The Subacute At Autumn Lake Healthcare

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

60.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 823 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 83.0% 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 406 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 0.82 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 124 beds and averages 119.5 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 4.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.81 hrs/resident/day on weekends vs 4.53 on weekdays — 16% thinner on weekends. RN hours go from 0.41 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

26 citations, most serious first. The 14 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 #: 398977Based on record review, interview, and document review, the facility failed to notify the physician of a resident's refusal to have an immediate (STAT) laboratory test on [DATE] and [DATE]; failed to obtain a Urine with Culture and Sensitivity (C&S) test when ordered on [DATE]; failed to monitor the resident after reports of nausea without emesis for three days, decreased appetite secondary to the nausea, and continued diarrhea; and failed to act upon a critically high white blood cell (WBC) count for one of 16 sampled residents (Resident (R) 7). These failures caused serious harm or death to R7.The facility's Director of Nursing (DON) and the Regional Nurse Consultant (RNC) were informed on [DATE] at 8:00 PM an Immediate Jeopardy (IJ) existed at F684: Quality of Care related to the failure of notifying the physician of the resident's refusal of laboratory tests, failing to monitor the resident after reports of nausea without emesis for three days, decreased appetite secondary to the nausea,…

  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
• Immediate jeopardy · J2025-09-26 · 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

  Complaint #: 398975Based on record review, interview, and document review, the facility failed to consistently provide pain management for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to administer the medication as ordered. R16 had pain levels up to a 10 (on a zero to 10 scale, with 10 being the most intense pain possible). This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death.The facility's Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed on 09/25/25 at 7:40 PM an Immediate Jeopardy (IJ) existed at F697 Pain Management related to the failing to manage R16's pain when they did not consistently provide physician ordered pain medications as ordered to R16. The Immediate Jeopardy began on 12/31/24, when R16 was admitted to the facility…

  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
• Immediate jeopardy · Jcited before2025-09-26 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: 398975Based on record review, interview, and document review, the facility failed to acquire pain medications as ordered by the physician for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to acquire the medication. This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death.The facility's Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) were informed on 09/25/25 at 7:40 PM an Immediate Jeopardy (IJ) existed at F755 Pharmacy Services related to the failure of not acquiring physician ordered pain medications which R16 had ordered since admission to the facility on [DATE]. The Immediate Jeopardy began on 12/31/24, the date of R16's admission to the facility.The facility…

  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
• Immediate jeopardy · Jdisputed · IIDR2024-11-27 · tag F0808 — failed to follow doctor-ordered diets — isolated
  Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Complaint #: NJ00180094 Based on interviews, medical record review, and review of other pertinent facility documentation on 11/26/2024 and 11/27/2024, it was determined that: the facility failed to provide the correct therapeutic diet to a cognitively impaired resident (Resident #3) with a known diagnosis of dysphagia, pharyngeal phase who had a physician's order and plan of care for ground diet and required feeding assistance. It was determined that on 11/12/2024 a Certified Nursing Assistant (CNA) delivered a meal tray containing a regular texture meal to Resident #3, who had orders for a ground diet. The regular texture meal was left with Resident #3. The CNA confirmed that Resident #3's meal tray included corn and tortillas that were not ground texture. The resident's family arrived shortly after the tray was left with Resident #3 and observed the resident with food in her/his mouth. The family reported to facility staff that Resident #3 was choking. The facility also failed to follow its policies titled Therapeutic Diet Orders and Comprehensive Care Plans. This deficient…

  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 · Past Non-Compliance
• Potential for harm · E2026-03-24 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  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, record review, and review of facility policy, it was determined that the facility failed to ensure that 1 of 4 residents (Resident #122) observed during the medication administration observation were given their medication. Specifically, Resident #122 did not have their medication Sevelamer HCl (phosphate binding medication) available for administration in the medication cart and was given another unidentified resident's home medication of Sevelamer HCl.This deficient practice was identified by the following: On 3/18/2026 at 9:04 AM, during medication pass observation on the third floor nursing unit, the surveyor observed a Licensed Practical Nurse (LPN #2) administer medications for Resident #122. The LPN was unable to locate Resident #122's medication, Sevelamer HCl (phosphate binding medication) Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day and take with meals. The LPN stated that the medication should have been available in 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-24 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 2699716, #398990 Based on observation, interview, and review of medical records it was determined that the facility failed to establish a system to ensure that residents on dialysis received their medications according to physician orders. This deficient practice was identified during the medication pass administration observation for 1 or 4 residents (Resident #122), observed and was evidenced by the following:On 3/18/2026 at 9:04 AM, during medication pass observation on the third floor, the surveyor observed a Licensed Practical Nurse (LPN) administer medications for Resident #122. The LPN was unable to locate Resident #122's medication, Sevelamer HCl (phosphate binding medication) Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day for take with meal. The LPN stated that the medication should be available in the medication cart, however she could not locate it. She explained that she could not obtain the medication in the back up medication dispensing machine because 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-24 · 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, interviews, record review and review of facility provided documents, it was determined that the facility failed to obtain a physician's order (PO) for a left leg immobilization device for 1 of 1 resident (Resident #9) reviewed for supportive devices. 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 states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and 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 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 licensed practical nurse…

  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 · D2026-03-24 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services 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, review of the medical record (MR) and review of other pertinent facility documents, it was determined that the facility failed to consistently ensure communication with a contracted dialysis facility according to facility policy and procedure. This deficient practice was evidenced for 1 of 1 resident (Resident #13) reviewed for dialysis. This deficient practice was evidenced by the following: On 03/18/2026 at 9:04 AM, the surveyor observed Resident #13 seated in the wheelchair eating breakfast. Resident #13 offered no complaints and told the surveyor that they attended dialysis for approximately two and a half years on Monday, Wednesday and Friday. On 3/18/2026 at 11:03 AM, the surveyor reviewed the medical record (MR) for Resident #13 which revealed the following:A review of the admission Record, an admission summary, revealed that Resident #13 had the following but not limited to diagnoses; Morbid obesity, end stage renal disease, malignant neoplasm (cancerous tumor) of liver and intrahepatic bile duct.A review of the resident's comprehensive…

  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 · D2026-03-24 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of the Electronic Medical Record (EMR) and other facility documentation, the facility failed to follow through on recommendations made by the Consultant Pharmacist (CP) during their medication review regimen (MRR) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #8) and was evidenced by the following: During the initial tour of the facility on 3/17/26 at 12:10 PM, Resident #8 was receiving care and was unavailable for an interview.A review of the electronic medical record (EMR) on 3/18/26 at 1:50 PM revealed the following:According to the admission Record, Resident #8 was admitted to the facility with diagnoses that included but was not limited to type II diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) and severe sepsis (a life-threatening, emergency condition where an infection triggers a severe, systemic immune response, causing organ dysfunction, such as kidney damage or low blood…

  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 · D2026-03-24 · 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, record review, and review of facility documentation, it was determined that the facility failed to properly store and secure medication left at resident's bedside (Resident #15 and #43). This deficient practice was identified for 2 of 2 residents (Resident #15, and #43). This deficient practice was evidenced by the following: 1. On 3/17/2026 at 12:25 PM, the surveyor observed Resident #15 in their room, sitting on the side of their bed. At that time, the surveyor observed a Trelegy Ellipta inhaler (a prescription inhaler designed for adults to help manage breathing difficulties over the long term.) on top of their bedside table. The surveyor reviewed the medical record for Resident #15. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; Chronic obstructive pulmonary disease (A progressive lung disease that makes it hard to breathe due to long-term damage and airway inflammation, usually caused by smoking or irritants.), and acute respiratory failure with hypoxia (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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-24 · tag F0806 — failed to honor food preferences — isolated
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interviews, and review of pertinent facility documents, it was determined that the facility failed to honor the food preference for one (1) of two (2) residents (Resident #141) reviewed for nutrition. This deficient practice was evidenced by the following: On 3/19/26 at 12:59 PM, the surveyor reviewed the medical record for Resident #141 which revealed the following:A review of the admission Record, an admission summary, revealed that Resident #141 had diagnoses which included but were not limited to dysphagia (difficulty swallowing), mild protein-calorie malnutrition (a nutritional deficiency characterized by inadequate intake of protein and calories), hyperlipidemia (elevated cholesterol), and type II diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) .A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/9/26, included the resident a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-24 · tag F0812 — failed to store, cook, and serve food safely — isolated
  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, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) prepare food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner, and c.)maintain food-contact equipment in a sanitary condition for 2 of 2 bistros (second and third floor bistros). This deficient practice was evidenced by the following:On 3/17/26 at 10:17 AM, the surveyor began the initial tour of the kitchen and observed the following:Immediately at the start of the tour, the surveyor observed the Food Service Director (FSD) with hair extending near her shoulder blades, uncovered and not within the hairnet that she was wearing. At that time, the surveyor interviewed the FSD, who stated that hairnets must be worn while in the kitchen. She added that if the hair cannot be tucked under the hairnet, the hair would be tucked behind them, in their shirts. She further stated that for food safety, hair should never be exposed.At 10:41 AM, the Regional Director of Operations (RDO) was observed making peanut butter 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-10 · 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

  C #: NJ00183386/398980, 2670006 Based on observation, interview, medical record review, and review of other pertinent facility documentation on 12/9/25 and 12/10/25, it was determined that the facility failed to consistently document and maintain a complete medical record regarding toileting, bowel & bladder continence/incontinent care for residents in accordance with the facility's policy and standard of care. This deficient practice was identified for 2 of 2 residents (Resident #4 and Resident #5) reviewed.The facility also failed to document when a resident was sent out of the facility for further evaluation after an allegation of a fall. This deficient practice was identified for 1 of 2 residents (Resident #5) reviewed and was evidenced by the following:1. According to the admission Record (AR) Resident #4 was admitted with diagnoses that included but were not limited to: type II diabetes, osteoarthritis, right artificial hip joint, and hypertension.The comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/3/25, revealed a Brief Interview of Mental Status (BIMS) 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-26 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  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 record review, interview, and document review, the facility failed to have an ongoing quality assurance and performance (QAPI) program demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse effects; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities to address systematic failures in recognizing a decline in a resident's change in condition for one of 16 residents (Resident (R) 7) and failing to consistently provide pain management and failing to have Dilaudid pain medication ordered upon admission for one of 16 residents (R) 16). These incidents created serious harm for R7 and R16. The lack of acknowledging the failures had the potential to affect all residents at the facility. Review of the undated facility's policy titled, Quality Assurance and Performance Improvement (QAPI) indicated, . it is the policy of the facility to develop, implement, and maintain an…

  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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$130,206 in federal fines across 2 penalties.

• $120,167 — penalty dated 2025-09-26
• $10,039 — penalty dated 2024-11-27

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 →

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

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

This home reported $4.6M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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

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