Autumn Lake Healthcare At Southgate

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

58.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 294 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 81.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 181 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 152 beds and averages 137.4 residents a day — about 90% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.98 hrs/resident/day on weekends vs 3.41 on weekdays — 13% thinner on weekends. RN hours go from 0.32 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

• Potential for harm · Dcited before2025-10-22 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Complaint # 2648625 Based on observation, interview, medical record review and review of pertinent facility documents on 10/22/2025 it was determined that the facility failed to: a.) implement infection control practices consistent with the Center for Disease Controls (CDC) Enhanced Barrier Precautions (EBP) for a resident with open wounds; b.) ensure appropriate infection control practices were maintained during wound care; and c.) maintain the urinary drainage bag in a position that prevents contact with environmental services to reduce risk of contamination. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for wound care and was evidenced by the following:According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to, quadriplegia (paralysis of all four limbs) and flaccid neuropathic bladder (inability to fully empty bladder requiring urinary drainage bag). A review of Resident #1's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 07/19/2025, revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-22 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ186169 Based on interviews, review of the Medical Records (MR), and pertinent facility documents on 5/22/2025, it was determined that the facility failed to ensure that the medication ordered by the physician was received and available to be administered for 1 out of 3 sampled residents (Resident #2). The deficient practice was evidenced by the following: According to Resident #2's MR, Resident #2 had diagnoses which included but were not limited to Chronic Kidney Disease, Aneurysm of Artery of Lower Extremity, and Peripheral Vascular Disease, Unspecified. According to the Minimum Data Set (MDS), an assessment tool dated 4/24/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #2 was cognitively intact. A review of Resident #2's Order Summary Report (OSR) received on 5/22/2025 from the Director of Nursing (DON), indicated, Xarelto Tablet 20MG (Milligram)(Rivaroxaban) give 1 tablet by mouth one time a day for Afib (Atrial fibrillation - an irregular…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-02-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 2/19/25 from 9:26 AM to 10:55 AM, the surveyor observed the following in the presence of [NAME] #1: 1. The Receptionist was observed exiting the walk-in refrigerator with a tray of food items and proceeded to give the tray to Dietary Aide (DA) #3. When interviewed, DA #3 stated that he was instructed to throw eight containers of the pudding in the trash. [NAME] #1 who was present, then proceeded to reach into the trash can and retrieved a single container which she identified as butterscotch pudding, and she stated that it was not labeled or dated. The surveyor interviewed DA #1, who was also present, stated that it was important to label and date food items to ensure that they were not out of date. 2. The surveyor observed [NAME] #1 wash her hands for nine seconds out…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ 169844 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 3 of 3 resident units (100, 200, and 300 Unit) and was evidenced by the following: 1.) On 2/20/25 at 9:58 AM, the surveyor, in the presence of Registered Nurse/Unit Manager (RN/UM) #1, observed the following in the pantry area on the 300 unit: -A water cooler had a build-up of white streaks and grime. -An ice cart that contained a plastic liner with multiple rips and brown stains. -The black lid on a large gray trash can contained a build-up of white and brown substances. At that same time in the day room, the following was observed: -The black lid on a large gray trash can also contained a build-up of white and brown grime throughout. On 2/20/25 at 10:14 AM , the surveyor interviewed Housekeeper (HSK) #5, who stated that when…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-26 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for 10 of 10 employee files reviewed. This deficient practice was evidenced by the following: On 2/25/25 at 11:00 AM, the surveyor reviewed the 10 randomly selected employee files, which revealed the following: 1. Registered Nurse (RN #1), with a hire date of 4/16/24, did not have a previous employee reference on file. 2. Licensed Practical Nurse (LPN #5), with a hire date of 1/21/25, did not have a previous employee reference on file. 3. Certified Nursing Assistant (CNA #5), with a hire date of 1/7/25, did not have a previous employee reference on file. 4. Housekeeper (HSK #8), with a hire date of 1/30/25, did not have a previous employee reference on file. 5. CNA #6, with a hire date of 10/15/24, did not have a previous employee reference on file. 6. LPN #6, with a hire date of 6/12/24, did not have a previous employee reference on file. 7. Dietary Aide (DA #4), with a hire…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-26 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Complaint #: NJ167424, NJ169906, NJ170986 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to include a.) tube feeding, b.) risk for pain, and c.) oxygen use. This deficient practice was identified in 3 of 28 residents (Resident #85, #108, and #391) reviewed and was evidenced by the following: 1.) On 2/25/25 at 10:14 AM, the surveyor reviewed the medical record for Resident #85. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, encounter for surgical aftercare following surgery on the digestive sysytem and gastrostomy (a flexible tube inserted through the abdominal wall and into the stomach). A review of the Minimum Data Set (MDS), an assessment tool, dated 2/3/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS in Section K…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-26 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Complaint #: NJ169906 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow-up on a healthcare provider's recommendation for a pain management appointment in a timely manner for 1 of 2 residents (Resident #108) reviewed for pain management. This deficient practice was evidenced by the following: On 2/19/25 at 10:05 AM, during the initial tour, the surveyor observed Resident #108 lying in bed. At that time, the nurse entered the room to administer the resident's medications and asked the resident if he/she had pain. The resident complained of nine out of 10 pain to his/her back. When the nurse left the room to get the resident pain medication, the resident stated his pain was not being managed properly. The resident explained that he/she had pain in his/her back from a prior surgery and that he/she had esophageal cancer as well. The resident further stated that he/she had been asking to see a pain management specialist, but that nothing is being done about it. On 2/21/25 at 9:35 AM, the surveyor reviewed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-26 · tag F0908 — failed to keep essential equipment working — pattern
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain dryer machines in a safe operating condition for 2 of 4 dryer machines observed. This deficient practice was evidenced by the following: On 2/21/25 at 12:20 PM, the surveyor, accompanied by the Interim Housekeeping Director (IDH), toured the facility's laundry room. The IDH explained that the laundry staff clean the dyer lint traps every two hours and sign off the completion in a logbook. The IDH retrieved the dyer lint trap cleaning log binder, opened the binder to review it, and stated the laundry staff had not completed the logs per the facility's policy. When asked when the logs were last completed, the IDH opened the binder and turned to the last page that was filled out which contained the dates for 8/20 and 8/21. The dates did not indicate the year it was completed. At that time, the surveyor requested to see the lint traps for the four dryer machines which revealed two out of the four dryer machines had a moderate amount of lint accumulation in the lint…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for bilateral heel boots (a pressure-relieving device) for a resident at risk for developing pressure ulcers. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for positioning and mobility and was evidenced by the following: On 2/20/25 at 12:37 PM, the surveyor observed Resident #7 resting in bed. The resident was awake and stated that he/she was not wearing heel boots at that time and would like to wear them. The resident's feet were noted to be resting on two green pillows. There were no heel boots observed in the resident's room. The surveyor reviewed the medical record for Resident #7. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, hemiplegia and hemiparesis, morbid obesity, mild protein calorie malnutrition, and restless leg syndrome. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Complaint #: NJ167424 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for a resident who required continuous oxygen. This deficient practice was identified for 1 of 3 residents (Resident #31) reviewed for respiratory care and was evidenced by the following: On 2/19/25 at 9:57 AM, during the initial tour of the facility, the surveyor observed Resident #31 resting in bed with their eyes closed and receiving oxygen via nasal cannula (N/C; a device that delivers extra oxygen through a tube and into the nose). On 2/20/25 at 9:02 AM, the surveyor observed Resident #31 resting in bed with their eyes closed. At that time, the surveyor observed the resident wearing a N/C which was connected to an empty portable oxygen tank on the back of the resident's wheelchair. At 9:06 AM, the surveyor interviewed Certified Nurse Aide (CNA) #4 who stated that she was assigned to care for Resident #31. She stated that the resident had not yet gotten out of bed that morning. At 9:10 AM, the surveyor…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to AUTUMN LAKE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 18 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ