Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health 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: 184
Deficiencies: 3
May 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint# 176168 to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to maintain a safe, clean, comfortable, and homelike environment, specifically failing to maintain cleanliness in 1 of 13 rooms on a nursing unit. Additionally, the facility failed to meet minimum staffing ratios for Certified Nurse Aides (CNAs) and nursing staff on multiple days during the review period.
Complaint Details
Complaint# 176168 was substantiated. The complaint involved concerns about cleanliness and staffing ratios. Observations and interviews confirmed the facility failed to maintain cleanliness in resident bathrooms and failed to meet minimum staffing requirements for CNAs and nursing staff.
Severity Breakdown
Level D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain a clean and homelike environment evidenced by dry brown substance on grab bars, back of toilet, wall behind toilet, and bathroom floor in resident rooms. | Level D |
| Failure to maintain required minimum staffing ratios for CNAs on multiple days from 08/04/2024 to 05/03/2025. | Level D |
| Failure to maintain required minimum nursing staffing levels for 1 of 14 days during 04/20/2025 to 05/03/2025. | Level D |
Report Facts
Census: 184
Sample size: 6
Deficient CNA staffing days: 20
Deficient nursing staffing days: 1
Required CNA staffing: 22
Actual CNA staffing: 15
Required nursing staffing hours: 514.25
Actual nursing staffing hours: 424
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 1
Sep 6, 2024
Visit Reason
The inspection was conducted in response to complaint NJ175765 to investigate compliance with staffing requirements and other regulatory standards at Autumn Lake Healthcare at Vineland.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 standards due to failure to meet mandatory staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts reviewed, potentially affecting all residents. No negative outcomes to residents were identified during the shifts with deficient staffing.
Complaint Details
Complaint #: NJ175765. The facility failed to meet required CNA staffing ratios for 14 of 14 day shifts reviewed from 08/18/2024 to 08/31/2024. The deficient practice had the potential to affect all residents but no negative outcomes were identified. The facility implemented multiple corrective actions including job postings, incentives, agency staffing, and weekly monitoring.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts reviewed, violating mandatory access to care requirements. |
Report Facts
Census: 176
Deficient shifts: 14
Staffing ratios required: 22
Staffing counts: 13
Staffing counts: 21
Inspection Report
Routine
Census: 148
Deficiencies: 0
Dec 22, 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 and CDC recommended practices for COVID-19 preparation.
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 to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 136
Capacity: 190
Deficiencies: 9
Apr 20, 2023
Visit Reason
A recertification survey with complaints was conducted on behalf of the New Jersey Department of Health to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements, with deficiencies noted in maintaining a safe, clean, and homelike environment, bed rail use and documentation, staffing ratios, infection control, emergency preparedness, and life safety code compliance. Multiple residents' rooms and furniture were in disrepair, and staffing shortages were documented.
Complaint Details
The survey was a recertification survey with complaints filed under NJ00152230 and NJ00152821. The facility was found not in substantial compliance based on this recertification and complaint visit.
Severity Breakdown
Level E: 4
Level G: 1
Level A: 1
Level F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean and safe environment on three resident care wings, including disrepair of furniture and loose commode seats. | Level E |
| Facility failed to ensure proper assessment, consent, and documentation for bed rail use for multiple residents. | Level E |
| Facility failed to provide medically related social services to meet residents' needs, causing frustration and unmet needs for one resident. | Level G |
| Facility failed to ensure infection prevention and control program was effective, including handling of linens and storage of masks. | Level E |
| Facility failed to maintain adequate staffing ratios for Certified Nurse Aides on multiple day shifts. | Level A |
| Facility failed to ensure emergency lighting was present and functioning at the emergency generator transfer switch. | Level F |
| Facility failed to ensure fire alarm system and smoke detectors were tested and maintained according to standards. | Level F |
| Facility failed to ensure fire doors were inspected annually and maintained properly. | Level F |
| Facility failed to conduct regular inspection and maintenance of bed frames, mattresses, and bed rails, risking resident injury. | Level E |
Report Facts
Survey Census: 136
Total Capacity: 190
Staffing Deficiency Count: 17
Staffing Deficiency Count: 14
Staffing Deficiency Count: 17
Staffing Deficiency Count: 16
Residents Sampled: 33
Residents with Bed Rail Assessments: 4
Residents with Bed Rails: 136
Residents with BIMS Scores: 15
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Dec 6, 2021
Visit Reason
The inspection was conducted based on a complaint visit identified as NJ 149042.
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 number NJ 149042 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 132
Deficiencies: 0
Aug 17, 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 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: 7
Inspection Report
Annual Inspection
Census: 140
Deficiencies: 1
Mar 22, 2021
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 failure to follow an active physician's order for pressure ulcer prevention and treatment, including failure to apply assistive devices as ordered and inadequate monitoring of residents' use of such devices.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow an active physician's order to prevent and treat pressure ulcers for a resident, including failure to apply assistive devices as ordered. | SS=D |
Report Facts
Census: 140
Sample Size: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding resident care and assistive device application | |
| Director of Nursing (DON) | Interviewed regarding expectations for resident care and reviewed facility policy |
Inspection Report
Life Safety
Deficiencies: 1
Mar 22, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012, specifically regarding the emergency electrical generating system alarm annunciator at Lincoln Specialty Care Center.
Findings
The facility was found not in substantial compliance with the minimum Life Safety Code requirements due to failure to provide a remote alarm annunciator for the emergency electrical generating system that includes required visual fault notifications. The facility had an audible alarm only and was in the process of upgrading their system to meet requirements.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a remote alarm annunciator for the emergency electrical generating system with required visual fault notifications as per NFPA 99. | SS=E |
Report Facts
Previous citations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Director of Maintenance | Observed the remote alarm and provided information about the alarm device and maintenance procedures |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Provided information about previous citations, waiver status, and plans for upgrading the generator alarm system |
Inspection Report
Routine
Census: 131
Deficiencies: 0
Feb 3, 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: 6
Inspection Report
Routine
Census: 130
Deficiencies: 0
Jan 5, 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
Routine
Census: 148
Deficiencies: 0
Dec 4, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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