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
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
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
Staffing
RN hours / resident day
0.26
Registered nurse staffing
LPN hours / resident day
1.08
Licensed practical nurse staffing
Aide hours / resident day
2.26
Nurse aide staffing
Weekend hours
3.19
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Install proper backup exit lighting.
Corrected 2025-07-02
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
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-11
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
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-01
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-07-01
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
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-01
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-11
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-10
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-10
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
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-11-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-10
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-30
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-06-30
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-06-30
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-06-30
Inspection history
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
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-27
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
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-27
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-27
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-27
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-27
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
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-27
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
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
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
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
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-03
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
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
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-03
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
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-30
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-06-30
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
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-30
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-30
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-30
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Nearby options
Wilmington, DE
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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
Wilmington, DE
3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
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