Deficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
75% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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
Annual Inspection
Deficiencies: 2
Nov 18, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments and safety measures, including the accuracy of Minimum Data Set (MDS) assessments and the functionality of wander guard systems for residents at risk of wandering or elopement.
Findings
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for 2 of 25 residents, resulting in missing diagnoses and care needs. Additionally, the facility did not consistently check the function of wander guards for 3 residents at risk of wandering, with issues in monitoring and documentation of the wander guard system.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to accurately complete the Minimum Data Set (MDS) for 2 of 25 residents, including missing diagnoses and tube feeding coding errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement a system for staff to consistently check the function of wander guards used on residents at risk for wandering/elopement for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS accuracy: 25
Residents with MDS deficiencies: 2
Residents reviewed for wander guard function: 3
BIMS score: 7
BIMS score: 9
BIMS score: 12
BIMS score: 6
BIMS score: 5
Wander guard expiration date: 2027
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding wander guard function and placement checks |
| Unit Manager | A-wing Unit Manager | Provided information on wander guard checking procedures and responsibilities |
| Unit Clerk | B-wing Unit Clerk | Responsible for checking wander guard function and maintaining elopement binder |
| Licensed Nursing Home Administrator | LNHA | Informed of MDS deficiencies by survey team |
| Corporate Director of Nursing | DON | Informed of MDS deficiencies by survey team |
| Registered Nurse #1 | RN | Described night shift procedures for checking wander guard function |
| Registered Nurse #2 | RN | Described procedures and knowledge about wander guard function checks |
| Regional Director of Nursing | RDON | Discussed wander guard system and responsibilities with survey team |
| Maintenance Director | MD | Provided information about wander guard system installation and compatibility issues |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 10, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with CDC pneumococcal vaccine guidelines and to assess whether residents were offered appropriate vaccinations.
Findings
The facility failed to follow CDC pneumococcal vaccine guidelines by not providing one resident (Resident 8) and/or their representative the opportunity to be vaccinated with Prevnar 20, potentially increasing the risk of pneumonia for that resident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure one resident and/or their representative was provided the opportunity to be vaccinated with one dose of Prevnar 20 (Pneumococcal Conjugate Vaccine 20). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist | Interviewed regarding pneumococcal vaccination policies | |
| Director of Nursing | Interviewed regarding vaccination opportunity for Resident 8 |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jul 19, 2024
Visit Reason
The inspection was conducted based on complaints alleging failure to properly investigate abuse allegations and incidents, provide appropriate incontinence and personal hygiene care, and ensure timely administration of physician-ordered medications.
Findings
The facility failed to ensure thorough investigations of abuse allegations, provide adequate incontinence and personal hygiene care to multiple residents, and administer medications timely according to physician orders, including proper monitoring of residents on intravenous cardiac medications.
Complaint Details
Complaint #NJ159516 involved failure to investigate verbal abuse and unplanned hospitalization. Complaint #NJ00175040 involved failure to provide appropriate incontinence and personal hygiene care. Complaints #NJ159619 and NJ173589 involved failure to provide appropriate treatment and care according to orders, including intravenous medication monitoring and timely medication administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure policy for Abuse Investigation and Incidents and Accidents was followed, resulting in incomplete investigations and documentation for verbal abuse and unplanned hospitalization incidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate incontinence care and personal hygiene for multiple residents, including residents found soaked with urine and feces, wearing multiple briefs, and with untreated skin redness. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care and assistance to perform activities of daily living for residents unable to do so, including timely incontinence care and nail care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents received treatment and care according to physician orders, including lack of policy and training for administration and monitoring of intravenous Milrinone medication and failure to timely administer ordered medications for newly admitted residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 8
Blood pressure readings expected: 84
Blood pressure readings documented: 28
Time elapsed since last incontinence care: 12
Hours worked: 6.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to failure to complete abuse investigations and medication administration monitoring. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in relation to incontinence care expectations and intravenous medication monitoring. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Named in relation to awareness of incomplete grievance forms and facility management. |
| Human Resource Director | Human Resource Director (HRD) | Mentioned as staff member receiving verbal abuse grievance. |
| Medical Director | Medical Director (MD) | Resident #88's physician interviewed regarding medication monitoring policies. |
| CNA #1 | Certified Nursing Assistant | Worked 7:00 AM to 1:30 PM, provided care to residents including Resident #50 and Resident #63. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 130
Deficiencies: 14
Jul 19, 2024
Visit Reason
The inspection was conducted based on complaint investigations regarding abuse allegations, unplanned hospitalizations, and concerns about staffing and care quality.
Findings
The facility failed to ensure thorough investigations of abuse allegations, timely and appropriate care for residents including incontinence care, medication administration, staff training, and infection prevention. Multiple deficiencies were found in care planning, medication management, staff competency, and facility sanitation.
Complaint Details
Complaint #NJ 159516 involved allegations of verbal abuse by staff and failure to investigate unplanned hospitalizations. Additional complaints NJ 00175040, NJ159619, and NJ173589 involved concerns about incontinence care, medication administration, and staffing.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Actual harm: 2
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure thorough investigation and documentation of abuse allegations and unplanned hospitalizations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately assess and revise care plans for residents with behavioral issues such as wandering and urinating in other residents' rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from verbal and physical abuse, including staff verbal abuse and resident-to-resident physical assault. | Level of Harm - Actual harm |
| Failure to provide timely and appropriate incontinence care and personal hygiene for multiple residents, including residents left soiled for extended periods and wearing multiple saturated briefs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents received treatment and care in accordance with professional standards, including failure to monitor and administer intravenous inotropic medication and failure to timely administer newly ordered medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate restorative nursing services and range of motion interventions for residents with limited mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents received oxygen as ordered, with documented instances of oxygen set below physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nurse aides received required training and competencies prior to providing independent direct resident care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post an up-to-date and accurate Nursing Home Staffing Report. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper pharmaceutical services including timely acquisition and administration of medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals were labeled properly and stored securely, including narcotics not affixed in refrigerator and intermingled unlabeled topical medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain the kitchen and food storage areas in a clean and sanitary manner, including unlabeled and expired foods, dirty equipment, and poor cleaning schedules. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to identify and implement interventions to address resident concerns through the Quality Assurance and Performance Improvement (QAPI) program, including issues with staffing, training, grievances, abuse, medication management, incontinence care, and use of uncertified nurse aides. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to designate a qualified infection preventionist to be responsible for the infection prevention and control program in the nursing home. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident census: 97
Total licensed capacity: 130
Blood pressure readings required: 84
Blood pressure readings documented: 28
Nurse Aide Training Module 1 completion date: Jul 12, 2024
Nurse Aide Training Module 2 test date: Jul 9, 2024
Nurse Aide Training Module 2 retest date: Jul 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to failure to investigate abuse allegations and medication administration oversight | |
| Licensed Nursing Home Administrator | Named in relation to oversight of grievance and QAPI program | |
| Human Resources Director | Named in relation to Nurse Aide training program and staffing | |
| Assistant Director of Nursing | Named in relation to medication administration and nurse aide training | |
| Licensed Practical Nurse/Unit Manager | Named in relation to medication storage and nurse aide training | |
| Food Service Supervisor | Named in relation to kitchen sanitation deficiencies | |
| Infection Preventionist | Named as facility IP and ADON with dual role | |
| Medical Director | Named in relation to medication monitoring and orders |
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 13, 2024
Visit Reason
The inspection was conducted as a routine annual survey of Autumn Lake Healthcare at Berkeley Heights to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
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
Routine
Deficiencies: 3
Nov 15, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, medication labeling, infection prevention, and control practices at Autumn Lake Healthcare at Berkeley Heights.
Findings
The facility was found deficient in performing blood glucose monitoring as ordered by physicians, labeling insulin pens with expiration dates, and performing adequate hand hygiene during wound treatment and medication administration. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to perform blood glucose monitoring as ordered by the physician for diabetic residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label insulin pens with expiration dates when opened in medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform hand hygiene in a manner that would decrease the possibility of spreading infection during wound treatment and medication administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Insulin pens inspected: 4
Handwashing durations: 7
Handwashing seconds: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed performing blood glucose monitoring incorrectly | |
| Registered Nurse (RN) | Assigned to medication cart with undated insulin pens | |
| Regional Registered Nurse (RRN) | Interviewed regarding insulin pen labeling and hand hygiene concerns | |
| Unit Manager/Registered Nurse (UM/RN) | Observed performing wound treatment with inadequate hand hygiene |
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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