Autumn Lake Healthcare At Memorial Bridge

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

have a corresponding nursing note. In the presence of the surveyor, the LPN UM reviewed the documented weights in the electronic medical record for Resident #1 and she stated that there should have been a weight taken in between 10/11/25 and 10/20/25, and weekly thereafter until discharge. The LPN UM stated that she did not know why the weights were not taken, but that they should have been. In the presence of

the surveyor, the LPN UM also reviewed the PN dated 10/29/25 which reflected a weight of 209 lbs. The LPN UM stated she was not aware that the resident had a weight gain to that extent. During an interview with the Registered Dietitian (RD) on 11/6/25 at 2:58 PM, she stated that she visited the facility weekly and that she reviewed the weights with the UMs. The RD stated that a resident's weight was taken immediately upon admission and weekly for four weeks thereafter, unless otherwise indicated. The RD further stated that any resident that refused a weight, there should be documentation indicating why. The RD stated that

she assessed Resident #1 on 10/15/25 and wrote a corresponding note that she reviewed in the presence of the surveyor. The RD reviewed the electronic medical record along with the 10/29/25 PN, and she stated that she was not aware of the 37 lb. weight gain that was significant. The RD further stated that she was not sure why the weights were not done in between 10/11/25 and 10/20/25, and weekly thereafter until discharge. During a telephone interview with the NS on 11/6/25 at 3:34 PM, she stated that upon admission, a resident's weight was taken and then weekly for four weeks. The NS stated that all weights were provided to the RD for review. The NS confirmed that she was the supervisor working on the evening of 10/29/25. The NS stated that while she was on the unit she recalled seeing Resident #1's family on the unit and they had concerns and seemed upset. The NS stated that she could not recall exactly what was said, but she remembered completing an assessment on the resident. The NS stated that the resident's weight was taken on that date, and that she was not aware of any missed weights. During a telephone

interview with the facility's Medical Director (MD) on 11/7/25 at 10:24 AM, he stated that he was familiar with Resident #1. The surveyor reviewed Resident #1's weights of 171.8 lbs. on 10/20/25, and then 209 lbs.

on 10/29/25. The MD stated that he was not aware of the resident's weights but that it was a significant change. The MD further stated that he expected the facility to monitor weights per the policy. The surveyor reviewed all printed documentation received from the facility which included weights for Resident #1's most recent admission. The surveyor noticed that two additional weights had been added to the resident's weights as follows:-10/16/25 [1:19 PM] 170.6 lbs.-10/23/25 [8:47 AM] 172 lbs. During an interview with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Nurse on 11/7/25 at 12:52 PM, they all agreed that a resident's weight was taken upon admission and weekly for four weeks, unless further indication was needed. In the presence of the surveyor, they each reviewed the screenshot that the surveyor took of Resident #1's previous weights and then the printed sheet that was provided to the surveyor. They each noted the addition of the weights. The DON then stated that when reviewing the weights at the time she was printing, she noted that weights were missing. The DON contacted a former employee that used to meet with the RD weekly, who told the DON that there were additional weights on a piece of paper that should have been added, so the DON added them. The DON further stated that the weights should have been entered right away. A review of the facility's undated Weight Monitoring policy revealed that the weekly weights would be conducted weekly and that weekly meetings would be held with the DON, UMs, and the RD to discuss weekly weights. A review of the facility's undated Charting Error and/or Omissions, which revealed that the facility would maintain accurate medical records. N.J.A.C. 8:39-27.1(a)

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Memorial Bridge

201 Fifth Avenue Penns Grove, NJ 08069

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

fax the notes to the facility within a few days so that they could be added to the medical record. The AP stated that he was not sure what happened in the case of Resident #1, #2, and #3, but that the documentation should have been there. During an interview with the LNHA, the DON, and the Regional Nurse (RN) on 11/7/25 at 12:52 PM, they each agreed that the expectation was that physicians ensure that documentation is entered into the system within a reasonable amount of time. A review of the facility's undated Attending Physician Responsibilities policy, which revealed that each Attending Physician was responsible for, . Providing appropriate, timely and pertinent documentation. The policy further revealed that, The note should be written or entered at the time of the visit or, if dictated or otherwise prepared after

the visit, should be returned to the facility for placement on the chart within a week. A review of the facility's undated Charting Error and/or Omissions, which revealed that the facility would maintain accurate medical records. NJAC 8:39-23.2 (b)

Event ID:

Facility ID:

If continuation sheet