Notice
Deficiencies: 0
Nov 19, 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, reasons for use and disclosure of health information, individuals' rights 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Jun 16, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ186893.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint #: NJ186893. The facility was found compliant based on the complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 109
Capacity: 120
Deficiencies: 9
Jan 9, 2025
Visit Reason
Routine standard survey conducted on 01/09/2025 to assess compliance with federal and state regulations for long term care facilities.
Findings
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.
Severity Breakdown
Level D: 3
Level E: 3
Level F: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to make survey results readily accessible to residents and visitors. | Level D |
| Facility failed to maintain a safe, clean, comfortable, and homelike environment including maintenance issues with PTAC units, walls, floors, and closets. | Level E |
| Facility failed to ensure respiratory care equipment was properly maintained and used according to professional standards. | Level E |
| Facility failed to ensure timely and adequate physician visits and documentation. | Level D |
| Facility failed to conduct monthly drug regimen reviews and follow up on pharmacist recommendations. | Level D |
| Facility failed to maintain kitchen sanitation and food safety including unlabelled food items and improper storage. | Level F |
| Facility failed to maintain proper housekeeping and refuse disposal practices. | Level F |
| Facility failed to maintain infection prevention and control program including hand hygiene and PPE use. | Level E |
| Facility failed to maintain life safety code compliance including fire sprinkler system maintenance, door latching, smoke barrier doors, and electrical safety. | Level F |
Report Facts
Sample Size: 26
Deficiencies cited: 10
Licensed beds: 120
Resident census: 109
Plan of correction completion date: Feb 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse / Unit Manager (LPN/UM) #1 | Licensed Practical Nurse / Unit Manager | Interviewed regarding medication equipment and facility policy |
| Licensed Practical Nurse / Unit Manager (LPN/UM) #3 | Licensed Practical Nurse / Unit Manager | Interviewed regarding facility policy for PRN medications and behavior charting |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Observed handling soiled linens and trash without proper sanitization |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Observed handling soiled linens and trash without proper sanitization |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding staffing and universal transfer form compliance |
| Maintenance Director | Maintenance Director | Responsible for conducting monthly audits and corrective actions for facility maintenance |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Dec 11, 2023
Visit Reason
The inspection was conducted due to complaints NJ163840, NJ166936, and NJ168638 regarding compliance with professional standards and staffing ratios at Autumn Lake Healthcare at Oceanview.
Findings
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 Details
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.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow standards of clinical practice for timely notification of physician regarding laboratory results for a resident. | SS=D |
| Failure to ensure staffing ratios were met for Certified Nurse Aides on 7 of 14 day shifts reviewed. | — |
Report Facts
Census: 97
Sample Size: 4
Deficient CNA staffing days: 7
CNA staffing counts: 10
CNA staffing counts: 11
CNA staffing counts: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Interviewed regarding lab result notification process and nurse responsibilities |
| Director of Nursing | DON | Interviewed confirming lab result notification dates and staffing corrective actions |
| Director of Nursing Services | Director of Nursing Services | Responsible for in-service education programs and monitoring corrective actions |
| Nurse Practitioner | NP | Interviewed acknowledging Resident #2 was their patient and discussed notification issues |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 3
Aug 1, 2023
Visit Reason
The inspection was conducted based on complaints NJ163054 and NJ165615 to investigate alleged deficiencies related to medication administration, treatment documentation, and staffing ratios.
Findings
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 Details
The complaint investigation was triggered by allegations NJ163054 and NJ165615 regarding medication administration errors, inadequate ADL documentation, and insufficient staffing levels.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow standards of clinical practice for medication and treatment administration as ordered by the physician for 2 of 5 residents, including incomplete documentation on Medication Administration Records (MARs) and Treatment Administration Records (TARs). | SS=D |
| Failure to consistently document Activities of Daily Living (ADL) care for 1 of 5 residents, with multiple blank spaces on ADL documentation sheets indicating tasks were not documented as completed. | SS=D |
| Failure to ensure staffing ratios were met for certified nursing assistants (CNAs) on 16 of 28 day shifts reviewed, with CNA staffing below required minimums. | — |
Report Facts
Census: 96
Sample size: 5
Deficient CNA staffing day shifts: 16
Required CNA staffing: 11
Actual CNA staffing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to medication and ADL documentation findings and corrective actions | |
| Unit Manager/Licensed Practice Nurse | Interviewed regarding blank spaces on MAR/TAR and ADL documentation | |
| Licensed Practice Nurse | Interviewed regarding blank spaces on TAR for Resident #4 | |
| Certified Nursing Assistant | Interviewed regarding ADL documentation practices |
Inspection Report
Follow-Up
Census: 88
Deficiencies: 1
Dec 29, 2022
Visit Reason
The visit was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically to investigate staffing levels and ensure correction of previously cited deficiencies.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 10 of 14 day shifts reviewed. |
Report Facts
Residents present: 88
CNA staffing deficiency days: 10
Required CNA per day shift: 11
Actual CNA staffing: 9
Correction completion date: Feb 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed by surveyor regarding staffing requirements and compliance | |
| Director of Nursing | Responsible for daily review of staffing schedules and reporting findings to Administrator |
Document
Deficiencies: 0
Sep 16, 2022
Visit Reason
The document does not contain any inspection or regulatory information; it is a prompt to open the PDF portfolio in a compatible reader.
Findings
No inspection findings or regulatory content are present in this document.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Mar 16, 2022
Visit Reason
The inspection was conducted based on Complaint # NJ 00153160 to investigate compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
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.
Complaint Details
Complaint # NJ 00153160 was substantiated with findings of failure to maintain a safe and sanitary environment, including outdoor litter and improper dumpster maintenance.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to keep the outdoor exterior clean and sanitary, including litter of used surgical masks and gloves in the parking lot and open dumpster lids with surrounding litter. | SS=E |
Report Facts
Census: 89
Used surgical masks found: 15
Used surgical gloves found: 5
Cardboard boxes on ground: 24
Inspection Report
Plan of Correction
Census: 91
Deficiencies: 1
Dec 10, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, specifically focusing on mandatory access to care and staffing ratios.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 5 of 14 day shifts reviewed. |
Report Facts
Residents on day shift: 91
CNA staffing deficiency days: 5
Required CNAs per shift: 12
Actual CNAs on 11/19/21: 11
Actual CNAs on 11/20/21: 10
Actual CNAs on 11/21/21: 9
Actual CNAs on 11/22/21: 11
Actual CNAs on 11/27/21: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as ultimately responsible to ensure adequate CNA staffing |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding awareness of staffing mandates and staffing challenges |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
May 13, 2021
Visit Reason
The inspection visit was conducted in response to a complaint (Complaint# NJ 135295) to assess compliance with regulatory requirements.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint# NJ 135295 was investigated and the facility was found to be in compliance.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 102
Deficiencies: 0
Feb 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended COVID-19 practices.
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 for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 90
Deficiencies: 0
Jan 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by 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 for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 97
Deficiencies: 0
Dec 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
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 for COVID-19.
Report Facts
Sample size: 3
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