Cycle 1
Health 2025-11-18 · Fire 2025-11-18
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Berkeley Heights, NJ
Autumn Lake Healthcare At Berkeley Heights
4-star overall rating with 3-star inspections with $102,660 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
35 Cottage Street, Berkeley Heights, NJ
(908) 897-1000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1983-07-19
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
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,402
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0121
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.45
Baseline 20.34% · Performance 17.98% · Measure score 7.45 · Achievement 7.45 · Improvement 6.64
Healthcare-associated infections
10
Baseline 6.52% · Performance 4.73% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
3.20
Performance 50.59% · Measure score 3.20 · Achievement 3.20 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.13
Baseline 3.62 hours · Performance 3.68 hours · Measure score 2.13 · Achievement 2.13 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 238 · Observed rate 8.4% · Lower 95% interval 6.9% |
| Discharge to community | 64.79% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 222 · Observed rate 57.21% · Lower 95% interval 57.05% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.98% |
95.27%
3.7 pts better
|
Numerator 195 · Denominator 197 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 197 |
| Discharge self-care score | 42.34% |
53.69%
11.3 pts worse
|
Numerator 58 · Denominator 137 |
| Discharge mobility score | 51.09% |
50.94%
0.2 pts better
|
Numerator 70 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 197 · Adjusted rate 1% |
| Healthcare-associated infections requiring hospitalization | 4.73% |
7.12%
2.4 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 1.46% · Lower 95% interval 2.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 93.06% |
42%
51.1 pts better
|
Numerator 161 · Denominator 173 |
| Discharge function score | 54.01% |
56.45%
2.4 pts worse
|
Numerator 74 · Denominator 137 |
| Transfer of health information to provider | 98.15% |
95.95%
2.2 pts better
|
Numerator 53 · Denominator 54 |
| Transfer of health information to patient | 96.3% |
96.28%
About the same
|
Numerator 104 · Denominator 108 |
| Resident COVID-19 vaccinations up to date | 12.2% |
25.2%
13 pts worse
|
Numerator 15 · Denominator 123 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.1
0.8 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.0%
7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.4%
1.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 2.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
11.4%
8.1 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 2.7% · Q4 2.4% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.6%
2.1 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 2.9% · Q4 3.9% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
19.0%
6.8 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 8.7% · Q3 11.6% · Q4 14.1% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
13.5%
0.8 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 11.5% · Q3 9.4% · Q4 12.1% · 4Q avg 12.7% · 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 | 4.0% |
9.8%
5.8 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.5% · Q3 2.6% · Q4 0.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
9.7%
1.8 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 10.4% · Q3 4.4% · Q4 6.7% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 18.5% |
15.9%
2.6 pts worse
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 19.1% · Q3 5.7% · Q4 34.2% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.0%
0.6 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.4% · Q3 1.8% · Q4 5.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.7%
21.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
8.2%
1.2 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
80.1%
19.4 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.0% |
25.4%
4.6 pts worse
|
23.9%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.0% · Observed 27.0% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2024-07-19
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-11-15 · Fire 2022-11-15
3 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-12-18
F · Potential for more than minimal harm
2025-11-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-11-18
K321 · Smoke Deficiencies
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 2025-12-18
E · Potential for more than minimal harm
2025-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-11-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-12-18
F · Potential for more than minimal harm
2024-07-19
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K321 · Smoke Deficiencies
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 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-07-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-10
F · Potential for more than minimal harm
2022-11-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-11-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-24
F · Potential for more than minimal harm
2022-11-15
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-24
F · Potential for more than minimal harm
2022-11-15
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-15
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
E · Potential for more than minimal harm
2025-11-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-02-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-05
G · Actual harm
2024-07-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
F728 · Nursing and Physician Services Deficiencies
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 2024-09-10
F · Potential for more than minimal harm
2024-07-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-07-19
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-07-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-07-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-10
D · Potential for more than minimal harm
2022-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-11-24
D · Potential for more than minimal harm
2022-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-24
Penalties and ownership
What sits behind the stars
$102,660
2024-07-19
Fine
Fine · fine $102,660
Fine
Ownership
Meisels, Morris
5% Or Greater Indirect Ownership Interest · Individual
Stern, Aryeh
5% Or Greater Direct Ownership Interest · Individual
Gluck, Rivka
5% Or Greater Direct Ownership Interest · Individual
Handler, Samuel
5% Or Greater Direct Ownership Interest · Individual
Bh Associates Realty LLC
5% Or Greater Mortgage Interest · Organization
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Sitzer, Shimon
Operational/Managerial Control · Individual
Nearby options
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5-star overall rating with 4-star inspections with $5,160 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Continuing Care At Lantern Hill
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3-star overall rating with 2-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Spring Grove Rehabilitation And Healthcare Center
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4-star overall rating with 3-star inspections with $10,527 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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