Inspection Reports for Autumn Lake Healthcare at Oceanview

Complaint #2649488, 2597199. The facility failed to thoroughly investigate an injury of unknown origin and failed to report it to the New Jersey Department of Health. The Director of Nursing did not report the injury because it was assumed to be caused by combative behavior and not of unknown origin. The investigation did not include checking other residents for injuries to rule out abuse.

The facility failed to complete a thorough investigation of an injury of unknown origin by not ruling out abuse and neglect and did not report the injury to the state. The injury involved a fracture to Resident #1's right hand due to combative behavior, and the facility assumed the cause was known without proper reporting or investigation of other residents.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, and New Jersey state regulations. Deficiencies were cited in areas including resident rights, safe environment, respiratory care, physician visits, drug regimen review, food safety, infection control, life safety code, and maintenance of building systems.

The facility was found deficient in multiple areas including failure to make survey results accessible to residents, maintaining a safe and homelike environment, proper respiratory equipment handling, ensuring physician face-to-face visits, timely pharmacist medication review follow-up, documentation of psychotropic medication use, kitchen sanitation, garbage disposal, and infection prevention practices.

The survey identified multiple deficiencies including failure to maintain sanitary conditions in resident and common bathrooms, incomplete and untimely care plans for residents with respiratory and fall risks, improper respiratory equipment maintenance, inaccurate implementation of fluid restriction orders, and unsafe food handling and sanitation practices in the kitchen and pantries.

Complaint investigation based on complaints NJ163840, NJ166936, and NJ168638. The facility was found not in substantial compliance with professional standards and staffing requirements. The complaint related to failure to notify physicians timely and inadequate CNA staffing. The complaint was substantiated as evidenced by interviews, record reviews, and policy review.

The facility was found not in substantial compliance with federal and state requirements, specifically failing to meet professional standards for clinical practice related to timely physician notification of laboratory results and failing to maintain adequate staffing ratios for Certified Nurse Aides (CNAs) on multiple day shifts.

Complaint #166936 regarding delayed physician notification of lab results for Resident #2 was substantiated with findings of delayed notification and failure to follow policy.

The facility failed to notify the physician promptly of Resident #2's urine culture and sensitivity (C&S) lab results received on 7/26/2023, with notification delayed until 7/31/2023 when antibiotic orders were given. Interviews with the Assistant Director of Nursing, Director of Nursing, and Nurse Practitioner confirmed the delay and lack of documentation. The facility policy requires timely notification of changes including new treatments.

The complaint investigation was triggered by allegations NJ163054 and NJ165615 regarding medication administration errors, inadequate ADL documentation, and insufficient staffing levels.

The facility was found not in substantial compliance with professional standards for medication and treatment administration for 2 of 5 residents reviewed, and failed to consistently document Activities of Daily Living (ADL) care for 1 of 5 residents. Additionally, the facility failed to meet required staffing ratios for certified nursing assistants (CNAs) on multiple day shifts.

Complaint NJ163054 alleged failure to follow clinical standards for medication and treatment administration and failure to document ADL care. The complaint was substantiated based on interviews, medical record reviews, and facility documentation review conducted on 7/25/2023, 7/31/2023, and 8/1/2023.

The facility failed to administer medications and treatments as ordered for 2 of 5 residents reviewed and failed to document administration properly. Additionally, the facility failed to consistently document ADL care for 1 of 5 residents, with numerous blank spaces on documentation forms indicating tasks were not completed or documented. Interviews with staff confirmed that blank documentation spaces indicated tasks were not done or not signed off. The facility policy requires complete and accurate documentation, which was not followed.

The facility failed to maintain the required minimum direct care staff to resident ratios for 10 of 14 day shifts reviewed in December 2022, not meeting the mandated CNA to resident ratios. A plan of correction was submitted with a completion date of February 15, 2023, and a follow-up revisit confirmed correction of the deficiency.

Complaint # NJ 00153160 was substantiated with findings of failure to maintain a safe and sanitary environment, including outdoor litter and improper dumpster maintenance.

The facility was found not in compliance due to failure to maintain a safe, clean, and homelike environment, specifically failing to keep the outdoor exterior clean and sanitary. Observations included used surgical masks and gloves on the ground, open dumpster lids with food and cardboard litter around them, indicating a repeat deficiency from the prior recertification survey.

The facility failed to maintain the required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 5 of 14 day shifts reviewed, specifically not meeting the CNA staffing ratio of 1 CNA to 8 residents on day shifts.

The facility was found deficient in multiple areas including failure to ensure privacy of resident electronic health records, inadequate cleanliness and maintenance of resident areas and equipment, unsafe food handling and storage practices, and improper disposal of garbage with uncovered dumpsters.