Inspection Reports for Autumn Lake Healthcare At Voorhees

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The inspection was conducted in response to complaints NJ176573 and NJ180199 to investigate compliance with long-term care facility regulations.

The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long-Term Care Facilities due to failure to meet mandatory staffing ratios on one of 14 day shifts reviewed, potentially affecting all residents.

Complaints NJ176573 and NJ180199 triggered the complaint investigation. The facility was found substantially non-compliant with staffing requirements but no explicit substantiation status was stated.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Deficiencies were cited related to reasonable accommodations, accuracy of assessments, professional standards in care, ADL care, medication administration, infection control, staffing, pharmacy services, food safety, emergency preparedness, and life safety code compliance.

Multiple complaints were investigated including NJ 156885, NJ 158428, NJ 159346, NJ 160533, NJ 163074, NJ 163435.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.

The inspection was conducted as a complaint survey based on complaints NJ152228, NJ150619, and NJ150305.

The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.

Complaint numbers NJ152228, NJ150619, and NJ150305 were investigated and found to be unsubstantiated as the facility was in compliance.

The inspection was conducted as a complaint survey based on multiple complaint intakes regarding the facility's compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.

The facility failed to develop and implement comprehensive care plans for residents, including failure to address pressure injuries and fall prevention. There were deficiencies in timely assessment, documentation, and updating of care plans following incidents such as falls and pressure ulcers. The facility also failed to properly assess and identify new pressure ulcers, delaying treatment and care.

The complaint investigation was based on multiple complaint intake numbers (NJ147131, NJ144631, NJ145879, NJ146555, NJ146603, NJ148518, NJ145505, NJ144737, NJ145676). The facility was found not in compliance with requirements related to care planning and pressure ulcer management.

The visit was conducted to assess compliance with New Jersey Administrative Code staffing requirements and to follow up on previously cited deficiencies related to minimum direct care staff to resident ratios.

The facility failed to maintain the required minimum direct care staff to resident ratios for the day shift on 13 of 14 days reviewed, as mandated by New Jersey law. The facility has implemented corrective actions including staff education, recruitment efforts, and weekly staffing schedule reviews to ensure compliance.

A Life Safety Code Survey was conducted by the New Jersey Department of Health on 09/09/21 and 09/10/21 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code.

The facility was found in noncompliance with several Life Safety Code requirements including failure to implement a fire watch during fire alarm system outage, malfunctioning delayed egress doors, failure to inspect fire alarm system batteries semi-annually, non-functioning fire/smoke dampers, inadequate bathroom ventilation in some resident rooms, non-functioning elevator emergency communication phones, and lack of certification that the emergency generator transfers power within 10 seconds.

The inspection was conducted as a complaint survey based on complaints NJ129504, NJ138559, and NJ139401 to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.

The facility was found not in compliance due to a significant medication error where Resident #2 was administered their roommate's medications without physician orders. The resident experienced no apparent harm, and corrective actions including staff education and audits were implemented.

Complaint Intake: NJ139401. The medication error involved one resident out of four reviewed. The resident was monitored with no adverse effects, and the incident was reported to the state health department as required.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.