Cycle 1
Health 2025-06-02 · Fire 2025-06-02
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Penns Grove, NJ
Autumn Lake Healthcare At Memorial Bridge
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
201 Fifth Avenue, Penns Grove, NJ
(856) 299-6800
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
161
Certified beds
Average residents
146
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1989-01-09
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
0.26
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.08
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
3.59
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.20
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
0.29
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,876
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.26
Baseline 22.64% · Performance 19.97% · Measure score 4.26 · Achievement 3.15 · Improvement 4.26
Healthcare-associated infections
0.68
Baseline 8.63% · Performance 8.20% · Measure score 0.68 · Achievement 0 · Improvement 0.68
Total nurse turnover
3.61
Baseline 55.64% · Performance 48.91% · Measure score 3.61 · Achievement 3.61 · Improvement 1.69
Adjusted total nurse staffing
4.04
Baseline 4.70 hours · Performance 4.23 hours · Measure score 4.04 · Achievement 4.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.55% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 15.31% · Lower 95% interval 7.89% |
| Discharge to community | 44.08% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 34.29% · Lower 95% interval 32.03% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0.99% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 101 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 36 · Denominator 66 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 36 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 101 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.2% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 11.25% · Lower 95% interval 5.33% |
| Staff COVID-19 vaccination coverage | 3.59% |
8.2%
4.6 pts worse
|
Numerator 7 · Denominator 195 |
| Staff flu vaccination coverage | 89.23% |
42%
47.2 pts better
|
Numerator 174 · Denominator 195 |
| Discharge function score | 60.61% |
56.45%
4.2 pts better
|
Numerator 40 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 23.64% |
25.2%
1.6 pts worse
|
Numerator 13 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.1
0.7 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
93.0%
6.8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 2.5% |
2.4%
0.1 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.6% · Q3 3.6% · Q4 2.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
11.4%
7.7 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.9% · Q3 4.2% · Q4 5.3% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
4.6%
1.7 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 8.2% · Q3 5.2% · Q4 4.6% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.2% |
19.0%
11.2 pts worse
|
19.6%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 32.5% · Q3 26.9% · Q4 28.6% · 4Q avg 30.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 50.4% |
13.5%
36.9 pts worse
|
16.7%
33.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.2% · Q2 52.3% · Q3 47.2% · Q4 52.7% · 4Q avg 50.4% · 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 | 5.5% |
9.8%
4.3 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 1.6% · Q3 5.6% · Q4 4.9% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
9.7%
0.3 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 11.1% · Q3 5.5% · Q4 4.0% · 4Q avg 9.4% · 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 | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
15.9%
4.5 pts worse
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 26.2% · Q3 22.2% · Q4 20.0% · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
6.0%
1.5 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.2% · Q3 4.6% · Q4 4.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
78.7%
19.9 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 99.1% · Q3 98.2% · Q4 99.0% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
8.2%
2.7 pts worse
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 12.5% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
80.1%
19.1 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
25.4%
0.5 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 27.5% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-29 · Fire 2023-09-29
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-05-31 · Fire 2022-05-31
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-07-02
F · Potential for more than minimal harm
2025-06-02
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 2025-07-01
F · Potential for more than minimal harm
2025-06-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-06-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-06-02
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-06-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-06-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-06-02
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 2025-07-03
F · Potential for more than minimal harm
2025-06-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-06-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-06-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-06-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-08
F · Potential for more than minimal harm
2023-09-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-29
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-29
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 2023-11-10
E · Potential for more than minimal harm
2023-09-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-10
E · Potential for more than minimal harm
2022-05-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-31
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-06-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-25
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-12
G · Actual harm
2025-06-02
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 2025-06-27
F · Potential for more than minimal harm
2025-06-02
F584 · Resident Rights Deficiencies
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 2025-06-27
E · Potential for more than minimal harm
2025-06-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-04
E · Potential for more than minimal harm
2025-06-02
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 2025-06-27
D · Potential for more than minimal harm
2025-06-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-02
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-02
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 2025-06-27
D · Potential for more than minimal harm
2025-06-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
F · Potential for more than minimal harm
2023-09-29
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 2023-11-03
D · Potential for more than minimal harm
2023-09-29
F584 · Resident Rights Deficiencies
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 2023-11-03
D · Potential for more than minimal harm
2023-09-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-03
C · Minimal harm
2023-09-29
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-11-03
E · Potential for more than minimal harm
2022-05-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-31
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 2022-06-30
E · Potential for more than minimal harm
2022-05-31
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-31
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 2022-06-30
E · Potential for more than minimal harm
2022-05-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-30
Penalties and ownership
What sits behind the stars
Ownership
Stern, Aryeh
5% Or Greater Direct Ownership Interest · Individual
Kerman, Neil
5% Or Greater Direct Ownership Interest · Individual
Kerman, Barbara
5% Or Greater Direct Ownership Interest · Individual
Lapa, Moshe
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Sultan, Wamiq
Operational/Managerial Control · Individual
Nearby options
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#2
Autumn Lake Healthcare At Southgate
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2-star overall rating with 2-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Gilpin Hall
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3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
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