Autumn Lake Healthcare at Berkeley Heights

Inspectors wroteDate: 01/20/2025Complaint #: 2712991Census: 92 Based on interviews, medical record review, and review of other pertinent facility documentation on 01/21/2026 it was determined that the facility failed to follow their protocol and policy to prevent the elopement of a resident (Resident #2) who exited the facility through the lobby, got a ride to the train station, and took public transportation out of town. The resident missed the return bus and spent the night in a hospital lobby before returning to the facility the next day. This deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident 2). This deficient practice was evidenced by the following: According to the admission Record (AR) Resident #2 was admitted to the facility with diagnoses including but not limited to: other lack of coordination; [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of pertinent facility documents, it was determined that the facility failed to implement a system for staff to consistently check the function of wander guards used on residents at risk for wandering/elopement. This deficient practice was identified for 3 of 3 residents (Resident #19, #43, and #79) reviewed for wander guards. The deficient practice was evidenced by the following:1. On 9/19/25 at 10:54 AM, during an initial tour on A-wing, the surveyor observed Resident #79 lying on their bed with a beige colored band around their right ankle. The surveyor reviewed the EMR for Resident #79. A review of the admission Record reflected that Resident #79 was admitted with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 25 residents reviewed (Resident #7 and Resident #93). This deficient practice was evidenced by the following: 1. On 9/19/2025 at 10:35 AM, the surveyor observed Resident #7 lying in bed with tube feeding infusing via a pump at 65 cc/hr (cubic centimeters per hour). On 9/23/2025 at 10:17 AM, the surveyor reviewed the electronic medical record (EMR) which revealed a physician order, dated 9/2/25, for continuous feeding of Glucerna 1.5 @ 65ml/hr (milliliters per hour) for a total volume of 1170 mls. [...]

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to follow CDC pneumococcal vaccine guidelines when the facility failed to ensure one resident (Resident (R) 8) and/or his/her representative out of a sample of five reviewed for vaccinations was provided the opportunity to be vaccinated with one dose of Prevnar 20 (Pneumococcal Conjugate Vaccine (PVC) 20). This practice had the potential to increase the risk for this resident to contract pneumonia.

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to follow their Abuse, Neglect and Exploitation Policy and Procedure, to protect residents from physical abuse and staff by failing to ensure: a.) Resident #37 was spoken to in a harsh and abusive manner which resulted in Resident #37 crying on 07/15/24, in the presence of the surveyor and b.) Resident #50 was protected from physical abuse by Resident #74, who had a history of wandering. On 01/24/2024, Resident #74 wandered into Resident #50's room and Resident # 74 physically assaulted Resident #50 by punching them in the mouth and knocking out their front tooth. This deficient practice was identified for 2 of 3 resident's (Resident #50 and #37) reviewed for abuse, and was evidenced by the following: 1. [...]

Inspectors wroteComplaint # NJ 159516 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure their policy for Abuse Investigation and Icidents and Accidents was followed to ensure a thorough investigation was completed, and documented for: a.) an allegation of verbal abuse by staff to Resident #60, and b.) for a resident who was found on the floor, facing upright with a folded jacket under head, was saturated with urine, difficult to arouse and required emergent transport via 911 to the hospital (Resident #295). This deficient practice occurred for 1 of 1 resident investigated for verbal abuse (Resident #60), 1 of 3 residents investigated for unplanned hospitalization (Resident #295) and was evidenced by the following: [...]

Inspectors wroteComplaint #NJ 00175040 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide a.) appropriate incontinence care, and personal hygiene care for 8 of 23 residents (Resident #2 and #31) unsampled residents, #9, #24, #30, #39, #50, #63, and #64, sampled on 2 of 4 resident units. The deficient practice was evidenced by the following: On 07/14/24 around 6:15 PM, the surveyor toured the North Wing of the facility. At 6:30 PM the surveyors entered the A Wing, a strong malodorous odor of urine and feces was permeated in the hallway. The surveyor observed Resident #63 sitting in a recliner chair by their door. Resident #63 could not speak, was mumbling and scratching. Resident #63 was unable to answer any question. 1. On 07/14/24 at 6:24 PM, the surveyor observed Resident #39 in bed by the door. [...]

Inspectors wroteComplaint#'s NJ159619, NJ173589 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that meet each resident's physical, mental and psychosocial needs by failing to: a) ensure a procedure was in place prior to caring for a resident who required an Inotropic (intravenous medication used for heart failure) medication that required specific monitoring and b) to ensure a system was in place to provide physician ordered cardiac medications for a newly admitted resident. This deficient practice was identified for two 2 of closed records reviewed for quality of care, (Resident #296 and #297) and was evidenced by the following: [...]

Inspectors wroteBased on observation, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure Nurse Aides (NAs) received the required training and competencies needed prior to receiving their own assignment to provide direct resident care independently. This deficient practice was identified for 2 of 2 NAs (NA #1 and NA #2) who worked on 2 of 3 Nursing units and were enrolled in a Nurse Aide Training School on 06/18/2024. The NAs failed to complete Module 2 of the NATCEP (Nurse Aide Training and Competency Evaluation Program) and there were no competencies provided by the facility to ensure training was adequate prior to receiving their own assignment. In addition, the facility had no record of the NAs having completed the required modules. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain the kitchen in a clean and sanitary manner to prevent the potential spread of food borne illness by failing to ensure: a) all foods were labeled with a use by date, foods were appropriately stored, and discarded after the expiration date, b) the environment, including the main kitchen, storage areas, and kitchen equipment were maintained in a clean and sanitary manner, and c) staff washed dishes in a clean and sanitary manner. The deficient practice was evidenced by the following: On 07/14/24 at 6:13 PM, the surveyor began the kitchen tour with the Food Service Supervisor (FSS) and observed the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to identify and implement interventions to address resident concerns regarding staffing issues, staff training, grievances, abuse, issues with medications incontinence care, staff competency and the use of uncertified nurse aides, through their Quality Assurance and Performance Improvement program (QAPI). This deficient practice was identified on all 4 residents care units and was evidenced by the following: Refer to: 558F, 600G, 610F, 677F, 684F, 688F, 728L On 07/14/24 during a care tour, the surveyors observed that several of the resident's were left soiled in their excrement for an extended period of time. Residents observed with 2 and 3 incontinent briefs which were soaked with urine. Residents with Fingernails long jagged and soiled. [...]

Inspectors wroteRepeat deficiency Based on facility staff interviews and review of pertinent facility documentation on 7/17/2024, it was determined that the facility failed to provide a designated qualified Infection Prevention and Control Nurse. This deficient practice is evidenced by the following: During an interview with the facility's Infection Preventionist (IP) on 7/17/24 at 12:04 PM, she stated that she had performed both role as facility's IP and Assistant Director of Nursing (ADON) since 2019 and that she is the only IP Control Nurse in the facility at this time. The ADON further stated that she is working full time as the ADON and the IP. She stated that on November 25th, 2020, she completed her Centers for Disease Control and Prevention training, receiving her certification as a Nursing Home Infection Preventionist. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to accurately assess Resident #74 for a behavior management program which would address the behavior of wandering and urinating on the floor/other residents's rooms. Resident #74 exhibited these behaviors since December 2023. The facility failed to revise the care plan to include meaningful interventions to address these behaviors. This deficient practice was observed for 1 of 3 residents reviewed for management of behaviors (Resident #74) and was evidenced by the following: On 07/15/24 at 8:30 PM, two awake and alert residents, reported that they were disturbed by Resident #74's behavior of wandering into their rooms and displacing their belongings. The wandering resident was identified as Resident #74 who resided on the back of the A Wing of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide appropriate services for a resident with limited mobility who was discharged from Physical therapy to restorative services to prevent further decline in Range of motion. This deficient practice was identified for 1 of 2 residents (Resident #13) reviewed for a limited range of motion (ROM). This deficient practice was evidenced by the following: On 07/17/24 at 09:49 AM, the surveyor observed Resident #13 seated in the hallway of the A Wing, by the Television area. Resident #13 had some black and bluish discoloration on the chin, and both hands were contracted. There were no splints or hand rolls in use at that time. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident received oxygen as ordered for 1of 3 residents (Resident #243) reviewed for oxygen administration. This deficient practice was evidenced by the following: On 7/14/24 at 6:45 PM, the surveyor observed Resident #243 in bed, with the Oxygen (O2) concentrator (a medical device used for delivering oxygen) set between 2 and 2.5 liters per minute (LPM). The resident was awake and conversant. On 7/15/24 at 12:25 PM, the surveyor observed the resident in bed, with the O2 concentrator set between 2 and 3 LPM. The resident was awake and conversant. The surveyor reviewed the medical record for Resident #243. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the posted Nursing Home Staffing Report (24-hour staffing report) was up to date and provided accurate information. This deficient practice was evidenced by the following: On 7/14/24 at 6:05 PM, the surveyors entered the facility and observed the posted nursing home [24-hour] staffing report (NHSR) dated 7/12/24, in a plastic covered frame, on a table next to the entrance. The NHSR reflected that the current resident census (total number of residents) of 101. The posting indicated the number of registered nurses, licensed nursing staff and certified nursing staff on a shift. The shift and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care. The staffing report was not up to date and was two days late. [...]

Inspectors wroteRefer 684 F Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to acquire routine medications without delay, for timely administration to Resident #245. This deficient practice was identified during the medication administration observation for one (1) of two (2) nurses, who administered medications to four (4) residents (Resident #245). The evidence was as follows: On 7/16/24 at 10:16 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #245 that included a physician's order for Cholecalciferol oral tablet 10 microgram (mcg; 400 unit), give 1 tablet one time a day for supplement, started on 6/20/24. At that time the LPN stated that she did not have the medication in stock for administration. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a.) provision of a permanently affixed compartment for storage of controlled dangerous substance (narcotic medications, with high potential for abuse and are tracked with detail) within the refrigerator, b.) drugs were labeled in accordance with acceptable pharmaceutical standards. This deficient practice was observed in one (1) of two (2) medication rooms, and one (1) of five (5) medication carts inspected during the medication storage and labeling task. The evidence was as follows: 1.) On 7/14/23 at 7:52 PM, during a meeting with the survey team and the Director of Nursing, the surveyor requested for the policy for Medication Storage. [...]

Inspectors wroteBased on observation, interview, and review of facility documents it was determined that the facility failed to perform blood glucose monitoring as ordered by the physician. This was found with 3 of 5 residents , Resident #39 and Resident # 54, observed during medication pass. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to label insulin pens with expiration dates when opened. This was found in 1 of 3 medication carts inspected. The deficient practice was evidenced by the following: On 10/27/22 at 1:06 PM the surveyor inspected the B Back medication cart in the presence of the Registered Nurse (RN) who was assigned to the cart. Inside of the medication cart there were four insulin pens that were open and undated. 1) An Insulin Aspart Flexpen, 2) An Insulin Glargine Pen, and 3 and 4) 2 additional Insulin Glargine Pens for a second resident that were in the same bag and were open and undated. There was a label on the bag that contained the insulin that read Refrigerate Until Opened. The surveyor asked the RN if the insulin pens were in use. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to perform hand hygiene in a manner that would decrease the possibility of spreading infection. This was found with 1 of 1 wound treatments observed and with 1 of 3 Nurses during the medication pass observation. The deficient practice was evidenced by the following: 1. On 10/31/22 at 12:26 PM the surveyor observed the Unit Manager/Registered Nurse (UM/RN) perform a wound treatment to the left foot and left leg of Resident # 13. The wound treatment started at 12:26 PM and ended at 1:07 PM. The UM/RN washed her hands seven times throughtout the wound treatment of the two wounds. The length of the handwashing was as follows; 15 seconds, 10 seconds, 12 seconds, 8 seconds, 15 seconds, 15 seconds, and 18 seconds. 2. On 11/1/22 at 8:12 AM the surveyor observed LPN # 1 administer medication to 2 different residents. [...]