11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Scotch Plains, NJ
1-star overall rating with 1-star inspections with $98,403 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1610 Raritan Road, Scotch Plains, NJ
(908) 889-5500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
114
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1967-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
60 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.59
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 17.59% · Performance 21.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.22% · Performance 8.08% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.11 hours · Performance 2.87 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 11.76% · Lower 95% interval 7.11% |
| Discharge to community | 49.25% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 40.71% · Lower 95% interval 39.5% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 77 |
| Discharge self-care score | 60.42% |
53.69%
6.7 pts better
|
Numerator 29 · Denominator 48 |
| Discharge mobility score | 56.25% |
50.94%
5.3 pts better
|
Numerator 27 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 5.19% |
2.29%
2.9 pts worse
|
Numerator 4 · Denominator 77 · Adjusted rate 5.12% |
| Healthcare-associated infections requiring hospitalization | 8.08% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 10.81% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 2.19% |
8.2%
6 pts worse
|
Numerator 3 · Denominator 137 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 68.75% |
56.45%
12.3 pts better
|
Numerator 33 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 42 · Denominator 42 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 2 · Denominator 44 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.1
0.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
93.0%
4.2 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.2%
1.6 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.4%
2.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.4%
11.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.6%
3.8 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.3% |
19.0%
11.7 pts better
|
19.6%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.8% · Q3 7.6% · Q4 9.5% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
13.5%
About the same
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 14.0% · Q3 12.0% · Q4 18.8% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.3% |
9.8%
1.5 pts worse
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 20.6% · Q4 18.7% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
9.7%
3.5 pts worse
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 3.2% · Q3 22.2% · Q4 14.5% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
15.9%
0.4 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.0% · Q3 23.0% · Q4 31.3% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.0%
1.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 5.6% · Q3 0.0% · Q4 1.5% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
78.7%
17.2 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 96.5% · Q3 96.2% · Q4 95.1% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
8.2%
1.7 pts worse
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 10.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
80.1%
16.5 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.0% |
25.4%
3.6 pts worse
|
23.9%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 28.3% · Expected 23.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-23
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-23
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-23
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-23
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-23
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-02-20
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-02-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-22
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-04
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-04
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-07
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-02-07
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-15
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-07
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-23
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-07
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-02-07
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-20
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-15
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-15
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-10
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-10
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-10
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-23
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-23
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-23
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-23
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-23
Health
Dispose of garbage and refuse properly.
Corrected 2025-06-23
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-20
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-10
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-01-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-19
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-01-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-20
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-15
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-01-22
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-01-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-16
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-20
Health
Post nurse staffing information every day.
Corrected 2023-12-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
Health
Implement a program that monitors antibiotic use.
Corrected 2023-12-20
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-12-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-13
Penalties and ownership
Fine · fine $44,486
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,235
Fine
Fine · fine $3,812
Fine
Fine · fine $3,529
Fine
Fine · fine $3,176
Fine
Fine · fine $2,823
Fine
Fine · fine $2,470
Fine
Fine · fine $2,117
Fine
Fine · fine $4,233
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
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