Autumn Lake Healthcare at Voorhees

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Voorhees, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 23, 2025

  Complaint #: 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. […]

• Actual harm, isolatedF656Nov 19, 2021

  Complaint Intake #NJ 5 Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive care plan needed to outline interventions to care for pressure ulcers for one (Resident #1) of three residents reviewed for care planning. This had the potential to affect all residents. Findings included: 1. A review of Resident #1's face sheet indicated the facility readmitted the resident on 04/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. […]

• Actual harm, isolatedF686Nov 19, 2021

  Complaint Intake #NJ 5 Based on observations, interviews, record reviews, and facility policy review, it was determined that the facility failed to accurately assess and identify the development of a new pressure ulcer for one (Resident #1) of two residents reviewed for pressure ulcers. This failure caused Resident #1 to develop an unstageable (dark layer of skin covering the wound bed preventing the ability to assess the wound) pressure ulcer to the resident's sacrum (tail bone) and delayed treatment. Findings included: 1. A review of Resident #1's face sheet indicated the facility readmitted the resident on 04/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2024

  Based 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 [DATE] 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. […]

• No harm, potential for more than minimal, widespreadF609Sep 17, 2021

  Based 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. […]