Below 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 Southgate during CMS and state inspections, most recent first.
A resident with quadriplegia, a stage 4 pressure ulcer, and an indwelling catheter did not receive proper infection control measures during wound care. An LPN failed to wear a gown as required by Enhanced Barrier Precautions, used soiled gloves to handle multiple medication tubes, and returned these containers to a shared cart without disinfection. The urinary drainage bag was also observed resting on the floor and then placed on the bed, contrary to infection control protocols.
A resident with multiple chronic conditions did not receive a physician-ordered dose of Xarelto for atrial fibrillation because the medication was unavailable, and staff were unable to borrow it from other units. There was no documentation that the physician was notified of the missed dose, and pharmacy records showed a delay in resupply. Facility policy requires nurses to follow physician orders, but this was not followed in this instance.
The facility failed to maintain proper food safety and sanitation practices, with issues such as unlabeled food, improper cooling of meatloaf, inadequate handwashing, and malfunctioning dishwashing equipment. Observations revealed multiple sanitation lapses, including personal items in food prep areas and unclean kitchen equipment, highlighting significant lapses in compliance with health regulations.
The facility failed to maintain a clean and safe environment across three resident units, with issues such as grime on water coolers, unclean ice carts, and cobwebs in windows. Housekeepers confirmed that certain cleaning tasks were not part of their routine, and the facility's policies on cleaning and disinfection were not being followed. The Licensed Nursing Home Administrator and Director of Maintenance acknowledged the deficiencies, including unclean windows and inadequate staffing in the housekeeping department.
The facility failed to document reference checks for 10 employees, including RNs, LPNs, CNAs, and other staff, as required by its abuse policy. The DHR admitted to not documenting verbal references and often relied on current employee references or did not pursue references for re-hires or agency staff. The LNHA was aware of the DHR's responsibility but was unsure about the need for checks for re-hires or agency staff. This lack of documentation led to the deficiency.
The facility failed to develop comprehensive care plans for three residents, neglecting critical areas such as tube feeding, pain management, and oxygen use. One resident with a gastrostomy tube lacked a care plan for PEG tube management, another with rib fractures and cancer had no pain management plan, and a third with COPD did not have a plan for oxygen use. Interviews with staff revealed a lack of clarity and responsibility in updating care plans to reflect residents' needs.
A resident with chronic pain and a history of rib fractures and esophageal cancer experienced a delay in receiving a recommended pain management consultation. Despite frequent administration of oxycodone, the facility failed to secure an appointment with a specialist who accepted the resident's insurance. Interviews revealed a lack of communication and follow-through in scheduling the necessary appointment, contrary to the facility's policy for prompt medical follow-ups.
The facility failed to maintain dryer machines safely, as two out of four machines had lint accumulation due to incomplete cleaning logs. The Interim Housekeeping Director noted that staff should clean lint traps every two hours, but logs were last completed in August without a specified year. The Licensed Nursing Home Administrator expressed concern over the lack of documentation, which is crucial for preventing fire hazards.
A facility failed to follow a physician's order for a resident at risk of pressure ulcers by not providing prescribed heel boots. Instead, the resident's feet were placed on pillows, contrary to the order. Staff interviews revealed a misunderstanding of the order, and the DON confirmed the requirement for heel boots, which were not initially provided.
A resident with COPD was observed with a nasal cannula connected to an empty oxygen tank, contrary to a physician's order for continuous oxygen therapy. Facility staff, including a CNA and LPN, confirmed the oversight, highlighting a failure to ensure the resident received the prescribed oxygen. The resident's care plan and facility policy emphasized the need for continuous oxygen, which was not adhered to.
The facility failed to maintain safe and palatable food temperatures, as observed during a survey. Residents reported receiving cold meals in their rooms, and surveyors confirmed that food temperatures were inconsistent, with some items falling below the safe holding temperature. The facility's policy on food temperatures was not followed, potentially allowing for bacterial growth.
A facility failed to minimize infection spread during incontinence care rounds due to inadequate hand hygiene by a CNA. The CNA, responsible for eight residents, washed her hands for only 10 and 9 seconds after providing care, contrary to the facility's policy of at least 20 seconds. This occurred despite some residents being on Enhanced Barrier Precautions due to medical conditions. Interviews with staff confirmed the expectation of proper hand hygiene, which was not met.
Failure to Follow Infection Control Practices During Wound Care and Catheter Management
Penalty
Summary
A deficiency was identified when a resident with quadriplegia, a flaccid neuropathic bladder requiring a urinary drainage bag, and a stage 4 pressure ulcer did not receive care in accordance with infection control protocols. During wound care, an LPN failed to don a gown as required under Enhanced Barrier Precautions (EBP) for hands-on care of residents with open wounds. The LPN also used the same pair of soiled gloves to handle multiple medication tubes and returned these medication containers to a shared wound cart without disinfecting them. Additionally, the LPN brought medication containers into the resident's room, contrary to facility policy, which states that such items should not enter resident rooms to prevent cross-contamination. Further observations revealed that the resident's urinary drainage bag was resting on the floor rather than being secured to an appropriate holder, and was subsequently placed on the resident's bed prior to wound care. Facility staff, including the Infection Preventionist and Director of Nursing, confirmed that these actions were inconsistent with established infection control practices, which require the use of gowns and gloves for EBP, proper handling of medication containers, and ensuring urinary drainage bags are kept off the floor to prevent infection.
Failure to Provide Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic kidney disease, aneurysm of artery of lower extremity, and peripheral vascular disease did not receive a physician-ordered medication, Xarelto 20mg, for atrial fibrillation. The resident was cognitively intact, as indicated by a BIMS score of 15/15. On the specified date, the medication was not administered during the 3:00 p.m. to 11:00 p.m. shift, as shown by a blank entry on the Medication Administration Report. The Director of Nursing confirmed that if a medication is not available, nurses are expected to check backup supplies and contact the pharmacy, and if a dose is missed, the physician should be notified. The Infection Preventionist nurse stated that attempts to borrow the medication from other units were unsuccessful. There was no documentation in the resident's progress notes that the physician was notified of the missed dose. Pharmacy records indicated that a resupply request for the medication was made the following day, and the medication was received from the contracted pharmacy over the next two days. Facility policy requires nurses to follow physician orders and recommendations. The failure to ensure the medication was available and administered as ordered, and the lack of physician notification regarding the missed dose, led to the cited deficiency.
Plan Of Correction
Corrective Action: On 5/22/25, notified PCP that Resident #2 missed a dose of NJ Exec Order 26.4b1; no new orders were given. NJ Exec Order 26.4b1 from not receiving medication. Resident #2 resumed the medication as ordered on NJ Exec Order 26.4b1. On 5/23/25, director of nursing received approval from medical director to have NJ Exec Order 26.4b1 added to back-up box. An audit was conducted on 6/11/25, by the director of nursing on all EMAR progress notes of medications not administered. Discrepancies were identified, addressed, and individual counseling was provided to each nurse. Identification of Residents at Risk: All residents prescribed medication(s) have the potential to be affected by this deficient practice; residents can be identified by reviewing physician's orders. Systemic Change: Facility-wide in-service on proper procedure on requesting a refill for medication in a timely manner & when a prescribed medication is not available was conducted on 6/11/25 with all nurses, by the director of nursing. "Medication Not Available" form was initiated to be completed by nurses and turned into the director of nursing. Quality Assurance: Unit managers, or designee, will conduct an audit on EMAR progress notes to assure proper procedure taken on any medication not administered. Audits will be completed weekly for 2 months, then monthly for 1 year. Any discrepancies will be corrected/ addressed immediately. These audits will be turned into the director of nursing. The results of the EMAR audits will be reviewed by the DON, or designee, weekly for 2 months, then monthly. The findings will be reported to the LNHA and QAA committee quarterly for one year. The QAA committee will review the effectiveness of the implemented corrective actions and determine if further action is needed. If necessary, adjustments to protocols or corrective actions will be made to assure continued compliance and improvement.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. Observations revealed multiple issues, including unlabeled and undated food items, improper handwashing techniques, and inadequate food storage practices. For instance, containers of pudding were found without labels or dates, and a staff member washed her hands for only nine seconds, contrary to the facility's hand hygiene policy. Additionally, frozen meatballs were left exposed to air, and temperature logs for the walk-in refrigerator and freezer were incomplete, with no temperatures recorded on a specific date. Further deficiencies were noted in the cooling and storage of meatloaf, which was not properly cooled to the required temperatures, posing a risk of bacterial growth. The meatloaf was found at 48.6°F, above the safe holding temperature of 41°F, and there were no temperature logs to demonstrate the cooling process. The facility's Regional Food Service Director confirmed that the meatloaf should have been discarded due to improper cooling. Other sanitation issues included a can opener with a dried black substance, personal items in the food preparation area, and a lack of cleanliness in various kitchen areas, such as the tilt skillet and deep fryer. The facility also failed to adhere to policies regarding food labeling, cleaning schedules, and equipment maintenance. Several items, including hot dogs and grape jelly, were found unlabeled and undated, and a thermometer was missing from a refrigerator. The dishwashing machine was not functioning correctly, with gauges not moving during use, indicating improper sanitization of dishes. Additionally, personal items were found in unit nourishment room refrigerators, and there were issues with cleanliness and maintenance, such as stained ceiling tiles and clogged drains. These deficiencies highlight significant lapses in food safety and sanitation practices within the facility.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment across three resident units, as evidenced by multiple observations and interviews. On the 300 unit, a water cooler was found with a build-up of white streaks and grime, an ice cart had a plastic liner with rips and brown stains, and trash can lids were covered in white and brown substances. Housekeeper #5 confirmed that her cleaning routine did not include the water cooler or trash can lids. The Infection Preventionist stated that the water cooler should be cleaned twice per shift, and the Food Service Director noted that ice carts should be cleaned weekly, but some units never bring them for cleaning. Resident council feedback and further observations revealed additional deficiencies. Residents reported unclean windows with cobwebs, and the housekeeping department was noted to be short-staffed. Observations on the 200 and 100 units showed large cobwebs in atrium windows, a cracked window, and black debris on doors. Resident #89's shower had a black substance on the floor, and a shower chair with washcloths was left hanging. Housekeepers on the 200 and 100 units confirmed that high dusting was not part of their routine, and the Interim Director of Housekeeping admitted that outside windows had not been cleaned in over five years. The Licensed Nursing Home Administrator confirmed the presence of cobwebs and acknowledged the difficulty in maintaining the exterior of the building. The Director of Maintenance stated that the facility should be kept in good repair, but the housekeeping department was responsible for dusting the lounges. Facility policies reviewed indicated that trash cans should be disinfected daily, and ice machines should be cleaned regularly, but these procedures were not being followed. The Routine Cleaning and Disinfection policy emphasized the importance of maintaining a clean environment to prevent infections, but the facility failed to adhere to these standards.
Failure to Document Employee Reference Checks
Penalty
Summary
The facility failed to implement its abuse policy by not completing reference checks for 10 out of 10 employee files reviewed. The surveyor found that the files of various staff members, including registered nurses, licensed practical nurses, certified nursing assistants, housekeepers, and dietary aides, lacked documented evidence of reference checks. The Director of Human Resources (DHR) admitted to not documenting verbal references and stated that she often relied on current employee references or did not pursue references for re-hires or agency staff who became employees. The DHR also acknowledged that reference checks were not completed for some employees due to unsuccessful attempts to reach references or because the employees were re-hires. The Licensed Nursing Home Administrator (LNHA) was aware that the DHR was responsible for reference checks but was unsure if checks were needed for re-hires or agency staff. The facility's policy required screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, which included conducting reference checks. However, the DHR confirmed that she did not have documented evidence of completed reference checks for the employees reviewed, and blank forms were provided instead. This lack of documentation and adherence to policy led to the deficiency identified by the surveyor.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop an individual comprehensive care plan (ICCP) for three residents, addressing critical areas such as tube feeding, pain management, and oxygen use. Resident #85, who had a gastrostomy tube for enteral feeding, did not have a care plan that included the management of the PEG tube. Despite having physician's orders for enteral feeding and tube maintenance, the ICCP lacked a focus area for the PEG tube. Interviews with the Director of Nursing (DON) and the Regional Nurse revealed a lack of clarity and responsibility in updating the care plan to reflect the resident's needs. Resident #108, who suffered from pain due to multiple rib fractures and esophageal cancer, did not have a care plan addressing pain management. The resident frequently experienced pain that affected daily activities, and the medication administration record showed regular administration of oxycodone for pain relief. However, the ICCP did not include a plan for managing the resident's pain, which was acknowledged as necessary by both the LPN and the DON during interviews. Resident #391, who had COPD and required continuous oxygen therapy, also lacked a care plan related to oxygen use. The resident's treatment records indicated consistent oxygen administration, but the ICCP did not reflect this critical aspect of care. Interviews with nursing staff highlighted the expectation that oxygen use should be included in the care plan, yet this was not done. The facility's policy on comprehensive care plans emphasized the need for timely development and regular updates, which were not adhered to in these cases.
Failure to Schedule Timely Pain Management Appointment
Penalty
Summary
The facility failed to follow up on a healthcare provider's recommendation for a pain management appointment for a resident with chronic pain. The resident, who had a history of rib fractures and esophageal cancer, reported severe back pain and expressed dissatisfaction with the management of their pain. Despite a recommendation from a Nurse Practitioner for a pain management consultation in October, the facility did not make timely arrangements for the appointment. The resident's medical records indicated that the recommendation for a pain management appointment was made in October, but the first documented attempt to schedule the appointment was not until December. The Unit Clerks responsible for scheduling appointments were aware of the recommendation but failed to secure an appointment with a specialist who accepted the resident's insurance. The resident's pain was managed with oxycodone, which was administered frequently, but the underlying issue of securing a specialist consultation was not addressed. Interviews with facility staff, including Licensed Practical Nurses, Unit Managers, and the Director of Nursing, revealed a lack of communication and follow-through in scheduling the necessary appointment. The Unit Clerks had a list of specialists who accepted the resident's insurance but had not contacted any of them. The facility's policy required medical follow-up appointments to be scheduled promptly, but this was not adhered to, resulting in a delay in the resident receiving appropriate pain management care.
Failure to Maintain Safe Dryer Conditions
Penalty
Summary
The facility failed to maintain dryer machines in a safe operating condition, as evidenced by the observation of lint accumulation in two out of four dryer machines. During a tour of the facility's laundry room, the Interim Housekeeping Director (IDH) revealed that the laundry staff were responsible for cleaning the dryer lint traps every two hours and documenting the completion in a logbook. However, upon reviewing the logbook, it was found that the logs were not completed according to the facility's policy, with the last entries dated 8/20 and 8/21, without indicating the year. This lack of documentation raised concerns about adherence to the facility's policy. Further inspection of the dryer machines revealed a moderate amount of lint accumulation in the lint traps of two machines, which contradicted the IDH's statement that the traps should have been cleaned two hours prior. The IDH acknowledged that the staff should follow the facility's policy to prevent fires. The Licensed Nursing Home Administrator (LNHA) expressed concern about the lack of documentation related to lint trap cleaning, which is a critical safety measure to prevent fire hazards. The facility's updated policy from 1/2025 mandates that lint traps be cleaned every two hours and that all cleaning activities be logged, highlighting the importance of maintaining these records for safety and compliance.
Failure to Follow Physician's Order for Heel Boots
Penalty
Summary
The facility failed to adhere to a physician's order for the use of bilateral heel boots for a resident at risk of developing pressure ulcers. During an observation, the surveyor noted that the resident was not wearing the prescribed heel boots and instead had their feet resting on green pillows. The resident expressed a desire to wear the heel boots, which were not present in the room at the time. The resident's medical record indicated a history of conditions such as hemiplegia, morbid obesity, and mild protein calorie malnutrition, and the resident was identified as being at risk for skin breakdown. The physician's order specified the use of heel boots when in bed to prevent pressure ulcers, which was not being followed. Interviews with facility staff, including an LPN and a CNA, revealed that the heel boots were supposed to be offered to the resident, and there was no record of the resident refusing them. The CNA admitted to using a green pillow instead of the heel boots. The Director of Nursing confirmed that the heel boots should have been used as per the physician's order. The facility's policy mandates that all nurses follow physician orders, which was not adhered to in this instance, leading to the deficiency.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for a resident who required continuous oxygen therapy. During an initial tour, a surveyor observed the resident resting in bed with a nasal cannula connected to an empty portable oxygen tank. This observation was confirmed by a Licensed Practical Nurse (LPN), who then connected the nasal cannula to an oxygen concentrator and replaced the portable oxygen tank. The resident's medical record indicated a diagnosis of chronic obstructive pulmonary disease (COPD) with acute exacerbation, and a physician's order required continuous oxygen at two liters via nasal cannula. Interviews with facility staff, including a Certified Nurse Aide (CNA), LPN, and the Director of Nursing (DON), revealed that the staff was responsible for ensuring the resident received continuous oxygen as per the physician's order. The resident's comprehensive care plan also highlighted the need for continuous oxygen therapy. Despite this, the resident was found without the necessary oxygen supply, indicating a lapse in following the physician's orders and facility policy, which mandates adherence to physician orders and recommendations.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature, as evidenced by observations and resident feedback. During a Resident Council Meeting, four out of five residents reported that meals served in their rooms were cold, with only the dining room receiving warm meals. One resident noted that meals were delivered on open racks that did not maintain warmth, particularly affecting the last unit served, which received cold food. Observations by surveyors confirmed that food temperatures on the steam table were inconsistent, with some items exceeding the desired temperature and others falling below the safe holding temperature of 135 degrees Fahrenheit. Further investigation revealed that during the lunch meal service, trays were prepared and placed on an uncovered food truck, leading to temperature discrepancies by the time they reached the residents. The Regional Food Service Director confirmed that the puree foods did not meet the desired temperatures, and cold items were not maintained at 41 degrees Fahrenheit or below. The facility's policy on food temperatures was not adhered to, as evidenced by the recorded temperatures of the meal trays, which were outside the safe range, potentially allowing for bacterial growth. This deficiency was noted on one of the three nursing units observed.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to minimize the spread of infection during incontinence care rounds on one of its nursing units. This deficiency was observed when a Certified Nursing Assistant (CNA) was seen performing hand hygiene inadequately after providing care to residents. The CNA was responsible for eight residents, four of whom required incontinence care. During the rounds, the CNA was observed washing her hands for only 10 seconds after changing a resident's brief, which was contrary to the facility's policy requiring at least 20 seconds of handwashing. This inadequate hand hygiene was repeated after providing care to another resident, where the CNA washed her hands for only nine seconds. The issue was further compounded by the fact that some residents were on Enhanced Barrier Precautions (EBP) due to their medical conditions, such as having a tracheostomy or gastrostomy tube, which necessitated additional infection control measures. Despite the presence of signs indicating the need for gowns and gloves, the CNA's failure to adhere to proper hand hygiene protocols posed a risk of spreading infection. Interviews with the Licensed Practical Nurse/Unit Manager, Infection Preventionist, and Director of Nursing confirmed that the facility's expectation was for staff to wash their hands for a minimum of 20 seconds to prevent the spread of germs, which was not met in this instance.
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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 Carneys Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Memorial Bridge | 3.5 mi | ★★★★★ | 2 | 0 |
| Kutz Rehabilitation And Nursing | 5.2 mi | ★★★★★ | 3 | 0 |
| Gilpin Hall | 6.3 mi | ★★★★★ | 11 | 0 |
| Complete Care At Hillside Llc | 6.3 mi | ★★★★★ | 4 | 0 |
| Regency Healthcare & Rehab Center | 6.5 mi | ★★★★★ | 0 | 0 |
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