Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Voorhees during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with severe cognitive impairment, requiring significant assistance with ADLs and safety, received care from a private sitter hired by the family. The sitter, who was not trained or overseen by facility staff, was observed feeding the resident and assisting during care, despite facility policy prohibiting such actions by companions. Staff interviews revealed a lack of clarity and documentation regarding the sitter's role and training, resulting in care being delivered by an unqualified individual outside the resident's written plan of care.
A resident with severe cognitive impairment alleged physical abuse by a CNA, but the CNA was only removed from the resident's assignment and continued working on the same unit, maintaining access to the resident and others. Despite facility policy requiring immediate removal of staff involved in abuse allegations, the CNA was not sent home until the end of the shift, and leadership was not promptly notified.
A resident with a prior Level I PASARR was later diagnosed with borderline personality disorder, but the EMR did not contain a Level II PASARR referral. The DSS stated a new mental health diagnosis should trigger a Level II referral, and the DON confirmed she was unaware of the diagnosis and that the referral should have been completed but was not.
The facility did not meet the required staffing ratios, having only 10 CNAs for 113 residents on a day shift, while at least 14 were needed according to New Jersey law. This deficiency was noted during a review of staffing records and had the potential to impact all residents.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Unqualified Private Sitter Provided Care Outside Resident's Plan
Penalty
Summary
The facility failed to ensure that care was provided by qualified staff in accordance with a resident's written plan of care. A private sitter, hired by the resident's family to be present daily, was not provided with any training by the facility and was not permitted to perform care tasks such as feeding, bathing, transferring, or assisting with incontinence. Despite this, the private sitter was observed by staff feeding the resident and holding the resident's hand during care provided by certified nursing assistants. The Director of Nursing acknowledged that the private sitter had been counseled multiple times for providing care, but there was no documentation of these conversations, and the facility had no policy in place regarding the training or oversight of private sitters or companions. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 0 out of 15, and required increased assistance with activities of daily living, transfers, and safety awareness. The resident's care plan specified one staff assistance and the use of appropriate equipment but did not mention the involvement of a private sitter. Facility policy stated that companions may help with social or basic care needs but cannot perform nursing or aide duties. Interviews with staff and administration revealed a lack of clarity and oversight regarding the role and training of the private sitter, resulting in care being provided by an unqualified individual outside the resident's plan of care.
Failure to Immediately Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure to protect all residents from abuse when a severely cognitively impaired resident alleged physical abuse by a CNA. After the incident, the CNA was removed from the resident's assignment but remained on the same nursing unit, continuing to assist other residents and having access to the alleged victim. This action did not ensure the immediate protection of the resident or others, as required by the facility's policy. The incident occurred when the resident, who had a history of severe cognitive impairment and multiple medical diagnoses including vascular dementia and muscle wasting, activated their call light. The CNA responded, and shortly after, the LPN heard the resident screaming. Upon entering the room, the LPN observed water on the floor and the resident alleging that the CNA had pulled their hair and beaten them. The LPN reported the incident to the Nursing Supervisor, who changed the CNA's assignment but did not remove the CNA from the unit. The CNA continued to work on the unit until the end of the shift, during which time the resident was observed following the CNA around, repeatedly stating that the CNA had beaten them. Interviews with facility leadership confirmed that staff involved in abuse allegations should be immediately separated from residents and sent home pending investigation. However, in this case, the CNA was not sent home until the end of the shift, several hours after the allegation was made. Documentation and interviews revealed inconsistencies in staff accounts of the incident and the timing of notifications to facility leadership. The failure to immediately remove the CNA from the unit after the allegation was made resulted in continued access to the resident and other residents, contrary to facility policy and regulatory requirements.
Removal Plan
- CNA #1 was suspended pending an investigation and received in-servicing on abuse upon her return to the facility.
- The local police, physician, and family were notified.
- Resident #1 received a skin assessment and neurological checks, a psychological and social services consultations, and their care plan was updated.
- LPN #1 and the Nursing Supervisor were verbally educated on abuse procedures.
- The Director of Nursing provided LPN #1 and the Nursing Supervisor with abuse training including: different forms, prohibiting, identifying, recognizing, compliance with reporting, prevention, and immediate response.
- The Regional Director of Nursing in-serviced the Director of Nursing and Licensed Nursing Home Administrator on abuse.
- The Director of Nursing began educating all staff on abuse.
- All supervisors and managers were educated to send employees home immediately upon allegations of abuse or neglect.
Failure to Complete Level II PASARR After New Mental Health Diagnosis
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was deficient for one resident who had a Level I PASARR on record but was later identified with a serious mental disorder. Review of the resident’s record showed a prior PASARR Level I screen dated 9/17/20 that indicated the resident was negative for mental health screening, and the resident was admitted to the facility on the date listed on the face sheet. The resident’s medical diagnosis record later showed borderline personality disorder on 05/30/25, and a Behavioral Solutions record dated 03/31/25 also documented borderline personality disorder. The quarterly MDS with an ARD of 06/12/25 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The resident’s EMR did not contain a referral for a Level II PASARR evaluation. During interview, the DSS stated that if there was a new mental health diagnosis, a Level II referral would be made to ensure the resident received appropriate services. The DON stated she was not aware of the resident’s new diagnosis of borderline personality disorder, confirmed that a Level II referral should have been completed, and confirmed that the referral was not completed.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically on one of the 14-day shifts reviewed. According to the New Jersey Department of Health memo, effective from February 1, 2021, the law mandates a minimum staffing ratio of one Certified Nurse Aide (CNA) to every eight residents during the day shift. However, on December 1, 2024, the facility had only 10 CNAs for 113 residents, whereas at least 14 CNAs were required to meet the legal staffing ratio. This deficiency was identified during a review of staffing records for the period from November 24, 2024, to December 7, 2024, and had the potential to affect all residents in the facility.
Plan Of Correction
Completion Date: 1/9/2025 CORRECTIVE ACTION: Efforts to hire facility staff will continue until there is adequate staff to serve all residents. Until that time, the facility will utilize staffing agencies to fill any open spots in the schedule. IDENTIFICATION OF THE RESIDENTS AT RISK: All residents have the potential to be at risk for deficient practice. SYSTEMIC CHANGE: The facility Administrator has put in place a bonus structure as to help increase the levels of staffing according to census. Hiring and recruitment efforts including wage analysis and adjustments, pay for experience, online job listings, job fairs, shift differentials, and referral bonuses are being utilized to become more competitive in the marketplace. In addition, the director of nursing or designee will meet daily with the staffing coordinator to ensure appropriate staffing. QUALITY ASSURANCE: The Director of Nursing or designee will review staffing schedules daily to ensure adequate staffing for all shifts. Findings from the review will be reported to the Administrator. Any issue from the findings will be addressed immediately. The results of the staffing review will be submitted to the QA/QAPI Committee quarterly until compliance is met.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Voorhees
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lions Gate | 0.4 mi | ★★★★★ | 0 | 0 |
| Echelon Care & Rehab | 0.7 mi | ★★★★★ | 0 | 0 |
| Voorhees Pediatric Facility | 0.7 mi | ★★★★★ | 2 | 0 |
| The Subacute At Autumn Lake Healthcare | 1 mi | ★★★★★ | 19 | 3 |
| Laurel Manor Healthcare And Rehabilitation Center | 2.1 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.