Autumn Lake Healthcare at Voorhees

Inspectors wroteCOMPLAINT #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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteComplaint #: 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteComplaint #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. [...]

Inspectors wroteComplaint # 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteComplaint #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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteComplaint #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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteComplaint 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteOn 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]