Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

AUTUMN LAKE HEALTHCARE AT BERKELEY HEIGHTS

BERKELEY HEIGHTS, NJ · 130 certified beds · Last Life Safety survey November 18, 2025

CMS Certification Number 315195 · first certified July 1983

Ownership

Operated by AUTUMN LAKE HEALTHCARE · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

24
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
6
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

Position within NJ

24 citations — more than 85% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens March 2027 — about 5 months from now. This facility’s last Life Safety survey was November 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.

This facility24NJ median15National median11
Citations on file over three years, compared
MeasureCitations
This facility24
Median facility in NJ15
Median facility nationally11

Survey history

Citations at each Life Safety survey
92022-11102024-0752025-11
Citations at each Life Safety survey
Survey dateCitations
November 15, 20229
July 19, 202410
November 18, 20255

Most-cited tags

Most-cited tags at this facility
K-03472K-03632K-03212K-03742K-09272K-09182K-03411K-09111
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0347Properly provide smoke detection systems in areas open to corridors.22025-11-18
K-0363Install corridor and hallway doors that block smoke.22024-07-19
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22025-11-18
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.22025-11-18
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.22024-07-19
K-0918Have generator or other power source capable of supplying service within 10 seconds.22024-07-19
K-0341Install a fire alarm system that can be heard throughout the facility.12022-11-15
K-0911Meet requirements for the installation and maintenance of electrical systems.12022-11-15

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 13
  • Gas, Vacuum, and Electrical Systems Deficiencies 6
  • Egress Deficiencies 4
  • Services Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies13
Gas, Vacuum, and Electrical Systems Deficiencies6
Egress Deficiencies4
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 18, 2025 — 5 citations

Citations issued on November 18, 2025
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (December 18, 2025)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (December 18, 2025)
K-0347Properly provide smoke detection systems in areas open to corridors.Deficient, Provider has date of correction (December 18, 2025)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (December 18, 2025)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (December 18, 2025)

July 19, 2024 — 10 citations

Citations issued on July 19, 2024
TagWhat the surveyor checksStatus
K-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.Deficient, Provider has date of correction (September 10, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (September 10, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 10, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (September 10, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (September 10, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (September 10, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (September 10, 2024)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (September 10, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 10, 2024)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (September 10, 2024)

November 15, 2022 — 9 citations

Citations issued on November 15, 2022
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (January 19, 2023)
K-0281Install proper backup exit lighting.Deficient, Provider has date of correction (December 16, 2022)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (December 16, 2022)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (January 24, 2023)
K-0347Properly provide smoke detection systems in areas open to corridors.Deficient, Provider has date of correction (November 24, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 16, 2022)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (December 16, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 16, 2022)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (December 16, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.