Autumn Lake Healthcare at Memorial Bridge

Inspectors wroteCOMPLAINT #2659218 Based on interview, medical record review and review of other pertinent facility documentation on 11/6/25 and 11/7/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents documented physician visit progress notes at the time of each visit. This deficient practice was identified for 3 of 4 residents reviewed (Resident #1, #2, and #3), and was evidenced by the following:1.) Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of left pubis, hypertension, and myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium). [...]

Inspectors wroteCOMPLAINT#: 2659218 Based on interview, review of medical records and other pertinent facility documents on 11/6/25 and 11/7/25, it was determined that the facility failed to implement and monitor weekly weights upon admission in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents (Resident #1) reviewed and was evidenced by the following: Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of left pubis, hypertension, and myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium). [...]

Inspectors wroteComplaint: NJ184164 Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to provide appropriate safety interventions to a cognitively impaired resident (Resident #124) with a history of refusal of care. On 3/4/25, Resident #124 fell when a Certified Nursing Assistant (CNA #4) refused to allow the resident to close his/her door causing the resident to fall and hit the back of their head causing a laceration. Resident #124 was sent to the hospital for evaluation. This deficient practice was identified for 1 of 2 Residents, (Resident # 124), reviewed for falls and evidenced by the following: On 5/28/25 at 11:19 AM, the surveyor observed Resident #124 in the C-wing dining room sitting in a chair. The C-wing unit was a locked unit for residents with behaviors. [...]

Inspectors wroteOn 05/27/2025 at 11:02 AM, Surveyor #2 observed the following on A Unit: the wall to left of Resident room [ROOM NUMBER]'s door had peeling paint. The wall to the left of Resident room [ROOM NUMBER] had paint peeling under the chair rail. There was missing floor tile to the right of the nurse's station. The shower room had multiple missing tiles on the wall. On 05/27/2025 at 01:43 PM, Surveyor #2 observed the following on A Unit: the paint under the heater in Resident room [ROOM NUMBER] was chipped. The ice machine at the nurse's station was missing a tile near the drainpipe and the black pad underneath the ice machine had a straw under it. On 05/28/2025 at 12:07 PM, Surveyor #2 observed the following on A Unit: there was black debris/discoloration next to the wardrobe and under the heater in Resident room [ROOM NUMBER]. There was peeling paint on the door to the smoking area. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified furnished services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 4 of 33 (Resident # 13, 80, 44, 47) residents reviewed for care plans, specifically a resident that required a hand orthotic (Resident 13), a resident with a Positive Pres-admission Screening and Resident Review (PASARR) Level 2, and a resident that required oxygen (Resident #80). This deficient practice was evidenced by the following: The deficient practice was evidenced by the following: On 05/27/2025 at 10:12 AM, Surveyor #1 observed Resident # 80 in bed receiving Oxygen via nasal cannula (a device used to deliver supplemental oxygen). [...]

Inspectors wroteComplaint # 173841 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to 1 of 1 resident reviewed for Bowel and Bladder (Resident # 47) and 3 of 11 resident reviewed for incontinence rounds. (Resident # 6, Resident #113, and Resident # 402) This deficient practice was evident by the following: On 05/27/2025 at 09:59 during initial rounds Resident # 47 was observed in bed in a t-shirt with the covers at the bottom of the bed. Resident # 47 was observed to have a saturated incontinent brief. Resident # 47 was unsure of the last time he/she was changed. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed accommodate resident's need by not keeping the nurse's call bell within the resident's reach. This deficient practice was identified for 2 of 33 residents (Resident #27 and #45) reviewed for accommodation of need and was evidenced by the following: Upon initial tour of the A Wing Unit on 05/27/2025 at 11:07 AM, the surveyor observed the call bell of Resident #27 on the floor underneath the head of the resident's bed. On the same date and time, the surveyor observed the call bell of Resident #45 wrapped around the wall unit of the nurse's call bell system. [...]

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: During the Resident Council Meeting on 05/29/2025 at 10:31 AM, four of four alert and oriented residents said they were not aware of the location of the State Survey results and that the facility had not spoken to them about the results. During a tour of each unit, the surveyor observed signs that stated the State Survey results were in the lobby. The C-wing unit is a locked unit. In the lobby the surveyor observed a sign on a buffet cabinet that said State Survey results here. The binder was located inside the buffet cabinet where a door had to be opened outward. [...]

Inspectors wroteComplaint: NJ184164 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for 1 of 2 residents (Resident #124) reviewed for abuse. This deficient practice was evidenced by the following: On 05/28/2025 at 11:19 AM, the surveyor observed Resident #124 in the Dining Room of C Wing sitting in a chair. The surveyor attempted to speak with the resident but was unable to do so due to cognitive impairment. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Metabolic Encephalopathy and Unspecified Dementia (Unspecified Severity) with Psychotic Disturbance. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate treatment and care for a resident with a indwelling, urinary catheter. The deficient practice was identified for 1 of 3 residents (Resident # 254) reviewed for Urinary Catheter or UTI (Urinary Tract Infection). The deficient practice was evidenced by the following: On 05/27/2025 at 10:37 AM during the initial tour, the surveyor observed Resident # 254 in bed in their room. At that time, the surveyor observed a urinary catheter drainage bag containing tinged, red urine. The drainage bag did not have a cover for privacy. At that time, the surveyor asked the resident if there was a device on his/her leg that secured the tube of the indwelling, urinary catheter. Resident # 254 denied having one and showed the surveyor his/her leg. [...]

Inspectors wroteNJ Complaint: #00173841 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #77's annual Minimum Data Set (an assessment tool) dated 03/08/2025, revealed that Resident #77 had a brief interview of mental status score of 0 which indicated he/she was not cognitively intact. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to properly store medications and failed to maintain a sanitary environment in a medication room. The deficient practice was identified for 1 of 3 medication rooms and 2 of 7 medications carts reviewed under the Medication Storage Task. The deficient practice was evidenced by the following: On 05/28/2025 at 9:17 AM during an inspection of the B Unit Medication Room, the surveyor observed six beverages in opened containers left on the counter inside the Medication Room. Two personal bags were also in the room. At the time of observation the Licensed Practical Nurse/Unit Manager (LPN/UM) replied, No when the surveyor asked if it is reasonable staff should be keeping their beverages and bags in the medication room. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices, specifically when facility staff failed to wear the appropriate personal protective equipment while in a room under Contact Precautions. The deficient practiced was identified for 1 of 7 Residents (Resident # 258) reviewed under the Infection Control task. The deficient practice was evidenced by the following: On 05/27/2025 at 1:32 PM during the initial tour of the facility, the surveyor observed housekeeper (HK) # 1 inside Resident # 258's room. HK # 1 was mopping the floor. Outside of the room was a sign that revealed, Stop: Everyone Must: Clean their hands, including before entering and when leaving the room. The sign further revealed that, Providers and Staff Must Also: [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to keep the kitchen's convection oven, stove spill pan, large manual can opener and base attachment, large electric mixer, and ice machine clean. Additionally, the date opened on bread products was not labeled with an use by date. This failure had the potential to affect 107 residents who consumed food prepared in the facility's kitchen.

Inspectors wroteBased on observation, review of the maintenance log, and interview, the facility failed to provide a clean, comfortable, homelike environment for two of three units (B and C units) of the facility.

Inspectors wroteCOMPLAINT#: NJ162927, NJ164068 Based on interview, record review, and facility policy review, the facility failed to ensure two (Resident (R) 20 and R57) of six sampled residents reviewed for abuse were free from resident-to-resident physical abuse out of a total sample of 28 residents.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to send a final investigation report within 5-days to the Department of Health, as required for one (Resident (R)260) of one sampled resident reviewed for misappropriation of resident property in a total sample of 28.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident in a total sample of 28 residents (Resident (R) 77) whose assessments were reviewed. The facility failed to accurately assess behaviors exhibited for R77. This failure placed the residents at risk of having unmet care needs and services.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to develop a comprehensive plan of care directing measurable goals and person-centered interventions for two (Residents (R)100 and R59) in a total sample of 28. The facility failed to develop specific care plan and person-centered interventions related to an anti-coagulant medication for R100, and failed to develop a person-centered care plan with interventions related activities of daily living (ADLs) for R59. These failures placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) for one of one resident observed (Resident) (R) 72) during medication pass.

Inspectors wroteBased on interview and record review, the facility failed to ensure an 855 application for facility name change was done in a timely manner. This failure had the potential to create confusion for not knowing the current name of the facility.

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that facility failed to obtain consents from a resident representative prior to administering the COVID-19 vaccination for 1 of 6 residents (Resident #34) reviewed for immunizations. This deficient practice was evidenced by the following: On 05/12/2022 at 12:52 PM, the surveyor observed Resident #34 sitting in a reclining chair. The surveyor greeted the resident, but he/she did not verbally respond. The resident lifted his/her left arm and shook his/her head at the surveyor. The surveyor asked the resident if he/she was okay and the resident shook his/her head yes. The surveyor also asked the resident if he/she received a shot in his/her arm last month and the resident shook his/her head yes. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow the resident's care plan to consistently assess residents to determine the level of supervision needed while smoking. This deficient practice was identified for 2 of 3 residents (Residents #88 and #90) reviewed for smoking and was evidenced by the following: 1. On 05/05/22 at 11:49, 05/10/22 at 11:45 AM, 05/12/22 at 1:26 PM, 05/13/22 at 11:54 AM and 05/16/22 at 11:30 AM, the surveyor observed Resident #88 in the smoking area seated in a wheelchair. The smoking area was supervised by a staff member who provided Resident #88 with a cigarette and lit the cigarette for the resident. According to the admission Record, Resident #88 was admitted to the facility with diagnoses that included, but were not limited to, Type 2 Diabetes Mellitus and Hypertension. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that facility failed to provide social services for a resident with severe cognitive impairment. This deficient practice was identified for 1 of 8 vulnerable residents (Resident #34) reviewed and was evidenced by the following: On 05/12/2022 at 12:52 PM, the surveyor observed Resident #34 sitting in a reclining chair. The surveyor greeted the resident, but he/she did not verbally respond. The resident lifted his/her left arm and shook his/her head at the surveyor. According to admission Record, Resident #34 had diagnoses that included, but were not limited to, Schizophrenia and Unspecified Dementia with Behavioral Disturbance. Further review of the admission Record revealed under Contacts that there were no known contacts. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to a). detect and remove expired medication in 1 of 1 medication storage areas, located in the C-Wing Nursing Unit, reviewed during the medication storage and labeling task and b). ensure accurate completion of a Drug Enforcement Agency (DEA) Form-222 (a federal narcotic requisition form), to enable accurate reconciliation of controlled-dangerous substances (medications, that due to their high potential for abuse, are tracked with detail) for 2 of 3 forms reviewed during the medication storage and labeling task. This deficient practice was evidenced by the following: 1. On 05/13/22 at approximately 10:35 AM, the surveyor found the following expired items in the medication storage area, in the presence of the Registered Nurse/Unit Manager (RN/UM): [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to accurately transcribe and ensure that a resident received psychotropic medication in accordance with the psychiatric recommendation and physician's order. The deficient practice was identified for 1 of 5 residents (Resident #83) reviewed for psychotropic medications and was evidenced by the following: According to the admission Record, Resident #83 was admitted with diagnoses that included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety, and paranoid schizophrenia. Review of the Progress Notes (PN) revealed that Resident #33 had a telehealth psychiatric consult (psych consult) on 05/14/20 and a recommendation to start Trazadone (a psychotropic medication used to treat depression) 25 milligrams (mg) in the AM was noted. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 3 residents, (Resident #86) reviewed for accidents and was evidenced by the following: During an interview with the surveyor on 05/16/22 at 12:25 PM, Resident #86 stated that he/she had smoked daily since admission to the facility. The resident confirmed that he/she was an independent smoker, meaning that the resident can go to the designated smoking area whenever Resident #86 desired and held his/her own cigarettes and lighter. According to the admission Record, Resident #86 was admitted to the facility with diagnoses that included, but were not limited to, Hypertension and heart failure. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medications and maintain a medication error rate of less than 5%. This deficient practice was identified for 2 of 3 nurses who were observed for the medication pass task. There was a total of 27 medication opportunities, administered to five residents, on one of three units (A-Wing Nursing Unit) during the medication pass. There were two errors observed (Resident #3 and Resident #82), which resulted in a medication error rate of 7%. This deficient practice was evidenced by the following: 1. On 05/06/22 at 9:05 AM, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM) administer medication to Resident #82. [...]