Deficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, the circumstances under which health information may be used or disclosed, the rights of individuals to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Routine
Census: 93
Deficiencies: 0
Feb 13, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Aug 30, 2023
Visit Reason
The inspection was conducted in response to complaint NJ00166529 to investigate allegations related to staffing ratios at Autumn Lake Healthcare at Berkeley Heights.
Findings
The facility was found not in compliance with New Jersey staffing regulations, failing to maintain the required minimum Certified Nursing Assistant (CNA) staffing ratios on 7 of 14 day shifts during the review period. The facility took corrective actions including hiring efforts and use of staffing agencies.
Complaint Details
Complaint #: NJ00166529. The facility was found deficient in CNA staffing ratios on multiple days, but no residents were found to be affected by the deficient practice.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-resident ratios for the day shift, specifically deficient in Certified Nursing Assistants (CNA) staffing on 7 of 14 day shifts. |
Report Facts
Census: 89
Deficient day shifts: 7
Required CNAs: 11
Actual CNAs: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding staffing issues and corrective actions. | |
| Director of Nursing | Director of Nursing | Responsible for daily review of staffing schedules and ensuring adequate staffing. |
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 15, 2022
Visit Reason
The inspection was conducted to assess compliance with the New Jersey LGBTQI+ and HIV+ Law requirements, specifically regarding staff training and facility policies related to care and rights of LGBTQI+ and HIV+ residents.
Findings
The facility failed to train two designated staff members and other facility staff within the required time frames on LGBTQI+ and HIV+ resident rights and care, as mandated by state law. The facility implemented corrective actions including staff training and ongoing quality assurance audits to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Failure to train two appointed designated staff members and facility staff within required time frames for LGBTQI+ and HIV+ program. |
Report Facts
Number of designated staff members not trained: 2
Number of staff members to be audited: 16
Training completion dates: First online portion completed on 2022-11-16; second portion completed on 2022-12-02.
Inspection Report
Life Safety
Census: 77
Capacity: 118
Deficiencies: 9
Nov 10, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/10/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be noncompliant with multiple Life Safety Code requirements including failure to inspect fire doors annually, inadequate illumination of means of egress, missing monthly inspections of kitchen Ansul system, lack of fire alarm notification devices in enclosed courtyard, deficient smoke detector maintenance, corridor doors not resisting smoke passage, unlocked electrical panels, generator transfer time not certified, and improper oxygen room lighting.
Severity Breakdown
SS=F: 5
SS=E: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to inspect fire doors annually in accordance with S&C 17-38-LSC for 7 of 7 fire doors observed. | SS=F |
| Failed to provide emergency illumination that operates automatically along means of egress affecting 2 of 6 exit access areas. | SS=E |
| Failed to ensure monthly inspection of kitchen Ansul system; inspection tag was blank. | SS=E |
| Failed to provide fire alarm notification by audible and visible signals for 1 enclosed courtyard. | SS=F |
| Failed to ensure testing, maintenance, and battery replacement program for 30 of 40 battery operated smoke detectors. | SS=F |
| Corridor doors failed to resist passage of smoke; 5 of 40 resident room doors did not latch or were warped. | SS=E |
| Electrical panels in exit corridor were unlocked and not guarded against accidental contact. | SS=E |
| Failed to certify generator transfer time within 10 seconds and lacked remote manual stop station. | SS=E |
| Oxygen trans filling room had a non-explosion proof light fixture, posing ignition risk. | SS=F |
Report Facts
Fire doors deficient: 7
Exit access areas deficient: 2
Kitchen Ansul system: 1
Enclosed courtyard: 1
Battery operated smoke detectors deficient: 30
Resident room doors deficient: 5
Unlocked electrical panels: 2
Generator: 1
Oxygen cylinders: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies | |
| Administrator | Informed of findings at Life Safety Code exit conference |
Inspection Report
Follow-Up
Census: 83
Deficiencies: 1
Aug 24, 2022
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing requirements and to follow up on previously identified deficiencies related to minimum direct care staff-to-resident ratios.
Findings
The facility was found deficient in maintaining the required minimum direct care staff-to-resident ratios on multiple day shifts during the weeks of 8/7/22 and 8/14/22, specifically lacking sufficient certified nurse aides on 5 of 14 day shifts. A follow-up revisit report dated 9/29/2022 indicates that the deficiency was corrected as of 9/1/2022.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
Report Facts
Certified Nurse Aides staffing deficiency: 5
Residents present: 85
Residents present: 86
Residents present: 83
Certified Nurse Aides required: 11
Certified Nurse Aides required: 10
Certified Nurse Aides present: 10
Certified Nurse Aides present: 8
Document
Deficiencies: 0
Feb 1, 2022
Visit Reason
This document does not contain any inspection or regulatory information; it is an instruction page for opening the PDF portfolio.
Findings
No inspection findings or regulatory content are present in this document.
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