Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Complete Care at Voorhees, LLC
VOORHEES, NJ · 190 certified beds · Last Life Safety survey January 13, 2025
CMS Certification Number 315219 · first certified February 1986
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed July 1, 2021 (change of ownership)from 3001 EVESHAM ROAD OPERATIONS LLC
Position within NJ
11 citations — more than 27% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (May 2026 to September 2026). Most NJ facilities have been surveyed by February 2027. This facility’s last Life Safety survey was January 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0909 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.
How that compares
Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 7, 2022 | 6 |
| September 29, 2023 | 3 |
| January 13, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0222 | 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. | 2 | 2023-09-29 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-09-29 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2022-06-07 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2023-09-29 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2022-06-07 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2025-01-13 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2022-06-07 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-01-13 |
What the citations cover
- Smoke Deficiencies 5
- Egress Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 13, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (February 21, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 21, 2025) |
September 29, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (October 28, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 28, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 28, 2023) |
June 7, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (June 30, 2022) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 30, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 30, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 30, 2022) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (June 30, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 10, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.