The October incident at Voorhees Pediatric Facility triggered an immediate jeopardy citation from federal inspectors, who found that staff failed to protect the resident from potential ongoing harm.
The chain of events began when one nursing assistant witnessed another yelling at a pediatric resident. But instead of immediate action, the facility allowed the accused worker to continue providing direct care to the child for hours.
CNA #2 admitted during interviews that she had yelled at Resident #1, calling the child "nasty" during a care incident. The resident had become covered in feces, which CNA #2 described as "a regular occurrence."
After yelling at the child, CNA #2 wiped the resident's hand and went to gather shower supplies. She then asked RN #1 to help transfer the resident onto a shower stretcher.
That's when RN #1 noticed something was wrong.
The registered nurse asked why Resident #1 looked sad. CNA #2's response was direct: "I yelled at [the resident]."
Despite this admission, RN #1 left the child alone with CNA #2 to complete the bathing. The nurse later told inspectors that CNA #2's admission "did alarm her," which was why she had asked what was wrong and tried to comfort the resident.
When inspectors asked if she considered the incident staff-to-resident abuse, RN #1 acknowledged that abuse could be "physical and verbal." But she didn't act on that recognition in the moment.
The reporting chain broke down immediately. RN #1 told inspectors she reported the incident to the unit manager after he pulled her aside to ask about it. But the unit manager denied receiving any report about yelling.
During interviews, the unit manager claimed RN #1 had only told him that Resident #1 "looked sad and had a tear in [their] eye when being transferred to the shower." No mention of yelling. No mention of CNA #2's admission.
The director of nursing confirmed he knew that RN #1 had been told about CNA #2's admission. He acknowledged that RN #1 "could have stopped the shower from occurring or inquired further as to what was going on."
She didn't.
The licensed nursing home administrator revealed the scope of the delay during his interview. He confirmed that CNA #2 had bathed Resident #1 "during the time it took CNA #1 to report her allegation of abuse against CNA #2."
Hours passed. The child remained in the care of the worker who had admitted to yelling.
The administrator said he wasn't aware that CNA #2 had told RN #1 about yelling at the resident. He acknowledged that "the facility policy for abuse was not followed" and that there was "a delay in timeliness" in reporting.
That delay had consequences. "The alleged abuser in this incident was left with the resident," the administrator told inspectors. He explained that when staff suspect abuse, "the facility's goal was to keep all residents safe and not leave the abuser with the residents."
The goal wasn't met.
Federal inspectors found the facility had failed to protect the pediatric resident from potential ongoing harm. The immediate jeopardy citation reflected the serious risk created by allowing an admitted abuser to continue providing direct care.
The facility scrambled to respond once the investigation began. On October 9, when the director of nursing was finally made aware, CNA #2 was immediately removed from resident care and suspended pending investigation.
Local police were notified that same day. The facility began its own investigation and assessed Resident #1's condition.
Eight days later, on October 17, CNA #2 was terminated. The facility reported her to the New Jersey Department of Health and filed required notifications under the Health Care Professional Responsibility and Reporting Enhancement Act.
But the damage was already done. For hours after admitting to yelling at a child, the nursing assistant had continued providing intimate personal care to that same vulnerable resident.
The facility implemented multiple corrective measures. RN #1 received individual counseling and remedial training on October 20. The abuse prevention policy was updated and redistributed to all staff, now including termination as a consequence for failure to report in a timely manner.
Quick reference posters for abuse reporting were installed in staff lounges. The facility began conducting daily abuse incident reporting audits, to be performed by the director of nursing or designee for 30 days.
The audits would verify timeliness of incident reporting, proper resident protection procedures, and staff compliance with facility policy. All measures that should have been in place before a nursing assistant yelled at a child and kept working.
Federal inspectors verified the facility's removal plan and determined the immediate jeopardy was resolved on October 21 at 12:21 PM.
The facility is disputing the citation.
For Resident #1, the dispute means little. The child experienced verbal abuse from a caregiver, then remained in that person's care while adults debated what to do about it. In a pediatric facility, where the most vulnerable patients depend entirely on staff for protection, the system designed to keep them safe had failed at every level.
The tears RN #1 noticed during the shower transfer told the story that took inspectors days to piece together from interviews and policy reviews. A child had been yelled at, left sad and crying, and then bathed by the same person who had caused that distress.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Voorhees Pediatric Facility from 2025-10-21 including all violations, facility responses, and corrective action plans.