Voorhees Pediatric Facility

In the surveyor’s words

From the most serious findings on record at Voorhees Pediatric Facility, in the surveyor’s own words.

• Immediate jeopardy, widespreadF656Apr 11, 2023

  Complaint # NJ00110496 Based on interviews, review of records, and review of facility policy, the facility failed to ensure for all 101 of 101 residents utilizing wheelchairs that their care plans addressed wheelchair safety (securing on wheelchair). The facility's deficient practice resulted in R5 suffering accidental asphyxiation [deprivation of oxygen supply to body tissues] by a chest harness when the resident was not properly secured in the wheelchair. On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) at F656: Develop/Implement Comprehensive Care Plan. The Immediate Jeopardy began on [DATE] when R5 suffered accidental asphyxiation after being improperly secured by staff in R5's wheelchair. […]

• Immediate jeopardy, patternF689Apr 11, 2023

  Complaint # NJ00110496 Based on interviews, review of records, and the facility policy, the facility neglected to ensure one resident out of 101 residents (Resident (R) 5) residing at the facility who utilized wheelchairs was safely secured in the wheelchair to prevent accident hazards. On [DATE], the facility's failure resulted in actual harm to R5 due to accidental asphyxiation [deprivation of oxygen supply to body tissues] by the wheelchair chest harness. The facility failed to have care planned interventions or physician's orders for wheelchair safety in place for four of four residents (R5, R18, R23, and R15) reviewed for wheelchair safety, and 97 other residents utilizing wheelchairs in the facility, increasing the risk of accident hazards for all 101 residents. […]

• Immediate jeopardy, isolatedF600Oct 21, 2025

  Complaint: 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 abuse a.) when the Certified Nursing Aide (CNA #1) alleged that she heard CNA #2 smacking Resident #1 and CNA #1 did not report the alleged abuse immediately and b.) when the Registered Nurse (RN #1) was made aware that Resident #1 was visibly upset from CNA #2 yelling at them and RN #1 left the resident in CNA #2's care and did not immediately report it. […]

• Immediate jeopardy, isolatedF600Apr 11, 2023

  Complaint # NJ00110496 Based on interviews, review of records, and the facility policy, the facility neglected to ensure one resident out of four residents (Resident (R) 5) reviewed for wheelchair safety was safely secured in the wheelchair to prevent accident hazards. On [DATE], the facility's failure resulted in actual harm of R5 due to accidental asphyxiation [deprivation of oxygen supply to body tissues] caused by the wheelchair chest harness. Following the incident, the facility determined human error as the cause and neglected to take measures to prevent future accidents. On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) for F600 Neglect. […]

• Actual harm, isolatedF710Apr 11, 2023

  Complaint # NJ00110496, NJ00107644 Based on record review, interviews, and policy review, the facility failed to ensure 101 of 101 residents utilizing wheelchairs at the facility had physician orders for wheelchair safety. This resulted in actual harm when Resident (R) 5 was not appropriately secured in the wheelchair and suffered asphyxiation. The facility failed to ensure two residents out of three residents (R23, R18) reviewed for physician services had physician's orders included for Remicade (Generic name infliximab, infusion therapy used to decrease inflammation and treat Crohn's disease, ulcerative colitis, and rheumatoid arthritis.) The facility's deficient practice increased R23 and R18's resident's risk of treatment (medication administration) overlooked and not administered. […]