A list of the most recent deficiencies for Complete Care at Voorhees, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-09-29 | 2023-11-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-29 | 2023-10-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-29 | 2023-10-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-29 | 2023-10-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-29 | 2023-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-29 | 2023-10-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-09-29 | 2023-10-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-09-29 | 2023-10-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-29 | 2023-10-28 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-09-29 | 2023-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-29 | 2023-10-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-29 | 2023-10-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-29 | 2023-10-28 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-09-29 | 2023-10-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-29 | 2023-10-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-29 | 2023-10-28 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-29 | 2023-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-29 | 2023-10-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-29 | 2023-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-07 | 2022-08-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-07 | 2022-07-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-07 | 2022-07-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-07 | 2022-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-07 | 2022-07-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-07 | 2022-07-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-07 | 2022-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-07 | 2022-07-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-07 | 2022-06-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-06-07 | 2022-06-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-07 | 2022-06-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-07 | 2022-06-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-06-07 | 2022-06-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-04 | 2022-01-24 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-08-31 | 2021-09-27 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-31 | 2021-07-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-06-22 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-10 | 2020-01-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-01-10 | 2020-01-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-10 | 2020-01-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-10 | 2020-01-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-10 | 2020-01-27 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-01-10 | 2020-01-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-10 | 2020-01-27 | N |
