Autumn Lake Healthcare: Immediate Jeopardy Death - NJ
The resident, identified in federal inspection records only as R7, died on the morning of January 2. The Subacute at Autumn Lake Healthcare, a skilled nursing facility on Route 73 in Voorhees, was cited for immediate jeopardy following a complaint inspection completed September 26, 2025.
R7 had diverticulitis. Imodium, an anti-diarrheal medication, is contraindicated for that condition. Staff gave it anyway. When a nurse called the doctor to report that R7 was declining, she told him the resident was nauseous and had vomited. She did not tell him R7 had been having diarrhea. She did not tell him R7 was now confused. She did not tell him the resident had been declining.
The doctor, working from that incomplete picture, decided R7 did not need to go to the hospital.
A family member identified in the inspection report as FM3 found out what had happened and confronted the nurse directly. "I said, 'Oh, so did you tell him that R7 has diarrhea and is being given Imodium which R7 shouldn't have because they had diverticulitis?'" FM3 told inspectors. The nurse said she had told the doctor about the nausea and vomiting. FM3 pressed further: had she told him about the confusion, about the decline? The nurse didn't answer.
"It wasn't good practice," FM3 said, "for a doctor to take the nurse's word on what is wrong with the patient and not even come in to see R7 to see if he/she needs to go to the hospital before refusing to have him/her transferred there."
FM3 said that if she had known the situation, she would have called 911 herself. "I feel that no one was watching R7 and paying attention to his/her needs."
Nobody had.
Inspectors also reviewed laboratory results connected to R7's care. The results identified LPN10 as the staff member who received them. In a phone interview, LPN10 said: "I don't remember R7."
A second nurse, LPN12, told inspectors she had admitted R7 when the resident first arrived. She recalled that R7 had not been having diarrhea at admission but did complain of minor pain all over. LPN12 said she had been off and returned to work on January 2. "The nurse told me R7 had passed away that morning."
The facility's own policy on laboratory services states that the facility is responsible for the timeliness of those services and must provide or obtain laboratory services to meet residents' needs. What that policy required and what R7 received were not the same thing.
CMS rated this deficiency at the immediate jeopardy level, its most serious classification, meaning the facility's failures had placed residents at risk of serious injury, serious harm, or death. The harm level was marked as affecting few residents.
FM3's account is the clearest record of what went wrong and when. A family member, not a clinician, was the one who understood that Imodium and diverticulitis don't mix. A family member was the one who had to tell the nurse that the doctor hadn't been given the full story. A family member was standing in that hallway, working through the logic of what had happened, while the nurse on the other end of the conversation went silent.
R7 died the next morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Subacute At Autumn Lake Healthcare from 2025-09-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
THE SUBACUTE AT AUTUMN LAKE HEALTHCARE in VOORHEES, NJ was cited for immediate jeopardy violations during a health inspection on September 26, 2025.
The resident, identified in federal inspection records only as R7, died on the morning of January 2.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.