Deficiencies per Year
12
9
6
3
0
Moderate
Low
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 explains 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: 143
Deficiencies: 1
May 22, 2025
Visit Reason
The inspection was conducted based on complaints NJ186169 and NJ186357 to determine compliance with pharmacy services regulations at Autumn Lake Healthcare at Southgate.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically related to pharmacy services and medication administration. Deficiencies included failure to ensure medication ordered by the physician was received and available for administration to residents, evidenced by issues with Resident #2's medication records and administration.
Complaint Details
Complaint numbers NJ186169 and NJ186357 triggered the investigation. The complaint was substantiated as the facility failed to ensure proper medication receipt and administration for Resident #2.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that the medication ordered by the physician was received and available to be administered for 1 out of 3 sampled residents (Resident #2). | Level D |
Report Facts
Census: 143
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Apr 21, 2025
Visit Reason
The inspection was conducted in response to a complaint (NJ185215) to assess compliance with long term care facility regulations.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and in compliance with New Jersey Administrative Code standards for licensure of long term care facilities based on this complaint visit.
Complaint Details
Complaint #: NJ185215. The facility was found to be in substantial compliance based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 115
Deficiencies: 0
Aug 16, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 114
Capacity: 114
Deficiencies: 10
Jan 17, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to safe environment, abuse/neglect policies, PASARR assessments, comprehensive care plans, medication administration, food safety, infection control, nurse staffing, fire safety, and evacuation planning. Corrective actions and systemic changes were planned or implemented for each deficiency.
Severity Breakdown
SS=D: 3
SS=E: 5
SS=B: 1
SS=F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to maintain cleanliness of floors and resident rooms, posing safety risks. | SS=D |
| Facility failed to develop and implement abuse, neglect, and exploitation policies and procedures. | SS=D |
| Facility failed to conduct required PASARR assessments and resident reviews. | SS=D |
| Facility failed to maintain professional standards of care in comprehensive care plans. | SS=E |
| Facility failed to maintain medication administration standards, including documentation and timely administration. | SS=E |
| Facility failed to maintain food safety standards including proper storage, labeling, and disposal. | SS=E |
| Facility failed to maintain infection prevention and control practices including hand hygiene and PPE use. | SS=E |
| Facility failed to post nurse staffing information in a prominent and accessible location. | SS=B |
| Facility failed to maintain fire alarm system sensitivity testing and smoke barrier integrity. | SS=F |
| Facility failed to maintain an adequate evacuation and relocation plan for emergencies. | SS=F |
Report Facts
Census: 114
Total Capacity: 114
Deficiency counts: 11
Staffing ratios: 5
Inspection Report
Routine
Census: 95
Deficiencies: 0
Sep 10, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 3
Jun 21, 2021
Visit Reason
The inspection was conducted based on a complaint (NJ144342) alleging failure to report and investigate an incident of physical restraint involving a resident.
Findings
The facility failed to report an allegation of physical restraint to the New Jersey Department of Health and did not follow its own Abuse-Reporting and Investigation policy. The Director of Nursing (DON) and Administrator acknowledged that the allegation was not reported or properly investigated, and corrective actions were planned including audits and staff education.
Complaint Details
Complaint NJ144342 involved an allegation that two Certified Nursing Assistants tied a resident to a part of the resident's body, which was not reported or investigated properly by the facility. The DON admitted to not reporting the incident because she could not prove abuse, and the Administrator confirmed the DON did not report the allegation. The investigation was incomplete and no staff interviews or statements were obtained.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report an allegation of physical restraint to the NJ Department of Health within required timeframes. | SS=D |
| Failure to investigate an allegation of physical restraint and follow facility policy for abuse reporting and investigation. | SS=D |
| Failure of administration to ensure facility policy for abuse reporting and investigation was followed. | SS=D |
Report Facts
Census: 98
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Director of Nursing | Named in findings related to failure to report and investigate abuse allegations. |
| Administrator | Facility Administrator | Named in findings related to failure to ensure abuse reporting and investigation policies were followed. |
Inspection Report
Routine
Census: 82
Deficiencies: 0
May 12, 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: 3
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Jan 19, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00131566, NJ00131615, and NJ00138792.
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 numbers NJ00131566, NJ00131615, and NJ00138792 were investigated and found to be without deficiencies.
Report Facts
Sample Size: 5
Loading inspection reports...
