Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Voorhees Pediatric Facility during CMS and state inspections, most recent first.
A resident with acute and chronic respiratory failure, gastrostomy status, and anoxic brain damage, who was rarely/never understood per MDS, had incomplete documentation of enteral nutrition. Staff reported that feeds are to be documented on the MAR, TAR, and an enteral nutrition log, and that all care is to be recorded in PCC within the shift. Review of the resident’s nutrition log showed a missing entry for a scheduled early-morning feeding, despite facility policies requiring timely, accurate, and complete EMR documentation of nursing interventions and enteral feedings.
A severely cognitively impaired, fully dependent resident was not protected from abuse when a CNA allegedly smacked and yelled at the resident, and both a witnessing CNA and an RN failed to immediately report or intervene, leaving the resident in the care of the alleged abuser in violation of facility policy.
Incomplete Documentation of Enteral Feeding in EMR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that clinical records were complete and accurately documented for a resident receiving enteral nutrition. The resident had diagnoses including acute and chronic respiratory failure (unspecified for hypoxia or hypercapnia), gastrostomy status, and anoxic brain damage, and was rarely/never understood per the most recent quarterly MDS, which prevented completion of a BIMS assessment. Facility staff, including an LPN and RN, reported that enteral feeds are to be documented on the MAR, TAR, and an enteral nutrition log, and that documentation for resident care is to be completed in PointClickCare (PCC) within the shift and as soon as possible. The RN stated that documentation is important to track what is happening with residents and that many residents are vulnerable and nonverbal. During review of the resident’s January nutrition log, the surveyor identified missing documentation for a scheduled feeding time on 1/7/26 at 5:00 AM. This omission was shown to the LNHA, ADON, and DSW. The DON later stated that the expectation is that all documentation for residents should be completed. Facility policies titled “EMR Documentation-PCC” and “Nutrition: Enteral (GT, JT, NJT, NGT)” require timely, accurate, and complete clinical documentation in PCC, including recording enteral feedings in the EMR. Despite these policies and stated expectations, the enteral feeding for the identified date and time was not recorded, resulting in an incomplete clinical record for the resident’s nutrition.
Failure to Protect Resident from Abuse Due to Delayed Reporting and Inaction
Penalty
Summary
A severely cognitively impaired resident, fully dependent on staff for care due to conditions including epilepsy and spastic quadriplegic cerebral palsy, was not protected from abuse by facility staff. During care, a Certified Nursing Aide (CNA) was alleged to have smacked the resident while the resident was soiled, and another CNA who witnessed the incident did not immediately report the suspected abuse. Instead, the witnessing CNA waited approximately 45 minutes to an hour before notifying the Director of Nursing, during which time the alleged abuser continued to provide care to the resident. Additionally, a Registered Nurse (RN) became aware that the resident was visibly upset and had a tear in their eye after being yelled at by the same CNA. The RN questioned the CNA, who admitted to yelling at the resident, but the RN did not immediately report this information to a supervisor or intervene to remove the CNA from caring for the resident. The RN later stated that she was alarmed by the situation but only reported it after being asked by the Unit Manager, who denied being informed about the yelling incident at that time. The facility's abuse policy required immediate action to protect residents from harm and prompt reporting of suspected abuse. However, both the CNA and RN failed to follow these procedures, resulting in the resident remaining in the care of the alleged abuser after the incidents of physical and verbal abuse. The delay in reporting and lack of immediate protective measures constituted a failure to protect the resident from further abuse, as required by facility policy.
Removal Plan
- CNA #2 was removed from resident care and suspended pending investigation and was terminated.
- The local police were notified.
- The facility started investigating the incident.
- Resident #1 was assessed.
- The facility reported CNA #2 to the NJDOH on the FRIDAY form and the Health Care Professional Responsibility and Reporting Enhancement Act.
- RN #1 was individually counseled and provided with remedial training.
- The facility's Abuse Prevention Policy was updated and redistributed to all staff to include termination for failure to report in a timely manner.
- Quick reference posters for abuse reporting were installed in staff lounges.
- A daily abuse incident reporting audit was started and will be conducted by the DON or appointed designee daily to verify timeliness of incident reporting, proper resident protection procedures, and staff compliance with facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Voorhees
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Echelon Care & Rehab | 0 mi | ★★★★★ | 0 | 0 |
| Lions Gate | 0.3 mi | ★★★★★ | 0 | 0 |
| The Subacute At Autumn Lake Healthcare | 0.5 mi | ★★★★★ | 19 | 3 |
| Autumn Lake Healthcare At Voorhees | 0.7 mi | ★★★★★ | 3 | 1 |
| Complete Care At Kresson View, Llc | 1.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.