sanitation in the kitchen.
Failure to maintain required means of egress and delayed egress locking arrangements.
Failure to maintain smoke barrier doors in proper condition.
Failure to maintain electrical systems and emergency power equipment.
Report Facts
Census: 104
Total Capacity: 190
Deficiencies cited: 11
Staffing ratios: 5
Document
Deficiencies: 0
Date: Jan 4, 2022
Visit Reason
The document is not an inspection or regulatory report but a placeholder page for a PDF portfolio.
Findings
No inspection or regulatory findings are present in this document.
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #NJ149559.
Complaint Details
Complaint #NJ149559 was investigated and the facility was found to be in substantial compliance.
Findings
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.
Report Facts
Sample size: 2
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Date: Aug 31, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility failed to obtain consent from residents' responsible parties before spending money from Personal Needs Allowance accounts for two residents.
Report Facts
Census: 114
Sample Size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding PNA accounts and facility policies on spending stimulus checks | |
| Social Service Director | Interviewed jointly with DON and NHA about management changes and compliance issues | |
| Director of Nursing | Interviewed jointly with SSD and NHA about management changes and compliance issues | |
| Nursing Home Administrator | Interviewed jointly with SSD and DON about management changes and compliance issues; provided current company policy |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 0
Date: Jul 22, 2021
Visit Reason
The inspection was conducted in response to complaints NJ 146260 and NJ 146468 to assess compliance with regulatory requirements.
Complaint Details
Complaint numbers NJ 146260 and NJ 146468 were investigated and the facility was found to be in substantial compliance.
Findings
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.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure meals were served at proper temperatures and failure to complete the Service Line Checklist to monitor food temperatures as per facility policy.
Report Facts
Census: 123
Food temperatures (Fahrenheit): 136
Food temperatures (Fahrenheit): 130.9
Food temperatures (Fahrenheit): 137
Food temperatures (Fahrenheit): 51.4
Food temperatures (Fahrenheit): 46.9
Food temperatures (Fahrenheit): 46.7
Milk container temperature (Fahrenheit): 39.1
Milk container temperature (Fahrenheit): 41.2
Sample size: 8
Test tray audits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director (FSD) | Agreed on food temperature standards and acknowledged temperature monitoring lapses | |
| Head Chef/Executive Chef (EC) | Verified food temperature checks but admitted not checking some cold items |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Date: May 31, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Certified nursing assistant administered medication outside scope of practice to a resident.
Report Facts
Census: 124
Sample Size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Allowed medication administration by temporary nursing assistant |
| CNA #1 | Temporary Certified Nursing Assistant | Administered medication outside scope of practice |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding training and scope of practice |
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure a resident was protected from actual abuse by a staff member who barricaded the resident in bed with furniture, and failure to timely report the abuse to police and health department.
Report Facts
Census: 137
Sample size: 4
Immediate Jeopardy duration: 7
Complaint number: 143044
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Staff member who barricaded the resident in bed |
| CNA #2 | Certified Nursing Assistant | Staff member who observed barricade but did not remove or report it |
| CNA #3 | Certified Nursing Assistant | Staff member who observed barricade but did not remove or report it |
| Director of Nursing | Director of Nursing (DON) | Notified of Immediate Jeopardy and abuse incident |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and abuse incident |
| Unit Manager | Unit Manager (UM) | Reported the barricade incident to DON and Administrator |
| Speech Therapist | Speech Therapist (ST) | Observed barricade and alerted Director of Rehabilitation |
| Occupational Therapy Assistant | Occupational Therapy Assistant (OTA) | Observed barricade and reported to Director of Rehabilitation |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Checked resident vital signs during the incident |
| Registered Nurse | Registered Nurse (RN) | Observed barricade during rounds |
| Director of Rehabilitation | Director of Rehabilitation (DR) | Notified of barricade incident and reported to Administrator |
Inspection Report
Routine
Census: 135
Deficiencies: 0
Date: Jan 5, 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 and recommended practices for 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: 5
Bed hold: 1
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