Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Memorial Bridge during CMS and state inspections, most recent first.
The facility did not ensure that physician visit progress notes were documented in a timely manner for three cognitively intact residents with multiple medical conditions. Medical records lacked required physician documentation at the time of review, and staff interviews revealed uncertainty about the process for entering or forwarding physician notes, resulting in missing documentation as required by facility policy.
A resident admitted with multiple medical conditions did not have weekly weights consistently monitored or documented as required by facility policy. Staff interviews confirmed awareness of the weight monitoring protocol, but gaps in documentation and a significant unaddressed weight gain were identified. Additional weights were added to the record after the surveyor's review, highlighting inconsistencies in record-keeping and failure to follow established procedures.
A cognitively impaired resident with a history of refusing care and at moderate fall risk sustained a head laceration after a CNA attempted to enter the resident's room against their wishes, resulting in a fall. Staff interviews and facility policies confirmed that residents' rights to refuse care and privacy were known and trained, but these were not followed during the incident, leading to the injury.
Surveyors identified widespread deficiencies in maintaining a safe, clean, and homelike environment, including peeling paint, missing tiles, unclean shower rooms, broken equipment, and cluttered common areas. Staff and leadership acknowledged these issues, which affected residents' access to amenities and contributed to an institutional atmosphere.
The facility did not develop or implement complete, person-centered care plans for several residents, omitting essential interventions such as oxygen therapy, PASARR Level 2 mental health needs, hand orthotic use, and incontinence care. These omissions were confirmed through record review, staff interviews, and direct observation, despite facility policy requiring all identified needs to be addressed in the care plan.
Surveyors found that multiple residents dependent on staff for incontinence care were left in saturated or soiled briefs, with some waiting extended periods for assistance despite facility policy requiring care every two hours or as needed. Staff interviews confirmed awareness of the policy, but delays in care and unaddressed call lights were observed, resulting in residents not being kept clean and dry as required.
Surveyors found that two residents with cognitive impairments and fall risks did not have their nurse call bells within reach, contrary to facility policy and care plan interventions. Staff interviews and document reviews confirmed that call bells should be accessible, but in these cases, one call bell was on the floor and another was wrapped around a wall unit, making them inaccessible.
The facility did not ensure that State Survey results were readily accessible, as required. Alert and oriented residents reported not knowing the location of the survey results or being informed about them. The binder with the results was kept inside a buffet cabinet in the lobby, requiring a door to be opened, and residents in a locked unit could not access it. Both the UM and LNHA confirmed the results were not easily accessible, contrary to facility policy.
A resident with an indwelling urinary catheter was observed without a securement device on the leg and with a drainage bag that was not properly covered for privacy or secured to the bed frame. The DON confirmed that securement devices and privacy covers are facility practice, but these were not in place for the resident, resulting in a failure to provide appropriate catheter care.
Surveyors found that medications were not properly stored and the medication room was not maintained in a sanitary manner. Opened beverage containers and personal bags were present in the medication room, and loose tablets were discovered in two medication carts. Facility policy requires medications to be stored in original packaging and storage areas to be kept clean and organized, but these standards were not met.
A housekeeper entered a resident's room under Contact Precautions for VRE UTI without wearing required PPE, despite clear signage and available gowns and gloves. The staff member believed PPE was only necessary for aides, not housekeeping. Both the Infection Preventionist and DON confirmed that all staff should use PPE per facility policy and posted instructions.
A resident with dementia and psychotic disturbances experienced a fall during an incident involving a CNA, but the facility failed to conduct a thorough investigation as required by policy. Key witnesses, such as roommates, were not identified or interviewed, and the care plan was not updated to reflect the allegation. The DON and LPN acknowledged gaps in the investigation, including uncertainty about reviewing available security footage and incomplete documentation.
A resident who was not cognitively intact did not receive prescribed medications, including diabetes, blood pressure, and seizure/mood disorder treatments, within the required time frame on multiple occasions. Medications scheduled for morning administration were given significantly late, contrary to facility policy and prescriber's orders. The RN acknowledged the late administration and the need to prioritize timely medication delivery.
The facility did not meet the required CNA staffing ratios on four day shifts, as mandated by New Jersey law. The facility was short of the required number of CNAs for the number of residents present, potentially affecting all residents.
Failure to Ensure Timely Physician Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure that the attending physician responsible for supervising the care of residents documented physician visit progress notes at the time of each required visit. This deficiency was identified for three residents, all of whom were cognitively intact and had various medical diagnoses, including fracture of the left pubis, hypertension, myocardial infarction, cellulitis, obstructive sleep apnea, asthma, spinal stenosis, type II diabetes, and anxiety disorder. For each of these residents, a review of their electronic medical records did not show documentation of a visit from the attending physician during the relevant period. During interviews, the DON stated that some providers entered notes directly into the electronic system while others forwarded notes to be scanned, and was unsure of the attending physician's process. The attending physician, who also served as the facility's Medical Director, reported that due to a recent change in the login system, he had been dictating and handwriting notes to be faxed to the facility for inclusion in the medical record, but was unsure why the documentation was missing for these residents. The facility's policy required timely and pertinent documentation, with notes to be written or entered at the time of the visit or returned to the facility within a week if prepared later. The absence of these notes at the time of the survey constituted the deficiency.
Failure to Monitor and Document Weekly Weights Upon Admission
Penalty
Summary
The facility failed to implement and monitor weekly weights upon admission in accordance with professional standards of practice for one resident. The resident was admitted with multiple diagnoses, including a fracture of the left pubis, hypertension, and a history of myocardial infarction, and was cognitively intact at the time of admission. The facility's policy required weights to be taken upon admission, the next day, and then weekly for four weeks, but documentation showed gaps in recorded weights, with missing entries between certain dates and a significant weight gain not being identified or addressed in a timely manner. Interviews with staff, including CNAs, LPNs, the Unit Manager, the Registered Dietitian, and the Nursing Supervisor, revealed that all were aware of the weight monitoring policy and the importance of regular weight checks. However, there was a lack of clarity and follow-through regarding the actual documentation and monitoring of the resident's weights. The staff could not account for the missing weights, and there was no documentation of refusals or reasons for the omissions. The Registered Dietitian and Medical Director were not aware of the significant weight change until it was brought to their attention by the surveyor. A review of the facility's documentation practices showed inconsistencies, with additional weights being added to the record after the surveyor's initial review, based on information from a former employee. The Director of Nursing acknowledged that weights should have been entered promptly and that missing weights were only discovered during the survey process. The facility's policies required accurate and timely documentation of weights and maintenance of accurate medical records, which was not followed in this case.
Failure to Honor Resident Refusal and Ensure Safety Leads to Fall and Injury
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a history of refusal of care and at moderate risk for falls sustained a head injury after a fall. The incident took place when a CNA attempted to enter the resident's room despite the resident's refusal, resulting in the resident falling backward and sustaining a laceration to the back of the head. The resident was subsequently sent to the hospital for evaluation. The resident's care plan documented severe cognitive impairment, destructive and intrusive behaviors, and a risk for falls, with interventions to redirect negative behaviors and monitor for changes in gait status. The CNA involved in the incident reported attempting to check on the resident, who persistently refused and tried to shut the door. The CNA continued to insist on entering, leading to the resident losing balance and falling. Statements from other staff confirmed that the resident was particular about care and could become upset if things were not done according to their preferences. Staff interviews indicated that training had been provided on respecting residents' rights, including the right to refuse care and the importance of not violating privacy, especially for those with cognitive impairments. Facility policies reviewed by the surveyor emphasized treating residents with dignity and respect, honoring refusals of care, and implementing fall prevention interventions based on risk assessments. Despite these policies and staff training, the CNA's actions did not align with established protocols, directly resulting in the resident's fall and injury. The deficiency was identified through observation, interviews, and review of medical records and facility documentation.
Failure to Maintain a Safe, Clean, and Homelike Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment across three units. On A Unit, there were repeated findings of peeling and chipped paint, missing floor tiles, black debris and discoloration, broken equipment, and cluttered areas such as the shower room and nurse's station. The presence of medical equipment and wheelchairs stored in front of the fish tank further detracted from the homelike atmosphere and limited residents' access to recreational features. Staff interviews confirmed that these issues were known and that storage space was insufficient, leading to institutional-like conditions. On B Unit, surveyors found personal items and grooming tools left unattended in the shower room, and a resident room lacking basic amenities such as a bathroom mirror and toilet paper. These observations indicated lapses in housekeeping and attention to residents' daily living needs. Staff acknowledged the need for improved housekeeping and maintenance services to address these concerns. C Unit was noted to have significant maintenance and cleanliness issues, including peeling paint, missing drawers, broken fixtures, cracked walls and moldings, and unclean shower areas with hair and debris. Damaged furniture and equipment, such as a ripped geriatric chair and a loose door handle, were also observed. Facility leadership and maintenance staff acknowledged the ongoing challenges in maintaining the unit, citing factors such as the resident population and environmental conditions, but confirmed that the observed deficiencies required repair and attention.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulation. For one resident with asthma who was observed receiving oxygen via nasal cannula, there was a physician's order and documentation in the medical record indicating the need for oxygen therapy, but no corresponding care plan addressing the use of oxygen was found. The Assistant Director of Nursing confirmed that oxygen use should have been included in the care plan, and the facility's policy requires measurable objectives and timeframes for all identified needs. Another resident with a state-level 2 PASARR determination for serious mental illness had documentation of depression and anxiety in the care plan, but the positive PASARR Level 2 status and associated specialized services were not identified or addressed in the care plan. Social workers acknowledged that this information was missing and should be included, and the Director of Nursing confirmed that the care plan should reflect PASARR Level 2 status and related services, as outlined in facility policy. Additional deficiencies were noted for residents requiring a hand orthotic and for a resident with frequent incontinence. In both cases, physician orders and assessment data indicated the need for specific interventions (hand roll and incontinence care), but these were not documented in the residents' care plans. Staff interviews confirmed that such needs should be included as focus areas in the care plans, in accordance with facility policy, but were omitted.
Failure to Provide Timely and Adequate Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to provide proper incontinence care to several residents who were dependent on staff for activities of daily living. During initial rounds, one resident was found in bed with a saturated incontinent brief and was unable to recall the last time they had been changed. The resident's medical record indicated frequent incontinence of bowel and bladder, and their care plan required regular incontinence checks and assistance. Another resident was observed with a saturated brief that had soaked through to their gown, and staff acknowledged that care was delayed as they were attending to other duties. Additional observations included two residents with visibly soiled briefs, one with urine and the other with both urine and feces. In both cases, staff confirmed the need for incontinence care but did not provide it immediately. One of these residents had their call light on for 20 minutes requesting assistance, but no staff responded during that time. Medical records for these residents documented diagnoses such as cerebral infarction, impaired mobility, and always being incontinent, with care plans specifying the need for routine and as-needed incontinence care to maintain skin integrity. Interviews with CNAs, LPNs, and the DON confirmed that facility policy and staff expectations were to provide incontinence care every two hours or as needed, and to respond promptly to call lights. Despite these policies, residents were found unclean and wet, and staff acknowledged that sometimes it took a while to reach all residents. Facility policy stated that incontinent residents should be maintained clean and dry, but this was not consistently achieved as evidenced by the surveyors' observations.
Failure to Ensure Call Bells Were Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to accommodate the needs of two residents by not ensuring that nurse call bells were within their reach. During an initial tour, one resident's call bell was found on the floor underneath the head of the bed, while another resident's call bell was wrapped around the wall unit of the nurse's call bell system, making them inaccessible. A CNA present at the time confirmed that call bells should be on the bed within the resident's reach but expressed an inability to address all issues. Both residents had significant cognitive impairments and were at risk for falls, as documented in their care plans, which included interventions to encourage the use of call bells for assistance. Further interviews with facility staff, including a CNA and the DON, confirmed that facility policy requires call bells to be easily accessible to residents and that staff are expected to ensure this when passing by rooms. Review of facility documents, including job descriptions and policies, reiterated the requirement for call bells to be within easy reach of residents when in bed or confined to a chair. The deficiency was cited under NJAC 8:39-27.1 (a).
Survey Results Not Readily Accessible to Residents and Public
Penalty
Summary
The facility failed to maintain the most recent State of New Jersey inspection results in a location that was readily accessible to residents, families, and the public. During a Resident Council Meeting, all four alert and oriented residents interviewed stated they were unaware of where the State Survey results were kept and had not been informed about them. Observations during a tour revealed that while signs indicated the survey results were in the lobby, the binder containing the results was stored inside a buffet cabinet that required opening a door to access. The C-wing unit, which is locked, also had residents who could not readily access the results. Interviews with the Unit Manager and the Licensed Nursing Home Administrator confirmed that the survey results were not readily accessible to residents, particularly those on the C-wing. Facility policy requires that survey reports and plans of correction be readily accessible to residents and the public.
Failure to Provide Appropriate Catheter Care and Securement
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed without appropriate catheter care. The surveyor noted that the resident's urinary catheter drainage bag contained tinged, red urine and was not covered for privacy. Additionally, the resident did not have a securement device on their leg to stabilize the catheter tubing, as confirmed by both observation and the resident's statement. On a subsequent observation, the drainage bag was found unsecured from the bed frame and instead left in a privacy cover, contrary to proper catheter management protocols. Interviews with the Director of Nursing confirmed that the facility's practice is to use privacy covers and securement devices, but these were not in place for the resident at the time of observation. The resident's medical record included orders for catheter maintenance due to urinary retention, and the care plan acknowledged the presence of an indwelling catheter. Facility policy requires daily evaluation of catheter necessity and prompt removal when no longer needed, but the observed lack of securement and privacy measures constituted a failure to provide appropriate treatment and care.
Improper Medication Storage and Unsanitary Medication Room
Penalty
Summary
Surveyors identified that the facility failed to properly store medications and maintain a sanitary environment in one of three medication rooms and two of seven medication carts reviewed. During an inspection of the B Unit Medication Room, six opened beverage containers and two personal bags were found on the counter, despite the availability of a staff breakroom for such items. The LPN/Unit Manager confirmed that staff should not keep beverages and bags in the medication room. Additionally, the Director of Nursing acknowledged that there are lockers available for staff belongings on the B-Wing. Further inspection revealed loose tablets in medication carts: two loose tablets were found in the drawer of B wing medication cart 2, and eleven loose tablets were found in the drawer of A wing medication cart 2. The Director of Nursing stated that medication carts are audited monthly for loose tablets. A review of the facility's policy indicated that drugs and biologicals should be stored in their original packaging and that medication storage and preparation areas must be kept clean, safe, and sanitary. The policy also requires that each resident's medications be stored separately to prevent mixing.
Failure to Use PPE During Contact Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices when a housekeeper was observed mopping the floor in a resident's room that was under Contact Precautions for Vancomycin Resistant Enterococcus (VRE) urinary tract infection. Despite clear signage and the availability of personal protective equipment (PPE) such as gowns and gloves at the room entrance, the housekeeper did not wear any PPE while inside the room. The signage specifically instructed all providers and staff to don gloves and gowns before entering and to discard them before exiting the room. The housekeeper stated that PPE was only required for aides providing direct care, not for housekeeping staff. The resident in question had an active order for special contact isolation precautions due to a VRE UTI, with all services to be provided in the resident's room. The care plan also included an intervention to maintain contact isolation precautions for the duration of antibiotic treatment. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that housekeeping staff should have been wearing PPE in accordance with facility policy and the posted instructions. Facility policy required staff and visitors to wear disposable gowns upon entering rooms under contact isolation and to avoid contaminating surfaces after gown removal.
Failure to Conduct Thorough Abuse Investigation and Maintain Documentation
Penalty
Summary
The facility failed to maintain adequate documentation and conduct a complete and thorough investigation into an alleged abuse incident involving a resident with significant cognitive impairment and a diagnosis of dementia with psychotic disturbances. The incident in question involved a Certified Nursing Assistant (CNA) entering the resident's room, after which the resident fell to the floor. Statements from staff indicated that the CNA was attempting to enter the room to check on the resident's roommate, and the resident, who was blocking the door, lost balance and fell. The facility submitted a Facility Reported Event (FRE) to the Department of Health, but the investigation documentation was incomplete. Upon review, it was found that the facility did not identify or interview all potential witnesses, including the resident's roommates, despite statements indicating that at least one roommate was present during the incident. The Licensed Nurse Practitioner Unit Manager (LPN/UM) and the Director of Nursing (DON) both acknowledged that the investigation did not confirm who was present in the room at the time of the incident, nor did it include attempts to interview the roommates. Additionally, the DON confirmed that the care plan was not updated to reflect the allegation, and there was uncertainty about whether available security camera footage was reviewed as part of the investigation. The facility's own policies require that all involved persons, including the alleged victim, perpetrator, witnesses, and others with knowledge of the incident, be identified and interviewed. The policies also specify that the investigator should review completed documentation forms and interview roommates, family members, and visitors. The failure to follow these procedures resulted in an incomplete investigation and insufficient documentation regarding the alleged abuse incident.
Failure to Administer Medications Within Required Time Frame
Penalty
Summary
A deficiency was identified when a resident, who was not cognitively intact as indicated by a Brief Interview of Mental Status score of 0, did not receive medications within the required time frame as per physician's orders and facility policy. The resident had orders for Jardiance 10mg once daily, metoprolol tartrate 25mg twice daily, and Depakote Sprinkles 125mg (three capsules in the morning). On two separate occasions, these medications, scheduled for administration at 8:00 AM, were instead given significantly later—at 9:36 AM and 10:08 AM, respectively. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. During an interview, the RN acknowledged administering the medications late and stated that the resident should have been prioritized for timely medication administration. The failure to follow the prescriber's orders and the facility's medication administration policy resulted in the resident not being free from significant medication errors.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels for nursing homes. During a review of staffing records from December 1, 2024, to December 14, 2024, it was found that the facility did not have the required number of Certified Nurse Aides (CNAs) on four separate day shifts. On December 2 and 3, 2024, the facility had 17 CNAs for 143 residents, falling short of the required 18 CNAs. On December 5, 2024, there were 17 CNAs for 141 residents, again requiring at least 18 CNAs. Finally, on December 13, 2024, the facility had 16 CNAs for 138 residents, when at least 17 CNAs were needed. This deficiency had the potential to affect all residents in the facility.
Plan Of Correction
1) Efforts to hire more facility staff to allow us to have adequate or more than adequate staff to serve our residents have been ramped up. In the meantime, the facility will utilize agencies to fill open slots in the schedule. 2) All residents in the Facility have the potential to be affected by the deficient practice. 3) The Administrator and Director of Nursing shall continue to review the daily Certified Nursing Assistant (CNA) staffing schedules to ensure compliance with the state's minimum CNA staffing requirement. Furthermore, the facility will review its recruitment program and hiring efforts to attract and hire CNAs, as evidenced by placing advertisements on Indeed, contacting recruitment agencies, and offering referral bonuses to current staff for securing additional staff. The center shall offer overtime, incentive pay, and bonuses to current staff when a staffing shortage is identified or occurs throughout the day and/or week. The facility staffing coordinator will work with sister facilities staffing coordinator for CNAs/License Nurses for daily backup when call outs occur. CNAs will receive free meals and incentives on top of their regular pay. The facility will offer overtime, bonuses, or incentives to Licensed Nurses to work as Nursing Assistants when warranted. The facility also maintains an agreement with nursing staffing agencies in the event of any staffing shortage. A meeting was conducted on Tuesday with Staffing Company, HR, and DON to discuss current needs. 4) The Administrator and Director of Nursing or designee shall review/audit the Certified Nursing Assistant (CNA) staffing schedule daily for 4 weeks, then monthly x 2 months, and then quarterly for 3 quarters to determine compliance with the state's minimum CNA staffing requirement. The Administrator shall continue to monitor the facility's recruitment and retention practices to identify potential areas of improvement. The results of these audits will be submitted monthly to the Quality Assurance and Performance Improvement (QAPI) committee for the next 6 months. This will be a part of the Quarterly Quality Assurance Program ongoing. Staffing Coordinator and DON will check staffing sheets the next day and initiate progressive discipline for those who are calling out. Weekend call outs will mandatorily be made up the following weekend. This will be ongoing.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 933 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Penns Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kutz Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 3 | 0 |
| Autumn Lake Healthcare At Southgate | 3.5 mi | ★★★★★ | 1 | 0 |
| Gilpin Hall | 4.7 mi | ★★★★★ | 11 | 0 |
| Wilmington Nursing & Rehabilitation Center | 4.7 mi | — | 26 | 2 |
| Encore At Foulk | 4.9 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.