Autumn Lake Healthcare at Vineland

In the surveyor’s words

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

• Actual harm, isolatedF745Apr 20, 2023

  Based on observation, interview, record review, and policy review, the facility failed to provide medically related social services to meet the resident's needs, by specifically failing to help one (Resident (R) 72) of 29 sampled residents obtain a birth certificate and state-issued identification (ID). This caused the resident harm as he has had extreme frustration for the past five years in his attempt to move back to his home in [NAME] Rico. Findings include: Review of R72's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R72 was admitted on [DATE] with a diagnosis of aphasia (communication disorder). […]

• No harm, potential for more than minimal, patternF656May 30, 2025

  2.) On 5/22/25 at 10:52 AM, during the initial tour, Resident #175 was not in his/her room and the surveyor observed a surgical shoe on the countertop. On 5/23/25 at 11:09 AM, the surveyor observed Resident #175 resting in bed while wearing a hinged brace and a surgical shoe on his/her right leg. The surveyor reviewed the medical record for Resident #175. A review of the admission Record revealed the resident had diagnoses which included, but were not limited to, fracture of shaft of right tibia (the inner and typically larger of the two bones between the knee and the ankle) and subsequent fracture of metatarsal (any of the bones of the foot). […]

• No harm, potential for more than minimal, patternF730May 30, 2025

  Based on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNA) on an annual basis. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed and was evidenced by the following: On 5/27/25 at 12:49 PM, the surveyor reviewed the personnel files for five CNAs. 1.) CNA #1, with a date of hire of 3/29/22, had their most recent Employee Evaluation completed on 1/30/24. 2.) CNA #2, with a date of hire of 4/28/10, had their most recent Employee Evaluation completed on 2/7/24. […]

• No harm, potential for more than minimal, patternF812May 30, 2025

  Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was identified in the facility's kitchen and 2 of 5 refrigerators designated for resident food, and was evidenced by the following: 1.) On 5/22/25 at 10:19 AM, during the initial tour of the kitchen, the surveyor, accompanied by the Food Service Director (FSD), observed a black bin containing four pitchers of juice for the residents. […]

• No harm, potential for more than minimal, patternF881May 30, 2025

  Based on interview and review of pertinent facility documentation, it was determined that the facility failed to implement their Antibiotic Stewardship Program by not utilizing a standardized infection surveillance criteria to determine if antibiotic use was appropriate. This deficient practice was identified for 5 of 5 residents (Resident #34, #77, #107, #109, and #382) reviewed for antibiotic use and was evidenced by the following: 1.) Review of the Infection Control Log for January 2025 revealed Resident #34 had a urinary tract infection (UTI) with an onset date of 12/30/24. Attached to the log was an Antibiotic Start Tracking Form that indicated the resident was started on an antibiotic for UTI on 12/30/24. […]