Autumn Lake Healthcare at Vineland

Inspectors wrote2.) On 5/22/25 at 10:52 AM, during the initial tour, Resident #175 was not in his/her room and the surveyor observed a surgical shoe on the countertop. On 5/23/25 at 11:09 AM, the surveyor observed Resident #175 resting in bed while wearing a hinged brace and a surgical shoe on his/her right leg. The surveyor reviewed the medical record for Resident #175. A review of the admission Record revealed the resident had diagnoses which included, but were not limited to, fracture of shaft of right tibia (the inner and typically larger of the two bones between the knee and the ankle) and subsequent fracture of metatarsal (any of the bones of the foot). A review of the resident's comprehensive MDS, dated [DATE], included the resident had a BIMS score of 10 out of 15, which indicated the resident's cognition was moderately impaired. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNA) on an annual basis. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed and was evidenced by the following: On 5/27/25 at 12:49 PM, the surveyor reviewed the personnel files for five CNAs. 1.) CNA #1, with a date of hire of 3/29/22, had their most recent Employee Evaluation completed on 1/30/24. 2.) CNA #2, with a date of hire of 4/28/10, had their most recent Employee Evaluation completed on 2/7/24. 3.) CNA #3, with a date of hire of 4/3/20, had their most recent Employee Evaluation completed on 3/6/24. 4.) CNA #4, with a date of hire of 3/29/17, had their most recent Employee Evaluation completed on 2/9/24. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, 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 identified in the facility's kitchen and 2 of 5 refrigerators designated for resident food, and was evidenced by the following: 1.) On 5/22/25 at 10:19 AM, during the initial tour of the kitchen, the surveyor, accompanied by the Food Service Director (FSD), observed a black bin containing four pitchers of juice for the residents. The bin had a whitish residue throughout its interior and exterior and the cart that the bin was resting on was stained. At that time, the FSD confirmed the findings as she took a paper towel and wiped the base of the bin. The whitish residue transferred onto the paper towel when wiped. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, it was determined that the facility failed to implement their Antibiotic Stewardship Program by not utilizing a standardized infection surveillance criteria to determine if antibiotic use was appropriate. This deficient practice was identified for 5 of 5 residents (Resident #34, #77, #107, #109, and #382) reviewed for antibiotic use and was evidenced by the following: 1.) Review of the Infection Control Log for January 2025 revealed Resident #34 had a urinary tract infection (UTI) with an onset date of 12/30/24. Attached to the log was an Antibiotic Start Tracking Form that indicated the resident was started on an antibiotic for UTI on 12/30/24. There was no evidence that a standardized infection surveillance criteria was used when the antibiotic was prescribed. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a resident's updated advance directive was implemented in a timely manner in accordance with the resident's wishes and the facility's policy. This deficient practice was identified for 1 of 2 residents (Resident #280) reviewed for Advance Directives and was evidenced by the following: On [DATE] at 10:51 AM, during the initial tour of the facility, the surveyor observed Resident #280 seated in a chair in his/her room. The resident stated that he/she was recently admitted to the facility. The surveyor reviewed the medical record for Resident #280. A review of the the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to obtain a physician's order for 1 of 1 resident (Resident #173) reviewed for positioning and mobility. 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 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 regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteComplaint NJ #: 185447 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 2 of 5 residents (Residents #127 and #150) reviewed for pressure ulcers and was evidenced by the following: 1.) On 5/28/25 10:50 AM, the surveyor observed Resident #127 lying in bed on an air mattress and the resident stated that he/she was in pain. At that time, the Licensed Practical Nurse (LPN) #2 entered the room to answer the call light. The surveyor observed the air mattress pump was attached to the foot board and was set between 280 and 320 pounds (lbs). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order. This deficient practice was identified for 1 of 3 residents (Resident #139) reviewed for respiratory care and was evidenced by the following: On 5/22/25 at 10:30 AM, during the initial tour of the facility, the surveyor observed Resident #139 lying in bed with a tracheostomy tube [a surgical opening in the neck directly into the trachea (windpipe)]. The resident did not respond to the surveyor when spoken to and the resident's oxygen concentrator (a medical device that extracts and concentrates oxygen from ambient air) was set at six liters. On 5/23/25 at 9:06 AM, the surveyor reviewed the medical record for Resident #139. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure palatable temperature of food for lunch meals served on 1 of 5 units (E-Unit). This deficient practice was evidenced by the following: On 5/23/2025 at 10:21 AM, the surveyor conducted a resident council meeting. During that meeting, 4 out of 5 residents (Resident #58, #71, #118, and #129) stated that their food was not served hot. On 5/27/2025 at 11:23 AM, the surveyor visited the kitchen to observe the food service distribution line: At 11:45 AM, the FSD calibrated (process used to make sure the instrument is taking an accurate temperature reading) the thermometer to 31.7 F (degrees Fahrenheit) and then proceeded to obtain the food temperatures from the food items on the steam table. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain a safe and sanitary environment. This deficient practice was identified for 2 of 2 courtyards and on 2 of 5 units (A-Unit and B-Unit) and was evidenced by the following: 1.) On 5/22/25 at 10:00 AM, during the initial tour of the facility, the surveyor observed a courtyard with a large gazebo which had very tall weeds. On 5/23/25 at 11:40 AM, the surveyor observed the courtyard with a large gazebo which had very tall weeds. On 5/27/25 at 11:32 AM, the surveyor interviewed Resident #118 who stated that the courtyard with the large gazebo had both rusted furniture, weeds, and the lawn decor was broken and in disrepair. The resident complained about the lack of maintenance and his/her inability to bring visitors out to there due to the condition of the area. [...]

Inspectors wroteComplaint#: NJ 176168 Based on observations and interviews during a complaint survey on 5/06/25, it was determined that the facility failed to maintain a clean and homelike environment for 1 of 13 rooms on a nursing unit (C Unit). The deficient practice was evidenced by the following: At 10:08 AM, Unit Manager/Licensed Practical Nurse (UM/LPN) toured unit with Surveyor and observed dry brown substance on the grab bars by the toilet, a large amount of the same dry brown substance on the back of the toilet, on the wall behind the toilet, and on the bathroom floor by the toilet in room [ROOM NUMBER]. At 10:17 A.M., during the observation in the bathroom of room [ROOM NUMBER], the Director of Housekeeping (DH) entered. The Surveyor showed the brown substance that was noted above to the DH. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide medically related social services to meet the resident's needs, by specifically failing to help one (Resident (R) 72) of 29 sampled residents obtain a birth certificate and state-issued identification (ID). This caused the resident harm as he has had extreme frustration for the past five years in his attempt to move back to his home in Puerto Rico.

Inspectors wroteBased on observations, interviews, and review of facility policy the facility failed to maintain a clean and safe environment on three of three resident care wings. Observations revealed residents' furniture in disrepair and loose commode seats in resident's bathrooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that four of four residents (Resident (R) 48, R50, R83 and R124) reviewed for bed rail use had documented alternatives to the use of bed rails attempted prior to the use of the bed rails. This failure had the potential to increase the potential for accidental entrapment or injury when an alternate assistive device may have been effective.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to handle clean linen in sanitary manner to prevent contamination before transporting to the resident care units. The facility failed to store nebulizer masks in a sanitary manner for three residents(R)10, R335, and R86) of five respiratory residents sampled from a total 33 residents.

Inspectors wroteBased on interview, document review, and review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect any of the current 136 residents that use a bed.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow an active physician's order to apply bilateral heel protectors (a cushioned pressure-relieving device for heels) (heel bows) while in bed. This deficient practice was identified for Resident #4, 1 of 3 residents reviewed for pressure ulcers, and was evidenced by the following: During the initial tour of the Sub-Acute Rehabilitation Unit on 03/11/21 at 10:26 AM, the surveyor observed Resident #4 lying supine in the bed with the head of bed (HOB) slightly elevated. The surveyor observed that Resident #4 had no heel bows or offloading of the bilateral lower extremities. The surveyor further observed that the resident's feet were lying directly on the mattress. When interviewed at that time, Resident #4 was unable to provide answers about the heel bow application. [...]