The Subacute At Autumn Lake Healthcare

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to be taken to the hospital. I [FM3] said, 'Oh, so did you tell him that [Resident R7] has diarrhea and is being given Imodium which [Resident R7] shouldn't have because they had diverticulitis?' The nurse said I told him that [Resident R7] was nauseous and vomited . I [FM3] said so you didn't tell him that [Resident R7] has been declining and now is confused with this also. The nurse didn't answer me back. I [FM3] told her [nurse] that it wasn't good practice for a doctor to take the nurse's word on what is wrong with the patient and not even come into see [Resident R7] to see if he/she needs to go to the hospital before refusing to have him/her transferred there. Had I had known [,] I could have called 911 and had taken Resident R7 to the hospital, I would have done that . I feel that no one was watching Resident R7 and paying attention to his/her needs.During a phone interview on [DATE REDACTED] at 4:24 PM, LPN10, who was identified on the lab results as receiving the results, stated, I don't remember [Resident R7].During a phone

interview on [DATE REDACTED] at 10:25 AM, LPN12 stated, I admitted [Resident R7] when she came in. [Resident R7] wasn't having diarrhea on admission that I can remember, but did complain of minor pain all over. I was off and then I came back to work on 01/02, and the nurse told me [Resident R7] had passed away that morning.Review of the undated facility's policy titled, Laboratory Services and Reporting indicated, . The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of

the services .::NJAC 8:39-27.1

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Subacute at Autumn Lake Healthcare

113 Route 73 Voorhees, NJ 08043

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

notify the Physician for an alternative medication so the resident could have relief from the pain. LPN13 stated pain should be assessed, documented, and reassessed for effectiveness after pain medication was given. She stated if the medication was not effective, the Physician should be notified to see what else could be done.During an interview on 09/26/25 at 1:56 PM, the DON was asked if she had any additional information after reviewing Resident R16's chart on 09/25/25 after our interview, as documented above. The DON stated she did not have any additional information.During an interview on 09/26/25 at 2:17 PM, LPN3 stated that if medications were not available for a resident, staff should pull the medications from the Pyxis, call the doctor, and call the pharmacy. LPN3 stated you could not just leave the residents in pain.Review of

the undated facility's policy Pain Management indicated, . to help the resident attain or maintain his/her highest practical level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs . Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences .NJAC 8:39-27.1(a)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Subacute at Autumn Lake Healthcare

113 Route 73 Voorhees, NJ 08043

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

not being available from the pharmacy. But the nurses and the nursing supervisor, once they noted the medications were not being delivered, they should have called the pharmacy back to ask about them. But to

the specifics of this case regarding the pain, I will have to review this further and get back to you.During a phone interview on 09/26/25 at 10:25 AM, LPN12 stated, I do remember there was a time we had to wait for pharmacy because there was no Dilaudid in the building. I didn't have access to the Pyxis because I was within my first 90 days of being employed at the facility. During that time, if medicines were taken out of

the Pyxis, another nurse would have to go and get them for me.During an interview on 09/26/25 at 1:16 PM, LPN13 stated if medications are not available for residents, there are supervisors to help. LPN13 stated you would call the pharmacy, notify the physician for an alternative medication, call the DON, and call the Medical Director if you had no results.During an interview on 09/26/25 at 1:30 PM, LPN7 stated if

an ordered medication was not available, staff should go to the Pyxis for that one time, but you do not give scheduled medications out of the backup. LPN7 stated you should call the pharmacy, obtain a prescription if one if needed, and ask for a STAT delivery if required.During an interview on 09/26/25 at 1:56 PM, the DON was asked if she had any additional information after reviewing Resident R16's chart on 09/25/25 after our interview, as documented above. The DON stated she did not have any additional information.During an

interview on 09/26/25 at 2:17 PM, LPN3 stated if medications were not available for a resident, staff should pull the medications from the Pyxis, call the doctor, and call the pharmacy. LPN3 stated you could not just leave the residents in pain.Review of the Pharmacy policy Providing Pharmacy Services dated February 2023 indicated, .When medication is needed prior to the next scheduled delivery and is not contained in the back-up box/ stat/ emergency kit drug supply, the pharmacist arranges for both the dispensing and delivery of medication to the facility within the time frame specified by contract; . Medication may be dispensed by either [Name of Pharmacy] or a back-up pharmacy and delivered by either a [Name of Pharmacy] driver, back-up pharmacy, or a courier service . NJAC 8:39-29.2(d)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Subacute at Autumn Lake Healthcare

113 Route 73 Voorhees, NJ 08043

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

of that would help in this situation.During an interview on 09/26/25 at 1:00 PM, the Administrator stated, We go over the reviews that the DON and the IDT team do for the deaths that occur in the building for each month. The PIP for this was started before I came in February, so I was told there was an unexpected death is the reason we were doing the PIP. The DON does the initial review of each death and brings to QAPI each month where we discuss the mortality reviews and he findings for each. I expect the DON to see the weaknesses that we had with each death to see what we can do better and then initiate these changes to reflect better quality of care.Review of the DON's job description indicated, . Develop, implement, and maintain an ongoing quality assurance program for the nursing service department . Assist the Quality Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies . NJAC 8:39-33.1

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Subacute at Autumn Lake Healthcare

113 Route 73 Voorhees, NJ 08043

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained during observation of medication administration for two of five residents (Resident (R)14 and Resident R13) observed out of a total sample of 15 residents. This failure had the potential to introduce infections to

the residents.1.Review of Resident R14's undated Face Sheet located under the Profile tab in the electronic medical

record (EMR) indicated Resident R14 was admitted to the facility in 9/2025.Observation on 09/11/25 at 5:40 AM, revealed Licensed Practical Nurse (LPN)1 was observed with her bare index and middle finger inside of the medication cup which contained Resident R14's medication. LPN1 administered the medications from the cup to Resident R14. 2.Review of Resident R13's undated Face Sheet located under the Profile tab in the EMR indicated Resident R13 was admitted to the facility in 08/2025.During an observation on 09/11/25 at 5:49 AM LPN1 was observed with her index finger touching the inside of the medication cup. LPN1 administered the medications from the cup to Resident R13. LPN1 did not have gloves on during this observation.During an interview on 09/11/25 at 5:50 AM, LPN1 stated, I should not have touched the inside of the medication cup with my bare fingers.During an

interview on 09/11/25 at 9:48 AM, the Infection Preventionist (IP) stated, The nurse should never touch the inside of the medication cup with her bare hands or fingers prior to giving the medication.During an

interview on 09/12/25 at 12:10 PM, the Director of Nursing (DON) stated, She [LPN1] should not have touched her bare fingers inside of the medication cup.NJAC 8:39-19.4 (a)(1)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet