Autumn Lake Healthcare at Old Bridge

Inspectors wroteBased on observations, interviews and review of facility documents, it was determined that the facility failed to properly store, label, and date foods to prevent the development of food-borne illness. This deficient practice was identified in the main kitchen and one of two pantries (A-wing), and was evidenced by the following: 1. On 1/29/26 at 9:13 AM, the surveyor toured the kitchen with the Regional Food Service Director (RFSD) and observed the following:Near the dry storage room, two cardboard boxes of bananas were stacked one on top of the other. The top box was partially open with several dark discolored bananas in a clear plastic bag inside. In the presence of the surveyor, the RFSD lifted a plastic bag out of the box. The bag contained several dark brown/black bananas and dark brown liquid. The RFSD stated the bananas were rotten. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain the necessary care and services for residents who were receiving oxygen (O2) treatment according to professional standards of practice and b.) ensure a physician's order was obtained for a resident receiving O2. The deficient practice was identified for three of three residents (Resident #9, #14 and #51) reviewed for Respiratory Care. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by a.) ensuring routine medications were acquired in a timely manner and administered as per prescribed physician's orders for one (1) of seven (7) residents, (Resident #110), reviewed for medication management and b.) ensuring proper procedures to acquire routine medications be available for administration for one (1) of four (4) residents, (Resident #13 ), observed during medication administration. The deficient practices were 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: [...]

Inspectors wroteBased on observation, interview and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for 1 of 2 nursing units (B Wing). This deficient practice was evidenced by the following:On 1/30/2026 at 9:47 AM, during an environmental tour on B wing, the surveyor interviewed unsampled Resident #30. During the interview, the surveyor observed a large white patched area with a hole in the wall below the patch on the left wall of the room, just beyond the bathroom door. Further review of the room revealed a white patched area around the soap dispenser near the sink, and a large white patch area on the right side wall, near the resident's bed. The surveyor asked Resident # 30 what happened to the walls. Resident #30 stated they did not know because it was like that since they were admitted in October. [...]

Inspectors wroteComplaint #2684176 Based on interviews, record review and review of facility provided documents, it was determined that the facility failed to ensure that a resident was free from exploitation and misappropriation of resident income. This deficient practice was identified for one of one resident (Resident #115) reviewed for misappropriation of personal property and was evidenced by the following: On 1/29/26 at 10:19 AM, during an initial tour of the facility, the surveyor observed Resident #115 in their room. Resident #115 was not interviewable. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #115. A review of the admission Record, an admission summary, reflected diagnoses which included but were not limited to; major depressive disorder, and altered mental status. Further review reflected: [...]

Inspectors wroteBased on interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered Care Plan (CP) to address the needs for a.) a resident who was on an anticoagulant (blood thinners) for Paroxysmal Atrial Fibrillation (A-fib; a type of irregular, rapid heart rhythm that comes and goes on its own) (Resident #51) and b.) a resident with a suprapubic catheter (a medical device used to drain urine from the bladder) (Resident #3). This deficient practice was observed for Two (2) of 23 residents reviewed for CP.This deficient practice was evidenced by the following: 1. On 1/29/26 at 12:07 PM, the surveyor observed Resident #51 sitting in their wheelchair, in the dining room. The surveyor reviewed the electronic medical records (EMR) for Resident #51. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss (specialized) mattress was functioning properly and accurately setup according to manufacturer instructions and a physician's order for residents who were previously identified to have had an alteration in skin integrity. This deficient practice was identified for 2 of 4 residents (Resident #14 and Resident #48) reviewed for pressure ulcers and was evidenced by the following:A.) On 1/29/26 at 10:14 AM, the surveyor observed Resident #14 lying in bed, resting on an air mattress. The resident's air mattress pump was observed to be set to a weight of 200 pounds. On 1/30/26 at 9:49 AM, the surveyor observed Resident #14 lying in bed, the air mattress pump was noted to be set to a resident weight of 200 pounds. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to consistently write a Progress Note (PN) as per physician orders for residents on hemodialysis (HD-a treatment that replicates the kidney's function and cleans the waste from the blood for individuals with kidney disease or failure) pre and post HD treatment. This deficient practice was identified for 2 of 2 residents (Resident #1 and #6) reviewed for dialysis. This deficient practice was evidenced by the following:1. On 1/29/26 at 10:04 AM, during the initial tour, the surveyor observed Resident #6 resting in their bed. The resident informed the surveyor that they received HD.The surveyor reviewed the electronic medical records (EMR) for Resident #6. A review of Resident #6's admission Record (AR; [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to post the daily Nursing Home Resident Care Staffing Report (NHRCSR) that was up to date. This deficient practice was identified on 1/29/2026 and was evidenced by the following:On 1/29/2026 at 8:55 AM, upon entrance to the facility, the surveyor observed the NHRCSR posted in the main lobby dated 1/22/2026 for all three shifts: 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. On 1/30/2026 at 11:41 AM, the surveyor interviewed the Staffing Coordinator (SC), who stated she was responsible for completing the staffing report. She stated she posted the staffing report daily during the week and the weekend supervisor posted it on the weekends. The surveyor made her aware of the above observations. She acknowledged the report should have been changed every day. [...]

Inspectors wroteBased on observation, interview, and review of medical records, it was determined that the facility failed to follow a physician's orders (PO) for medications with a parameter and acceptable professional standards of practice for one (1) of seven (7) residents (Resident #1), reviewed for medication management. The deficient practice is 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: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to: a.) consistently follow a physician's order for the application of a bolster (cushion used for support) to the left arm rest of a wheelchair for a resident with decreased range of motion and mobility, b.) follow the residents individualized comprehensive care plan (ICCP), and c:) consistently document accountability for the placement of the device. The deficient practice was identified for 1 of 1 resident (Resident #10) reviewed for positioning and mobility. This deficient practice was evidenced by the following: On 10/01/24 at 11:40 AM, the surveyor observed Resident #10 in his/her wheelchair in the dayroom without a bolster applied to the left arm of the wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication administration times to accommodate for a resident's dialysis scheduled times. The deficient practice was identified for one (1) of one (1) resident, (Resident #151) reviewed for dialysis services and 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: [...]

Inspectors wroteCOMPLAINT # NJ00169735, NJ00170064 and NJ00170351 Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a.) medications were administered to a resident in a timely manner as ordered by a physician, (Resident #72). This was identified for one (1) of eight (8) residents, reviewed for medication management. and b.) a controlled drug (Oxycodone) was available for administration and accurately documented as per a physician's order in the electronic medication administration record (Resident #87). This was identified for one (1) of eight (8) residents, reviewed for medication management. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation on 10/2/24, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 31 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.45 %. This deficient practice was identified for one (1) of five (5) residents, (Resident #72), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced as follows: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide the resident representative with written notification of the reason for emergency transfer for 1 Resident #106, of 2 residents reviewed for hospitalization. The deficient practice is evidenced by the following: A review of the electronic medical record revealed the following information. The Census tab indicated the resident was transferred to the hospital on [DATE]. On 5/12/23 at 9:15 AM, the surveyor interviewed the Regional Director of Nursing (RDON) who stated the facility is responsible for providing written documentation to the resident representative and the Long-Term Care Ombudsman (LTCO) with the reason for a resident's emergency transfer. She further stated the notification was sent to the LTCO, however, it was not sent to the resident representative. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide written notification of the bed hold policy to the resident representative upon emergency transfer for 1 Resident, #14, of 2 residents reviewed for hospitalization. The deficient practice is evidenced by the following. Resident #14 was observed on 5/4/23 seated in a wheelchair in the unit day room. The resident pleasantly engaged in conversation with the surveyor. A review of the electronic medical record revealed the following information. The Census tab indicated the resident was transferred to the hospital on 2/27/23 and 3/4/23. On 5/12/23 at 9:15 AM, the surveyor interviewed the Regional Director of Nursing (RDON) regarding written notification of the bed hold party to Resident #14's resident representative for the emergency transfers on 2/27/23 and 3/4/23. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately assess and properly code a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for three (3) of 27 residents (Residents #26, #53 and #66). This deficient practice was evidenced by the following: Reference: According to the CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual dated October 2019 indicates the completion of the RAI process has multiple regulatory requirements. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure that the resident was provided with the consistency of liquid in accordance with the physician's order. This was found with Resident # 57, 1 of 1 residents reviewed for thickened liquids. The deficient practice was evidenced by the following: On 5/9/23 at 1:15 PM, the surveyor observed Resident # 57 being fed by a Certified Nursing Assistant (CNA). The CNA poured a packet of thickening powder that read Honey Consistency into 4 ounces of apple juice that the CNA had poured into a cup. The CNA held the cup and the resident drank the thickened apple juice after feeding the resident half of a portion of chocolate pudding. The surveyor checked the meal ticket. The meal ticket read Nectar Thick. [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to sanitize and air-dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 5/8/23 at 11:06 AM, in the presence of Director of Dietary (DD) the surveyor observed the following: In the dishwashing area, the surveyor observed a dishware drying rack with four shallow one quarter steam table pans stacked with water between them, three deep quarter steam table pans stacked with water between them, and two sheet pans stacked with water between them as well. The DD stated that the dishware should not be stacked on top of each other when wet. On 5/8/23 at 1:13 PM, the surveyor discussed the above concerns with the Administrator, Director of Nursing (DON), and Regional DON. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to store four of four linen carts in a sanitary manner. This deficient practice was as evidenced by the following: On 5/8/23 at 11:20 AM, the surveyor observed four blue linen carts outside of the facility on the sidewalk located underneath a tree, which were not covered. The surveyor observed that the items inside the first blue linen bin, nearest the building outside, which were washable incontinence under pads, bed sheets and blankets, was soiled with a small tree branch on top of the items and brown and tan colored debris from the tree above the bin. The surveyor observed that the items inside the second blue linen bin, which were resident gowns, was soiled with brown and tan colored debris from the tree above the bin. [...]