Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oceanview during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of combative behavior sustained a hand fracture of unknown origin. The facility did not conduct a thorough investigation to rule out abuse or neglect, nor did it report the injury to the Department of Health as required. The DON assumed the injury was related to the resident's combative behavior during care, and the investigation did not include checking other residents or timely collection of staff statements.
The facility was found deficient in maintaining kitchen sanitation and food storage standards. Staff were observed without hairnets while handling food, and temperature logs for refrigeration units were incomplete. Additionally, unsanitary conditions and improperly stored food items were noted, with the AFSD acknowledging these issues.
The facility failed to maintain a safe and sanitary environment, as evidenced by mold in a resident's room and various maintenance issues on two units. Observations revealed damaged drywall, stained floors, and peeling paint, while interviews indicated a lack of structured maintenance and cleaning processes. The absence of a housekeeping director and ineffective implementation of cleaning policies contributed to the deficiencies.
The facility failed to properly contain respiratory equipment for four residents, leading to potential contamination. A resident's nebulizer mask was left uncovered, another's nebulizer face mask was exposed on a nightstand, and a BiPAP mask was unbagged on a windowsill. Additionally, a resident's oxygen tubing was undated. The facility's protocol for bagging respiratory equipment was not followed.
The facility failed to follow proper hand hygiene and PPE protocols, as observed by surveyors. Staff, including housekeepers and CNAs, did not wash or sanitize hands after glove removal or contact with contaminated surfaces. Additionally, housekeeping staff sorted soiled linens wearing only gloves, without using available gowns, contrary to facility policies and CDC guidelines.
The facility failed to make state survey results accessible to residents and visitors. Five residents were unaware of the survey results' location, and the receptionist was unfamiliar with the State Survey Results Book, which was found unmarked behind the reception desk. At the Serenity Unit Nursing Station, staff initially could not locate the book, which was eventually found on an inaccessible shelf. These issues were discussed with the administration.
The facility failed to ensure physicians conducted face-to-face visits and documented progress notes every thirty days for two residents. One resident, admitted with hemiplegia and lung cancer, reported not seeing the doctor, and their records lacked physician notes. Another resident with end-stage renal disease also had no physician visit documentation. Staff interviews confirmed the expectation for physician documentation, which was not met.
A facility failed to promptly act on a consultant pharmacist's recommendation to discontinue a PRN medication for a resident with severe cognitive impairment. Despite indicating the medication was discontinued, records showed a delay of 45 days before action was taken. The DON admitted to not regularly reviewing recommendations for accuracy, contrary to facility policy.
A facility failed to document non-pharmacological interventions before administering Lorazepam to a resident with Alzheimer's, as required by policy. The resident received the medication 52 times over two weeks, but documentation was missing for 23 instances. Staff interviews confirmed the expectation to document behaviors and interventions in the EMR, highlighting a significant oversight in following protocols.
The facility failed to maintain a sanitary environment by not ensuring garbage containers were covered and the surrounding area was free of debris. Three dumpsters had exposed garbage due to lids not being fully closed, and the area was littered with various debris. The AFSD confirmed the shared responsibility for the garbage area, and the facility's policy mandates proper disposal and maintenance, which was not followed.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to complete a thorough investigation and timely reporting of an injury of unknown origin for a resident with severe cognitive impairment and a history of combative behavior. The resident, who had diagnoses including dementia and cerebral infarction, was found with swelling and discoloration to the right hand, which later was confirmed as a fracture. Staff noted the resident was unable to state what happened, and documentation indicated the resident had been physically aggressive with staff during care prior to the injury. Despite the injury being of unknown origin, the facility did not report the incident to the New Jersey Department of Health as required. The DON stated that the injury was not considered of unknown origin because the resident was known to be combative, and it was assumed the injury occurred during care. The investigation did not include checking other residents for injuries to rule out abuse, and staff statements were collected only after management returned following the weekend, focusing on general encounters rather than the specific incident. Facility policy required immediate investigation and reporting of suspected abuse, neglect, or injuries of unknown source, including notification to state agencies and other relevant parties. However, the investigation did not fully adhere to these procedures, as it did not thoroughly rule out abuse or neglect, nor did it ensure timely and complete reporting to the appropriate authorities.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain kitchen sanitation standards, as observed by a surveyor in the presence of the Assistant Food Service Director (AFSD). Three staff members working on the breakfast tray line were not wearing hairnets, exposing their hair while handling food. The AFSD acknowledged the oversight. Additionally, the temperature logs for the walk-in refrigerator and freezer were incomplete, with missing entries for several days. The AFSD confirmed that the morning and evening cooks were responsible for recording these temperatures. Further observations revealed unsanitary conditions, including wilted lettuce and an unidentified white substance on the floor near the prep table, as well as undated and improperly stored food items in the walk-in refrigerator. The AFSD agreed that the area had not been cleaned and that all food products should be dated. The facility's policies on food storage and staff attire were not adhered to, contributing to the deficiencies noted during the survey.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by multiple observations and interviews conducted by surveyors. On one occasion, a resident expressed concerns about mold in their room, which had been reported to the Maintenance Department multiple times without resolution. The surveyor observed dark blackish stains and shiny substances around the air conditioning unit and pipes in the resident's room, indicating the presence of mold. The Director of Maintenance acknowledged the issue and mentioned that other rooms were also affected, but corrective actions were pending approval. Further observations on the Serenity unit revealed various maintenance issues, including damaged and peeling drywall, missing drawers, stained wardrobes, and dark marks along the baseboards. The common areas also showed signs of neglect, such as peeling wallpaper, chipped tiles, and rusted door frames. The hallway floors were stained, and the radiator covers and toilet grab bars were in poor condition. These observations indicate a lack of regular maintenance and cleaning, contributing to an unsafe and unsanitary environment for residents. On the B wing, similar deficiencies were noted, including peeling and chipped paint, damaged baseboards, and cigarette butts improperly disposed of in the smoking patio. The dayroom had a cracked switch plate and chipped ledges, while the nurse's station showed signs of wear and damage. Interviews with staff revealed a lack of a structured schedule or checklist for maintenance rounds, and the absence of a director of housekeeping further exacerbated the situation. The facility's cleaning policy was not being effectively implemented, leading to the accumulation of dirt and damage throughout the facility.
Failure to Properly Contain Respiratory Equipment
Penalty
Summary
The facility failed to properly contain and protect respiratory equipment for four residents, leading to potential contamination and infection control issues. For Resident #55, a nebulizer machine was observed on top of a dresser with the mask exposed and not covered, despite an active order for nebulizer use. The resident's care plan did not address the use of respiratory equipment, and the facility's practice of bagging masks when not in use was not followed. Resident #26 was observed with a nebulizer face mask on a nightstand, not contained in a bag, exposing it to air. The resident had a physician's order for nebulizer use, but the care plan did not address the use or care of the equipment. Similarly, Resident #42 had a BiPAP face mask unbagged on a windowsill and side table, with no active physician's order for BiPAP use until after the survey. The facility's protocol for bagging respiratory equipment was not adhered to. Resident #368 was observed with continuous oxygen therapy via nasal cannula, but the tubing was unlabeled and undated. The facility's policy required oxygen delivery devices to be covered when not in use, but this was not done. The facility was unable to provide a policy specifically addressing the use of nebulizer equipment, indicating a lack of comprehensive guidelines for respiratory care.
Failure to Follow Hand Hygiene and PPE Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) protocols, as observed by surveyors. On multiple occasions, staff members, including housekeepers and certified nursing assistants, did not wash or sanitize their hands after removing gloves or after contact with potentially contaminated surfaces. For instance, a housekeeper was seen transferring soiled linens without sanitizing hands after glove removal, and a CNA touched a trash can cover with bare hands without subsequent hand hygiene. Another CNA handled soiled linens without gloves and did not perform hand hygiene before handling clean linens. Additionally, the facility did not ensure the use of appropriate PPE during the sorting of soiled linens. Housekeeping staff were observed sorting soiled linens wearing only gloves, without additional protective gear such as gowns, despite the availability of reusable gowns in the sorting area. The Housekeeping District Manager confirmed the expectation for staff to wear gloves and gowns during these tasks, as outlined in the facility's policies. These observations indicate a failure to comply with the facility's hand hygiene and PPE policies, as well as CDC guidelines, potentially increasing the risk of infection spread.
Inaccessible State Survey Results
Penalty
Summary
The facility failed to make survey results readily accessible to residents and visitors, as evidenced by multiple observations and interviews. During a resident council task, five long-term residents were unaware of the location of the most recent state survey results and had not been informed about the existence of a state survey book. When the surveyor visited the front reception area, the receptionist was unfamiliar with the State Survey Results Book, which was found unmarked behind the reception desk. Additionally, at the Serenity Unit Nursing Station, staff were initially unable to locate the book, which was eventually found on a shelf behind the nursing station, inaccessible to residents in wheelchairs. These observations were discussed with the administration, highlighting the deficiency in making survey results accessible.
Deficiency in Physician Face-to-Face Visits and Documentation
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficiency was identified for two residents. Resident #367, who was admitted with diagnoses including hemiplegia, hemiparesis, and malignant neoplasm of the lungs, reported not having seen the doctor. A review of their medical records from December 2024 to January 2025 revealed no progress notes from the attending physician, only notes from a nurse practitioner. Similarly, Resident #7, admitted with end-stage renal disease and cerebral infarction, also lacked documentation of physician visits in their medical records from November 2024 to January 2025. Despite the facility's policy requiring physicians to see residents within 30 days of admission and document each visit, there were no progress notes from the attending physician for this resident either. Interviews with facility staff confirmed that physicians were expected to document their visits, but this was not reflected in the records reviewed.
Delayed Response to Pharmacist's Recommendation
Penalty
Summary
The facility failed to consistently and promptly follow through on recommendations made by the consultant pharmacist during the monthly medication regimen review. This deficiency was observed in the case of a resident who was admitted with diagnoses including Alzheimer's disease, dementia, anxiety disorder, major depressive disorder, and atherosclerotic heart disease. The consultant pharmacist recommended discontinuing a PRN medication, Diphenhydramine, that had not been used for over 60 days. Although the facility indicated that the medication was discontinued, the Medication Administration Record revealed that the order was not actually discontinued until approximately 45 days later, coinciding with the survey team's review. The Director of Nursing (DON) explained that the facility's process involves unit managers addressing the consultant pharmacist's recommendations before the next visit, with the DON conducting spot checks. However, the DON admitted to not regularly reviewing the recommendations for accuracy or completion. The facility's policy requires reviewing the consultant pharmacist's reports before the next review, but this was not adhered to in this instance, leading to the delay in discontinuing the medication as recommended.
Failure to Document Non-Pharmacological Interventions Before PRN Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation and implementation of non-pharmacological interventions before administering an antianxiety medication to a resident. This deficiency was identified during a survey when a resident was observed appearing lethargic and having difficulty staying awake. The resident, who had a history of cognitive communication disorder and Alzheimer's disease, was prescribed Lorazepam as needed for agitation. However, the facility's records showed that the medication was administered 52 times over a two-week period without proper documentation of the resident's behaviors or the non-pharmacological interventions attempted prior to medication administration for 23 of those instances. Interviews with facility staff, including LPNs and the Director of Nursing, revealed that the facility's policy required documentation of non-pharmacological interventions and the resident's behaviors before administering PRN psychotropic medications. The staff confirmed that such documentation should be recorded in the Electronic Medical Record (EMR) under progress notes. Despite this policy, the survey found that the required documentation was missing for nearly half of the medication administrations, indicating a failure to adhere to the facility's procedures. The facility's policy on the use of psychotropic medications, reviewed in October 2024, emphasized the need for documentation of the indications for use, non-pharmacological interventions attempted, and target symptoms for monitoring. The lack of documentation in the EMR for the resident's behaviors and interventions prior to administering Lorazepam highlights a significant oversight in following established protocols, as confirmed by the facility's own staff during the survey.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to maintain a sanitary environment by not ensuring that garbage containers were properly covered and the surrounding area was free of debris. During an observation, three out of four dumpsters designated for garbage had their contents exposed due to lids not being fully closed. Specifically, Dumpster #1 had both lids open, Dumpster #2 had one lid open, and Dumpster #3 also had one lid open, exposing bagged garbage. Additionally, the area around the dumpsters was littered with garbage, including plastic cups, disposable gloves, plastic bags, plastic milk crates, and other debris. The Assistant Food Service Director (AFSD) confirmed that the garbage area was a shared responsibility between the kitchen and environmental staff. The facility's policy, titled 'Dispose of Garbage and Refuse,' mandates that all garbage and refuse be collected and disposed of safely and efficiently, with the Dining Services Director coordinating with the Director of Maintenance to ensure the area is free of rubbish. However, this policy was not adhered to, as evidenced by the exposed garbage and debris around the dumpsters. The Licensed Nursing Home Administrator acknowledged the requirement for dumpsters to be covered at all times during a meeting with facility administration.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ocean View
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountain Springs At Cape May Nursing & Rehab Cente | 4.1 mi | ★★★★★ | 0 | 0 |
| United Methodist Communities At The Shores | 8 mi | ★★★★★ | 9 | 0 |
| Crest Haven Nursing And Rehabilitation Center | 8.7 mi | ★★★★★ | 2 | 0 |
| Complete Care At Court House, Llc | 9.8 mi | ★★★★★ | 1 | 0 |
| Complete Care At Linwood, Llc | 12.1 mi | ★★★★★ | 17 | 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.