Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
94% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
The inspection was conducted based on Complaint #2648625 to investigate infection control practices related to a resident with open wounds and a urinary catheter.
Complaint Details
Complaint #2648625 was substantiated based on observations, interviews, and record reviews showing failures in infection control practices for Resident #1.
Findings
The facility failed to implement infection control practices consistent with CDC Enhanced Barrier Precautions for a resident with open wounds, including improper handling of wound care and urinary drainage bag placement, posing a risk of contamination.
Deficiencies (1)
Failure to implement infection control practices consistent with CDC Enhanced Barrier Precautions for a resident with open wounds.
Report Facts
Resident BIMS score: 12
Stage 4 pressure ulcer: 4
Date of MDS assessment: Jul 19, 2025
Date of TAR: Oct 1, 2025
Date of TAR: Oct 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed performing wound care without proper infection control precautions |
| Infection Preventionist | Infection Preventionist | Provided interview confirming infection control expectations and practices |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control policies and practices |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Present during interview with Director of Nursing about infection control |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The inspection was conducted based on a complaint alleging that the facility failed to ensure that medication ordered by the physician was received and available to be administered for one resident.
Complaint Details
Complaint #NJ186169 regarding failure to administer ordered medication to Resident #2; substantiation status not explicitly stated.
Findings
The facility failed to administer the ordered medication Xarelto Tablet 20MG to Resident #2 on 5/2/2025, with no documentation that the doctor was notified of the missed dose. The medication was later received from the contracted pharmacy on 5/3 and 5/4/2025. The facility policy requires nurses to follow physician orders and notify the doctor if a dose is missed.
Deficiencies (1)
Failure to ensure that the medication ordered by the physician was received and available to be administered for Resident #2.
Report Facts
Sampled residents: 3
Residents affected: 1
Medication dose missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided information about medication administration expectations during interview | |
| Infection Preventionist nurse | Provided information about attempts to borrow medication during interview | |
| Administrator | Provided information about agency nurse working on 5/2/25 during exit conference |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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).
Report Facts
Census: 143
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
The inspection was conducted in response to a complaint (NJ185215) to assess compliance with long term care facility regulations.
Complaint Details
Complaint #: NJ185215. The facility was found to be in substantial compliance based on this complaint visit.
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.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 26, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a safe, clean, and homelike environment, and failure to develop comprehensive care plans for residents, including pain management and oxygen use.
Complaint Details
Complaint #NJ169844 and others related to environmental cleanliness and care plan deficiencies. The complaint investigation found substantiated issues with facility cleanliness and care planning.
Findings
The facility was found deficient in maintaining cleanliness in resident units and common areas, including unclean water coolers, ice carts, trash cans, windows with cobwebs, and general housekeeping shortages. Additionally, the facility failed to develop comprehensive care plans for residents related to tube feeding, pain management, and oxygen use. There was also a failure to timely follow up on a pain management specialist appointment for a resident.
Deficiencies (3)
Failure to maintain resident environment, equipment, and living areas in a safe, sanitary, and homelike manner, including unclean water cooler, ice cart, trash can lids, and windows with cobwebs.
Failure to develop an individual comprehensive care plan (ICCP) to include tube feeding, risk for pain, and oxygen use for residents.
Failure to follow-up on a healthcare provider's recommendation for a pain management appointment in a timely manner for a resident.
Report Facts
Residents interviewed in resident council: 5
Pain medication administrations: 31
Pain management specialists on list: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding care plan creation and pain management responsibilities. |
| Licensed Practical Nurse/Unit Manager #1 | Licensed Practical Nurse/Unit Manager | Interviewed regarding care plan creation, pain management, and appointment scheduling responsibilities. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan policies and confirmed deficiencies in care planning and appointment scheduling. |
| Unit Clerk #2 | Unit Clerk | Interviewed regarding scheduling of pain management appointments and handling of insurance issues. |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding pain management for Resident #108 and difficulties scheduling specialist appointments. |
| Admissions Director | Admissions Director | Interviewed regarding communication about insurance calls for pain management specialist. |
| Housekeeper #1 | Housekeeper | Interviewed regarding cleaning responsibilities and limitations. |
| Housekeeper #2 | Housekeeper | Interviewed regarding cleaning responsibilities and limitations. |
| Housekeeper #5 | Housekeeper | Interviewed regarding cleaning practices in pantry area. |
| Interim Director of Housekeeping | Interim Director of Housekeeping | Interviewed regarding housekeeping staffing and cleaning responsibilities. |
| Food Service Director | Food Service Director | Interviewed regarding cleaning responsibilities for ice carts. |
| Director of Maintenance | Director of Maintenance | Interviewed regarding facility maintenance and housekeeping responsibilities. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Feb 26, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a safe, clean, and homelike environment, failure to implement abuse prevention policies, failure to develop comprehensive care plans, failure to provide appropriate pressure ulcer care, failure to provide safe respiratory care, failure to provide appropriate pain management, failure to ensure food safety and palatable food temperatures, failure to maintain sanitation in food handling, failure to minimize infection spread during incontinence care, and failure to maintain essential equipment safely.
Complaint Details
The complaint investigations NJ 169844, NJ167424, NJ169906, and NJ170986 involved issues such as environmental cleanliness, abuse prevention, care planning, pressure ulcer prevention, respiratory care, pain management, food safety, infection control, and equipment maintenance.
Findings
The facility was found deficient in multiple areas including environmental cleanliness and maintenance, incomplete employee reference checks, lack of comprehensive care plans for residents' specific needs, failure to follow physician orders for pressure ulcer prevention and respiratory care, delayed pain management appointments, unsafe food temperatures and sanitation practices, inadequate infection control during incontinence care, and failure to maintain dryer machines properly.
Deficiencies (10)
Failure to maintain resident environment, equipment, and living areas in a safe, sanitary, and homelike manner.
Failure to implement facility's abuse policy to ensure reference checks were completed for 10 of 10 employee files reviewed.
Failure to develop and implement a complete care plan that meets all the resident's needs, including tube feeding, pain, and oxygen use.
Failure to provide appropriate pressure ulcer care by not following physician's order for bilateral heel boots.
Failure to provide safe and appropriate respiratory care by not ensuring continuous oxygen administration as ordered.
Failure to provide safe, appropriate pain management by not timely following up on healthcare provider's recommendation for pain management appointment.
Failure to ensure food and drink are palatable, attractive, and served at safe and appetizing temperatures.
Failure to procure food from approved sources and maintain sanitation in food handling, including improper food storage, unclean equipment, and inadequate dishwashing.
Failure to minimize the spread of infection during incontinence care rounds, including inadequate handwashing.
Failure to maintain dryer machines in a safe operating condition and failure to follow lint trap cleaning policy.
Report Facts
Medication administrations: 31
Residents in Resident Council: 5
Temperature readings: 125
Temperature readings: 48.6
Lint trap cleaning frequency: 2
Number of employee files reviewed: 10
Number of highlighted pain management specialists: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Human Resources | Director of Human Resources | Interviewed regarding incomplete employee reference checks |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding care planning and pain management |
| Licensed Practical Nurse/Unit Manager #1 | Licensed Practical Nurse/Unit Manager | Interviewed regarding care planning and pain management |
| Director of Nursing | Director of Nursing | Interviewed regarding care planning, pain management, and infection control |
| Regional Nurse | Regional Nurse | Interviewed regarding care planning |
| Food Service Director | Food Service Director | Interviewed regarding food safety and cleaning schedules |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding employee reference checks and dryer maintenance |
| Interim Director of Housekeeping | Interim Director of Housekeeping | Interviewed regarding housekeeping staffing and cleaning |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control and hand hygiene |
| Unit Clerk #2 | Unit Clerk | Interviewed regarding scheduling pain management appointments |
| Unit Clerk #1 | Unit Clerk | Interviewed regarding scheduling appointments |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding pain management |
Inspection Report
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
The inspection was conducted as a regulatory survey of Autumn Lake Healthcare at Southgate to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 115
Deficiencies: 0
Date: 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
Deficiencies: 10
Date: Jan 17, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements including cleanliness, abuse prevention, PASRR assessments, medication administration, staffing postings, food safety, infection control, and equipment handling.
Findings
The facility was found deficient in maintaining cleanliness of floors and resident rooms, implementing abuse prevention policies, conducting PASRR level II assessments for newly diagnosed mental illness, following physician orders for medication administration, posting nurse staffing information, ensuring pharmacist oversight of medication irregularities, proper food storage and labeling, infection prevention practices including hand hygiene and PPE use, and proper storage of respiratory and urinary catheter equipment.
Deficiencies (10)
Failure to maintain cleanliness of floors and resident rooms, including dirty hallway floors and tube feeding spillage.
Failure to appropriately implement Abuse, Neglect and Exploitation Policy and Procedure for one resident.
Failure to conduct new PASRR level II assessments after residents were newly diagnosed with major mental illness.
Failure to follow physician's order for administration of Midodrine medication for low blood pressure in one resident.
Failure to post nurse staffing information in a prominent and accessible location for all shifts.
Failure of Consultant Pharmacist to identify and report medication irregularities regarding Midodrine administration.
Failure to store, label, and date potentially hazardous foods properly and discard expired foods.
Failure to ensure staff practiced appropriate hand hygiene and PPE use during meal tray distribution and infection control practices including improper use of meal carts in COVID-19 positive rooms.
Failure to properly store respiratory equipment and maintain infection control for oxygen tubing.
Failure to properly store indwelling urinary catheter drainage bag off the floor to prevent infection.
Report Facts
Residents reviewed: 23
Deficiency citations: 10
Medication administration dates: Jul 7, 2022
Medication administration dates: Aug 17, 2022
Medication administration dates: Sep 28, 2022
Blood pressure parameters: 11060
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN#1 | Licensed Practical Nurse | Named in medication administration deficiency and interview regarding Midodrine order confusion |
| LPN#2 | Licensed Practical Nurse | Named in medication administration deficiency and interview regarding Midodrine order confusion |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including medication administration, infection control, and staffing postings |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Interviewed regarding infection control and urinary catheter care |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding failure to identify medication irregularities |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding food storage and labeling deficiencies |
Inspection Report
Routine
Census: 114
Capacity: 114
Deficiencies: 10
Date: 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.
Deficiencies (10)
Facility failed to maintain cleanliness of floors and resident rooms, posing safety risks.
Facility failed to develop and implement abuse, neglect, and exploitation policies and procedures.
Facility failed to conduct required PASARR assessments and resident reviews.
Facility failed to maintain professional standards of care in comprehensive care plans.
Facility failed to maintain medication administration standards, including documentation and timely administration.
Facility failed to maintain food safety standards including proper storage, labeling, and disposal.
Facility failed to maintain infection prevention and control practices including hand hygiene and PPE use.
Facility failed to post nurse staffing information in a prominent and accessible location.
Facility failed to maintain fire alarm system sensitivity testing and smoke barrier integrity.
Facility failed to maintain an adequate evacuation and relocation plan for emergencies.
Report Facts
Census: 114
Total Capacity: 114
Deficiency counts: 11
Staffing ratios: 5
Inspection Report
Routine
Census: 95
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (3)
Failure to report an allegation of physical restraint to the NJ Department of Health within required timeframes.
Failure to investigate an allegation of physical restraint and follow facility policy for abuse reporting and investigation.
Failure of administration to ensure facility policy for abuse reporting and investigation was followed.
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
Date: 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
Date: Jan 19, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00131566, NJ00131615, and NJ00138792.
Complaint Details
Complaint numbers NJ00131566, NJ00131615, and NJ00138792 were investigated and found to be without deficiencies.
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.
Report Facts
Sample Size: 5
Inspection Report
Deficiencies: 8
Date: Oct 21, 2020
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and sanitation standards in the kitchen and food handling areas.
Findings
The facility was found to have multiple deficiencies related to improper handling and storage of food, inadequate sanitation of kitchen equipment, and failure to maintain proper labeling and dating of food products. Several items were discarded by the Food Service Director during the inspection due to these issues.
Deficiencies (8)
Opened and exposed box of plastic knives in dry storage area.
Wet nesting of steam table pans preventing proper drying.
Opened and exposed boxes of Foodservice Film on prep table.
Unidentifiable brownish/black substance inside ice machine backsplash.
Opened and exposed box of frozen beef patties in walk-in freezer.
Opened bags of Parmesan and shredded cheddar cheese without open or use by dates.
Uncovered and not inverted stacks of cleaned plates used to serve resident meals.
Electrical outlet covers and cord covered with brown debris/grease-like substance.
Report Facts
Dates of ice machine cleaning invoices: Invoices dated 5-4-2020 and 7-31-2020 provided for ice machine cleaning.
Inspection observation times: Observations made on 10/14/20 from 8:36 to 9:22 AM and on 10/20/20 from 9:50 to 10:20 AM.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Accompanied surveyor and took corrective actions during inspection. | |
| Administrator | Interviewed regarding cleaning responsibilities and maintenance actions. |
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