Inspection Reports for
Autumn Lake Healthcare at Southgate

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.

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 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.

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.

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.