Complete Care At Voorhees, Llc
Complete Care at Voorhees, LLC in VOORHEES, NJ — inspection on August 29, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) on 08/29/2025 at 12:06 PM, the DON stated medications should be given an hour before or an hour after, except specified by the provider and that the rights of medication administration should be followed including; right medication, the right dose, the right route, the right patient, and the right time.
The DON stated that the nurse should call the provider to inform the provider that the medications she was about to administer were outside the scheduled administration time window, and obtain instructions to make sure it was okay to give the medications outside the scheduled timeframe. DON further stated that nurses should document in the resident's PNs if a medication is not administered on time, and document that provider was notified and that they obtained order for the medications to be administered later than ordered time.
The DON further stated the expectation is that the medication should be administered an hour before and an hour later.
If a resident is out of the facility, there should be a progress note to say the patient is out of the facility and ok to administer medication later as per the provider.
The DON stated, the policy was not followed if none of the above was done for medication administration. A review of the facility's policy titled Medication Administrations, dated 091/2024, revealed .12 .b.
Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . NJAC 8:39-29.2 (d)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.