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Complaint Investigation

Autumn Lake Healthcare At Memorial Bridge

November 25, 2025 · Penns Grove, NJ · 201 Fifth Avenue
Citations 2
CMS Rating 2/5
Beds 161
Provider ID 315271
Healthcare Facility
Autumn Lake Healthcare At Memorial Bridge
Penns Grove, NJ  ·  View full profile →
Inspection Summary

AUTUMN LAKE HEALTHCARE AT MEMORIAL BRIDGE in PENNS GROVE, NJ — inspection on November 25, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0692
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

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)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Memorial Bridge

201 Fifth Avenue Penns Grove, NJ 08069

SUMMARY STATEMENT OF DEFICIENCIES

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)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PENNS GROVE, NJ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AUTUMN LAKE HEALTHCARE AT MEMORIAL BRIDGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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