Complete Care at Voorhees, LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Voorhees, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF880Sep 29, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF600Feb 24, 2021

  COMPLAINT # NJ 4 Based on interviews, review of Medical Records (MR), and review of other pertinent Facility documents on 2/19/21 and 2/24/21, it was determined that the Facility staff failed to ensure a resident with severe cognitive impairment was appropriately protected to prevent the resident from actual abuse by a staff member. The facility staff also failed to follow their policy titled: Abuse Prohibition, to notify the Police and the New Jersey Department of Health (NJDOH) timely, for 1 of 3 residents (Resident #1) reviewed for abuse. On 2/10/21, during the 11:00 p.m. to 7:00 a.m. shift a Certified Nursing Assistant (CNA #1) used a floor mat and furniture to barricade a Resident in the bed. Several staff members on the 7:00 a.m. to 3:00 p.m. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF550Jan 13, 2025

  Based 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. […]