Autumn Lake Healthcare at Southgate

Inspectors wroteComplaint # 2648625 Based on observation, interview, medical record review and review of pertinent facility documents on 10/22/2025 it was determined that the facility failed to: a.) implement infection control practices consistent with the Center for Disease Controls (CDC) Enhanced Barrier Precautions (EBP) for a resident with open wounds; b.) ensure appropriate infection control practices were maintained during wound care; and c.) maintain the urinary drainage bag in a position that prevents contact with environmental services to reduce risk of contamination. [...]

Inspectors wroteComplaint #: NJ186169 Based on interviews, review of the Medical Records (MR), and pertinent facility documents on 5/22/2025, it was determined that the facility failed to ensure that the medication ordered by the physician was received and available to be administered for 1 out of 3 sampled residents (Resident #2). The deficient practice was evidenced by the following: According to Resident #2's MR, Resident #2 had diagnoses which included but were not limited to Chronic Kidney Disease, Aneurysm of Artery of Lower Extremity, and Peripheral Vascular Disease, Unspecified. According to the Minimum Data Set (MDS), an assessment tool dated 4/24/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #2 was cognitively intact. [...]

Inspectors wroteBased on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 2/19/25 from 9:26 AM to 10:55 AM, the surveyor observed the following in the presence of [NAME] #1: 1. The Receptionist was observed exiting the walk-in refrigerator with a tray of food items and proceeded to give the tray to Dietary Aide (DA) #3. When interviewed, DA #3 stated that he was instructed to throw eight containers of the pudding in the trash. [NAME] #1 who was present, then proceeded to reach into the trash can and retrieved a single container which she identified as butterscotch pudding, and she stated that it was not labeled or dated. [...]

Inspectors wroteComplaint #NJ 169844 Based 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 evidenced on 3 of 3 resident units (100, 200, and 300 Unit) and was evidenced by the following: 1.) On 2/20/25 at 9:58 AM, the surveyor, in the presence of Registered Nurse/Unit Manager (RN/UM) #1, observed the following in the pantry area on the 300 unit: -A water cooler had a build-up of white streaks and grime. -An ice cart that contained a plastic liner with multiple rips and brown stains. -The black lid on a large gray trash can contained a build-up of white and brown substances. At that same time in the day room, the following was observed: [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for 10 of 10 employee files reviewed. This deficient practice was evidenced by the following: On 2/25/25 at 11:00 AM, the surveyor reviewed the 10 randomly selected employee files, which revealed the following: 1. Registered Nurse (RN #1), with a hire date of 4/16/24, did not have a previous employee reference on file. 2. Licensed Practical Nurse (LPN #5), with a hire date of 1/21/25, did not have a previous employee reference on file. 3. Certified Nursing Assistant (CNA #5), with a hire date of 1/7/25, did not have a previous employee reference on file. 4. Housekeeper (HSK #8), with a hire date of 1/30/25, did not have a previous employee reference on file. 5. [...]

Inspectors wroteComplaint #: NJ167424, NJ169906, NJ170986 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to include a.) tube feeding, b.) risk for pain, and c.) oxygen use. This deficient practice was identified in 3 of 28 residents (Resident #85, #108, and #391) reviewed and was evidenced by the following: 1.) On 2/25/25 at 10:14 AM, the surveyor reviewed the medical record for Resident #85. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, encounter for surgical aftercare following surgery on the digestive sysytem and gastrostomy (a flexible tube inserted through the abdominal wall and into the stomach). [...]

Inspectors wroteComplaint #: NJ169906 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow-up on a healthcare provider's recommendation for a pain management appointment in a timely manner for 1 of 2 residents (Resident #108) reviewed for pain management. This deficient practice was evidenced by the following: On 2/19/25 at 10:05 AM, during the initial tour, the surveyor observed Resident #108 lying in bed. At that time, the nurse entered the room to administer the resident's medications and asked the resident if he/she had pain. The resident complained of nine out of 10 pain to his/her back. When the nurse left the room to get the resident pain medication, the resident stated his pain was not being managed properly. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain dryer machines in a safe operating condition for 2 of 4 dryer machines observed. This deficient practice was evidenced by the following: On 2/21/25 at 12:20 PM, the surveyor, accompanied by the Interim Housekeeping Director (IDH), toured the facility's laundry room. The IDH explained that the laundry staff clean the dyer lint traps every two hours and sign off the completion in a logbook. The IDH retrieved the dyer lint trap cleaning log binder, opened the binder to review it, and stated the laundry staff had not completed the logs per the facility's policy. When asked when the logs were last completed, the IDH opened the binder and turned to the last page that was filled out which contained the dates for 8/20 and 8/21. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for bilateral heel boots (a pressure-relieving device) for a resident at risk for developing pressure ulcers. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for positioning and mobility and was evidenced by the following: On 2/20/25 at 12:37 PM, the surveyor observed Resident #7 resting in bed. The resident was awake and stated that he/she was not wearing heel boots at that time and would like to wear them. The resident's feet were noted to be resting on two green pillows. There were no heel boots observed in the resident's room. The surveyor reviewed the medical record for Resident #7. [...]

Inspectors wroteComplaint #: NJ167424 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for a resident who required continuous oxygen. This deficient practice was identified for 1 of 3 residents (Resident #31) reviewed for respiratory care and was evidenced by the following: On 2/19/25 at 9:57 AM, during the initial tour of the facility, the surveyor observed Resident #31 resting in bed with their eyes closed and receiving oxygen via nasal cannula (N/C; a device that delivers extra oxygen through a tube and into the nose). On 2/20/25 at 9:02 AM, the surveyor observed Resident #31 resting in bed with their eyes closed. At that time, the surveyor observed the resident wearing a N/C which was connected to an empty portable oxygen tank on the back of the resident's wheelchair. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to ensure a palatable temperature of food for 1 of 1 lunch meals observed on 1 of 3 nursing units (300 Unit). This deficient practice was evidenced by the following: On 2/20/25 at 10:35 AM, the surveyor conducted a Resident Council Meeting with five residents (Resident #5, #14, #28, #44, and #64). Four out of five residents stated that if meals were served in the resident's room the meals were cold, that only the dining room received warms meals, and that the eggs were always cold. Resident #28 stated that the meals were delivered on open racks that did not keep the food warm and that the last unit served, nursing unit 100, was served cold food. On 2/21/25 at 11:34 AM, the surveyors observed [NAME] #1 testing the temperatures of the food on the steam table. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to minimize the spread of infection to residents during incontinence care rounds. This deficient practice was identified on 1 of 3 nursing units (100 Unit) and was evidenced by the following: On 2/21/25 at 9:09 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #7 who stated that she was assigned to eight residents and had four residents who still awaited incontinence care. On 2/21/25 at 9:11 AM, the surveyor accompanied CNA #7 into Resident #17's room with the resident's permission. Resident #17 stated that he/she was wet and needed to be changed. CNA #7 donned (put on) gloves. CNA #7 then proceeded to unfasten the resident's brief and adjusted the resident's linens to demonstrate the resident's incontinence status. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice for not following a physician's order for one (1) of 23 residents, (Resident #74) reviewed. The deficient practice was evidenced by the following: Refer to 756 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 registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported on irregularities in the resident's medical record to the facility staff and the attending physician. This deficient practice was identified for one (1) of 23 residents reviewed, (Resident #74) for medication management and was evidenced by the following: Refer to F658 According to the admission Record, Resident #74 was admitted with the diagnoses which included but was not limited to ESRD, diabetes mellites, and glaucoma. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/03/22, indicated that the resident was cognitively intact and required limited assistance with activities of daily living. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) store, label, and date potentially hazardous foods to prevent food-borne illness and b.) discard potentially hazardous foods past their date of expiration. This was evidenced by the following: On 01/04/23 at 10:10 AM, the surveyor conducted an initial tour of the kitchen in the presence of the Food Service Director (FSD). 1. At 10:18 AM, the surveyor observed above the sink in the kitchen a spice rack that contained a variety of 20 different spices. Five of the spice's lids were observed to be open, in the upright position. At that time, the FSD stated that the lids to the spices should not have been left open. 2. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent documentation, it was determined that the facility failed to ensure: a.) staff practiced appropriate hand hygiene in accordance with the Centers for Disease Control (CDC) and Prevention guidelines for infection control during the distribution of the lunch meal trays to residents on the 300 unit (Resident #58, #102, #316, #318, #319, #320, and #321), b.) staff performed appropriate hand hygiene prior to donning (putting on) appropriate Personal Protective Equipment (PPE) in accordance with CDC guidelines for infection prevention and control upon entering the room of residents who were identified as COVID-19 positive, c.) staff maintained appropriate CDC guidelines by bringing a dietary meal cart into a resident's room who were COVID-19 positive during the lunch meal tray distribution on the 300 unit, (Resident #322 and #323), [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to: a.) maintain the cleanliness of floors on the 100-unit and b.) maintain the cleanliness of a resident's room who was receiving a tube feeding. This deficient practice was identified on one (1) of three (3) nursing units, (100-unit) and for one (1) of 23 residents, (Resident #15) reviewed for comfortable, clean rooms. This was evidenced by the following: 1. On 01/04/23 at 10:52 AM, during initial tour the surveyor observed that the left and right hallway floors on the 100 unit were visibly dirty with brown debris, discolored with brownish/black upraised oval and circular marks scattered throughout out the halls. There was also paper debris and a used inside out glove lying on the hallway floor. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was identified that facility staff failed to appropriately implement their Abuse, Neglect and Exploitation Policy and Procedure. This deficient practice was identified for one (1) of one (1) resident's reviewed, (Resident #24) for abuse and was evidenced by the following: On 01/05/23 at 12:16 PM, the surveyor observed Resident #24 seated in the lounge area of the 200 unit. The resident was observed wearing a surgical mask, with their rolling walker next to the table. The surveyor attempted to interview the resident. The resident did not respond verbally back to the surveyor, instead the resident lifted his/her cup up and nodded at the surveyor. The surveyor reviewed the medical record for Resident #24. [...]

Inspectors wroteBased on interview, review of medical records and review of other pertinent facility documentation, it was determined that the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level I assessment after residents were newly diagnosed with a major mental illness. This deficient practice was identified for Residents #1 and Resident #25, (two) 2 of (two) 2 residents reviewed for the PASRR requirement and was evidenced by: 1. The admission Record (AR) dated 08/09/22, indicated that Resident #1 initial admission to the facility was on 05/04/19 with a diagnoses of anxiety. The AR reflected that on 05/13/19 the resident was diagnosed with major depressive disorder and on 05/19/20 was diagnosed with bipolar disorder. The AR also reflected that on 02/27/20 the resident was diagnosed with schizoaffective disorder. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to post the nurse staffing information in a prominent location that was readily accessible for residents and visitors to see. This deficient practice was evidenced by the following: On 01/04/23, 01/05/23, and 01/06/23, the surveyors did not observe the nurse staffing information posted in the facility. On 01/09/23 at 10:12 AM, the surveyor asked the facility's Administrator where the nurse staffing information was posted. The surveyor observed the Administrator call the Director of Nursing (DON) on his cell phone to ask where the nurse staffing information was posted and overheard him say, it's on the board. The surveyor followed the Administrator down the hallway to a bulletin board that had no nurse staffing information posted at that time. [...]

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, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 10/14/20 from 8:36 to 9:22 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage area on a middle shelf of a multi-tiered rack, a box of plastic knives was opened and exposed. When interviewed at that time, the FSD stated, I'm gonna discard these right now. The FSD threw the plastic knives in the trash. 2. Several steam table 1/2 pans (a pan used to hold cooked food on the steam table) were stacked on top of each other on a middle shelf in the pot rack/drying area. When separated by the surveyor, the top pan was wet to the touch. [...]