Inspection Reports for
Autumn Lake Healthcare At Voorhees

The facility failed to ensure that services were delivered by qualified staff with the necessary skills, experience, and knowledge, specifically related to a private sitter providing care without training or facility oversight, resulting in care not being provided in accordance with the resident's assessed needs and plan of care.

Complaint #2613158 involved an allegation that CNA #1 physically abused Resident #1 on 09/07/2025 at 11:30 PM. The allegation was substantiated by interviews, medical record review, and facility documents. The facility failed to immediately remove CNA #1, who continued working until the next morning, placing residents at risk. The Immediate Jeopardy began on 09/07/2025 at 11:30 PM and was notified to the facility on 09/18/2025.

The facility failed to immediately remove CNA #1 from the nursing unit after an allegation of physical abuse against Resident #1, allowing CNA #1 continued access to the resident and other residents, resulting in an Immediate Jeopardy situation. The facility submitted an acceptable Removal Plan and implemented staff education on abuse policies.

The facility failed to ensure that one resident with a Level I PASARR and a subsequent serious mental disorder diagnosis was evaluated through the Level II PASARR process, resulting in the resident not receiving specialized care and treatment.

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.

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.

Multiple complaints (NJ00158428, NJ00163435, NJ00156885, NJ156885, NJ158428, NJ159346, NJ160533, NJ163074, NJ163435) triggered the investigation. Substantiation status is not explicitly stated.

The facility was found deficient in honoring resident preferences, providing timely and hygienic incontinence care, documenting and investigating accidents properly, and maintaining adequate staffing levels. Several residents were observed with saturated briefs and linens, delayed call bell responses, and improper perineal care technique. Staffing reports showed consistent CNA shortages on day shifts over multiple periods.

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

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.

The investigation was based on multiple complaints including NJ00158428, NJ00156885, NJ00159746, NJ00160533, NJ00163074, and NJ00163435.

The facility was found deficient in multiple areas including failure to honor resident preferences, inaccurate resident assessments, inadequate incontinence care, failure to follow nursing professional standards, medication administration errors, improper medication storage, inadequate food temperature control, staffing shortages, infection control lapses, and failure to notify CMS of a facility name change.

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 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 revealed failures in timely reporting of abuse and injury, failure to implement fire watch during fire alarm system failure, medication administration errors, and expired medications in storage. The injury of unknown origin for Resident #7 was not reported to NJDOH. The fire alarm system was in trouble mode since 09/03/21 and no fire watch was implemented. The Licensed Nursing Home Administrator did not notify NJDOH or fire department and failed to follow emergency procedures.

The facility failed to notify the NJ Department of Health about a non-operational fire alarm system and an injury of unknown origin for a resident. Medication errors were identified including incorrect dosing and failure to order appropriate lab tests. Expired medications were found in storage. The Licensed Nursing Home Administrator failed to implement a fire watch during the fire alarm system outage, posing an immediate jeopardy to resident safety.

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.

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.

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.

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.