Inspection Reports for Voorhees Pediatric Facility
1304 Laurel Oak Road, Voorhees, NJ, 08043
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025, did not identify any deficiencies. Earlier inspections showed a mixed pattern, with several complaint investigations substantiating issues related to medication misappropriation, abuse prevention, resident safety, and care planning. Inspectors cited deficiencies involving failure to prevent medication errors and abuse, inadequate care plans, and safety hazards, including problems with wheelchair safety and reporting incidents. Some complaints were substantiated with findings of actual harm and immediate jeopardy, while others were unsubstantiated. The facility appears to have taken corrective actions over time, with the most recent report showing no deficiencies, suggesting improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
90% occupied
Based on a February 2024 inspection.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, the circumstances under which health information may be used or disclosed, and the rights of individuals to access, amend, and restrict their health information.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
Initial inspection for licensure of renovated long term care facilities, including converted office space into semi-private resident rooms and addition of beds.
Findings
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.
Report Facts
Beds requested for addition: 3
Inspection Report
Complaint Investigation
Census: 107
Capacity: 119
Deficiencies: 10
Date: Feb 22, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (10)
Failure to ensure residents were free from misappropriation of medications and abuse.
Failure to investigate and prevent alleged abuse, neglect, exploitation, or mistreatment.
Failure to develop and implement comprehensive care plans for residents.
Failure to meet professional standards in services provided.
Failure to provide pharmacy services that assure accurate acquiring, receiving, dispensing, and administering of drugs.
Failure to establish a system of records for controlled drugs to enable accurate reconciliation.
Failure to label drugs and biologicals properly and store them securely.
Failure to ensure quality of care and appropriate techniques for residents.
Failure to ensure fire doors were inspected annually as required.
Failure to conduct required electrical outlet testing and maintenance.
Report Facts
Survey Census: 107
Total Capacity: 119
Survey Dates: 02/19/2024 to 02/22/2024
Deficiency Completion Dates: 3
Medication doses misappropriated: 41
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 3
Date: Oct 5, 2023
Visit Reason
The inspection was conducted in response to complaints NJ# 166667 and 167982 regarding alleged violations involving abuse, neglect, exploitation, or mistreatment at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately as required.
Failure to ensure the resident environment remains free of accident hazards and adequate supervision to prevent accidents.
Failure to maintain complete, accurate, and confidential medical records as required.
Report Facts
Complaint numbers: 2
Sample size: 6
Resident census: 119
Deficiency completion date: Nov 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated RN administered medication to Resident #3 and discussed incident with CNA |
| RN Supervisor | Registered Nurse Supervisor | Completed Incident Report and provided statements about the incident involving Resident #3 |
| Licensed Nursing Home Administrator | LNHA | Notified of incident and provided statements about facility response |
| Director of Quality Safety and Compliance | DQSC | Provided statements regarding incident and facility policies |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 4
Date: Apr 11, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Neglect related to failure to ensure staff safely secured Resident 5 in the wheelchair, resulting in actual harm.
Comprehensive care plans did not include individualized safety interventions for residents using wheelchairs.
Accident hazards due to lack of care plan interventions or physician's orders for wheelchair safety.
Failure to ensure residents received treatment and care in accordance with professional standards, including physician supervision and medication administration.
Report Facts
Resident Sample Size: 6
Deficiencies cited: 4
Date Survey Completed: Apr 11, 2023
Date of Revisit: May 25, 2023
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ 00160157 and NJ 00155728.
Complaint Details
Complaint # NJ 00160157 and # NJ 00155728 were investigated and the facility was found to be in compliance.
Findings
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.
Report Facts
Sample size: 5
Inspection Report
Abbreviated Survey
Census: 102
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 3
Sample size: 5
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Date: Oct 22, 2021
Visit Reason
The inspection was conducted as a complaint survey related to Complaint # NJ 149498.
Complaint Details
Complaint # NJ 149498 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
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.
Report Facts
Sample size: 4
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 4
Date: Sep 30, 2021
Visit Reason
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.
Findings
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.
Deficiencies (4)
Failure to accurately complete Minimum Data Set (MDS) assessments for residents related to nutrition.
Failure to identify and address significant weight changes in residents, including lack of timely re-weighing and follow-up.
Failure to ensure food was stored to minimize cross contamination, discard expired foods, maintain kitchen equipment in a clean and sanitary manner, and ensure staff consistently covered hair.
Failure to test staff for COVID-19 at a frequency consistent with facility policy during an active outbreak.
Report Facts
Census: 107
Deficiency completion dates: 2021
COVID-19 testing intervals: 3
COVID-19 testing intervals: 7
COVID-19 test frequency noncompliance: 7
Inspection Report
Life Safety
Census: 107
Capacity: 119
Deficiencies: 2
Date: Sep 29, 2021
Visit Reason
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.
Findings
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.
Deficiencies (2)
Automatic sprinkler heads were obstructed by combustible cardboard boxes stored within 5 inches of the drop ceiling and sprinkler heads.
Required clearance of 36 inches was not maintained around electrical panels, with combustible cardboard boxes stored in front of panels in two electrical rooms.
Report Facts
Certified beds: 119
Census: 107
Combustible cardboard boxes near sprinkler heads: 10
Combustible cardboard boxes near electrical panels: 6
Combustible cardboard boxes near electrical panels: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Present during observations confirming deficiencies | |
| Respiratory Director | Present during observations confirming deficiencies |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Date: Jul 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint NJ146583.
Complaint Details
Complaint NJ146583 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
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.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Mar 30, 2021
Visit Reason
The inspection was conducted in response to complaints NJ 144137 and 136090.
Complaint Details
Complaint numbers NJ 144137 and 136090 were investigated; the facility was found in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Report Facts
Sample size: 5
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