Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Salem County during CMS and state inspections, most recent first.
A resident with multiple comorbidities and incontinence was not given a complete and accurate skin assessment upon admission, resulting in missed documentation of excoriation and edema. The initial assessment failed to identify skin impairment, and wound care orders were delayed until a subsequent assessment by an LPN. Required incident reporting and documentation were not completed as per facility policy.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
A resident with diabetes experienced a critically low blood sugar, but the LPN did not notify the physician as required by orders and facility policy. Review of records and staff interviews confirmed the lack of notification and documentation, despite clear protocols for such events.
Staff failed to consistently document ADL care provided or refused for three residents with complex medical needs, resulting in missing entries in the DSR and progress notes. Despite the use of a mobile documentation system and clear policy expectations, required ADL documentation was incomplete on multiple shifts, and supervisory checks did not ensure compliance.
A facility failed to develop a comprehensive care plan for a resident with diabetes and elongated toenails, despite the resident's severe cognitive impairment. The facility's policy required a person-centered care plan, but interviews with staff, including the UM and DON, confirmed the absence of such a plan. This oversight was identified during a survey, highlighting a deficiency in the care planning process.
A resident with diabetes and dementia did not have a care plan for their conditions, and there was a delay in podiatry care for elongated toenails. Additionally, there was a significant delay in notifying the physician of abnormal urine culture results, contrary to facility policy. These lapses in care highlight deficiencies in adhering to clinical standards.
A facility failed to provide timely podiatry care for a diabetic resident admitted with elongated toenails, who was not seen by a podiatrist for nearly nine months. Despite the facility's policy for prompt podiatry referrals, the resident's toenails were only addressed after a significant delay. Interviews revealed a breakdown in communication and procedure adherence among staff, contributing to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses had an abnormal urine culture result that was not promptly communicated to the physician, contrary to facility policy. The urine culture was collected and reported in early September, but the physician was not informed until several days later, delaying necessary antibiotic treatment. Interviews with facility staff confirmed the expectation for immediate notification of abnormal lab results to prevent potential escalation of the resident's condition.
The facility failed to maintain a homelike environment for three resident rooms on the C/D unit. Observations included damaged furniture, walls, and leaking sinks. Staff confirmed that maintenance issues were reported in a log, but some entries were incomplete, and repairs were not made. The Interim Maintenance Director acknowledged the unresolved issues and the need for repairs.
The facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross-contamination. Observations included undated raw chicken, wilted lettuce, undated liquids, unlabeled scalloped potatoes, damaged pork loins, a dented can, a dirty slicer, and a stained cutting board. The Dietary Director acknowledged these issues, which were not in compliance with the facility's policies.
An LPN failed to follow infection control practices and perform hand hygiene during a meal tray pass, handling food and interacting with residents without cleaning her hands. This was confirmed by multiple staff members and a review of the facility's hand hygiene policy.
The facility failed to follow professional standards by not obtaining a diagnosis for the use of an IV antibiotic for a resident admitted with cellulitis and a PICC line. The physician's order for Vancomycin did not include a diagnosis, and the resident and LPN were unaware of the infection being treated. The LPN/UM later confirmed the antibiotic was for MRSA in the blood, but acknowledged the order should have included a diagnosis. The facility's policy requires medication orders to include the clinical condition, which was not followed.
The facility failed to obtain a physician order for a skin tear treatment and did not update a resident's Care Plan with fall prevention interventions after an unwitnessed fall. The resident, who had a history of falls and was cognitively impaired, fell while trying to retrieve something from the closet, resulting in a skin tear. Despite claims in the incident report, no documentation was found in the Care Plan or Electronic Medical Record to support these actions.
The facility failed to ensure proper handling of a urinary catheter drainage bag for a resident with urinary retention. The drainage bag was observed touching the floor and not kept below the bladder level, contrary to the care plan and staff statements. The facility's Catheter Care policy did not specify that the drainage bag should be kept off the floor.
A resident receiving IV antibiotic therapy for cellulitis had an unlabeled and undated IV medication bag and tubing hanging on the IV pole. The medication was not administered due to a clogged PICC line, and the nurse failed to discard the medication as required. The facility's policies lacked specific instructions on labeling and dating IV tubing, contributing to the deficiency.
A facility failed to maintain an accurately documented and complete medical record for a resident who experienced an unwitnessed fall, resulting in a skin tear. Multiple staff members confirmed the absence of documentation in the progress notes, violating the facility's policy on charting and documentation.
Failure to Complete Timely and Accurate Skin Assessment on Admission
Penalty
Summary
The facility failed to perform an initial full body skin assessment and implement timely interventions for a resident upon admission, as required by its Skin Assessment Policy. Upon review, the admission screening indicated the resident's skin was intact, but a subsequent body check performed within 24 hours identified edema in both lower extremities and excoriation to both buttocks. The initial assessment did not document these findings, and the discrepancy was acknowledged by the Director of Nursing, who stated that the excoriation may have been missed during the first assessment. The resident in question had significant medical conditions, including aphasia, hemiplegia, hemiparesis following a stroke, diabetes, and major depressive disorder. The resident required one-person assistance for transfers and was incontinent of urine and frequently incontinent of bowel. Despite these risk factors, the initial skin assessment failed to identify the presence of skin impairment, and the need for wound care with Zinc Oxide was not recognized until the second assessment was completed by another nurse. Interviews with facility staff revealed that if skin issues were identified, an incident report should have been initiated and documented in the electronic medical record, but this was not done. The Treatment Administration Record indicated that a previous skin impairment was present, but there was no corresponding documentation in the progress notes or incident reporting. The delay in identifying and treating the skin impairment resulted in a delay in the administration of prescribed wound care.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Critically Low Blood Sugar
Penalty
Summary
A deficiency was identified when a nurse failed to notify a resident's physician of a critically low blood sugar result, as required by both physician orders and facility policy. The resident, who had intact cognition and a history of diabetes, hypertension, and chronic pain syndrome, had a blood sugar reading of 52, which was below the threshold specified in the physician's orders for mandatory physician notification. Review of the medical record and progress notes revealed no documentation that the physician was informed of this low blood sugar event. Interviews with nursing staff and the Director of Nursing confirmed that the physician should have been notified immediately and that documentation of this notification was required. The facility's policy on Notification of Changes also mandates prompt communication with the physician and the resident's representative when significant changes occur. The incident report further confirmed that the responsible nurse did not notify the physician as required.
Failure to Consistently Document ADL Care in Resident Records
Penalty
Summary
Facility staff failed to consistently document Activities of Daily Living (ADL) care in the Documentation Survey Report (DSR) for multiple residents, as required by facility policy. For three out of four residents reviewed, there were missing entries in the DSR and progress notes regarding whether ADL care was provided or refused on specific dates and shifts. The residents involved had significant medical conditions, including quadriplegia, acute respiratory failure, dysphagia, bipolar disorder, dementia, hyperlipidemia, diabetes, hypertension, and chronic pain syndrome. Their cognitive statuses ranged from intact to severely impaired, as indicated by their Brief Interview of Mental Status (BIMS) scores. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were responsible for documenting ADLs using a mobile app, and documentation was expected to be completed by the end of each shift. The Director of Nursing (DON) and Unit Manager (UM) confirmed that blank documentation fields did not necessarily mean care was not provided, but acknowledged that documentation should not be left incomplete. The facility's ADL Documentation Policy required all nursing staff and caregivers to document ADLs as part of their daily routines, with supervisors responsible for regular compliance checks. Despite these requirements, the review found multiple instances where ADL documentation was missing, indicating a failure to follow established policy and professional standards.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with diabetes and admitted with elongated toenails. The resident, who had severe cognitive impairment as indicated by a BIMS score of 5 out of 15, did not have a care plan addressing these specific needs. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, which was not followed in this case. Interviews with staff, including an LPN, the Unit Manager (UM), and the Director of Nursing (DON), confirmed the absence of a care plan for the resident's diabetes and toenails, highlighting a lapse in the facility's adherence to its care plan policy. The UM was responsible for updating the resident's care plan, typically every quarter and as needed, and acknowledged the oversight in not addressing the resident's toenails. The DON confirmed that the care plan should have included interventions for the resident's diabetes and toenails, as per the facility's policy. The failure to develop and implement a care plan for the resident's specific needs was identified during a survey, revealing a deficiency in the facility's care planning process.
Failure to Follow Clinical Standards for Resident Care
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in several areas concerning Resident #2. The resident, who was admitted with diagnoses including Diabetes, Major Depressive Disorder, and Unspecified Dementia, did not have a care plan developed to address their diabetes and elongated toenails. Despite the resident's severely impaired cognition, as indicated by a BIMS score of 5 out of 15, the facility did not create a care plan to manage these conditions, which is a requirement under the facility's care plan policy. Additionally, there was a delay in the resident being seen by a podiatrist. The resident was admitted with elongated toenails, a condition noted in the admission screener, but was not seen by a podiatrist until several months later. The podiatry consult revealed that the resident was at risk for complications without treatment of the toenails, indicating a lapse in timely care. The Unit Manager and Director of Nursing acknowledged that the process for scheduling podiatry visits was not followed, as the nurse should have notified the physician to get a treatment order in place. Furthermore, there was a significant delay in notifying the physician of abnormal urine culture results. The urine culture, collected on September 5, 2024, showed abnormal results reported on September 7, 2024, but the physician was not informed until September 14, 2024. This delay in communication and subsequent treatment initiation was contrary to the facility's policy, which requires immediate notification of abnormal results to the physician. The Director of Nursing confirmed that the facility's procedures for laboratory notifications and care plan initiation were not followed, contributing to the deficiency.
Failure to Provide Timely Podiatry Care for Diabetic Resident
Penalty
Summary
The facility failed to provide timely foot care for a resident with diabetes, who was admitted with elongated toenails and was not seen by a podiatrist until nearly nine months later. The resident, who had severe cognitive impairment, was admitted to the facility with elongated toenails, as noted in the admission records. Despite the facility's policy requiring prompt referral to podiatry for residents with identified foot issues, the resident's toenails were not addressed until a podiatry consult in October, where the toenails were debrided. The delay in podiatric care was noted as a deficiency, particularly given the resident's diabetic condition, which increases the risk of complications. Interviews with facility staff revealed a breakdown in communication and procedure adherence. The LPN responsible for the resident's care did not ensure timely podiatric intervention, and the Unit Manager and Director of Nursing acknowledged the delay in treatment. The facility's policy required nurses to notify the Unit Clerk to schedule podiatry appointments, but this process was not effectively followed. The Director of Nursing confirmed that the delay constituted a lapse in care, especially for a diabetic resident, highlighting a failure to adhere to the facility's podiatry services policy.
Delayed Notification of Abnormal Urine Culture Result
Penalty
Summary
The facility failed to promptly notify the physician of an abnormal urine culture result for a resident, which was a violation of their policy on laboratory services and reporting. The resident, who had severe cognitive impairment and was diagnosed with conditions including diabetes, major depressive disorder, and unspecified dementia, had a urine culture collected on September 5, 2024. The results, which were abnormal, were reported on September 7, 2024, but were not reviewed by the Unit Manager until September 11, 2024. The physician was not informed of these results until September 14, 2024, at which point an antibiotic therapy order was obtained. Interviews with facility staff, including an LPN, the Unit Manager, and the Director of Nursing, revealed that the facility's policy required immediate notification of the physician upon receiving abnormal lab results. The delay in notifying the physician was acknowledged by the staff as a significant lapse, with the Director of Nursing confirming that the expectation was for immediate communication to prevent potential escalation of the resident's condition. The physician also confirmed that they rely on the nursing staff to inform them of any abnormal results, as they do not see long-term care residents frequently.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for three resident rooms on the C/D unit. During the initial tour, the surveyor observed various deficiencies in room 211, including a missing drawer handle, gouged walls, scratched and missing paint, and a leaking sink with water on the floor. Similar issues were found in room 212, where the window blind was broken, and the walls and furniture were damaged. In room 213, the window blind was also broken, and the CNA acknowledged that the room's condition was not homelike. The surveyor interviewed multiple staff members, including a CNA, an LPN, the LPN Unit Manager, the Director of Nursing (DON), and the Interim Maintenance Director (IMD). The staff members confirmed that the process for reporting maintenance issues involved recording them in a maintenance log. However, the log revealed incomplete entries, indicating that some issues, such as the leaking sink in room 211, were not addressed. The LPN and DON acknowledged that the rooms were not homelike and that the maintenance requests had been overlooked. The IMD admitted that he and one other maintenance man were responsible for the facility's repairs and that the maintenance book was checked daily. Despite this, the IMD acknowledged that the issues in the resident rooms had not been resolved and that the maintenance log had blank spots for some entries. The facility's policies on reporting maintenance concerns and repairs were reviewed, revealing that the maintenance book should be checked daily and signed as work is completed. The IMD admitted that the leaking sink in room 211 had not been fixed and that the maintenance issues in the rooms needed to be resolved.
Deficiencies in Food Handling and Kitchen Maintenance
Penalty
Summary
The facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross-contamination. During a kitchen tour, the surveyor observed several deficiencies, including undated raw chicken drumsticks, wilted and blackened lettuce, undated lidded cups of liquids, and an unlabeled bag of scalloped potatoes. Additionally, there were pork loins with unreadable dates and damaged packaging, a dented can of sweetened applesauce, and a slicer with tan debris despite being covered with a plastic bag. A stained cutting board was also found in the dry pots and pans area. The Dietary Director (DD) acknowledged these issues, stating that the food items should have been labeled with pull and use-by dates, and that the equipment should have been cleaned and sanitized to prevent cross-contamination. The facility's policies on food receiving and storage, sanitation, and food preparation and service were reviewed, revealing that the observed practices were not in compliance with the established guidelines. The administrative team was made aware of these concerns during the survey.
Failure to Perform Hand Hygiene During Meal Tray Pass
Penalty
Summary
The facility failed to follow appropriate infection control practices and perform hand hygiene during a meal tray pass in the Main Dining area. An LPN was observed handling food and interacting with residents without performing hand hygiene. Specifically, the LPN opened a packet of powder, mixed it into a cup, touched her phone, and continued to handle food items without cleaning her hands. She also touched her nose and various inanimate objects before feeding a resident, all without performing hand hygiene. This was confirmed through interviews with the LPN, the LPN Unit Manager, the LPN Infection Preventionist, and the Director of Nursing, all of whom acknowledged the failure to perform hand hygiene correctly during the meal tray pass. The LPN stated that hand hygiene should be performed between resident contact and when trays were passed, but admitted she did not remember if she had done so during the observation period. The LPN Unit Manager and the LPN Infection Preventionist both confirmed that hand hygiene should have been performed after touching the phone, nose, and before feeding the resident. The Director of Nursing also acknowledged that hand hygiene was not performed correctly and emphasized its importance in preventing the spread of germs. A review of the facility's hand hygiene policy and the Charge Nurse/Staff Nurse job description revealed that all personnel are required to follow handwashing procedures to prevent the spread of infections. The policy specifically states that hand hygiene should be performed after contact with objects in the immediate vicinity of the resident and before and after assisting a resident with meals. The administrative team was made aware of the observation, and the deficiency was documented as a failure to adhere to these established infection control practices.
Failure to Obtain Diagnosis for IV Antibiotic Use
Penalty
Summary
The facility failed to follow professional standards of clinical practice by not obtaining a diagnosis for the use of an antibiotic intravenous medication for a resident. The resident was admitted with IV antibiotic therapy and a PICC line for cellulitis, but the physician's order for Vancomycin did not include a diagnosis. The resident was unaware of the reason for the medication, and the LPN, who was employed through an agency, also did not know the type of infection being treated as it was not documented on the physician's order. The LPN/UM later confirmed that the IV antibiotic was for MRSA in the blood, but acknowledged that the order should have included a diagnosis. The DON explained the policy for residents with a PICC line, emphasizing the need for physician orders to include diagnoses for the IV antibiotic, which was not followed in this case. The LNHA also confirmed that the physician's order should have had a diagnosis associated with the medication use. The surveyor observed that the resident's room had a sign indicating transmission-based precautions/contact isolation, and an IV medication bag labeled with the resident's name was hanging on the IV pole. The resident mentioned that they did not receive the medication the previous night. The facility's policy on medication and treatment orders stated that orders must include the clinical condition or symptoms for which the medication is prescribed, which was not adhered to in this instance. This deficiency was identified through observation, interviews, and review of the resident's medical records and facility documentation.
Failure to Obtain Physician Order and Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to obtain a physician order for the treatment of a skin tear that occurred during a fall and did not update a resident's Care Plan (CP) with fall prevention interventions after the resident fell. This deficiency was identified for one resident who was admitted with diagnoses including osteomyelitis, sepsis, and malignant neoplasm of the brain. The resident was cognitively impaired and had a history of falls prior to admission. On the date of the incident, the resident had an unwitnessed fall while trying to retrieve something from the closet, resulting in a skin tear on the right elbow. The incident report indicated that the resident was not using a walker and was not wearing shoes or socks at the time of the fall. Although the incident report stated that the resident's CP was updated and the physician was notified, the surveyor found no documentation in the CP or the Electronic Medical Record (EMR) to support these claims. Additionally, there was no treatment order for the skin tear in the Physician Order Summary Report (POSR) or the Treatment Administration Record (TAR). Interviews with facility staff, including the Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA), Licensed Practical Nurse Unit Manager (LPN/UM), Registered Nurse (RN), Director of Nursing (DON), and Regional Clinical Director (RCD), confirmed that the required documentation and updates to the CP were not completed. The facility's policies on incidents and accidents, wound treatment and management, and comprehensive care plans were not followed, leading to the deficiency.
Improper Handling of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper handling of a urinary catheter drainage bag for a resident with urinary retention. The surveyor observed the resident's drainage bag touching the floor and not being kept below the level of the bladder on multiple occasions. The resident's care plan specifically included an intervention to keep the drainage bag below the bladder, but this was not followed. The CNA and LPN/UM acknowledged the improper positioning of the drainage bag and corrected it during the surveyor's visit. The facility's Catheter Care policy did not specify that the drainage bag should be kept off the floor, although staff interviews confirmed this practice for infection control reasons. The resident had an intact cognition as indicated by a Brief Interview for Mental Status score of 15 on the admission MDS. The resident's physician had ordered weekly changes of the urinary catheter drainage bag. Despite these orders and the care plan, the CNA initially secured the drainage bag to the resident's waistband, which was level with the bladder, and later left it touching the floor. The LPN/UM and DON confirmed that the drainage bag should be secured below the bladder and not touch the floor to prevent infection and ensure proper urinary flow.
Failure to Label and Dispose of Medications Properly
Penalty
Summary
The facility failed to label and dispose of medications in accordance with accepted professional principles for a resident receiving antibiotic therapy. The resident, admitted in March 2024, was on IV antibiotic therapy for cellulitis and had a PICC line in the right upper arm. During a tour, the surveyor observed an IV medication bag and vial hanging on the IV pole without proper labeling or dating. The resident was unaware of the reason for the medication and mentioned that the nurse had hung the IV the previous night but did not think any medication was administered. The physician's order and Medication Administration Record indicated that the IV Vancomycin was to be administered every 12 hours, but the dose scheduled for the previous night was not given due to a clogged PICC line. The LPN, who was employed through an agency, confirmed that the resident was on IV antibiotics but was unsure of the specific infection being treated. She stated that the previous nurse had reported the clogged PICC line and that the medication should have been discarded when it could not be administered. The LPN/UM confirmed that the IV medication was for MRSA in the blood and that the medication should have been discarded when the nurse realized the PICC line was clogged. The LPN/UM also noted that the IV medication and tubing were not dated or timed, making it unclear how long they had been hanging. The DON explained the facility's policy for residents with a PICC line, including assessing the line for patency and obtaining physician orders for flushing. The DON confirmed that the IV medication should have been labeled and discarded if not administered. The LNHA also confirmed that the medication should have been disposed of after the nurse realized the PICC line was not functional. The facility's policies on discarding medications and intravenous therapy did not include specific instructions on labeling and dating IV tubing, which contributed to the deficiency.
Failure to Document Resident Fall Incident
Penalty
Summary
The facility failed to maintain an accurately documented and complete medical record for a resident who experienced an unwitnessed fall. The resident, who had diagnoses including osteomyelitis, sepsis, and malignant neoplasm of the brain, was found lying on the floor at the foot of the bed. The incident report indicated that the resident was not using a walker and was not wearing shoes or socks at the time of the fall, resulting in a skin tear on the right elbow. However, there was no corresponding documentation in the Nursing Progress Notes (NPN) in the Electronic Medical Record (EMR) regarding the fall and subsequent assessment and care provided to the resident on that date. Multiple staff members, including the LPN, CNA, LPN/UM, RN, and RCD, confirmed the absence of documentation in the progress notes for the fall incident. The facility's policy on charting and documentation requires that all services provided, progress notes, and any changes in the resident's condition be documented in the medical record to facilitate communication between the interdisciplinary team. The lack of documentation in this case represents a failure to adhere to these standards, resulting in an incomplete and inaccurate medical record for the resident. The deficiency was confirmed by the Director of Nursing (DON) and the Regional Clinical Director (RCD), who acknowledged the importance of accurate and complete documentation in the progress notes for legal and communication purposes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Southgate | 6.7 mi | — | 1 | 0 |
| Autumn Lake Healthcare At Memorial Bridge | 10.1 mi | — | 2 | 0 |
| New Castle Health And Rehabilitation Center | 10.9 mi | — | 13 | 1 |
| Kutz Rehabilitation And Nursing | 11.9 mi | — | 3 | 0 |
| Complete Care At Hillside Llc | 12.2 mi | — | 4 | 0 |
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