Inspection Reports for Voorhees Pediatric Facility

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Initial inspection for licensure of renovated long term care facilities, including converted office space into semi-private resident rooms and addition of beds.

No deficiencies were noted during the inspection. The facility is requesting the addition of 3 beds to their license, but these areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.

A Recertification and Complaint Survey was conducted due to a complaint (NJ169974) to assess compliance with federal regulations, including allegations of medication misappropriation and abuse.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on findings of medication misappropriation and failure to prevent abuse, neglect, and exploitation. Multiple residents had medications misappropriated or administered incorrectly, placing all residents at risk. The facility initiated audits, education, and new processes to address these deficiencies.

Complaint # NJ169974 triggered the survey. The complaint involved allegations of medication misappropriation and abuse. The complaint was substantiated as evidenced by multiple findings of medication misappropriation and failure to prevent abuse. The facility initiated audits, education, and corrective actions.

The inspection was conducted in response to complaints NJ# 166667 and 167982 regarding alleged violations involving abuse, neglect, exploitation, or mistreatment at the facility.

The facility was found not in substantial compliance with federal requirements based on the complaint visit. A Certified Nursing Assistant (CNA) performed a procedure outside her scope of practice and the facility failed to report this incident to the New Jersey Department of Health. Resident #3 was affected by this deficient practice. The facility implemented corrective actions including staff re-education and monitoring.

Complaint investigation based on allegations of abuse, neglect, exploitation or mistreatment. The facility failed to report an incident involving a CNA performing a procedure outside her scope of practice on Resident #3. The incident was not reported to the NJ Department of Health. The CNA was suspended pending investigation with intent to terminate. The facility conducted a wide inspection and re-educated nursing staff. The Director of Nursing and Director of Quality Safety and Compliance stated the incident was not willful neglect or abuse.

A complaint survey was conducted by Healthcare Management Solutions LLC on behalf of the New Jersey Department of Health due to allegations of neglect and failure to ensure resident safety, specifically related to wheelchair safety and care plan interventions.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were cited related to neglect, comprehensive care plans, accident hazards, and failure to ensure residents were safely secured in wheelchairs, resulting in actual harm to residents. The facility submitted an acceptable removal plan which was verified as implemented.

Complaint survey #NJ00110496 was substantiated. The facility was found not in substantial compliance with 42 CFR 483 subpart B due to neglect and failure to ensure safety of residents in wheelchairs, resulting in immediate jeopardy and actual harm to residents.

The inspection was conducted as a complaint survey based on complaints NJ 00160157 and NJ 00155728.

The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint visit.

Complaint # NJ 00160157 and # NJ 00155728 were investigated and the facility was found to be in compliance.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.

The inspection was conducted as a complaint survey related to Complaint # NJ 149498.

The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint visit.

Complaint # NJ 149498 was investigated and found to be unsubstantiated as the facility was in compliance.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey by the New Jersey Department of Health.

Deficiencies were cited related to accuracy of resident assessments, nutrition and hydration status maintenance, food procurement and safety, and COVID-19 testing compliance for staff. The facility failed to accurately complete Minimum Data Set assessments, identify and address significant weight changes in residents, maintain sanitary food storage and preparation practices, and ensure staff COVID-19 testing frequency met policy requirements.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 National Fire Protection Association Life Safety Code standards.

The facility was found noncompliant due to obstructions near automatic sprinkler heads and electrical panels, posing fire safety risks. Immediate corrective actions were taken, and staff re-education and ongoing monitoring were planned.

The inspection was conducted as a complaint investigation based on complaint NJ146583.

The facility was found to be in compliance with the requirements of 42 CFR, Part 483, Subpart B, for long term care facilities based on this complaint visit.

Complaint NJ146583 was investigated and found to be unsubstantiated as the facility was in compliance.

The inspection was conducted in response to complaints NJ 144137 and 136090.

The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities.

Complaint numbers NJ 144137 and 136090 were investigated; the facility was found in substantial compliance.