The Subacute at Autumn Lake Healthcare

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, it was determined that the facility failed to ensure that 1 of 4 residents (Resident #122) observed during the medication administration observation were given their medication. Specifically, Resident #122 did not have their medication Sevelamer HCl (phosphate binding medication) available for administration in the medication cart and was given another unidentified resident's home medication of Sevelamer HCl. This deficient practice was identified by the following: On 3/18/2026 at 9:04 AM, during medication pass observation on the third floor nursing unit, the surveyor observed a Licensed Practical Nurse (LPN #2) administer medications for Resident #122. [...]

Inspectors wroteComplaint # 2699716, #398990 Based on observation, interview, and review of medical records it was determined that the facility failed to establish a system to ensure that residents on dialysis received their medications according to physician orders. This deficient practice was identified during the medication pass administration observation for 1 or 4 residents (Resident #122), observed and was evidenced by the following:On 3/18/2026 at 9:04 AM, during medication pass observation on the third floor, the surveyor observed a Licensed Practical Nurse (LPN) administer medications for Resident #122. The LPN was unable to locate Resident #122's medication, Sevelamer HCl (phosphate binding medication) Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day for take with meal. [...]

Inspectors wroteBased on observation, interviews, record review and review of facility provided documents, it was determined that the facility failed to obtain a physician's order (PO) for a left leg immobilization device for 1 of 1 resident (Resident #9) reviewed for supportive devices. 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: [...]

Inspectors wroteBased on observation, interview, review of the medical record (MR) and review of other pertinent facility documents, it was determined that the facility failed to consistently ensure communication with a contracted dialysis facility according to facility policy and procedure. This deficient practice was evidenced for 1 of 1 resident (Resident #13) reviewed for dialysis. This deficient practice was evidenced by the following: On 03/18/2026 at 9:04 AM, the surveyor observed Resident #13 seated in the wheelchair eating breakfast. Resident #13 offered no complaints and told the surveyor that they attended dialysis for approximately two and a half years on Monday, Wednesday and Friday. [...]

Inspectors wroteBased on observation, interview, and review of the Electronic Medical Record (EMR) and other facility documentation, the facility failed to follow through on recommendations made by the Consultant Pharmacist (CP) during their medication review regimen (MRR) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #8) and was evidenced by the following: During the initial tour of the facility on 3/17/26 at 12:10 PM, Resident #8 was receiving care and was unavailable for an interview. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to properly store and secure medication left at resident's bedside (Resident #15 and #43). This deficient practice was identified for 2 of 2 residents (Resident #15, and #43). This deficient practice was evidenced by the following: 1. On 3/17/2026 at 12:25 PM, the surveyor observed Resident #15 in their room, sitting on the side of their bed. At that time, the surveyor observed a Trelegy Ellipta inhaler (a prescription inhaler designed for adults to help manage breathing difficulties over the long term.) on top of their bedside table. The surveyor reviewed the medical record for Resident #15. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; [...]

Inspectors wroteBased on record review, interviews, and review of pertinent facility documents, it was determined that the facility failed to honor the food preference for one (1) of two (2) residents (Resident #141) reviewed for nutrition. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) prepare food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner, and c.)maintain food-contact equipment in a sanitary condition for 2 of 2 bistros (second and third floor bistros). This deficient practice was evidenced by the following:On 3/17/26 at 10:17 AM, the surveyor began the initial tour of the kitchen and observed the following:Immediately at the start of the tour, the surveyor observed the Food Service Director (FSD) with hair extending near her shoulder blades, uncovered and not within the hairnet that she was wearing. At that time, the surveyor interviewed the FSD, who stated that hairnets must be worn while in the kitchen. [...]

Inspectors wroteC #: NJ00183386/398980, 2670006 Based on observation, interview, medical record review, and review of other pertinent facility documentation on 12/9/25 and 12/10/25, it was determined that the facility failed to consistently document and maintain a complete medical record regarding toileting, bowel & bladder continence/incontinent care for residents in accordance with the facility's policy and standard of care. This deficient practice was identified for 2 of 2 residents (Resident #4 and Resident #5) reviewed. The facility also failed to document when a resident was sent out of the facility for further evaluation after an allegation of a fall. This deficient practice was identified for 1 of 2 residents (Resident #5) reviewed and was evidenced by the following:1. According to the admission Record (AR) Resident #4 was admitted with diagnoses that included but were not limited to: [...]

Inspectors wroteComplaint #: 398977Based on record review, interview, and document review, the facility failed to notify the physician of a resident's refusal to have an immediate (STAT) laboratory test on [DATE] and [DATE]; failed to obtain a Urine with Culture and Sensitivity (C&S) test when ordered on [DATE]; failed to monitor the resident after reports of nausea without emesis for three days, decreased appetite secondary to the nausea, and continued diarrhea; and failed to act upon a critically high white blood cell (WBC) count for one of 16 sampled residents (Resident (R) 7). These failures caused serious harm or death to R7. The facility's Director of Nursing (DON) and the Regional Nurse Consultant (RNC) were informed on [DATE] at 8:00 PM an Immediate Jeopardy (IJ) existed at F684: [...]

Inspectors wroteComplaint #: 398975Based on record review, interview, and document review, the facility failed to consistently provide pain management for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to administer the medication as ordered. R16 had pain levels up to a 10 (on a zero to 10 scale, with 10 being the most intense pain possible). This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death. [...]

Inspectors wroteComplaint #: 398975Based on record review, interview, and document review, the facility failed to acquire pain medications as ordered by the physician for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to acquire the medication. This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death. [...]

Inspectors wroteBased on record review, interview, and document review, the facility failed to have an ongoing quality assurance and performance (QAPI) program demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse effects; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities to address systematic failures in recognizing a decline in a resident's change in condition for one of 16 residents (Resident (R) 7) and failing to consistently provide pain management and failing to have Dilaudid pain medication ordered upon admission for one of 16 residents (R) 16). These incidents created serious harm for R7 and R16. The lack of acknowledging the failures had the potential to affect all residents at the facility. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control was maintained during observation of medication administration for two of five residents (Resident (R)14 and R13) observed out of a total sample of 15 residents. This failure had the potential to introduce infections to the residents.1. Review of R14's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R14 was admitted to the facility in 9/2025. Observation on 09/11/25 at 5:40 AM, revealed Licensed Practical Nurse (LPN)1 was observed with her bare index and middle finger inside of the medication cup which contained R14's medication. LPN1 administered the medications from the cup to R14. 2. Review of R13's undated Face Sheet located under the Profile tab in the EMR indicated R13 was admitted to the facility in 08/2025. [...]

Inspectors wroteComplaint #: NJ00180094 Based on interviews, medical record review, and review of other pertinent facility documentation on 11/26/2024 and 11/27/2024, it was determined that: the facility failed to provide the correct therapeutic diet to a cognitively impaired resident (Resident #3) with a known diagnosis of dysphagia, pharyngeal phase who had a physician's order and plan of care for ground diet and required feeding assistance. It was determined that on 11/12/2024 a Certified Nursing Assistant (CNA) delivered a meal tray containing a regular texture meal to Resident #3, who had orders for a ground diet. The regular texture meal was left with Resident #3. The CNA confirmed that Resident #3's meal tray included corn and tortillas that were not ground texture. The resident's family arrived shortly after the tray was left with Resident #3 and observed the resident with food in her/his mouth. [...]

Inspectors wroteComplaint #: NJ00180094 Based on observation, interview, and record review, it was determined that the facility failed to appropriately respond to a resident family's request regarding resident food preferences and follow the facility policy related to resident self-determination. This deficient practice was identified for 1 of 1 resident reviewed for choices (Resident #3) and was evidenced by the following: A review of the admission Record (AR) reflected that Resident #3 was admitted to the facility with diagnoses which included but were not limited to dysphagia, pharyngeal phase (difficulty swallowing); other lack of coordination; and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop an individualized person-centered comprehensive care plan to address the needs of the resident for 4 of 25 sampled residents (Resident #1, #6, #96, and #99). This deficient practice was evidenced by the following: 1). On 10/23/2024 at 11:04 AM during the initial tour of the facility the surveyor observed Resident #1 who was seated on their bed eating breakfast. According to the admission record Resident #1 was admitted to the facility with the following but not limited to diagnoses: Type 2 diabetes mellitus. alcohol abuse, anxiety disorder, encounter for surgical aftercare following surgery on the circulatory system, and acute embolism and thrombosis of right tibial vein (conditions that disrupt blood flow). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a comprehensive Minimum Data Set (MDS), an assessment tool, within 14 days of resident admission to the facility. This deficient practice was identified for 1 of 25 sampled residents, (Resident #241) and was evidenced by the following: On 10/24/2024 at 09:55 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #241. The surveyor accessed the MDS tab in the EMR and reviewed the following: 10/17/2024 Admission/Medicare - 5 Day Status: In Progress In addition, review of the Next Tracking/Dischrg bar revealed that Resident #241's ARD (assessment reference date) was 10/24/2024 and was 5 days overdue. On 10/29/2024 at 09:42 AM, the surveyor conducted an interview with the facility MDS coordinator. [...]

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 develop and implement a baseline care plan (BCP) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. This deficient practice was identified for 2 of 25 sampled residents (Resident #90, #241) and was evidenced by the following: 1.) According to the admission Record, Resident #90 was admitted to the facility with diagnoses including but not limited to: Malignant Neoplasm of the Mandible, Type 2 Diabetes, unspecified Protein-Calorie Malnutrition, and Tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and help with breathing). [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that the Infection Preventionist was at 1 of 1 Quality Assurance Performance Improvement (QAPI) quarterly meeting and that QAPI meetings were held on a quarterly basis . This deficient practice was identified for 1 of the last 3 quarters and 2 of the last 3 quarters and was evidenced by the following: During a review of the facility QAPI 2024 book on 10/29/2024 at 08:44 AM, there was a sign in sheet with the topic of QAPI/QA Quarter 3. There was no signature or name for the Infection Preventionist. On 10/29/2024 at 09:25 AM the surveyor requested all of the last 3 quarter sign in sheets from the Regional DON (RDON) who said I came to the building in April and I asked where is the QAPI. There was nothing done since last year for QAPI. [...]

Inspectors wroteComplaint # NJ00175045 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that meet each resident's physical, mental and psychosocial needs for a resident with a history of falls. This deficient practice was identified for 1 of 3 residents reviewed for quality of care, (Resident #3) and was evidenced by the following: Review of the Electronic Medical record revealed the following: According to the admission Record, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but not limited to: Difficulty Walking, Fall Risk and Muscle Weakness and Fall. [...]

Inspectors wroteComplaint # NJ170236 Based on observations, interviews, and review of pertinent facility documents on 1/11/24, it was determined that the facility failed to ensure there were sufficient nursing staff to provide care for all residents on 1/10/2024 on the 11:00 P.M. to 7:00 A.M. shift. The facility also failed to follow its policy titled Staffing. This deficient practice occurred on 2 of 2 units, affected 8 of 8 residents (Resident #1, #2, #3, #4, #5, #6, #7 and #8) reviewed and had the potential to affect all other residents. This deficient practice was evidenced by the following: 1.) On 1/11/2024 at 5:50 A.M., Surveyor #1 accompanied by the Licensed Practical Nurse (LPN#1) completed an incontinence tour on the third floor (Subacute Nursing Unit). LPN#1 identified 6 random residents as being dependent on staff for care. [...]

Inspectors wroteComplaint #NJ161715 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 20 residents (Resident #6, Resident #364, Resident #41, and Resident #44) reviewed for comprehensive care plans. The deficient practice was evidenced by the following: 1.) On 06/13/2023 at 08:44 AM, Surveyor #1 observed Resident #6 sitting up in bed eating breakfast. The resident was able to state his/her name but could not remember why he/she was in the facility or for how long. On 06/20/2023 at 12:20 PM, Surveyor #1 observed Resident # 6 sitting in a wheelchair in the resident's room eating his/her lunch meal. The resident was feeding himself/herself. While smiling, Resident #6 stated that he/she was doing well. [...]

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 6/13/2023 from 9:05 to 9:43 AM the surveyor, accompanied by the District Manager (DM) and the Food Service Director (FSD), observed the following in the kitchen: 1. On the Metro Storage Rack stacks of what the FSD described as dessert plates, desert bowls, and salad bowls were cleaned and sanitized. The plates and bowls were not covered and were not in the inverted position leaving the cleaned and sanitized dishware exposed to contamination. On interview the FSD was not aware at the time that cleaned and sanitized equipment needs to be covered/inverted to not expose the equipment to contamination. 2. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently document in the Treatment Administration Record (TAR) for 1 of 1 resident (Resident #28) reviewed for pressure ulcer. 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 regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain infection control standards and procedures by failing to follow appropriate hand hygiene practices and perform wound treatment in a safe and sanitary manner for 1 of 1 resident (Resident #28) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 06/13/23 at 9:38 AM, the surveyor observed Resident #28 lying in bed, awake and alert, with his/her daughter at the bedside. The daughter stated that the resident had a wound on his/her buttocks and that the treatment was just done. The surveyor observed an air mattress on the bed. According to the admission Record, Resident #28 was admitted with medical diagnoses which included but not limited to: [...]