Autumn Lake Healthcare at Oceanview

Inspectors wroteComplaint # 2649488, 2597199Based on interviews, medical record review and review of pertinent facility documents on 10/30/2025 it was determined that the facility failed to: a.) complete a thorough investigation of an injury of unknown origin by ruling out abuse and neglect; b.) ensure it reported an injury of unknown origin to the New Jersey Department of Health. This deficient practice occurred for 1 of 3 residents reviewed for accidents and injuries (Resident #1). This deficient practice is evidenced by the following:A review of the admission Record (an admission summary) reflected that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Dementia (poor blood flow that causes memory and thinking problems) and cerebral infarction (lack of blood and oxygen to the brain that causes damage). [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 01/05/2025 from 08:54 to 9:38 AM,, the surveyor, accompanied by the Assistant Food Service Director (AFSD), observed the following in the kitchen: 1. Upon entry to the kitchen the surveyor observed three (3) staff actively working on the breakfast tray line. 3 of 3 female staff did not have hairnets and their hair was exposed while actively working with food. One (1) staff had lengthy hair in a ponytail, a second staff had lengthy hair in a bun style with a head band around their forehead and the third staff also had lengthy hair pulled back and in a hair tie. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment, and living areas in a safe, sanitary and homelike manner. This deficient practice was idenfied on 2 of 3 units, (Serenity and B Wing) and was evidenced by the following: On 01/05/2025 at 10:44 AM, Resident # 3 approached Surveyor # 1 and stated that he/she wanted Surveyor #1 to go to his/her room (#126) to observe a concern. Resident #3 stated that he/she reported mold to the Maintenance Department many times yet it remains present in his/her room and that he/she is concerned that it is affecting his/her health. Resident #3 directed Surveyor #1 to the area of the packaged terminal air conditioner unit (PTAC) under the window. [...]

Inspectors wroteBased on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to contain nebulizer/respiratory equipment (a machine used to administer medication in the form of a mist inhaled into the lungs) delivery systems in protective coverings for 4 of 4 residents (Resident #26, #42, #55 and #368) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 01/05/2025 at 10:28 AM, Surveyor #1 observed a nebulizer machine on top of Resident #55's dresser. The nebulizer machine was not currently in use. The nebulizer mask was lying on top of the dresser with the interior of the mask facing upwards. The mask was not covered while not in use and was exposed to contamination. The nebulizer tubing was dated but not able to determine exact date except 24. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 4 of 6 staff (2 Housekeepers, 2 Certified Nursing Assistants) to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to make survey results readily accessible to residents and visitors. This deficient practice was evidenced by the following: On 01/07/2025 at 10:30 AM, the surveyor conducted the resident council task with five (5) facility long-term residents. When asked if the residents were made aware of the location of the most recent state survey results, 5 of 5 resident responded that they were not aware of the existence of a state survey book and were not notified as to where the most recent survey results were located. On 01/07/2025 at 11:30 AM, the surveyor went to the front reception area to look for the State Survey Result Book. The surveyor did not visualize the State survey book. The surveyor asked the receptionist where the State Survey Results Book was, she replied she was not familiar with the book. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documentation, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficient practice was observed for 2 of 25 sampled residents, (Resident #367 and #7) . This deficient practice was evidenced by the following: 1. On 01/05/2025 at 09:45 AM, the surveyor observed Resident #367 lying in bed. Resident #367 stated they had not seen the doctor but just saw their bills. A review of Resident #367's hybrid (electronic and paper) medical records (MR) from December 2024 - January 2025 revealed the following: [...]

Inspectors wroteBased on interview and review of pertinent facility records it was determined that the facility failed to follow through on recommendations made by the consultant pharmacist (CP) during their monthly medication regimen review (MRR) in a consistent and timely manner. This deficient practice was observed for 1 of 5 residents (Resident #55) and was evidenced by the following: On 01/07/2025 at 08:48 AM Resident #55 was observed lying in bed awake and alert. Resident #55 was pleasant and cooperative and answered surveyor questions. No maladaptive behaviors were observed, and Resident #55 did not appear to be in any distress. Resident #55 was observed to be confused at times. According to the admission record, Resident #55 was admitted to the facility with the following but not limited to diagnoses: [...]

Inspectors wroteBased on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to ensure that specific target behaviors exhibited were documented as well as the non-pharmacological interventions attempted prior to the administration of an antianxiety medication. This deficient practice was identified for 1 of 1 resident reviewed for Psych (psychotropic)/Opioid side effects, (Resident # 45) and was evidenced by the following: On 01/05/2025 at 09:52 AM, the surveyor observed Resident #45 in the unit activity room sitting in his/her wheelchair (w/c) at the table. Resident appeared lethargic, leaning forward in the w/c, and appeared to have difficulty staying awake. A review of the EMR on 01/06/2025 at 01:00 PM, revealed the following: [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris and failed to have a cover over the opening of 3 of 3 garbage containers/dumpsters. This deficient practice was evidenced by the following: On 01/05/2025 at approximately 9:30 AM, the surveyor, accompanied by the Assistant Food Service Director (AFSD), observed four (4) yard dumpsters that were designated for garbage in the facility parking lot. According to the AFSD three of the dumpsters were designated for garbage and one dumpster was designated for recyclables. 3 of 3 dumpsters designated for garbage had the contents of bagged trash exposed due to the dumpster lids not being fully closed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain services necessary to maintain a sanitary, orderly, and comfortable interior. The deficient practice was identified for 3 of 3 shower rooms and 1 out of 5 residents investigated (Resident #9) under the Environmental Task. The deficient practice was evidenced by the following: On 01/04/2024 at 10:09 AM, Surveyor # 1 observed Resident # 9 in his/her room. At that time, Resident # 9 said housekeeping doesn't clean his/her room every day, and that there was mold around the bottom of the toilet. At that time, Surveyor # 1 observed a crumbled paper towel on Resident # 9's floor next to the bed. Surveyor # 1 observed a detached floor baseboard exposing drywall. At that time, Surveyor # 1 then observed Resident # 9's bathroom. Surveyor # 1 observed the trash can. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, 1). it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs specifically by failing to include focuses and interventions for a respiratory diagnosis and 2). failing to implement Care Plan interventions for fall prevention. The deficient practice was identified for 2 of 3 residents (Resident # 20 and # 90) investigated for Respiratory and 1 of 2 residents (Resident # 46) investigated for Falls. The deficient practice is evidenced as follows: 1a). On 01/03/2024 at 10:36 AM during the initial tour of the facility, Surveyor # 1 observed Resident # 20 in his/her room. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 01/03/2024 from 9:34 to 10:12 AM, the surveyors, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. The meat slicer on a stainless steel counter was observed to be cleaned/sanitized and covered while not in use. The FSD confirmed that the meat slicer was cleaned, sanitized, and not in use. Further observation of the underside of the slicing wheel/ blade revealed brown unidentified food debris on the bottom of the blade guard. The FSD stated, The meat slicer needs to be re-cleaned. FSD then directed a staff member to clean the meat slicer. 2. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was discovered that the facility failed to a.) follow professional standards of practice specifically by not changing nebulizer (device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) tubing weekly and as needed, and b).failed to maintain respiratory equipment in a sanitary manner and follow their policy and procedure for respiratory equipment care. The deficient practice was identified for 2 of 3 residents (Resident #20 and #90) investigated for Respiratory Care. The deficient practice was evidenced by the following: a.) On 01/03/2024 at 10:36 AM during the initial tour, Surveyor # 1 observed Resident # 20 in his/her room. At that time, Surveyor # 1 observed a nebulizer set on top of a cardboard box adjacent to the resident's bed. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility records, it was determined that the facility failed to accurately implement a physician prescribed fluid restriction order for 1 of 1 resident (Resident #91) on 1 of 3 units (subacute) reviewed for dialysis. This deficient practice was evidenced by the following: On 01/04/2024 at 09:40 AM the surveyor observed Resident #91 observed in their room after completion of their breakfast meal. Resident #91 was lying in bed. When asked by the surveyor how their appetite was Resident #91 responded, Not good. Resident #91 suspected he/she had lost weight. According to the admission record, Resident #91 was admitted to the facility with the following but not limited to diagnoses: [...]

Inspectors wroteComplaint # 166936 Based on interviews, medical records review, and review of other pertinent facility documentation on 12/11/2023, it was determined that the facility failed to follow standards of clinical practice for notification of the physician in a timely frame for laboratory results of a resident (Resident #2) that was received. The facility also failed to follow its policy titled Notification of Change. This deficient practice was evidenced by the following: 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 within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/2/2021 from 9:31 AM to 11:01 AM, the surveyor, accompanied by the cook and the Food Service Director (FSD) observed the following in the kitchen: 1. Upon entry to the kitchen the cook was observed to wear a surgical type hair net. The hair net covered a bun on the top of her head, leaving all hair around the circumference of their head exposed. The surveyor questioned the cook if hair coverings were required to cover all the hair on their head. The cook responded, Ok and then proceeded to adjust their surgical type hair net to cover all of her exposed hair. 2. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to keep resident areas, the outdoor exterior, and equipment clean, sanitary and in good repair for one of three units (B Unit Wing) observed for the Environmental Task. The deficient practice was evidenced by the following: during the initial tour of the facility on 12/2/21 at 10:13 AM, Surveyor #1 observed the following: 1. debris on the floor that appeared to be dust and food crumbs near the doorway of Resident #19's room. Surveyor #1 also observed a brown, dried substance on the mobility pole and formula pump (pump used to deliver nutritional formula to a resident). 2. heavily brown color stained ceiling tiles in the shower room. 3. cobb webs on the wall near the ceiling across from the nurses station. 4. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 3 of 3 garbage dumpster's and 1 of 1 recycling dumpster's. This deficient practice was evidenced by the following: 1. On 12/2/2021 at 9:41 AM the surveyor, accompanied by the cook observed 4 dumpster's outside the facility in the parking lot area. The cook told the surveyor that (3) dumpster's were designated for trash and (1) dumpster was designated for cardboard recyclables. 3 of 4 dumpster's had their doors opened and trash and cardboard were exposed. In addition, a clear plastic bag of garbage was observed to lie on the ground adjacent and in contact with a garbage dumpster. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure the privacy and confidentiality of resident information on the Electronic Health Records (EMR) systems. This deficient practice was identified for 1 of 1 Licensed Practical Nurse (LPN #2) observed during medication pass and was evidenced by the following: On 12/6/21 from 8:25 AM to 9:10 AM, the surveyor observed LPN #2 administer medications on the Serenity Unit using a computer attached to the Serenity Unit medication cart. The surveyor observed Resident # 9's medical information to include residents' picture, name, date of birth and medications, visible to unauthorized staff. [...]