Autumn Lake Healthcare at Southgate

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Southgate, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 26, 2025

  Based on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 2/19/25 from 9:26 AM to 10:55 AM, the surveyor observed the following in the presence of [NAME] #1: 1. The Receptionist was observed exiting the walk-in refrigerator with a tray of food items and proceeded to give the tray to Dietary Aide (DA) #3. When interviewed, DA #3 stated that he was instructed to throw eight containers of the pudding in the trash. […]

• No harm, potential for more than minimal, patternF584Feb 26, 2025

  Complaint #NJ 169844 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 3 of 3 resident units (100, 200, and 300 Unit) and was evidenced by the following: 1.) On 2/20/25 at 9:58 AM, the surveyor, in the presence of Registered Nurse/Unit Manager (RN/UM) #1, observed the following in the pantry area on the 300 unit: -A water cooler had a build-up of white streaks and grime. -An ice cart that contained a plastic liner with multiple rips and brown stains. […]

• No harm, potential for more than minimal, patternF607Feb 26, 2025

  Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for 10 of 10 employee files reviewed. This deficient practice was evidenced by the following: On 2/25/25 at 11:00 AM, the surveyor reviewed the 10 randomly selected employee files, which revealed the following: 1. Registered Nurse (RN #1), with a hire date of 4/16/24, did not have a previous employee reference on file. 2. Licensed Practical Nurse (LPN #5), with a hire date of 1/21/25, did not have a previous employee reference on file. 3. Certified Nursing Assistant (CNA #5), with a hire date of 1/7/25, did not have a previous employee reference on file. 4. […]

• No harm, potential for more than minimal, patternF656Feb 26, 2025

  Complaint #: NJ167424, NJ169906, NJ170986 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to include a.) tube feeding, b.) risk for pain, and c.) oxygen use. This deficient practice was identified in 3 of 28 residents (Resident #85, #108, and #391) reviewed and was evidenced by the following: 1.) On 2/25/25 at 10:14 AM, the surveyor reviewed the medical record for Resident #85. […]

• No harm, potential for more than minimal, patternF697Feb 26, 2025

  Complaint #: NJ169906 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow-up on a healthcare provider's recommendation for a pain management appointment in a timely manner for 1 of 2 residents (Resident #108) reviewed for pain management. This deficient practice was evidenced by the following: On 2/19/25 at 10:05 AM, during the initial tour, the surveyor observed Resident #108 lying in bed. At that time, the nurse entered the room to administer the resident's medications and asked the resident if he/she had pain. The resident complained of nine out of 10 pain to his/her back. When the nurse left the room to get the resident pain medication, the resident stated his pain was not being managed properly. […]