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
The surveyor did not find documented evidence of harm to the Resident #7 from the late administration of their medications.
During an interview with the Licensed Practical Nurse/Unit Manager (LPN/UM) on 08/29/25 at 11:42 AM, she stated medications can be administered up to 1 hour before and 1 hour after the time the medication is due.
The LPN/UM further stated, it's important to give medications on time to avoid interactions or adverse reaction.
Some medications are scheduled with food, some multiple times during the day, so you do not want to cause an overdose.
That is why it's important to follow the five rights of medication administration.
She also stated that if a medication is not administered on time, the nurse should call the PCP to notify them and receive an order to give the medication after the administration time. LPN/UM stated, the nurse should also document why the medication was not administered on time, and that a PCP approved to give the medication after the allowed time.
The LPN/UM stated, the expectation is for all nurses to follow the facility's policy for medication administration, looking at the MAAR for Resident #7, the policy was not followed.
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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