Cycle 1
Health 2025-02-26 · Fire 2025-02-26
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Carneys Point, NJ
Autumn Lake Healthcare At Southgate
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
449 S Pennsville-Auburn Road, Carneys Point, NJ
(856) 299-8900
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
152
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1986-08-13
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
0.30
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,376
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.91
Baseline 27.02% · Performance 19.61% · Measure score 6.91 · Achievement 3.92 · Improvement 6.91
Healthcare-associated infections
3.05
Baseline 7.16% · Performance 6.92% · Measure score 3.05 · Achievement 3.05 · Improvement 0.59
Total nurse turnover
4.60
Baseline 42.37% · Performance 44.86% · Measure score 4.60 · Achievement 4.60 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.89 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.01% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 306 · Observed rate 11.76% · Lower 95% interval 8.2% |
| Discharge to community | 58.21% |
50.57%
7.6 pts better
|
Better than the National Rate · Eligible stays 294 · Observed rate 51.7% · Lower 95% interval 51.99% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 275 · Denominator 275 |
| Falls with major injury | 0.73% |
0.77%
About the same
|
Numerator 2 · Denominator 275 |
| Discharge self-care score | 52.78% |
53.69%
0.9 pts worse
|
Numerator 95 · Denominator 180 |
| Discharge mobility score | 51.11% |
50.94%
0.2 pts better
|
Numerator 92 · Denominator 180 |
| Pressure ulcers or injuries, new or worsened | 2.91% |
2.29%
0.6 pts worse
|
Numerator 8 · Denominator 275 · Adjusted rate 2.75% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 221 · Observed rate 6.79% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 1.35% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 148 |
| Staff flu vaccination coverage | 75.13% |
42%
33.1 pts better
|
Numerator 145 · Denominator 193 |
| Discharge function score | 58.89% |
56.45%
2.4 pts better
|
Numerator 106 · Denominator 180 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 87 · Denominator 87 |
| Transfer of health information to patient | 99.21% |
96.28%
2.9 pts better
|
Numerator 126 · Denominator 127 |
| Resident COVID-19 vaccinations up to date | 12.26% |
25.2%
12.9 pts worse
|
Numerator 19 · Denominator 155 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.1
0.3 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.6 · 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 | 2.1% |
2.4%
0.3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.6% · Q4 3.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.8% |
11.4%
12.4 pts worse
|
11.4%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 32.0% · Q3 26.0% · Q4 16.8% · 4Q avg 23.8% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.6%
1.5 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 2.9% · Q4 5.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
19.0%
0.2 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 19.6% · Q3 17.6% · Q4 22.3% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
13.5%
1 pts worse
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 10.6% · Q3 15.8% · Q4 19.2% · 4Q avg 14.5% · 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 | 5.9% |
9.8%
3.9 pts better
|
16.3%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 5.1% · Q3 5.7% · Q4 5.5% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
9.7%
4.1 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 5.4% · Q3 5.8% · Q4 5.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.7%
0.1 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.7% · Q4 0.6% · 4Q avg 0.8% · 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 | 13.5% |
15.9%
2.4 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 16.1% · Q3 9.9% · Q4 20.6% · 4Q avg 13.5% |
| 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 8.4% · Q2 3.1% · Q3 5.9% · Q4 4.1% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
78.7%
21 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
8.2%
6.4 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 14.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.8% · Q3 2.1% · Q4 2.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
80.1%
18.4 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
25.4%
0.4 pts better
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 24.1% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-17 · Fire 2023-01-17
8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-10-21 · Fire 2020-10-21
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-02-26
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 2025-02-27
F · Potential for more than minimal harm
2025-02-26
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-27
F · Potential for more than minimal harm
2025-02-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-26
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-02-27
F · Potential for more than minimal harm
2023-01-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-08
F · Potential for more than minimal harm
2023-01-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-08
F · Potential for more than minimal harm
2023-01-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-08
E · Potential for more than minimal harm
2023-01-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-05-22
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 2025-06-16
F · Potential for more than minimal harm
2025-02-26
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 2025-02-27
E · Potential for more than minimal harm
2025-02-26
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 2025-02-27
E · Potential for more than minimal harm
2025-02-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-02-26
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 2025-03-19
E · Potential for more than minimal harm
2025-02-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-19
E · Potential for more than minimal harm
2025-02-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-18
E · Potential for more than minimal harm
2023-01-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-24
E · Potential for more than minimal harm
2023-01-17
F756 · Pharmacy Service Deficiencies
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 2023-01-24
E · Potential for more than minimal harm
2023-01-17
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 2023-01-24
E · Potential for more than minimal harm
2023-01-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-17
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 2023-01-24
D · Potential for more than minimal harm
2023-01-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-01-24
D · Potential for more than minimal harm
2023-01-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-24
B · Minimal harm
2023-01-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-24
E · Potential for more than minimal harm
2020-10-21
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 2020-11-04
Penalties and ownership
What sits behind the stars
Ownership
Kerman, Neil
5% Or Greater Direct Ownership Interest · Individual
Stern, Aryeh
5% Or Greater Direct Ownership Interest · Individual
Alrs Group LLC
5% Or Greater Indirect Ownership Interest · Organization
M & M Capital Ventures LLC
5% Or Greater Indirect Ownership Interest · Organization
Deb, Ashoke
Operational/Managerial Control · Individual
Feifer, Yechiel
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Southgate Realty LLC
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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Autumn Lake Healthcare At Memorial Bridge
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2-star overall rating with 2-star inspections with 13 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Kutz Rehabilitation And Nursing
Wilmington, DE
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $168,019 in total fines with 27 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Gilpin Hall
Wilmington, DE
3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies
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