Voorhees Pediatric Facility

Inspectors wroteBased on interviews, medical records and review of other pertinent facility documentation on 1/30/26, it was determined that the facility failed to ensure clinical records were complete and accurately documented. This failure had the potential to affect the facility's ability to monitor the resident's nutritional status. This deficient practice was identified for 1 of 3 residents reviewed for resident records (Resident #2), and was evidenced by the following:According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a clinical condition where a patient with a pre-existing, long-term (chronic) respiratory impairment experiences a new, sudden (acute) worsening of their ability to exchange oxygen and carbon dioxide. [...]

Inspectors wroteComplaint: 2642805Based on interviews, review of the medical records, and review of other pertinent facility documents, it was determined that the facility failed to protect a severely cognitively impaired resident (Resident #1) from harm when a the Certified Nursing Aide yelled at and hit Resident #1, who was visibly upset after the encounter. This deficient practice was identified for 1 of 3 residents reviewed for abuse. The evidence was as follows:A review of the facility's policy titled Safety: Abuse, Neglect and Exploitation updated 5/21/25, included Policy: [name redacted] has an obligation to protect the welfare of its residents and to fully investigate and correct any circumstances bearing upon that welfare. The approach should be as proactive as possible. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that there was sufficient competent staff to ensure a) all residents were provided with appropriate and timely incontinence care and were consistently available to provide appropriate care to maintain residents highest practicable physical, mental, and psychosocial well-being and b) the minimum staffing requirements per the New Jersey Department of Health based on acuity of the residents was maintained. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: Refer to 677F, 688D A. On 05/18/25 at 7:17 PM, the Registered Nurse Nursing Supervisor for the B -Wing Unit, informed the survey team the B- Wing Unit had 60 residents. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to a) ensure the formula preparation process and nourishment area was implemented in a clean and sanitary manner, b) food items were labeled with a use by date, and c) appropriate cleaning items were utilized to prevent potential contamination. The deficient practice had the potential for development of food borne illness and was evidenced by the following: On 5/19/25 at 8:43 AM, the surveyor conducted a tour of the kitchen with a Food Service Director (FSD) from another facility, the District Manager for the Food Service Management Company was present, and did not join the tour.

Inspectors wroteBased on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all residents received the care and services needed to maintain residents highest practicable physical, mental, and psychosocial well-being by failing to ensure: a) a thorough investigation of an injury of unknown origin was completed, b) staffing was appropriate to meet resident needs to provide incontinence care in an appropriate and timely manner and according to the facility policy, c) staff followed the Center for Disease Control (CDC) guidelines and the facility's infection control policy to prevent the spread of potential infection, d) there was a process in place to ensure staff completed their annual competency evaluations. [...]

Inspectors wroteBased on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 2 of 4 residents (Resident #82 and #58) reviewed for Activities of Daily Living (ADLs) on 1 of 2 resident units, (B Wing Unit). The deficient practice was evidenced by the following: 1. On 5/18/25 at 7:45 PM, the surveyor toured the B Wing Unit, and observed a strong feces and urine odor in the hallway. All the residents were observed in bed at that time. On 5/18/25 at 8:29 PM, the surveyor observed Resident #82 in an enclosure bed (a complete bed system resembling a tent, designed to provide safety). The resident was facing the window. From a clear unobstructed view through the open door, the surveyor observed the resident's incontinence brief was bulging from the back. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of Certified Nurse Aides (CNA) at least every 12 months. The deficient practice was identified for 4 of 5 Certified Nurse Aides reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by: A review of the facility-provided CNA annual performance evaluations revealed that 4 of the 5 CNAs did not have an annual performance evaluation for 2024. On 05/22/25 09:41 AM during an interview with the surveyor, the Liscensed Nursing Home Administrator (LNHA) confirmed there were no performance evaluations for 2024 for 4 out of 5 CNA's. The LNHA stated, I know we should have them, but we don't, the place fell apart. The LNHA stated they have had two Director of Nursing's and an interim DON in the past year. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a) appropriate Personal Protective Equipment was utilized while providing care to a resident who required Enhanced Barrier Precautions (EBP), b) soiled linens were appropriately handled, and c) appropriate hand hygiene was performed per facility and Center for Disease Control Guidance. The deficient practice occurred on 1 of 3 resident units (The Annex) and was evidenced by the following: On 05/21/25 at 9:54 AM, the surveyor entered the Annex Unit and observed Resident #103 was in the room, the curtain was pulled, and staff were heard talking to resident while providing care. On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed Enhanced Barrier Precautions, Everyone Must: [...]

Inspectors wroteBased on observation, interview it was determined that the facility failed to ensure a) the required ambient air temperature (between 71-81 degrees Farenheight) was maintained in all resident areas, and the shower room with an adjacent storage area was maintained in a clean and sanitary manner. The deficient practice was identified for 1 of 2 shower areas on the B-Wing Unit, for the 6 bed Annex Unit and was evidenced by the following: On 5/18/25 at 7:29 PM, during a tour of the B-Wing Unit shower room the surveyor observed what appeared to be a brown feces covered washcloth wrapped around the bath sprayer nozzle which was below the bath stretcher that was on top of the bath. The surveyor showed the Registered Nurse Supervisor (RNS) who stated, she was not sure what happened. [...]

Inspectors wroteREPEAT DEFICIENCY Based on interview, medical record review and review of other facility documents, it was determined that the facility failed to complete a thorough investigation of an injury of unknown origin, and to rule out abuse. This deficient practice was identified for 1 of 4 residents reviewed for abuse, Resident #37 and was evidenced by the following: On 5/22/25 at 10:08 AM, the surveyor reviewed the electronic medical record for Resident #37. According to the admission Record, Resident #37 was admitted to the facility with diagnoses which included, but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure a system was in place to ensure devices used to prevent contractures were consistently applied per physician order. The deficient practice occurred for 1 of 6 residents reviewed for positioning (Resident #84) and was evidenced by the following: On 5/18/25 at 8:00 PM, the surveyor observed Resident #84 in bed sleeping with both hands visibly contracted and there was no device inside both hands. There were two posters on the wall above Resident #84's bed detailing the use of Resident #84's right and left hand roll (a device used to prevent the hands from closing into the palms). On 5/19/25 at 9:30 AM, the surveyor reviewed the medical record for Resident #84 which revealed the following: [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview and record review, it was determined that the facility failed to ensure that nurses administer all prescribed medications according to the physician's order. This deficient practice occurred to 1 of 7 residents (Resident #85) observed during the medication pass observation and was evidenced by the following: On 5/21/25/25 at 9:45 AM, during the medication administration observation the Licensed Practical Nurse (LPN ) informed the surveyor that Resident #85's Propanolol dose was not available. The surveyor inquired regarding the facility's protocol to reorder medications. The LPN informed the surveyor that the medication should be reordered before reaching the remaining 8 doses on the Bingo cart or remaining 3 doses left in multidose bottle. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview and record review it was determined that the facility failed to properly label, dispose and store medication in 1 of 2 medication storage areas. The deficient practice was evidenced by the following: On 5/20/25 at 10:45 AM, the surveyor inspected the Unit 2 Medication Room in the presence of the Registered Nurse Unit Manager (RN #7) found a bottle of iron liquid with an expiration date of 2/2025. RN #7 informed the surveyor that the Nursing Supervisor checked the storage room daily and could not provide the rationale for the expired medication to be among other medications. On 5/20/25 at 11:00 AM, the surveyor inspected the Unit 2 Medication Cart #1 in the presence of the Licensed Practical Nurse (LPN#3) and noted a vial of Lantus Insulin that was opened and not dated. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation for seven of seven unsampled residents reviewed for misappropriation (Resident (R) 39, R36, R35, R94, R6, R87, and R70). Specifically, nursing staff borrowed medications from the residents and administered the medications to other residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to identify and investigate misappropriation of residents' narcotic medications for seven of seven unsampled residents (Resident (R) 39, R36, R35, R94, R6, R87, and R70). This placed all residents at risk for further incidents of misappropriation.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility staff failed to: 1. have correct labels on medications and failed to obtain pharmacy labels to affix to the Controlled Drug Receipt/Record/Disposition Form for three of 19 residents (Resident (R)94, R55, and R15); 2. waste a narcotic medication after the physician's order end date for one of 19 residents (R6); and 3. failed to have a pharmacy label on an opened bottle of liquid lorazepam (antianxiety medication) stored in the medication refrigerator on one of three units (Annex unit).

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a care plan for intermittent urinary catheterization for one of three residents (Resident (R) 24) reviewed for a urinary catheter.

Inspectors wroteBased on staff interview, record review, and facility document review, the facility staff failed to follow professional standards of practice regarding the signing of the on coming and off going nurse when narcotics were counted for each shift. This occurred on two of three units in the facility (B wing medication cart 1 and 2, and A wing high side medication cart).

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate techniques were used for a residents who were dependent on respirators during for one of three residents reviewed for respiratory care (Resident (R) 20). R20 had an episode of apnea when a respirator therapist performed a sternal rub on the resident even though the resident was conscious. R20 sustained a bruised area to the chest.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure medications were acquired and dispensed for one of three residents reviewed for medication administration (Resident (R) 58). The facility failed to notify the resident's family timely to ensure the medication was ordered and delivered to the facility.

Inspectors wroteNJ# 166667 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility's administration failed to ensure that the facility's policy Reportable Events was followed and implemented for an incident that occurred at the facility on 7/24/23. The incident involved a Certified Nursing Assistant (CNA) who performed a procedure outside of her scope of practice. The facility also failed to report the actions of the CNA to the New Jersey Department of Health (NJDOH). This deficient practice was identified for Resident #3, 1 of 6 sampled residents and was evidenced by the following: According to the admission Record, Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: [...]

Inspectors wroteC#: NJ#166667 Based on interviews, medical records review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility failed to ensure that a Certified Nursing Assistant (CNA) worked within her scope of practice. The deficient practice was identified for Resident #3, 1 or 6 sampled residents reviewed and was evidenced by the following: According to the admission Record (AR), Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system), spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), artificial opening of gastrointestinal tract, and constipation. [...]

Inspectors wroteComplaint #: NJ 166667 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility failed to maintain a complete MR which contained a Universal Transfer Form (UTF) for a resident who was sent to the hospital. The deficient practice was identified for Resident #3, 1 of 6 sampled residents, and was evidenced by the following: According to the admission Record, Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to identify and address significant weight changes. This deficient practice was identified for 2 of 2 residents reviewed for nutrition (Residents #25 and #84) and was evidenced by the following: 1. On 09/24/21 at 1:09 PM, the surveyor observed Resident #25 lying in bed with his/her eyes closed. He/she was receiving Pediasure Peptide (a nutritional feeding formula) 1.0 at a rate of 95 milliliters (ml) per hour. According to the admission Record, Resident #25 was over three years of age and was admitted with diagnoses which included, but were not limited to, unspecified dysphagia (a difficulty or discomfort in swallowing), unspecified lack of expected normal physiological development in childhood, and failure to thrive. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) ensure food was stored in a manner to minimize the potential for cross contamination, b.) discard potentially hazardous foods past their date of expiration, c.) maintain kitchen equipment in a clean and sanitary manner to prevent microbial growth, and d.) ensure staff consistently covered hair to minimize the potential for contamination. This deficient practice was identified in the main kitchen and on one of two resident units (A-Wing Unit) and was evidenced by the following: On 09/22/21 at 10:33 AM, the surveyor, in the presence of the Dining Service Director (DSD), observed the following during the kitchen tour: 1. The surveyor observed the DSD with a hat on his head and hair exposed out of the back of his hat. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that staff were tested for Coronavirus Disease 2019 (COVID-19) at a frequency per facility policy. This deficient practice was identified for 7 of 11 staff members reviewed for testing and was evidenced by the following: On 09/22/21 at 8:30 AM, the surveyor met with the Director of Nursing (DON), who stated that the facility was currently in an active COVID-19 outbreak (outbreak) and that there were two staff members that tested positive on 09/09/21 and 09/10/21. The DON stated that staff were being tested weekly and that she based the frequency of the testing on the COVID-19 Activity Level Index ([NAME]) Weekly Report (a report that provides data on COVID-19 transmission risk by regions). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) assessments for 1 of 2 residents (Resident #84) reviewed for nutrition. This deficient practice was evidenced by: According to the admission Record, Resident #84 was admitted with diagnoses, that included but were not limited to, unspecified intellectual disabilities and dysphagia (difficulty swallowing). Review of the Quarterly MDS, dated [DATE], included coding that the resident did not have a significant weight loss of 5% or more in the last month or 10% or more in the last six months. Review of the Weights and Vitals Summary, dated 01/01/2020 - 12/31/2020, included the following weights: [...]