Complete Care At Voorhees, Llc
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
at 9:00 A.M., administered on 07/27/2025 at 11:39 A.M., and on 07/28/2025 at 10:16 A.M. A review of Resident #7's Progress Notes (PNs) from 07/27/25 to 07/28/25, showed no indication in the PNs that the Resident's Primary Care Physician (PCP) was notified that the aforementioned medications were not administered according to the scheduled time. There was also no documentation regarding why the medications were administered late. 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)
Event ID:
Facility ID:
If continuation sheet
COMPLETE CARE AT VOORHEES, LLC in VOORHEES, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VOORHEES, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPLETE CARE AT VOORHEES, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.