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Autumn Lake Healthcare At Voorhees

1086 Dumont Circle, Voorhees, NJ 08043 · For profit - Limited Liability company · 120 certified beds · (856) 454-9100 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse1 immediate-jeopardy citation$84,835 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
  • 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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $84,835 in federal fines (most recent 2025-09-23)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 19% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 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 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Eyeland<0.1 mi
(856) 783-1040 · Call to confirm hours
Pharmacy
433 Laurel Oak Rd · (856) 741-7100 · Call to confirm hours
Grocery
Acme0.5 mi
700 Haddonfield Berlin Rd · (856) 782-1122 · Call to confirm hours
Park
121 Laurel Oak Rd · (856) 428-5499 · Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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 improved from 2 to 3 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 rating3★
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 increased6.1%8.7%15.4%better
Long-stay residents who lose too much weight3.6%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms4.4%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 injury2.4%2.3%3.3%better
Long-stay residents whose ability to walk worsened17.7%8.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.7%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine98.2%97.2%95.3%typical
Long-stay residents with pressure ulcers1.9%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control23.7%15.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.4%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine89.0%80.1%79.4%better
Short-stay residents rehospitalized after admission29.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit2.3%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.032.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.301.111.80better

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.

32.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

32.2%U.S. median 51.5%
Got home and stayed home
13.6%U.S. median 10.7%
Went back to hospital
80.0%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 80.0% 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 90 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 SNF32.2%CMS range 24.6–43.451.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.6%CMS range 10.5–17.710.7%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 discharge80.0%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 discharge47.8%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 discharge57.8%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 identified98.5%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 setting98.6%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened3.1%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 hospitalization7.2%CMS range 4.2–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.141.02Oct 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

0.28
RN hours/ resident / day
1.19
LPN hours/ resident / day
2.35
Aide hours/ resident / day
3.82
Total nurse hours/ resident / day
0.12
RN hoursweekends
28.7%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 111.1 residents a day — about 93% occupied, or roughly 9 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.68 hrs/resident/day on weekends vs 3.88 on weekdays — 5% thinner on weekends. RN hours go from 0.35 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% 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

1
deficiencies at the latest standard inspection (2025-07-24)
15
at the previous standard inspection (2024-01-26)

Deficiencies are fewer than at the previous inspection — improving. 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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2025-09-23 · 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 #: 2613158 Based on interviews, medical record review, and review of pertinent facility documents on 09/18/2025, it was determined that the facility failed to implement their abuse policy and procedure to ensure all residents were protected from abuse when a severely cognitively impaired resident (Resident #1) alleged the Certified Nursing Aide (CNA #1) physically abused them, and CNA #1 was taken off the resident's assignment, but remained on that nursing unit assisting other residents as well as having access to Resident #1. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1).On 09/07/2025 at 11:30 PM, Resident #1 put on their call light, and CNA #1 responded to the resident's room. The Licensed Practical Nurse (LPN #1) heard Resident #1 screaming and entered the resident's room. LPN #1 observed water on the resident's floor, and Resident #1 stated that CNA #1 pulled their hair and beat them up. LPN #1 immediately reported it to the Nursing Supervisor (NS), who removed…

    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 · D2026-03-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    COMPLAINT #2716078 Based on interviews, review of medical records and other pertinent facility documentation on 3/16/26 and 3/17/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1) 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 first cervical vertebra, heart failure, and type II diabetes. The comprehensive Minimum Data Set (MDS), an assessment tool, dated 1/12/26, revealed a Brief Interview of Mental Status (BIMS) of 12 out of 15, which indicated that the resident was moderately cognitively impaired. Further review of the MDS indicated that Resident #1 required substantial assistance with toileting hygiene and toilet transfer. A review of Resident #1'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 · D2025-11-07 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure that services were delivered by qualified staff with the necessary skills, experience, and knowledge. As a result, care was not provided in accordance with the resident's assessed needs and plan of care. This deficiency was identified in 1 of 3 residents reviewed (Resident #1).This deficient practice was evidenced by the following: During an interview with the surveyor on 11/07/25 at 11:10 AM, the Director of Nursing (DON) explained that the Resident #1's family pays for a private sitter (PS) to be with the resident from 3:00 PM to 8:00 PM, Sunday through Saturday. The facility did not provide any training to the PS before she began working with the resident. The DON reported that the PS is not permitted to provide care such as feeding, bathing, transferring, or assisting with incontinence, and is expected to report any care needs to facility staff. Despite this, the PS has been counseled multiple times for providing care. The DON discussed 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 · D2025-07-24 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 that one out of three resident (Resident (R) 79) with a Level I PASARR (Preadmission Screening and Resident Review), who later was identified with a serious mental disorder, was evaluated through the Level II PASARR process in a total sample of 38 residents. This deficient practice resulted in R79 not being evaluated for and/or provided specialized care and treatment for a serious mental illness. Findings include: Review of a Resident Face Sheet found in R79's electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document titled New Jersey Department of Human Services . Pre- admission Screening and Resident Review (PASRR) Level 1 Screen. located under the Misc (Miscellaneous) tab dated 9/17/20 indicated the resident was negative for mental health screening. Review of R79s' EMR tab titled Med (Medical) Diag (Diagnosis) indicated the resident was diagnosed with borderline…

    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 · F2024-01-26 · 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

    Based on observations, interviews, and other facility documentation, 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 01/17/24 from 9:40 AM until 10:31 AM, the surveyor observed the following in the presence of the Dietary Director (DD): 1. A rolling rack of plastic bowls was stored in front of the handwashing sink. At that time, a Dietary Aide (DA) retrieved the rack and proceeded to place salad inside of the bowls. When interviewed, the DD stated that since the bowls were stored upside down it did not pose a risk of contamination. 2. In the galley the kitchen: Caribbean Jerk Seasoning, Poultry Seasoning, and Old Bay Seasoning were not labeled with an opened date and a use-by date. DD stated that when the spices were opened they should have been labeled and dated with a use by date. DD then proceeded to place labels on the spices with an opened date of 12/01/23 and an expired date of 05/01/24. When asked how he knew when the spices were…

    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 · E2024-01-26 · 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

    Complaint #NJ00158428 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 4 residents (Residents #54 and #156) observed for incontinence care on 1 of 2 nursing units (Medbridge) and for 1 of 3 residents (Resident #20) reviewed for bowel and bladder incontinence on 1 of 2 nursing units (Second Floor). This deficient practice was evidenced by the following: 1. During an interview with the surveyor on 01/22/24 at 9:40 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 stated that the census on the unit was 42 and there were four Certified Nursing Assistants (CNAs) and three nurses present on the unit to provide resident care. On 01/22/24 at 9:44 AM, the surveyors completed an incontinence tour on the Medbridge Unit and observed the following: During an interview with the surveyor on 01/22/24 at 9:44 AM, Certified Nursing Assistant (CNA) #1 stated that she worked at the facility for eight years and…

    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 · E2024-01-26 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # NJ 156885, NJ 158428, NJ 159346, NJ 160533, NJ 163074, NJ 163435 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to: a. maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey and b.) provide adequate staff to ensure all residents were provided with timely incontinent care for 2 of 4 residents reviewed for incontinence care (Resident #154 and Resident #156) on 1 of 2 units (Medbridge) and for 1 of 3 residents (Resident #20) reviewed for bowel and bladder incontinence on 1 of 2 units (Second Floor). This deficient practice was evidenced by the following: Refer to F677E 1. Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · 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 pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic shift count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 3 of 3 medication carts and was evidenced by the following: On 1/17/24 at 9:58 AM, the surveyor, interviewed Licensed Practical Nurse #4 (LPN #4) who stated all nurses assigned to carts were responsible for the organization, and maintenance of the medication cart. She further stated that narcotic shift to shift count logs were to be completed by two nurses (the incoming and outgoing nurses) at the same time once they confirmed an accurate count of the narcotics in the cart. She also confirmed that logs should not be missing any documentation, signatures, or have a pre-signed field for future count times. The surveyor, in the presence of LPN #4, then reviewed the Strawbridge nursing unit's medication cart 1 narcotic log binder. The log binder…

    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 · E2024-01-26 · tag F0761 — failed to label and store drugs safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, it was determined that the facility failed to properly store medications, maintain clean and sanitary medication storage areas, and properly label opened multidose medications. This deficient practice was observed in 3 of 3 observed medication carts on 2 of 2 nursing units and 1 of 1 medication storage rooms and was evidenced by the following: On 1/17/24 at 9:58 AM, the surveyor interviewed Licensed Practical Nurse #4 (LPN #4) who was assigned to the [NAME] nursing unit medication cart 1. LPN #4 stated that all nurses assigned to the medication carts were responsible for maintaining the cart and keeping it organized and clean. She further stated that all opened multi-dose medication containers should be labeled with date opened as well as with the resident's name on the actual medication containing device or container and there should be no loose pills in the cart. At that time, the surveyor reviewed [NAME] medication cart 1 in the presence of LPN…

    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 · E2024-01-26 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 ensure appetizing and palatable temperature of food for 1 of 1 lunch meals observed on 1 of 2 nursing units (Medbridge). This deficient practice was evidenced by the following: On 01/18/24 at 11:00 AM, the surveyor conducted a Resident Council meeting which included five residents (Residents #14, #37, #53, #71, and #74). All five residents informed the surveyor that the food was served cold on all shifts. On 01/23/24 at 11:15 AM, the surveyors informed the Dining Director (DD) that they wanted to observed the lunch meal service for that day including food temperatures. The DD acknowledged the request and stated that the lunch service began at 11:20 AM. On 01/23/24 at 11:20 AM, the [NAME] informed the surveyor that he had already calibrated (procedure used to confirm accuracy) his thermometer prior to the surveyors arrival. The [NAME] then proceeded to obtain food temperatures from the food that was on the steam table. The temperature were recorded as follows:…

    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 · D2024-01-26 · 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

    Complaint #NJ00158428 Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to honor the recreational needs and preferences of a resident who was not provided with a remote control for their television upon admission to the facility and was not assisted to change the channel to a preferred station. This deficient practice was identified for 1 of 1 residents (Resident #155) reviewed for accommodation of needs. This deficient practice was evidenced by the following: On 01/22/24 at 10:21 AM, the surveyors, who were accompanied by Certified Nursing Assistant (CNA) #1 during an incontinence tour of dependent residents, observed Resident #155 lying in bed awake. Resident #155 immediately stated that he/she had not had a television remote for two to three days. The resident stated that they asked a couple of people, whose names were unknown by the resident, for a television remote control and still had not received one. The resident stated that he/she had to watch nothing but sports during that time. 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
Show the remaining 14 citations
  • Potential for harm · D2024-01-26 · 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, and record review it was determined that the facility faciled to accurately code the Minimum Data Set (MDS) for 3 of 29 residents reviewed, Residents # 94, #93, and #50. This deficient practice was evidenced by the following: 1. a. According to the admission Record, Resident #94 was admitted to the facility with diagnosis which included but were not limited to pneumonia. A review of the resident's progress notes dated, 10/21/23 at 11:30 AM, revealed that the resident's family member was present for wound care teaching and supplies were provided for home care. Further review of the resident's progress notes dated, 10/21/23 at 12:02 PM revealed a discharge note that indicated that the resident was scheduled for discharge, and that prescriptions, paperwork, belongings and discharge instructions were given to the resident's family member. A review of the resident's discharge MDS dated [DATE] revealed that the MDS section A2105 Discharge Status was coded 11, Critical Access Hospital instead of 01…

    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 before2024-01-26 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by incorrectly transcribing a physician's order for laboratory blood work. This deficient practice was identified for 1 of 2 residents (Resident #90) reviewed for nutrition. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act…

    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 · D2024-01-26 · 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

    Complaint #NJ00156885 Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure hygienic incontinent care was provided to prevent urinary tract infection. This deficient practice was identified for 1 of 5 residents (Resident #155) reviewed for incontinence care. This deficient practice was evidenced by the following: On 01/22/24 at 10:21 AM, the surveyors observed Certified Nursing Assistant (CNA) #1 as she provided incontinence care to Resident #155 with resident permission. The surveyors observed that the resident had an indwelling urinary catheter (an internal device inserted in the bladder that collects urine that is drained into an attached urinary drainage bag) and wore an adult incontinence brief. On 01/22/24 at 10:48 AM, CNA #1 used disposable cleansing cloths as she proceeded to clean the resident's genitalia and wiped in an upward motion from the back to front. CNA #1 then used a wash rag to clean the area and patted the area dry with a towel. CNA #1 then proceeded to turn the resident…

    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 · D2024-01-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review it was determined that the facility failed to a.) ensure appropriate storage for respiratory equipment and b.) obtain a physician's order for a BIPAP machine (a machine that can help push air into your lungs). This deficient practice was identified for 1 of 3 residents reviewed for respiratory equipment (Resident #31) and was evidenced by the following: On 1/18/24 at 9:53 AM, the surveyor toured the subacute unit and entered Resident #31's room. Resident #31 was awake and in bed. The surveyor observed the resident's nebulizer mask face down on top of the nebulizer machine. There was a plastic drawstring bag that was hung from the side of nebulizer machine. The surveyor observed a BIPAP machine placed on the resident's side table with a mask inside of the bag. At that time, the surveyor interviewed Resident #31 who stated she/he received his/her BIPAP every night since readmission to the facility on [DATE] and the BIPAP mask was removed daily by the 05:00 AM…

    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 · D2024-01-26 · tag F0697 — failed to manage pain — isolated
    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

    Based on observation, interview, and record review it was determined that the facility failed to ensure a pain management regime was followed in accordance with physician orders. This deficient practice was identified in 1 of 1 resident reviewed for pain (Resident #5) and was evidenced by the following: On 01/17/24 at 10:52 AM, during the initial tour of the facility the surveyor observed Resident #5 in bed and awake. The surveyor asked the resident if he/she were having any pain. Resident #5 told the surveyor that he/she had knee pain and that x-rays were completed at the facility. The resident told the surveyor he/she was currently receiving pain medications as ordered by the physician. The surveyor asked if the medication was effective and the resident responded, Sometimes. The surveyor reviewed Resident #5 admission Record which indicated the resident had medical diagnoses which included but were not limited to encephalopathy (any brain disease that alters brain function), hypertension (high blood pressure), pain in knee, and major depressive disorder. The surveyor then 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 · D2024-01-26 · 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, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure all medications were administered without error of 5% or more, and b.) ensure medications were properly stored, dispensed, prepared for administration and administered. This deficient practice was observed during the medication administration observation on 1/18/24, and during medication storage observations on 1/17/24. The surveyor observed three (3) nurses administer medications to four (4) residents with a total of 34 opportunities, and two (2) errors were observed which calculated a medication administration error rate of 5.88% during medication administration observation. This deficient practice was identified for 2 of 4 residents (Resident #96 and Resident #36) that were administered medications by 2 of 3 nurses on the second-floor nursing unit, and 1 of 3 medication carts observed during medication storage observation. The deficient practice was evidenced by the following: a.) On 1/18/24 at 9:43 AM, during medication administration…

    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 · D2024-01-26 · 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, and review of pertinent facility documents, it was determined that the facility failed to maintain proper infection control practices by performing appropriate hand hygiene: a.) during incontinence care and b.) during medication administration. This deficient practice was identified for 2 of 2 Certified Nursing Assistants (CNAs) observed on 1 of 2 nursing units (Medbridge) and for 1 of 3 nurses observed during medication administration on 1 of 2 nursing units (Ashland). This deficient practice was evidenced by: 1. On 01/22/24 at 10:03 AM, the surveyors observed CNA #1 as she provided incontinence care to an unsampled resident with resident permission. When finished, CNA #1 doffed (removed) her gloves and washed her hands for 13 seconds. CNA #1 then donned gloves and assisted the resident to sit on the edge of the bed before she assisted the resident out of bed to the wheelchair. CNA #1 then assisted the resident into the bathroom and set the resident up with the necessary supplies for the resident to brush his/her teeth. CNA #1 then removed 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 · D2024-01-26 · 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 NJ 00163435 Based on interviews, record review, and review of facility documentation, it was determined that the facility failed to follow their policies and procedures for documenting and investigating accidents and incidents for 1 of 2 residents reviewed for accidents (Resident #148). This deficient practice was evidenced by the following: According to the admission Record, Resident # 148 was admitted to facility with diagnoses that included but not limited to chronic respiratory failure with hypoxia (difficulty breathing with low blood oxygen levels). Review of Resident #148's Discharge minimum data set (MDS), an assessment tool dated 3/25/23 indicated a brief interview of mental status (BIMS) of 15, indicating intact cognition. The MDS also revealed that Resident #148 received extensive assist to total assist for activities of daily living (ADLs) except supervision for eating and no ambulation; always incontinent of bowel and bladder, and one fall with no injuries. On 01/23/24 at 12:04 PM, the surveyor interviewed the Director of Nursing (DON) who stated there were no…

    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 · F2021-09-17 · tag F0609 — failed to report abuse allegations — widespread
    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

    Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to notify the NJ Department of Health (NJDOH), within the appropriate deadline, of a.) a fire alarm system that was not operational in dispatching the fire department, in case of a fire; This deficient practice was identified for all residents, staff, and visitors, and b.) an injury of unknown origin for 1 of 1 resident (Resident #7) reviewed for injuries of unknown origin. This deficient practice was evidenced by the following: 1. On 09/09/21 at 9:30 AM, the Life Safety Code (LSC) Surveyor observed the fire alarm annunciator panel located in the front entrance between the two sets of entrance doors. The panel indicated TROUBLE MODE and flashed COMMUNICATION ERROR. During an interview with the LSC surveyor on 09/09/21 at 10:00 AM, the Maintenance Director (MD) stated that the fire alarm annunciator panel had been in trouble mode since the storm on 09/03/21. The MD further stated that the fire alarm company emailed him on 09/03/21 to inform him that…

    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 · F2021-09-17 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility was in compliance with the following regulatory requirement which affected all residents' safety in the facility. The LNHA failed to follow their Emergency Response policy and procedure and implement a Fire Watch when notified that the fire alarm system was unable to notify the authorities in the event of a fire. This posed a serious and immediate threat to the safety and well-being of all the residents, staff, and visitors in the facility, which resulted in an Immediate Jeopardy (IJ) situation. The facility Administration was notified of the Immediate Jeopardy situation on 09/09/21 at 2:00 PM. The immediacy was removed on 09/09/21 at 5:17 PM. The removal plan was accepted and verified by surveyors on 09/10/21 at 2:00 PM. This deficient practice was evidenced by the following: A review of the Administrators' job description provided by the facility included but not…

    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
  • Potential for harm · D2021-09-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 09/10/21 at 11:50 AM, the surveyor observed Resident #7 lying in bed with eyes closed. According to the Medical Practitioner Note, completed by the Advanced Practice Nurse (APN) on 09/07/21 at 17:07 (5:07 PM), Resident #7 had a past medical history of End Stage Renal Disease, orthostatic hypotension (low blood pressure when standing up from a lying or sitting position) and sustained a fall with no injury on 09/03/21. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], an assessment tool used to facilitate the management of care, reflected that Resident #7 had short and long term memory problems with poor decision making and required cues/supervision from staff. The MDS further reflected the resident sustained a fall with no injury. The surveyor reviewed an Incident Report - Patient Involved report dated 09/03/21, which reflected that Resident #7 sustained a fall without injury. Review of the General Progress Note, dated 09/03/21 at 22:16 (10:16 PM), reflected that the resident was sitting 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 staff failed: A). to administer medication according a physician's order and B). to order labs according to a physician's order, both in accordance with professional standards. This deficient practice was identified for 1 of 4 residents observed during medication pass (Resident #94) and in 1 of 5 residents reviewed for unnecessary medication use (Resident #45). These practices were evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey…

    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 before2021-09-17 · 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

    Based on observation, interview, and record review, it was determined that the facility failed to detect and remove expired medication in 1 of 2 medication storage rooms. This deficient practice was evidenced by the following: On 09/14/21 at 11:35 AM, the surveyor inspected the medication storage room, located on the Second Floor Nursing Unit, in the presence of the Registered Nurse (RN), who also serves as the Unit Manager (UM). The surveyor found the following expired medications: two bottles of Cranberry Supplement 450 milligram (mg) tablets (a dietary supplement), which expired on 07/2021; one bottle of Aspirin Enteric Coated 325 mg tablets (a pain and heart medication), which expired on 07/2021; and one bottle of Vitamin B-12 100 microgram (mcg) tablets (a vitamin supplement), which expired on 08/2021. During an interview with the surveyor on 09/14/21 at 11:44 AM, the RN-UM acknowledged that the medication bottles were expired as referenced and further stated that nurses should dispose of expired medication when they are retrieving new supplies of medication. In addition, he…

    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 · C2024-01-26 · 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 observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive approval from the New Jersey Department of Health for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on 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.

    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

$84,835 in federal fines across 1 penalty.

  • $84,835 — penalty dated 2025-09-23

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 3 of 52.8+0.2 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 5 of 54.3+0.7 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 Memorial BridgePenns Grove, NJ 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 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
1086 DUMONT CIRCLE HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2024
SCHWARTZ, MARKIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
STERN, ARYEHIndividualINDIRECT OWNERSHIP INTERESTsince 01/01/2024
STERN, SAMUELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
IACONA, JUSTINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
PECORA, ANDREWIndividualADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$12.5M
Net patient revenuemost recent cost report
-13.9%
Operating marginrevenue minus expenses
$2.7M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 10%Other / private 16%

About 73% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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. 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

$401per resident / day
operating cost
$12,191per month
≈ monthly operating cost
$352per 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 315500. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-24, 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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