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 May 1, 2026
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
9 citations — more than 16% 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 4 citations; the earlier surveys on file averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens August 2027 — about 9 months from now. This facility’s last Life Safety survey was May 2026. Facilities in NJ are typically surveyed 16–19 months after the last one (median 17), measured over 464 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 about three years in Virginia. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
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 9 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 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-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 | 9 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 29, 2023 | 3 |
| January 13, 2025 | 2 |
| May 1, 2026 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2026-05-01 |
| 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. | 1 | 2023-09-29 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2026-05-01 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2026-05-01 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2023-09-29 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2026-05-01 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2025-01-13 |
| 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 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 1, 2026 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 11, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 12, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (June 18, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 18, 2026) |
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) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.