Inspection Reports for
Voorhees Pediatric Facility
1304 Laurel Oak Road, Voorhees, NJ, 08043
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
5% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Deficiencies: 1
Date: Jan 30, 2026
Visit Reason
The inspection was conducted to assess compliance with clinical record documentation standards and ensure accurate and complete medical records for residents, specifically focusing on nutritional status monitoring.
Findings
The facility failed to ensure clinical records were complete and accurately documented for one of three residents reviewed, which could affect monitoring of the resident's nutritional status. Documentation gaps were identified in feeding records and medical administration logs.
Deficiencies (1)
Failure to ensure clinical records were complete and accurately documented, affecting monitoring of resident nutritional status.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Interviewed regarding documentation of feeds on Medical Administration Record, Treatment Administration Record, and Enteral Nutrition Log. |
| Registered Nurse | RN | Interviewed about documentation expectations in Point Click Care and importance of timely documentation. |
| Licensed Nursing Home Administrator | LNHA | Presented with nutrition log documentation issues. |
| Assistant Director of Nursing | ADON | Presented with nutrition log documentation issues. |
| Director of Social Work | DSW | Presented with nutrition log documentation issues. |
| Director of Nursing | DON | Interviewed regarding staff documentation expectations. |
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
Complaint Investigation
Deficiencies: 3
Date: Oct 21, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging abuse of a severely cognitively impaired resident (Resident #1) by a Certified Nursing Aide (CNA #2), including physical abuse and failure to report the abuse in a timely manner.
Complaint Details
Complaint number 2642805 involved allegations that CNA #2 physically abused Resident #1 by smacking them and verbally abused the resident by yelling. CNA #1 heard the abuse but delayed reporting it. RN #1 was aware Resident #1 was upset but did not report the verbal abuse. The complaint was substantiated, resulting in an Immediate Jeopardy determination.
Findings
The facility failed to protect Resident #1 from abuse by CNA #2, who was alleged to have physically slapped the resident and yelled at them. CNA #1 did not immediately report the abuse, and RN #1 failed to report the incident after being informed. This failure placed residents at risk and resulted in an Immediate Jeopardy situation, which was later removed after corrective actions were implemented.
Deficiencies (3)
Failure to protect Resident #1 from abuse by CNA #2, including physical abuse and verbal abuse.
Failure of CNA #1 to immediately report alleged abuse.
Failure of RN #1 to report CNA #2's verbal abuse of Resident #1.
Report Facts
Complaint number: 2642805
Residents affected: 3
Date of abuse incident: Oct 9, 2025
Date of survey completion: Oct 21, 2025
Date Immediate Jeopardy removed: Oct 21, 2025
Date CNA #2 terminated: Oct 17, 2025
Date Removal Plan submitted: Oct 20, 2025
Duration of abuse incident reporting audit: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Alleged witness to abuse who delayed reporting |
| CNA #2 | Certified Nursing Aide | Alleged abuser who physically and verbally abused Resident #1 |
| RN #1 | Registered Nurse | Observed Resident #1 upset but failed to report verbal abuse |
| Director of Nursing | Director of Nursing | Received delayed abuse report and oversaw investigation |
| Director of Social Work | Director of Social Work | Interviewed regarding abuse incident and facility response |
| Unit Manager | Unit Manager | Did not receive immediate abuse report from CNA #1 or RN #1 |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Acknowledged failure to follow abuse policy and timeliness issues |
Inspection Report
Routine
Deficiencies: 4
Date: May 23, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care, staffing, infection control, and staff competency evaluations.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate an injury of unknown origin, inadequate staffing to provide timely incontinence care, non-adherence to CDC infection control guidelines, and failure to ensure annual competency evaluations for CNAs. These deficiencies affected many residents and posed minimal or potential harm.
Deficiencies (4)
Failure to complete a thorough investigation of an injury of unknown origin (bruises) on Resident #37.
Inadequate staffing leading to failure to provide timely and appropriate incontinence care to residents, including Resident #82 and Resident #58.
Failure to follow CDC guidelines and facility infection control policies, including improper use of gowns and hand hygiene by staff during care of Resident #103.
Failure to ensure CNAs completed annual performance evaluations as required by facility policy.
Report Facts
Date of injury noted: Mar 31, 2025
Date of survey completion: May 23, 2025
Observation dates: May 18, 2025
Observation dates: May 19, 2025
Observation date: May 20, 2025
Observation date: May 21, 2025
Interview date: May 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed not wearing gown during incontinence care and improper hand hygiene with Resident #103 |
| CNA #2 | Certified Nurse Aide | Assigned to Resident #82 and observed providing incontinence care |
| LPN #2 | Licensed Practical Nurse | Assisted CNA #2 with incontinence care for Resident #82 |
| CNA #3 | Certified Nurse Aide | Interviewed regarding urine odor near Resident #82 |
| CNA #4 | Certified Nurse Aide | Observed providing incontinence care for Resident #82 |
| CNA #6 | Certified Nurse Aide | Observed providing incontinence care for Resident #58 |
| RN #6 | Registered Nurse | Informed surveyor about CNA responsibilities for Resident #58 |
| IPRN | Infection Preventionist Registered Nurse | Interviewed regarding infection control observations and protocols |
| LNHA | Licensed Nursing Home Administrator | Interviewed about job responsibilities, investigations, and quality assurance |
| DON | Director of Nursing | Confirmed lack of investigation statements and participated in exit conference |
Inspection Report
Routine
Census: 6
Deficiencies: 11
Date: May 23, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, safety, staffing, infection control, medication management, and facility environment.
Findings
The facility was found deficient in maintaining appropriate ambient air temperatures, ensuring thorough investigations of injuries of unknown origin, providing timely and adequate incontinence care, ensuring proper use of positioning devices, maintaining adequate staffing levels, completing annual CNA performance evaluations, medication management, medication storage and labeling, food safety and sanitation, infection control practices, and overall facility management and oversight.
Deficiencies (11)
Failure to maintain ambient air temperature between 71-81 degrees Fahrenheit in resident areas and maintain cleanliness in shower and storage areas.
Failure to complete a thorough investigation of an injury of unknown origin and to rule out abuse for Resident #37.
Failure to provide appropriate incontinence care and personal hygiene for Residents #82 and #58, including prolonged exposure to soiled briefs and inadequate staffing.
Failure to ensure devices to prevent contractures were consistently applied per physician order for Resident #84.
Failure to provide sufficient competent nursing staff to meet resident care needs and maintain minimum staffing requirements.
Failure to complete annual performance evaluations for 4 of 5 Certified Nurse Aides.
Failure to ensure all prescribed medications were administered according to physician orders, including missed doses of Propanolol for Resident #85.
Failure to properly label, dispose, and store medications, including expired iron liquid and undated insulin vial.
Failure to ensure formula preparation and nourishment areas were clean and sanitary, with unlabeled food items and inappropriate storage of feeding containers.
Failure of Licensed Nursing Home Administrator to ensure thorough investigations, adequate staffing, infection control compliance, and staff competency evaluations.
Failure to ensure appropriate personal protective equipment use, proper handling of soiled linens, and hand hygiene according to CDC guidelines during resident care.
Report Facts
Residents in Annex Unit: 6
Residents in B-Wing Unit: 60
Staffing hours deficit: 2.75
Staffing hours deficit: 79
Number of missed Propanolol doses: 5
Number of CNAs without 2024 performance evaluation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed not wearing gown during Enhanced Barrier Precautions care and improper hand hygiene |
| LNHA | Licensed Nursing Home Administrator | Acknowledged lack of formal abuse investigation training and incomplete CNA evaluations |
| DON | Director of Nursing | Acknowledged lack of awareness of infant brief use and incomplete abuse investigation |
| CNA #2 | Certified Nurse Aide | Provided incontinence care to Resident #82 with assistance from LPN |
| LPN #2 | Licensed Practical Nurse | Assisted CNA #2 with incontinence care for Resident #82 and unable to provide rationale for infant brief use |
| RN #7 | Registered Nurse Unit Manager | Confirmed missed Propanolol doses due to pharmacy delay |
| IPRN | Infection Preventionist Registered Nurse | Confirmed gown use required for Enhanced Barrier Precautions and proper hand hygiene |
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
Deficiencies: 7
Date: Feb 22, 2024
Visit Reason
The inspection was conducted due to allegations of misappropriation of residents' narcotic medications and failure to respond appropriately to alleged violations, including medication management and resident care concerns.
Complaint Details
The complaint investigation was substantiated with findings of misappropriation of narcotic medications for seven residents, failure to investigate and respond appropriately, and multiple medication management deficiencies.
Findings
The facility failed to prevent and investigate misappropriation of narcotic medications for multiple residents, failed to develop appropriate care plans, failed to follow professional standards for narcotic counts, failed to ensure appropriate respiratory care techniques, failed to timely notify family for medication refills, and failed to properly label and manage controlled substances.
Deficiencies (7)
Misappropriation of narcotic medications for seven residents, including borrowing and administering medications to other residents.
Failure to respond appropriately to alleged violations related to misappropriation of narcotic medications.
Failure to develop a care plan for intermittent urinary catheterization for one resident.
Failure to follow professional standards for signing narcotic counts on medication carts.
Failure to ensure appropriate respiratory care techniques; inappropriate use of sternal rub causing bruising.
Failure to ensure timely notification to family for medication refill resulting in resident going without medication for 2.5 days.
Failure to have correct pharmacy labels on controlled drug records and failure to waste narcotic medication after order expiration.
Report Facts
Doses of lorazepam misappropriated: 15
Doses of diazepam misappropriated: 41
Doses of diazepam misappropriated: 3
Doses of diazepam misappropriated: 1
Narcotic count log missing signatures: 20
Days medication not administered: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT1 | Respiratory Therapist | Performed inappropriate sternal rub causing resident bruising |
| RN2 | Registered Nurse | Nursing supervisor who documented resident's bruise and interviewed about incident |
| NS1 | Nursing Supervisor/Registered Nurse | Informed about medication refill issues and labeling problems |
| LPN3 | Licensed Practical Nurse | Responsible for contacting family about medication refill |
| DON | Director of Nursing | Provided multiple interviews regarding medication management and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Feb 22, 2024
Visit Reason
The inspection was conducted to investigate allegations of misappropriation of residents' narcotic medications and other complaints related to care and medication management at the facility.
Complaint Details
The complaint investigation was substantiated with findings that nursing staff misappropriated narcotic medications from multiple residents and failed to properly investigate and report these incidents. Additional complaints included failure to develop care plans, improper medication management, and inappropriate respiratory care techniques.
Findings
The facility failed to prevent and investigate misappropriation of narcotic medications for multiple residents, failed to develop a care plan for intermittent urinary catheterization for one resident, failed to ensure proper narcotic counts and signatures, failed to use appropriate respiratory care techniques causing injury to a resident, failed to timely notify family for medication refills, and failed to properly label and manage controlled substances.
Deficiencies (7)
Misappropriation of narcotic medications for seven residents by nursing staff borrowing medications and administering them to other residents.
Failure to identify and investigate misappropriation of residents' narcotic medications placing residents at risk.
Failure to develop a care plan for intermittent urinary catheterization for one resident.
Failure to follow professional standards for narcotic counts and signatures on medication logs across multiple units.
Failure to ensure appropriate respiratory care techniques; a resident sustained a bruise from a sternal rub performed by respiratory therapist.
Failure to timely notify resident's family to ensure medication was ordered and delivered, resulting in missed doses.
Failure to have correct pharmacy labels on controlled drug records and medication bottles; failure to waste narcotic medication after order expiration.
Report Facts
Doses of lorazepam misappropriated: 15
Doses of diazepam misappropriated: 41
Doses of diazepam misappropriated: 3
Doses of diazepam misappropriated: 1
Narcotic count log missing signatures: 17
Days medication missed: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT1 | Respiratory Therapist | Performed inappropriate sternal rub causing resident injury |
| RN 2 | Registered Nurse | Nursing supervisor who documented resident injury and interviewed |
| NS1 | Nursing Supervisor/Registered Nurse | Informed about medication refill issues and labeling problems |
| LPN3 | Licensed Practical Nurse | Responsible for contacting family about medication refill |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding findings and facility policies |
| Administrator | Facility Administrator | Interviewed regarding misappropriation and facility response |
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
Deficiencies: 3
Date: Oct 5, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding a Certified Nursing Assistant (CNA) performing a procedure outside her scope of practice and failure to maintain complete medical records for a resident transferred to the hospital.
Complaint Details
The complaint investigation was substantiated with findings that the CNA inserted a rectal tube outside her scope of practice and the facility failed to report the incident to the NJDOH. The facility also failed to maintain a complete medical record for a resident transferred to the hospital, missing the Universal Transfer Form.
Findings
The facility failed to ensure the CNA adhered to her scope of practice by inserting a rectal tube without an order, and failed to report this incident to the New Jersey Department of Health. Additionally, the facility did not maintain a complete medical record for a resident transferred to the hospital, missing the Universal Transfer Form.
Deficiencies (3)
Facility failed to ensure timely reporting of suspected abuse, neglect, or theft related to CNA inserting a rectal tube outside her scope of practice and failure to report to NJDOH.
Facility failed to ensure that a nursing home area is free from accident hazards and provided adequate supervision to prevent accidents, specifically CNA working outside her scope of practice by inserting a rectal tube.
Facility failed to safeguard resident-identifiable information and maintain complete medical records, missing the Universal Transfer Form for a resident transferred to the hospital.
Report Facts
Residents sampled: 6
Residents affected: 1
Incident date: Jul 24, 2023
Hospital admission date: Jul 24, 2023
Hospital discharge date: Jul 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Performed rectal tube insertion outside scope of practice | |
| Registered Nurse (RN) | Administered soap suds enema, discovered rectal tube insertion, removed tube, reported incident | |
| Director of Nursing (DON) | Interviewed regarding incident and reporting failure | |
| Director of Quality Safety and Compliance (DQSC) | Interviewed regarding scope of practice and incident | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding incident and reporting decision | |
| RN Supervisor | Completed incident report and interviewed about CNA actions | |
| Nurse Practitioner (NP) | Present during soap suds enema administration |
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: 101
Deficiencies: 5
Date: Apr 11, 2023
Visit Reason
The inspection was conducted due to complaints regarding wheelchair safety and medication administration, specifically involving incidents of neglect and failure to provide physician orders for wheelchair safety and Remicade infusions.
Complaint Details
The complaint involved neglect related to wheelchair safety resulting in actual harm to Resident 5, and failure to provide physician orders for wheelchair safety and Remicade medication for multiple residents. The facility was notified of Immediate Jeopardy status during the investigation.
Findings
The facility failed to ensure residents using wheelchairs were safely secured, resulting in a resident (R5) suffering accidental asphyxiation due to improper wheelchair harness use. Additionally, the facility failed to have physician orders for wheelchair safety and Remicade medication administration for multiple residents, increasing risk of harm.
Deficiencies (5)
Failure to ensure wheelchair safety for residents, resulting in accidental asphyxiation of Resident 5 due to improper securing in wheelchair.
Failure to develop and implement comprehensive care plans including wheelchair safety interventions for all residents using wheelchairs.
Failure to provide appropriate treatment and care according to physician orders, resulting in missed Remicade infusions for Resident 23.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically wheelchair safety for 101 residents.
Failure to obtain and maintain physician orders for wheelchair safety and Remicade medication administration for multiple residents.
Report Facts
Residents using wheelchairs: 101
Residents reviewed for wheelchair safety: 4
Residents reviewed for medication orders: 3
Time ventilation initiated: 1408
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Witnessed Resident 5 hanging from wheelchair and described the incident. |
| Registered Nurse Charge 3 | RNC | Responded to Resident 5 incident, provided artificial respirations, and described wheelchair safety issues. |
| Director of Nursing | DON | Investigated Resident 5 incident and provided statements on facility failures. |
| Nurse Practitioner 1 | NP | Provided care and statements regarding Resident 5 and medication administration issues. |
| Medical Director | Examined Resident 5, provided statements on incident and facility care plan deficiencies. | |
| Nurse Manager | NM | Provided information on Resident 23's care and medication orders. |
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
Complaint Investigation
Deficiencies: 4
Date: Sep 30, 2021
Visit Reason
The inspection was conducted to investigate complaints related to nutritional assessments, weight monitoring, food safety, and COVID-19 testing compliance at Voorhees Pediatric Facility.
Complaint Details
The complaint investigation focused on nutritional assessment inaccuracies, failure to monitor and address significant weight loss, food safety violations, and inadequate COVID-19 testing frequency for staff during an outbreak. The investigation substantiated these issues with multiple interviews, record reviews, and observations.
Findings
The facility failed to accurately complete Minimum Data Set (MDS) assessments for nutrition, failed to identify and address significant weight changes in residents, failed to maintain food storage and kitchen sanitation standards, and failed to ensure staff COVID-19 testing was conducted at the required frequency during an active outbreak.
Deficiencies (4)
Failure to accurately complete Minimum Data Set (MDS) assessments for nutrition, including incorrect coding of significant weight loss for Resident #84.
Failure to identify and address significant weight changes for Residents #25 and #84, including lack of timely notification and follow-up.
Failure to ensure food was stored to minimize cross contamination, discard expired foods, maintain kitchen equipment cleanliness, and ensure staff consistently covered hair.
Failure to ensure staff COVID-19 testing was conducted at the frequency required by facility policy and public health guidance during an active outbreak.
Report Facts
Weight loss percentage: 16.5
Weight loss percentage: 10.9
Weight loss percentage: 15
Weight loss percentage: 10
Weight measurements: 33.5
Weight measurements: 35.2
Weight measurements: 29.4
Weight measurements: 18.4
Weight measurements: 16.3
COVID-19 testing interval days: 10
COVID-19 testing interval days: 11
COVID-19 testing interval days: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged incorrect MDS coding and weight loss issues; provided information on COVID-19 testing and weight monitoring. |
| Registered Dietician | Registered Dietician (RD) | Responsible for tracking weights and nutritional assessments; confirmed lack of timely notification of significant weight loss. |
| MDS Nurse | MDS Nurse | Responsible for completing Section K of MDS; acknowledged incorrect coding of weight loss. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Described weighing procedures and responsibility for tracking weights. |
| Registered Nurse | Registered Nurse (RN) | Confirmed weighing procedures and importance of reporting weight discrepancies. |
| Registered Nurse Supervisor | RN Supervisor | Described weight recording and notification process. |
| Dining Service Director | Dining Service Director (DSD) | Observed with hair exposed; unable to explain altered food label dates; acknowledged food storage and sanitation issues. |
| Infection Preventionist | Infection Preventionist (IP) | Described COVID-19 testing procedures and tracking. |
| Local Health Department representative | Local Health Department representative | Provided guidance on COVID-19 testing frequency during outbreak. |
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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