Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Routine
Census: 129
Deficiencies: 0
Dec 6, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 4
Sep 19, 2023
Visit Reason
The inspection was conducted in response to complaints NJ00160399, NJ00165369, and NJ00167145 alleging abuse, neglect, exploitation, and misappropriation of resident property at Lakeland Nursing & Rehab.
Findings
The facility was found not in compliance with requirements related to reporting and investigating alleged violations of abuse, neglect, exploitation, and misappropriation of property. Deficiencies included failure to report allegations timely, failure to thoroughly investigate allegations, and failure to maintain adequate documentation of resident care and staffing ratios.
Complaint Details
The complaint investigation was substantiated as the facility failed to report and investigate allegations of abuse and neglect timely and adequately. Specific complaints involved residents #2, #7, and #9. The facility did not follow policy titled 'Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention' and failed to report allegations to the New Jersey Department of Health. The investigation included interviews, record reviews, and policy reviews.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse, neglect, exploitation, or mistreatment immediately or within required timeframes. | SS=D |
| Failure to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment. | SS=D |
| Failure to maintain resident records that are complete, accurate, readily accessible, and systematically organized. | SS=D |
| Failure to ensure staffing ratios met the required minimum staff-to-resident ratios as mandated by state law. | — |
Report Facts
Census: 133
Sample Size: 10
Staffing Deficiency Counts: 32
Certified Nurse Aide Staffing Deficiencies: 14
Inspection Report
Annual Inspection
Census: 127
Deficiencies: 22
Sep 1, 2022
Visit Reason
Annual recertification survey conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with multiple regulatory requirements including resident self-determination, advance directives, complaint reporting, PASARR coordination, baseline and comprehensive care planning, nutrition and hydration management, staffing ratios, fire safety, and electrical system maintenance.
Severity Breakdown
SS=D: 8
SS=E: 4
SS=G: 1
SS=F: 9
Deficiencies (22)
| Description | Severity |
|---|---|
| Failed to promote and facilitate resident self-determination by restricting one resident's (R101) ability to go for walks in the community without adequate documented plan or resident-centered care plan. | SS=D |
| Failed to ensure advance directives and POLST forms were completed, dated, and signed for three residents (R68, R62, R105). | SS=D |
| Failed to report an alleged resident-to-resident altercation involving R68 and R22 to administration and conduct appropriate investigation. | SS=D |
| Failed to coordinate PASARR screening and resident review for a resident (R17) with a new diagnosis requiring reassessment. | SS=D |
| Failed to notify state mental health authority of significant change in condition for resident (R68) with mental illness. | SS=D |
| Failed to develop and implement baseline care plans within 48 hours of admission for two residents (R61, R103) and failed to provide written summary to residents or representatives. | SS=D |
| Failed to develop comprehensive care plans with measurable goals and interventions for five residents (R3, R32, R43, R101, R103), including pain management, side rails, behaviors, nutrition, and resident preferences. | SS=E |
| Failed to ensure appropriate care and neuro checks following an unwitnessed fall with head injury for one resident (R66). | SS=D |
| Failed to reconcile resident weights and review hospital documentation for one resident (R103) with significant weight loss, resulting in inadequate nutritional assessment and care. | SS=G |
| Failed to offer pneumococcal vaccination to two residents (R31, R103) in accordance with CDC guidelines and document education and vaccination status. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios on day shifts for multiple days in August 2022. | SS=F |
| Annex building is Type V (000) unprotected combustible construction exceeding allowed height for health care occupancies without full sprinkler protection; facility requested time-limited waiver with plan to install smoke detection by April 15, 2024. | SS=F |
| Failed to ensure corridor widths met minimum 4 feet clearance for exit access in some areas; facility submitted FSES as equivalent. | SS=F |
| Failed to provide directional exit signage where direction of travel was not apparent when smoke barrier doors were closed on first and second floors. | SS=F |
| Failed to ensure smoke detection sensitivity testing was completed as required by NFPA 72 (2010 edition). | SS=F |
| Failed to install sidewall spray sprinkler at bottom of elevator hoistway not more than 2 ft above pit floor containing combustible hydraulic fluids. | SS=F |
| Failed to ensure corridor doors closed and latched with no impediments and were maintained to resist passage of smoke; multiple doors failed to latch or were blocked. | SS=F |
| Penetrations in smoke barriers on first and second floors were not protected by materials capable of restricting smoke transfer. | SS=E |
| Failed to provide ashtrays of noncombustible material with self-closing cover and metal container with self-closing cover in designated smoking area. | SS=E |
| Failed to maintain and inspect fire door assemblies; fire door to stairway adjacent to first floor clinic had holes above and below doorknob. | SS=F |
| Failed to maintain electrical junction boxes with suitable covers securely fastened in place; open junction boxes observed above ceiling tiles near smoke barrier walls on multiple floors. | SS=F |
| Emergency power supply (generator) was not equipped with a remote manual stop station to prevent inadvertent or unintentional operation. | SS=F |
Report Facts
Survey Census: 127
Sample Size: 25
Deficiency counts: 31
Staffing ratios: 10
Staffing ratios: 17
Weight discrepancy: 40
Neuro checks: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R101 | Resident restricted from community walks without documented plan | |
| R68 | Resident involved in unreported altercation | |
| R62 | Resident with incomplete POLST form | |
| R105 | Resident with incomplete advance directives and POLST | |
| R17 | Resident with new diagnosis requiring PASARR reassessment | |
| R61 | Resident without baseline care plan or summary | |
| R103 | Resident without baseline care plan or summary, nutrition issues | |
| R3 | Resident without comprehensive care plan for pain | |
| R32 | Resident without care plan for side rails | |
| R43 | Resident without measurable goals for behaviors | |
| R66 | Resident with unwitnessed fall without complete neuro checks | |
| R31 | Resident not offered pneumococcal vaccine | |
| R103 | Resident not offered pneumococcal vaccine, nutrition issues | |
| Director of Nursing | DON | Interviewed about care planning, neuro checks, weight discrepancies |
| Social Services Director | SSD | Interviewed about advance directives, care planning, PASARR |
| Licensed Practical Nurse 1 | LPN1 | Interviewed about resident falls and neuro checks |
| Licensed Practical Nurse 2 | LPN2 | Interviewed about resident falls and care planning |
| Registered Nurse 2 | RN2 | Interviewed about resident falls and neuro checks |
| Certified Nursing Assistant 4 | CNA4 | Interviewed about resident weight and nutrition |
| Director of Maintenance | Interviewed about fire safety, sprinkler system, corridor doors, smoke barriers, electrical junction boxes | |
| Administrator | Interviewed about resident walks, staffing, fire safety | |
| Infection Control Preventionist | ICP | Interviewed about immunizations |
| Registered Dietitian | RD | Interviewed about nutrition assessment and weight discrepancies |
| Regional Registered Dietitian | Regional RD | Interviewed about nutrition assessment and weight discrepancies |
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