Inspection Reports for
Complete Care At Voorhees, Llc

The complaint investigation found that medications were administered late without documentation of the reason or notification to the Primary Care Physician. The deficiency was substantiated with evidence from medication administration records and interviews with nursing staff and the Director of Nursing.

The facility failed to administer medications on time for one of nine sampled residents, Resident #7, with no documentation explaining the late administration or notification to the Primary Care Physician. The facility policy requiring administration within one hour before or after the scheduled time was not followed.

The investigation was triggered by complaints NJ 00185028 and NJ00185373 concerning medication administration errors and failures.

The facility failed to administer medications according to acceptable nursing standards and facility policy for 4 of 7 sampled residents. Several medications were either not administered, administered late, or not documented properly, with no evidence of harm to residents but failure to notify physicians or document refusals.

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.

Complaint numbers NJ180809, NJ168726, NJ168827, NJ175632, NJ175632, NJ176860, NJ172440 were investigated. Substantiation status is not explicitly stated.

The facility was found deficient in maintaining sanitary conditions in resident bathrooms, ensuring proper medication administration within physician orders, providing appropriate foot care, maintaining safe food temperatures and palatability, and accurately honoring resident dietary preferences. Multiple residents' rooms and bathrooms were observed with cleanliness issues, medication patches were applied without physician orders, foot care was inconsistently provided, food was served at improper temperatures and lacked palatability, and meal trays often did not match residents' dietary orders or preferences.

The facility was found deficient in multiple areas including failure to ensure residents' dining experience promoted dignity and respect, inadequate environmental cleanliness and temperature control, medication administration errors including applying patches without physician orders and late medication administration, failure to provide proper nail and foot care, failure to adjust medication times for dialysis patients, food temperature and palatability issues, inaccurate meal tray contents not matching dietary preferences, and unsafe food handling and sanitation practices in the kitchen.

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

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.

The complaint involved a resident-to-resident abuse incident reported on 04/01/2023 where resident R44 hit resident R121 on the arm after becoming agitated about bathroom use. The facility investigated, interviewed staff and residents, and reviewed records. The investigation concluded the incident was isolated with no premeditated intent to cause harm. Both residents have severe cognitive impairment and neither recalled the incident. The facility notified the State Survey Agency, police, physicians, families, and other relevant parties. Increased supervision and follow-up actions were implemented.

The facility failed to protect one resident (R121) from physical abuse by another resident (R44), both with severe cognitive impairment. The incident involved R44 hitting R121 on the arm multiple times after becoming agitated over bathroom use. The facility investigated and concluded the incident was isolated with no premeditated intent to cause harm. The facility also failed to develop policies and procedures that adequately identified and prevented resident-to-resident abuse.

The facility had multiple deficiencies including failure to maintain accurate advance directives, incomplete liability notices, failure to protect residents from resident-to-resident abuse, incomplete care plans, delayed wound assessment and treatment, inadequate supervision leading to a resident fall, improper feeding tube positioning, inappropriate use and assessment of bed rails, poor food palatability and meal timing, unsanitary kitchen and laundry conditions, improper hand hygiene during meal service, failure to monitor antibiotic use, inaccurate medical record documentation, and failure to properly sanitize glucometers between uses.

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.

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 facility was found deficient in multiple areas including failure to obtain physician orders for bed siderails, failure to follow physician orders for pressure ulcer care and palm protector application, inadequate fall prevention measures, delayed pharmacist response to medication irregularities, inaccurate transcription of medication orders, and unsafe food handling and sanitation practices.

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 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.

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 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 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 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 # 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.

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.