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Autumn Lake Healthcare At Memorial Bridge

201 Fifth Avenue, Penns Grove, NJ 08069 · For profit - Corporation · 161 certified beds · (856) 299-6800 Medicare & Medicaid certified

Call the home — (856) 299-6800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 20231 actual-harm citation$15,935 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2023
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,935 in federal fines (most recent 2025-06-02)
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
341 Shell Rd · (856) 299-4600 · Call to confirm hours
Pharmacy
Walgreens1.0 mi
2 N Virginia Ave · (856) 299-0744 · Call to confirm hours
Grocery
300 N Broad St · (856) 299-2182 · Call to confirm hours
Park
229 Penns Grove Auburn Rd · (856) 299-0070 · Typically dawn to dusk
Place of worship
128 Lanning Ave · (856) 299-4049

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

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.8%8.7%15.4%better
Long-stay residents who lose too much weight4.7%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.1%0.6%0.9%better
Long-stay residents with a urinary tract infection0.2%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms4.2%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%2.3%3.3%better
Long-stay residents whose ability to walk worsened5.7%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.4%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%97.2%95.3%typical
Long-stay residents with pressure ulcers5.0%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control21.2%15.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table48.4%12.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.1%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine99.2%80.1%79.4%better
Short-stay residents rehospitalized after admission30.3%24.9%22.6%worse
Short-stay residents with an outpatient ER visit11.3%8.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.292.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.761.111.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

44.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.1%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
77.2%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 77.2% 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 79 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 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.1%CMS range 32.0–58.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 7.9–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge77.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.2%CMS range 5.3–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.23
RN hours/ resident / day
1.11
LPN hours/ resident / day
2.39
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.18
RN hoursweekends
38.0%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 161 beds and averages 143.4 residents a day — about 89% occupied, or roughly 18 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 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 3.37 hrs/resident/day on weekends vs 3.87 on weekdays — 13% thinner on weekends. RN hours go from 0.24 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as 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

11
deficiencies at the latest standard inspection (2025-06-02)
8
at the previous standard inspection (2023-09-29)

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.

ABCDEFGHIJKL

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-06-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint: NJ184164 Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to provide appropriate safety interventions to a cognitively impaired resident (Resident #124) with a history of refusal of care. On 3/4/25, Resident #124 fell when a Certified Nursing Assistant (CNA #4) refused to allow the resident to close his/her door causing the resident to fall and hit the back of their head causing a laceration. Resident #124 was sent to the hospital for evaluation. This deficient practice was identified for 1 of 2 Residents, (Resident # 124), reviewed for falls and evidenced by the following: On 5/28/25 at 11:19 AM, the surveyor observed Resident #124 in the C-wing dining room sitting in a chair. The C-wing unit was a locked unit for residents with behaviors. The surveyor attempted to speak with the resident but was unable due to cognitive impairment. On 5/29/25 the surveyor reviewed the admission Record, an admission summary, that revealed Resident #124 had diagnoses which included, but were not limited…

    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 · E2025-11-25 · tag F0711 — pattern
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 #2659218 Based on interview, medical record review and review of other pertinent facility documentation on 11/6/25 and 11/7/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents documented physician visit progress notes at the time of each visit. This deficient practice was identified for 3 of 4 residents reviewed (Resident #1, #2, and #3), and was evidenced by the following:1.) Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of left pubis, hypertension, and myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium). According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/16/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    COMPLAINT#: 2659218 Based on interview, review of medical records and other pertinent facility documents on 11/6/25 and 11/7/25, it was determined that the facility failed to implement and monitor weekly weights upon admission in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents (Resident #1) reviewed and was evidenced by the following: Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of left pubis, hypertension, and myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium). According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/16/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. During a review of Resident #1's electronic medical record on 11/6/25 at 1 PM, 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
  • Potential for harm · Fcited before2025-06-02 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    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 On 05/27/2025 at 11:02 AM, Surveyor #2 observed the following on A Unit: the wall to left of Resident room [ROOM NUMBER]'s door had peeling paint. The wall to the left of Resident room [ROOM NUMBER] had paint peeling under the chair rail. There was missing floor tile to the right of the nurse's station. The shower room had multiple missing tiles on the wall. On 05/27/2025 at 01:43 PM, Surveyor #2 observed the following on A Unit: the paint under the heater in Resident room [ROOM NUMBER] was chipped. The ice machine at the nurse's station was missing a tile near the drainpipe and the black pad underneath the ice machine had a straw under it. On 05/28/2025 at 12:07 PM, Surveyor #2 observed the following on A Unit: there was black debris/discoloration next to the wardrobe and under the heater in Resident room [ROOM NUMBER]. There was peeling paint on the door to the smoking area. There was a broken cover on the thermometer in the dining room. There was chipped and peeling paint on the door jam and molding near 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified furnished services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 4 of 33 (Resident # 13, 80, 44, 47) residents reviewed for care plans, specifically a resident that required a hand orthotic (Resident 13), a resident with a Positive Pres-admission Screening and Resident Review (PASARR) Level 2, and a resident that required oxygen (Resident #80). This deficient practice was evidenced by the following: The deficient practice was evidenced by the following: On 05/27/2025 at 10:12 AM, Surveyor #1 observed Resident # 80 in bed receiving Oxygen via nasal cannula (a device used to deliver supplemental oxygen). Surveyor #1 reviewed Resident #80's medical record which reflected that the resident had a diagnosis which included asthma (narrowing and swelling of the airway). A review of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-02 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 # 173841 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to 1 of 1 resident reviewed for Bowel and Bladder (Resident # 47) and 3 of 11 resident reviewed for incontinence rounds. (Resident # 6, Resident #113, and Resident # 402) This deficient practice was evident by the following: On 05/27/2025 at 09:59 during initial rounds Resident # 47 was observed in bed in a t-shirt with the covers at the bottom of the bed. Resident # 47 was observed to have a saturated incontinent brief. Resident # 47 was unsure of the last time he/she was changed. A review of Resident # 47's admissions record revealed that, Resident # 47 was admitted with but not limited to Benign Prostatic Hyperplasia (a condition where the prostate gland is enlarged), and Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels.) A review of Resident #47's…

    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 · D2025-06-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 observation, interview, record review, and review of facility documents, it was determined that the facility failed accommodate resident's need by not keeping the nurse's call bell within the resident's reach. This deficient practice was identified for 2 of 33 residents (Resident #27 and #45) reviewed for accommodation of need and was evidenced by the following: Upon initial tour of the A Wing Unit on 05/27/2025 at 11:07 AM, the surveyor observed the call bell of Resident #27 on the floor underneath the head of the resident's bed. On the same date and time, the surveyor observed the call bell of Resident #45 wrapped around the wall unit of the nurse's call bell system. While in the room with the residents, a Certified Nursing Assistance (CNA) who identified herself as an agency nurse confirmed that nursing call bells were to be located on the bed within resident's reach and further stated, I cant fix everything here. The surveyor reviewed the medical record for Resident #27. A review of the admission…

    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 · D2025-06-02 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: During the Resident Council Meeting on 05/29/2025 at 10:31 AM, four of four alert and oriented residents said they were not aware of the location of the State Survey results and that the facility had not spoken to them about the results. During a tour of each unit, the surveyor observed signs that stated the State Survey results were in the lobby. The C-wing unit is a locked unit. In the lobby the surveyor observed a sign on a buffet cabinet that said State Survey results here. The binder was located inside the buffet cabinet where a door had to be opened outward. During an interview on 05/29/2025 at 11:06 AM with the surveyor, the Unit Manager (UM) of C-wing said the Survey Results were in lobby and all the residents had to do was ask to see them. When asked if the State Survey result were readily accessible…

    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 · D2025-06-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint: NJ184164 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for 1 of 2 residents (Resident #124) reviewed for abuse. This deficient practice was evidenced by the following: On 05/28/2025 at 11:19 AM, the surveyor observed Resident #124 in the Dining Room of C Wing sitting in a chair. The surveyor attempted to speak with the resident but was unable to do so due to cognitive impairment. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Metabolic Encephalopathy and Unspecified Dementia (Unspecified Severity) with Psychotic Disturbance. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/20/2025, identified that the resident was unable to complete the Brief Interview for Mental Status (BIMS). A review of the resident's individual comprehensive care plan (ICCP) included a focus…

    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 · D2025-06-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate treatment and care for a resident with a indwelling, urinary catheter. The deficient practice was identified for 1 of 3 residents (Resident # 254) reviewed for Urinary Catheter or UTI (Urinary Tract Infection). The deficient practice was evidenced by the following: On 05/27/2025 at 10:37 AM during the initial tour, the surveyor observed Resident # 254 in bed in their room. At that time, the surveyor observed a urinary catheter drainage bag containing tinged, red urine. The drainage bag did not have a cover for privacy. At that time, the surveyor asked the resident if there was a device on his/her leg that secured the tube of the indwelling, urinary catheter. Resident # 254 denied having one and showed the surveyor his/her leg. There was no securement device observed on his/her leg. On 05/28/2025 at 11:23 AM, the surveyor observed Resident # 254 in bed in their room. At that time, the surveyor observed the urinary catheter…

    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 · Dcited before2025-06-02 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NJ Complaint: #00173841 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #77's annual Minimum Data Set (an assessment tool) dated 03/08/2025, revealed that Resident #77 had a brief interview of mental status score of 0 which indicated he/she was not cognitively intact. A review of Resident #77's physician's orders revealed the following orders but not limited to Jardiance 10mg (milligrams, a medication used to manage and treat diabetes) one time a day, metoprolol tartrate 25mg (milligrams, a medication used to treat high blood pressure) twice a day, and Depakote Sprinkles delayed release 125mg (milligrams, a seizure medication often used for mood disorders) 3 capsules in 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-06-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to properly store medications and failed to maintain a sanitary environment in a medication room. The deficient practice was identified for 1 of 3 medication rooms and 2 of 7 medications carts reviewed under the Medication Storage Task. The deficient practice was evidenced by the following: On 05/28/2025 at 9:17 AM during an inspection of the B Unit Medication Room, the surveyor observed six beverages in opened containers left on the counter inside the Medication Room. Two personal bags were also in the room. At the time of observation the Licensed Practical Nurse/Unit Manager (LPN/UM) replied, No when the surveyor asked if it is reasonable staff should be keeping their beverages and bags in the medication room. The LPN/UM confirmed that there is a staff breakroom where beverages can be kept. On the same date at 9:35 AM, the surveyor inspected the B wing medication cart 2. At that time, the surveyor observed two, loose tablets inside the drawer of the medication…

    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 · Dcited before2025-06-02 · 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

    Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices, specifically when facility staff failed to wear the appropriate personal protective equipment while in a room under Contact Precautions. The deficient practiced was identified for 1 of 7 Residents (Resident # 258) reviewed under the Infection Control task. The deficient practice was evidenced by the following: On 05/27/2025 at 1:32 PM during the initial tour of the facility, the surveyor observed housekeeper (HK) # 1 inside Resident # 258's room. HK # 1 was mopping the floor. Outside of the room was a sign that revealed, Stop: Everyone Must: Clean their hands, including before entering and when leaving the room. The sign further revealed that, Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry, Discard grown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or…

    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 · F2023-09-29 · 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

    Based on observation, staff interview, and facility policy review, the facility failed to keep the kitchen's convection oven, stove spill pan, large manual can opener and base attachment, large electric mixer, and ice machine clean. Additionally, the date opened on bread products was not labeled with an use by date. This failure had the potential to affect 107 residents who consumed food prepared in the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation, dated January 2023, indicated, All kitchens, kitchen areas and dining areas shall be kept clean. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Review of the facility's policy titled, Dating and Labeling, dated January 2023, indicated, It is the policy of this facility for the kitchen to assure food safety by maintaining proper dates and labels to all food products. All food must have a receive date as well as a use by date.…

    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 · Dcited before2023-09-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 Based on observation, review of the maintenance log, and interview, the facility failed to provide a clean, comfortable, homelike environment for two of three units (B and C units) of the facility. Findings include: 1. Observation on 09/26/23 at 12:20 PM of C unit revealed in room [ROOM NUMBER] on the B side of the room there were water marks going down the wall by the air conditioning window unit. The molding around the air conditioner appeared dark in color and not clean. There was no resident currently residing on the B side, however there was a resident in the room on the A side. 2. Observation on 09/26/23 at 12:50 PM of the B unit revealed the plastic handrail on the B hall across from the nurse's station had a crack in the rail which could fit a hand inside and could cause possible injury. There was also a handrail with a crack and hole in it across from room [ROOM NUMBER]. Review of the Maintenance Log provided by the Maintenance Director (MD) dated August 2023 did not reveal the handrails or room [ROOM…

    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 · D2023-09-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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#: NJ162927, NJ164068 Based on interview, record review, and facility policy review, the facility failed to ensure two (Resident (R) 20 and R57) of six sampled residents reviewed for abuse were free from resident-to-resident physical abuse out of a total sample of 28 residents. Findings include: 1. Review of R20's admission Record, located in the Profile section of the electronic medical record (EMR), revealed R20 was admitted to the facility on [DATE]. Review of R20's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/12/20, located in the MDS tab of the EMR, revealed R20 scored seven of 15 on the Brief Interview Mental Status (BIMS) which indicated severe cognitive impairment. Review of R20's Nursing Notes,' located in the Progress Notes section of the EMR, dated 05/05/23 at 4:48 PM, revealed, Called to C wing by nurse on floor s/p [status post] resident to resident altercation. Observed [R20] seated in WC [wheelchair] at nurse's station with 3-centimeter (cm)…

    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 · D2023-09-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 interview, record review, and review of facility policy, the facility failed to send a final investigation report within 5-days to the Department of Health, as required for one (Resident (R)260) of one sampled resident reviewed for misappropriation of resident property in a total sample of 28. Findings include: Review of an undated facility policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revealed, .Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .It is the policy of Facility (sic) that all reports of theft or misappropriation of resident property be promptly and thoroughly investigated . Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R260 was admitted to the facility on [DATE] and discharged on 08/31/23. Review of the annual Minimum Data Set (MDS)…

    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 · Dcited before2023-09-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident in a total sample of 28 residents (Resident (R) 77) whose assessments were reviewed. The facility failed to accurately assess behaviors exhibited for R77. This failure placed the residents at risk of having unmet care needs and services. Findings include: Review of the RAI Manual 3.0, dated 10/19 revealed, .If an MDS assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . Review of the admission Record found on the Profile page of the electronic medical record (EMR) revealed R77 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, and major depressive disorder. Review of R77's behavior and medication administration notes found on the Progress Notes tab revealed the following entries: On 05/26/23 at 2:20 PM…

    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 · Dcited before2023-09-29 · tag F0656 — failed to write and follow a full care plan — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to develop a comprehensive plan of care directing measurable goals and person-centered interventions for two (Residents (R)100 and R59) in a total sample of 28. The facility failed to develop specific care plan and person-centered interventions related to an anti-coagulant medication for R100, and failed to develop a person-centered care plan with interventions related activities of daily living (ADLs) for R59. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included: Review of an undated facility policy titled, Care Plan, Comprehensive Person-Center, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Describes the services that are to be furnished to attain or maintain the resident's…

    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 · Dcited before2023-09-29 · 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

    Based on observation, staff interview, and facility policy review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) for one of one resident observed (Resident) (R) 72) during medication pass. Findings include: Observation during medication pass on 09/27/23 at 1:32 PM revealed Licensed Practical Nurse (LPN) 2 placed the medication cart by the door to R72's room. Posted on the wall by the entrance to R72's room was a sign that indicated R72 was on EBP. The signage revealed, Staff must wear gloves and gown for the following high contact resident care activities; device care use, central line, urinary catheter, feeding tube LPN2 removed a stethoscope from a drawer in the medication cart, placed two-barrel syringes on top of the cart and removed a 10 milligram (mg) tablet of Isosorbide from R72's bubble pack. LPN2 entered R72's room without donning (putting on) a gown and placed all the gathered supplies on the top of R72's over the bed table without cleaning the table or using a barrier. After doffing gloves and performing hand hygiene, LPN 2 picked up 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-31 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documents, it was determined that facility failed to obtain consents from a resident representative prior to administering the COVID-19 vaccination for 1 of 6 residents (Resident #34) reviewed for immunizations. This deficient practice was evidenced by the following: On 05/12/2022 at 12:52 PM, the surveyor observed Resident #34 sitting in a reclining chair. The surveyor greeted the resident, but he/she did not verbally respond. The resident lifted his/her left arm and shook his/her head at the surveyor. The surveyor asked the resident if he/she was okay and the resident shook his/her head yes. The surveyor also asked the resident if he/she received a shot in his/her arm last month and the resident shook his/her head yes. The surveyor then asked the resident if he/she knew the name of the shot, if he/she knew what the shot was for, and if the facility asked him/her about the shot. To each question, the resident shook his/her head no. According to admission Record, Resident #34 had diagnoses that included,…

    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 before2022-05-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 observation, interview, and record review, it was determined that the facility failed to follow the resident's care plan to consistently assess residents to determine the level of supervision needed while smoking. This deficient practice was identified for 2 of 3 residents (Residents #88 and #90) reviewed for smoking and was evidenced by the following: 1. On 05/05/22 at 11:49, 05/10/22 at 11:45 AM, 05/12/22 at 1:26 PM, 05/13/22 at 11:54 AM and 05/16/22 at 11:30 AM, the surveyor observed Resident #88 in the smoking area seated in a wheelchair. The smoking area was supervised by a staff member who provided Resident #88 with a cigarette and lit the cigarette for the resident. According to the admission Record, Resident #88 was admitted to the facility with diagnoses that included, but were not limited to, Type 2 Diabetes Mellitus and Hypertension. Review of the Annual Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, dated 10/16/21, indicated that Resident #88 had a…

    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 · E2022-05-31 · tag F0745 — failed to provide medically-related social services — pattern
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documents, it was determined that facility failed to provide social services for a resident with severe cognitive impairment. This deficient practice was identified for 1 of 8 vulnerable residents (Resident #34) reviewed and was evidenced by the following: On 05/12/2022 at 12:52 PM, the surveyor observed Resident #34 sitting in a reclining chair. The surveyor greeted the resident, but he/she did not verbally respond. The resident lifted his/her left arm and shook his/her head at the surveyor. According to admission Record, Resident #34 had diagnoses that included, but were not limited to, Schizophrenia and Unspecified Dementia with Behavioral Disturbance. Further review of the admission Record revealed under Contacts that there were no known contacts. Review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/25/2022, included, Should Brief Interview for Mental Status [BIMS] be Conducted? with a response of, No (resident is rarely/never…

    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 · E2022-05-31 · tag F0755 — failed to provide safe pharmacy services — pattern
    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

    Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a). detect and remove expired medication in 1 of 1 medication storage areas, located in the C-Wing Nursing Unit, reviewed during the medication storage and labeling task and b). ensure accurate completion of a Drug Enforcement Agency (DEA) Form-222 (a federal narcotic requisition form), to enable accurate reconciliation of controlled-dangerous substances (medications, that due to their high potential for abuse, are tracked with detail) for 2 of 3 forms reviewed during the medication storage and labeling task. This deficient practice was evidenced by the following: 1. On 05/13/22 at approximately 10:35 AM, the surveyor found the following expired items in the medication storage area, in the presence of the Registered Nurse/Unit Manager (RN/UM): three bottles of Calcium 600 milligrams (mg) with each bottle containing 60 tablets and an expiration date of 07/20 and one box of 24HR-Prevacid 15 mg capsules with the box containing 42 capsules and an expiration date of…

    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 · Ecited before2022-05-31 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to accurately transcribe and ensure that a resident received psychotropic medication in accordance with the psychiatric recommendation and physician's order. The deficient practice was identified for 1 of 5 residents (Resident #83) reviewed for psychotropic medications and was evidenced by the following: According to the admission Record, Resident #83 was admitted with diagnoses that included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety, and paranoid schizophrenia. Review of the Progress Notes (PN) revealed that Resident #33 had a telehealth psychiatric consult (psych consult) on 05/14/20 and a recommendation to start Trazadone (a psychotropic medication used to treat depression) 25 milligrams (mg) in the AM was noted. The PN further revealed that the NP [nurse practitioner] was aware and in agreement. Review of the 05/14/20 psych consult included a recommendation for Trazadone 25 mg in the AM and Trazadone 50 mg at HS [hour…

    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 · Dcited before2022-05-31 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 3 residents, (Resident #86) reviewed for accidents and was evidenced by the following: During an interview with the surveyor on 05/16/22 at 12:25 PM, Resident #86 stated that he/she had smoked daily since admission to the facility. The resident confirmed that he/she was an independent smoker, meaning that the resident can go to the designated smoking area whenever Resident #86 desired and held his/her own cigarettes and lighter. According to the admission Record, Resident #86 was admitted to the facility with diagnoses that included, but were not limited to, Hypertension and heart failure. Review of Resident #86's handwritten Care Plan under Other Helpful Information for Care reflected that resident was an independent smoker. Review of the Annual MDS with an ARD (Assessment Reference Date) of 10/14/21 indicated that 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-31 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medications and maintain a medication error rate of less than 5%. This deficient practice was identified for 2 of 3 nurses who were observed for the medication pass task. There was a total of 27 medication opportunities, administered to five residents, on one of three units (A-Wing Nursing Unit) during the medication pass. There were two errors observed (Resident #3 and Resident #82), which resulted in a medication error rate of 7%. This deficient practice was evidenced by the following: 1. On 05/06/22 at 9:05 AM, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM) administer medication to Resident #82. The surveyor observed the LPN/UM administered Artificial Tears Eye Drops to the resident and indicated to him/her that he was administering one drop to each eye. Artificial Tears Eye drops are used to treat burning or dryness of the eyes, that may be associated with various conditions of the eye. During an interview…

    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
  • No harm found · C2023-09-29 · tag F0836 — widespread
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted 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 interview and record review, the facility failed to ensure an 855 application for facility name change was done in a timely manner. This failure had the potential to create confusion for not knowing the current name of the facility. Findings include: On 09/26/23 at 9:20 AM, the survey team entered the facility. The front door of the facility and all signs leading to the facility indicted that the name of the facility was [NAME] Lake Healthcare at Memorial Bridge despite documentation, provided by the State of New Jersey indicating the name of the facility was Carney's Point Rehabilitation and Nursing Center. Upon entrance, the survey team was met by the Human Resources Director (HR) who was asked about the difference in the name of the facility as compared to what the survey team had. The HR Director was then asked if there was an 855-application on file, indicating the State of New Jersey had acknowledged the name change. The HR Director stated she did not know what an 855-application was and to ask…

    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.

    Administration 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$15,935 in federal fines across 1 penalty.

  • $15,935 — penalty dated 2025-06-02

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

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 →

RatingThis homeChain avg
Overall 2 of 52.8-0.8 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 3 of 54.3-1.3 vs chain
The other 58 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Autumn Lake Healthcare At Crystal SpringsElkins, WV 1 of 5Autumn Lake Healthcare At Glen BurnieGlen Burnie, MD 1 of 5Autumn Lake Healthcare At HomewoodBaltimore, MD 1 of 5Autumn Lake Healthcare At Long GreenBaltimore, MD 1 of 5Autumn Lake Healthcare at GreenfieldMilwaukee, WI 1 of 5Nella's At Autumn Lake HealthcareElkins, WV 2 of 5Ashbrook Care & Rehabilitation CenterScotch Plains, NJ 2 of 5Autumn Lake Healthcare At Arlington WestBaltimore, MD 2 of 5Autumn Lake Healthcare At Ballenger CreekFrederick, MD 2 of 5Autumn Lake Healthcare At Baltimore WashingtonGlen Burnie, MD 2 of 5Autumn Lake Healthcare At BridgeparkBaltimore, MD 2 of 5Autumn Lake Healthcare At CatonsvilleCatonsville, MD 2 of 5Autumn Lake Healthcare At Glade ValleyWalkersville, MD 2 of 5Autumn Lake Healthcare At Loch RavenBaltimore, MD 2 of 5Autumn Lake Healthcare At MadisonMadison, CT 2 of 5Autumn Lake Healthcare At NorwalkNorwalk, CT 2 of 5Autumn Lake Healthcare At OverleaBaltimore, MD 2 of 5Autumn Lake Healthcare At PikesvillePikesville, MD 2 of 5Autumn Lake Healthcare At RuxtonTowson, MD 2 of 5Autumn Lake Healthcare At Salem CountySalem, NJ 2 of 5Autumn Lake Healthcare At SouthgateCarneys Point, NJ 2 of 5King David Nursing And Rehabilitation CenterBaltimore, MD 2 of 5The Subacute At Autumn Lake HealthcareVoorhees, NJ 3 of 5Autumn Lake Healthcare At Alice ManorBaltimore, MD 3 of 5Autumn Lake Healthcare At Calvert ManorRising Sun, MD 3 of 5Autumn Lake Healthcare At Chesapeake WoodsCambridge, MD 3 of 5Autumn Lake Healthcare At Chevy ChaseChevy Chase, MD 3 of 5Autumn Lake Healthcare At Patuxent RiverLaurel, MD 3 of 5Autumn Lake Healthcare At Perring ParkwayBaltimore, MD 3 of 5Autumn Lake Healthcare At RiverviewEssex, MD 3 of 5Autumn Lake Healthcare At Silver SpringSilver Spring, MD 3 of 5Autumn Lake Healthcare At Spa CreekAnnapolis, MD 3 of 5Autumn Lake Healthcare At Summit ParkCatonsville, MD 3 of 5Autumn Lake Healthcare At VinelandVineland, NJ 3 of 5Autumn Lake Healthcare At VoorheesVoorhees, NJ 3 of 5Autumn Lake Healthcare At West HartfordWest Hartford, CT 3 of 5Autumn Lake Healthcare Post-Acute Care CenterBaltimore, MD 3 of 5Autumn Lake Healthcare at BeloitBeloit, WI 3 of 5Autumn Lake Healthcare at OceanviewOcean View, NJ 3 of 5Cornell Hall Care & Rehabilitation CenterUnion, NJ

Showing 40 of 58; lowest-rated first.

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

Owner / managerTypeRoleShareSince
KERMAN, BARBARAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 01/01/2008
KERMAN, NEILIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST39%since 01/01/2008
SCHWARTZ, MARKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2008
LAPA, MOSHEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/20/2021
SULTAN, WAMIQIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2017
ACCURATE STAFFING LLCOrganizationADP OF THE SNFsince 01/01/2008
BRAND SONNENSCHINE LLPOrganizationADP OF THE SNFsince 01/01/2008

CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$11.6M
Net patient revenuemost recent cost report
-26.6%
Operating marginrevenue minus expenses
$492K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 86%Medicare 6%Other / private 8%

About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $492K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$372per resident / day
operating cost
$11,321per month
≈ monthly operating cost
$294per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315271. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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