Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Voorhees, Llc during CMS and state inspections, most recent first.
A resident with acute kidney failure, diabetes, and a UTI had a urine culture collected, and the abnormal result was reported to the facility but not promptly communicated to a practitioner. Facility staff, including the UM/LPN and DON, stated that nurses are expected to notify providers as soon as abnormal lab results are received and that clinicians, although able to access labs in the electronic record, rely on nursing notification. The resident’s abnormal urine culture was not acted upon until several days later, when an NP reviewed the result, noted a severe UTI, and ordered antibiotics, and the NP confirmed this delay in notification and treatment was contrary to expectations and represented a delay in care.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Surveyors found that multiple residents did not receive their medications within the required time frame, and there was a lack of documentation explaining late or missed doses or notification to the PCP. Medications for conditions such as infection, pain, hypertension, and glaucoma were affected, and staff interviews confirmed inconsistent adherence to the facility's medication administration policy.
The facility was found deficient in handling potentially hazardous foods and maintaining sanitation. Observations included improper hand hygiene, lack of temperature logs, and soiled kitchen equipment. A dietary aide wore an inadequate beard guard, and opened food items were not dated. The District Food Service Manager failed to follow proper handwashing procedures, and a resident's cup was improperly stored in the freezer, raising infection control concerns.
The facility failed to provide a dignified dining experience for residents, as observed in one unit where meal trays were not delivered simultaneously to roommates. During a resident council meeting, residents expressed concerns about the timing of meal deliveries. A surveyor observed delays and missing items in meal trays, which were confirmed by a CNA. The LNHA acknowledged the issue, highlighting a discrepancy between observed practices and facility policies on resident dignity and meal distribution.
The facility failed to maintain a safe and sanitary environment, with issues including low air temperatures and unclean bathrooms. A resident reported feces left uncleaned for hours, while another had a discolored toilet seat not promptly replaced. The facility's cleaning policy was not adequately followed, leading to these deficiencies.
The facility failed to administer medications within the scheduled time for two residents, leading to a deficiency in professional standards. One resident had multiple medications administered late over several months, and another resident was found with pain patches applied without a physician's order. The facility's policies require medications to be administered within a specific timeframe and only upon a signed order, which was not adhered to in these cases.
A facility failed to provide adequate foot care for a resident with diabetes, gait abnormalities, and Alzheimer's. Despite a care plan requiring daily foot inspections, the resident's feet were observed to be dry with untrimmed toenails. The Podiatrist had not seen the resident since May 2024 due to combative behavior, and the facility was unaware of the resident's do-not-return status. The RDON confirmed that CNAs were responsible for daily foot care, but the facility's policies were not followed, resulting in the deficiency.
A resident with end-stage renal disease did not receive their noon dose of Midodrine on dialysis days due to the facility's failure to adjust medication times. The resident experienced low blood pressure and dizziness during dialysis. Staff interviews revealed a lack of communication and coordination, and the facility's policies prohibited sending medications with residents to dialysis.
The facility failed to serve food at appetizing and palatable temperatures, as observed during a survey. Residents reported meals being cold and unappetizing. Observations showed food temperatures below required levels, with puree green beans at 116°F and puree meatballs at 112°F. Cold items like puree apple sauce were above 40°F. Breakfast sampling revealed unseasoned scrambled eggs and an unidentifiable brown puree. Facility policies on food temperature were not followed.
A facility failed to provide adequate nail care and implement a care plan for a resident with impaired cognition and physical limitations. The resident was observed with medium-length fingernails containing residue, despite requiring assistance with personal hygiene. The care plan included keeping nails short to prevent skin impairment, but this was not followed. Staff interviews confirmed the responsibility for nail care was not met, contrary to facility policies on maintaining personal hygiene.
The facility failed to honor resident dietary preferences, resulting in multiple instances where residents did not receive the correct items on their meal trays. A resident with a swallowing disorder was served bread against their dietary restrictions, and another resident did not receive condiments as indicated on their meal ticket. The facility's policy requires meal accuracy, but this was not consistently followed, leading to dissatisfaction among residents.
Failure to Promptly Notify Practitioner of Abnormal Urine Culture Result
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of an abnormal urine culture result and to follow its own lab notification policy for one resident. The resident was admitted with diagnoses including acute kidney failure, diabetes, and a urinary tract infection, and had a BIMS score of 6/15, indicating severely impaired cognition. A urine culture collected on 11/12/2025 was reported to the facility on 11/14/2025 at 1:49 PM as abnormal. However, progress notes show that antibiotic therapy was not ordered until 11/18/2025, when a nurse practitioner reviewed the urine culture results and initiated treatment. Interviews with the UM/LPN, DON, Regional Nurse, and the nurse practitioner established that facility expectations and policy required nurses to promptly notify the practitioner of abnormal lab results once received. The UM/LPN stated that a four-day delay in notifying the provider of an abnormal lab result would be considered a delay in care and acknowledged that policy was not followed for this resident. The DON and Regional Nurse confirmed that although clinicians can access lab results in the electronic system, nurses are expected to alert them when abnormal results are received, and that lack of notification and documentation means the policy was not followed. The nurse practitioner caring for the resident stated that the provider should have been notified on the date the abnormal result was reported and confirmed that the delay constituted a delay in care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Administer and Document Medications According to Policy
Penalty
Summary
Surveyors identified that the facility failed to administer medications in accordance with accepted nursing standards and the facility's own medication administration policy for four out of seven sampled residents. For one resident with multiple chronic conditions, a one-time dose of Fosfomycin Tromethamine for a urinary tract infection was ordered but not documented as administered, and there was no evidence that the primary care physician (PCP) was notified of the missed dose or any refusal. Additionally, there was no documentation in the progress notes regarding the missed administration or any resulting harm. For three other residents, multiple scheduled medications were not administered within the required time frame of one hour before or after the scheduled dose, as stipulated by facility policy. The medications included treatments for constipation, infection, pain, hypertension, cough, and glaucoma. The medication administration records (MAR) and audit reports showed repeated late administrations, sometimes by several hours, with no documentation explaining the delays or indicating that the PCP was notified. Progress notes for these residents also lacked any mention of the late administrations or communication with the PCP, and there was no documented evidence of harm resulting from the delays. Interviews with nursing staff and the Director of Nursing (DON) confirmed that facility policy requires medications to be administered within a one-hour window of the scheduled time and that any late or missed doses should be documented, with the PCP notified as appropriate. However, the DON was unable to confirm whether the missed dose for the resident with the UTI was given, and staff interviews revealed inconsistent documentation practices. The facility's policy on medication administration, dated September 2024, was reviewed and confirmed the one-hour administration window requirement.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. During an inspection, it was observed that the handwashing sink at the kitchen entrance lacked a trash can, and the nearest trash can was covered with a lid without a foot pedal. The ovens in the kitchen were heavily soiled, and the Food Service Director (FSD) could not provide documentation of recent cleaning. Additionally, a dietary aide was improperly wearing a beard guard, leaving facial hair exposed, which was corrected after being pointed out by the FSD. In the nursing unit pantries, several issues were identified. In the 100 Unit Pantry, there was no temperature log for the refrigerator and freezer, and an opened carton of thickened water was not dated. The freezer lacked a thermometer, and a container of ice cream was hard to the touch. In the 200 Unit Pantry, the refrigerator temperature was outside the acceptable range, and an opened carton of orange juice was not dated. A clear plastic cup with ice, belonging to a resident, was found in the freezer, which was identified as an infection control issue. Further observations in the kitchen revealed improper hand hygiene practices by the District Food Service Manager (DFSM), who washed his hands for only eleven seconds outside the stream of running water and failed to perform hand hygiene after removing gloves. Interviews with the Infection Preventionist and the Director of Nursing highlighted the importance of proper handwashing techniques and the need for facial hair to be properly restrained. The facility's policies on staff attire, food preparation, and hand hygiene were reviewed, indicating requirements for proper sanitation and food safety practices.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure that residents' dining experiences were conducted in a manner that promoted dignity and respect. This deficiency was observed in one of the five units, specifically the 100 unit. During a resident council meeting, four residents expressed that their meal trays were not served simultaneously with their roommates. On a separate occasion, a surveyor observed that several residents, including a resident and their roommate, did not receive their breakfast trays at the same time. The delay in meal delivery was confirmed by a Certified Nursing Assistant (CNA), who had to call the kitchen for missing trays. Additionally, one resident received a tray missing an item listed on the meal ticket, and the CNA did not provide the tray to the resident until the missing item was addressed. The Licensed Nursing Home Administrator (LNHA) acknowledged the issue, stating that the expectation was for meal trays to be delivered without missing items and for residents in the same room to receive their meals simultaneously. The facility's policies on promoting resident dignity and meal distribution emphasize the importance of timely and accurate meal delivery. However, the observed practices did not align with these policies, leading to a failure in maintaining the residents' right to a dignified dining experience.
Deficiencies in Environmental Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by several observations and interviews. During a tour of the 500 Unit, the hallway was found to be chilly with an air temperature of 65 degrees, which is below the comfortable range of 71 to 81 degrees. The Director of Maintenance confirmed the low temperature, and the Licensed Nursing Home Administrator was unaware of the required temperature range. Additionally, air temperature logs from various units showed consistent temperatures below the recommended range. Resident #126 expressed concerns about the cleanliness of their bathroom, noting that feces were left on the toilet and floor by a roommate and were not cleaned by housekeeping until hours later. The resident's cognition was intact, as indicated by a BIMS score of 15 out of 15. Similarly, Resident #106's bathroom was observed with a black substance and yellow stains, and the resident was unsure when it was last cleaned. The resident had moderate cognitive impairment and was continent of bowel and bladder. Housekeeping staff were expected to clean rooms three times during their shift, but there was no staff from 10:00 PM to 7:00 AM, leading to delays in addressing cleanliness issues. Resident #107 reported a discolored toilet seat, which was not replaced despite previous discussions with the LNHA and DM. The resident's cognition was fully intact, with a BIMS score of 15 out of 15. A housekeeper confirmed that the yellow substance on the toilet was urine, not staining, and cleaned it promptly. The DM acknowledged the need to replace the toilet seat but had not documented the task. The facility's Routine Cleaning and Disinfection policy emphasized the importance of maintaining a sanitary environment to prevent infections, but the observed deficiencies indicated a failure to adhere to this policy.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered within the physician's order scheduled time for two residents, leading to a deficiency in professional standards of practice. Resident #86 had multiple medications scheduled for specific times, but the Medication Administration Audit Report revealed that medications were administered late a total of 47 times in June, 58 times in July, and 34 times in August. The facility's staff, including the LPN/UM and LPN, acknowledged that medications should be administered within a one-hour window before or after the scheduled time, and failure to do so constitutes a medication error. However, the Progress Notes did not indicate that the physician was notified of these late administrations. In another instance, Resident #160 was observed with undated and unidentified pain patches on both knees, which were not supported by a physician's order. The resident, who had a history of chronic pain related to arthritis, reported increased pain, but the facility's records did not show any physician's order for the patches prior to the surveyor's inquiry. The LPN/UM confirmed that the patches should not have been applied without a physician's order, and the facility's Medication Administration policy requires medications to be administered only upon a signed order from an authorized prescriber. The facility's policies on Medication Administration and Medication Errors emphasize the importance of adhering to the six rights of medication administration and ensuring medications are administered according to physician's orders and professional standards. The failure to administer medications within the prescribed timeframe and the application of pain patches without a physician's order highlight deficiencies in the facility's adherence to these standards, as evidenced by the surveyor's observations and interviews with the facility's nursing staff.
Failure to Provide Adequate Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident with diabetes mellitus, abnormalities of gait and mobility, and Alzheimer's disease. The resident's comprehensive care plan included daily foot inspections and care, but observations revealed that the resident's feet were dry and the toenails needed trimming. The Licensed Practical Nurse (LPN) and the Hospice Aide (HA) were unsure of when the resident's toenails were last trimmed by the Podiatrist, and the HA admitted to not performing foot care on the day of the surveyor's observation. The resident's representative also noted that the resident's feet were often dry and flaky, requiring her to request foot care from the staff. The facility's Regional Director of Nursing (RDON) confirmed that the resident had not been seen by the Podiatrist since May 2024 due to the resident's combative behavior, and the facility was unaware that the resident was on a do-not-return list. The RDON acknowledged that the Certified Nursing Assistants (CNAs) were responsible for daily foot care and should report any concerns to the nurse. The facility's policies on Activities of Daily Living and Skin Integrity - Foot Care were not followed, as the resident's feet were not properly cared for, leading to the deficiency.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to adjust medication administration times for a resident requiring dialysis, leading to a deficiency. The resident, who had diagnoses including end-stage renal disease and chronic kidney disease, was observed to have missed a scheduled dose of Midodrine, a medication for low blood pressure, on dialysis days. The medication was supposed to be administered three times a day, including at noon, but was not sent with the resident to dialysis, resulting in the resident experiencing low blood pressure and dizziness during dialysis. The resident's comprehensive care plan did not include interventions to adjust medication times around dialysis schedules. The facility's staff, including LPNs and the Regional Director of Nursing, acknowledged that medications should not be scheduled during dialysis times and that the physician should have been contacted to adjust the medication schedule. However, the medication was not adjusted, and the facility's policy prohibited sending medications with residents to dialysis. Interviews with staff revealed a lack of communication and coordination regarding medication administration for dialysis patients. The facility's policies required timely communication with the dialysis facility about medication administration, but this was not effectively implemented. The Licensed Nursing Home Administrator and other regional staff were made aware of the issue, highlighting a gap in adherence to the facility's medication administration and hemodialysis policies.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at appetizing and palatable temperatures, as evidenced by observations and resident feedback. During a Resident Council meeting, four residents reported that their meals were served cold and were not appetizing or recognizable. Subsequent observations by the surveyor revealed that while food temperatures on the steam table were initially above 135°F, the temperatures of the food served to residents were significantly lower. For instance, puree green beans were at 116°F, and puree meatballs were at 112°F, both below the required 135°F. Additionally, cold items like puree apple sauce and mandarin oranges were not served at the appropriate temperature, being above the required 40°F. Further issues were noted during a breakfast test tray sampling, where the scrambled eggs with red and green peppers lacked seasoning and taste, and a brown pureed substance was unidentifiable with a pasty texture. The facility's policies on meal distribution and food preparation, which emphasize maintaining proper food temperatures, were not adhered to. The Licensed Nursing Home Administrator expressed surprise at the residents' concerns, indicating a lack of awareness of the ongoing issues with food temperature and palatability.
Failure to Provide Nail Care and Implement Care Plan
Penalty
Summary
The facility failed to provide adequate nail care to a resident who required assistance with activities of daily living, as well as failed to implement the comprehensive care plan. During an incontinence tour, a surveyor observed a resident with multiple blister-like areas on their lower legs and medium-length fingernails containing reddish-brown residue and thick brown matter. The resident had a history of hemiplegia and hemiparesis following a stroke, chronic kidney disease, and depression, and was assessed to have severely impaired cognition. The resident required moderate assistance with personal hygiene and substantial assistance with other activities of daily living. The resident's comprehensive care plan included interventions to prevent skin impairment, such as keeping fingernails short and assisting with general hygiene. However, the resident's fingernails were not trimmed or cleaned as required, and the care plan was not followed. Interviews with facility staff, including an LPN and the Regional Director of Nursing, confirmed that the CNAs were responsible for maintaining the resident's nail hygiene, but this was not done. The facility's policies on activities of daily living and comprehensive care plans emphasized the need for providing necessary services to maintain personal hygiene, which was not adhered to in this case.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that resident dietary preferences were accurately identified and implemented for several residents. During a resident council meeting, multiple residents reported that condiments and food preferences were not consistently honored on their meal trays. Additionally, when residents requested substitute food items, they experienced delays or did not receive them at all. Specific instances included a resident receiving bread despite a dietary restriction against it, and another resident not receiving margarine, salt, and pepper as indicated on their meal ticket. In one case, a resident with a swallowing disorder and a need for a mechanically altered diet was served a biscuit, contrary to their dietary restrictions. The resident's family had previously reported similar issues, and the facility's Director of Social Services confirmed the discrepancy. The Registered Dietician expressed concern about the risk of aspiration if the resident consumed bread products. Another resident did not receive a ham and cheese sandwich with the specified lettuce and tomato, highlighting a recurring issue of missing items from meal trays. The facility's Meal Distribution policy requires nursing staff to verify meal accuracy and ensure timely delivery, but this was not consistently followed. The Licensed Nursing Home Administrator acknowledged the importance of adhering to meal tickets, diet orders, and resident preferences, emphasizing that it is the residents' right. Despite these expectations, the facility's failure to comply with dietary preferences and orders was evident in multiple instances, as observed by the surveyor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Voorhees
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Kresson View, Llc | 0.6 mi | ★★★★★ | 0 | 0 |
| Wiley Mission | 1.6 mi | ★★★★★ | 0 | 0 |
| Careone At Evesham | 1.7 mi | ★★★★★ | 13 | 0 |
| St Mary's Center For Rehabilitation & Healthcare | 1.9 mi | ★★★★★ | 1 | 0 |
| The Subacute At Autumn Lake Healthcare | 2.3 mi | ★★★★★ | 19 | 3 |
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