Inspection Reports for
The Oaks at Denville
19 Pocono Road, Denville, NJ, 07834
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
79% occupied
Based on a September 2022 inspection.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 31, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident dignity, medication management, care planning, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during wound care, failure to issue required Medicare non-coverage notices, incomplete care plan revisions, inadequate monitoring of psychotropic medications, unsecured medication carts, and improper kitchen sanitation practices.
Deficiencies (6)
Failure to treat a resident with dignity during wound care by writing directly on surgical tape on the resident's wound site.
Failure to issue Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 of 3 residents reviewed.
Failure to revise comprehensive care plans for 2 of 15 residents within 7 days of assessment.
Failure to consistently monitor, document, and evaluate ongoing benefits of psychotropic medications for 3 of 5 residents reviewed.
Failure to secure medications within the medication cart; medication cart left unlocked during wound care.
Failure to maintain proper kitchen sanitation practices; uncovered food items and missing labels/use-by dates in refrigerators and freezers.
Report Facts
Residents reviewed for dignity deficiency: 16
Residents reviewed for SNF ABN deficiency: 3
Residents reviewed for care plan revision deficiency: 15
Residents reviewed for psychotropic medication monitoring deficiency: 5
Fluid restriction order: 1200
BIMS scores: 13
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed performing wound care and writing initials and date on resident's surgical tape |
| Director of Nursing | Director of Nursing (DON) | Provided facility policies and participated in survey discussions regarding deficiencies |
| Licensed Nursing Home Administrator | LNHA | Participated in survey discussions and exit conference |
| Unit Manager/Registered Nurse | UM/RN | Interviewed regarding care plan and psychotropic medication monitoring deficiencies |
| Social Worker | Social Worker (SW) | Interviewed regarding failure to issue SNF ABN forms |
| Certified Nursing Assistant | CNA | Interviewed regarding resident fluid restriction compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
The inspection was conducted following a complaint investigation triggered by a report on 10/09/23 regarding Resident #251's allegation of being hit by a male nurse and concerns about improper assessment and use of bed rails.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews indicating failure in bed rail safety assessment and resulting bruising to Resident #251. The Power of Attorney reported the resident's statement about being hit by a male nurse, which led to investigation and removal of the involved staff as a precaution.
Findings
The facility failed to properly assess, obtain physician orders, educate and obtain consent, monitor, and maintain bed rails for Resident #251, resulting in bruising and potential harm. The bed rails were incorrectly coded as enablers, blocking proper assessment and documentation. The facility initiated a Quality Assurance and Performance Improvement process after discovery.
Deficiencies (1)
Failure to properly assess bed rails safety, obtain physician order, educate and obtain consent, monitor and maintain bed rails, and follow facility policy and procedures.
Report Facts
Event date: Oct 5, 2023
Report call-in date: Oct 9, 2023
Assessment dates: Sep 14, 2023
Assessment dates: Sep 20, 2023
Care Plan intervention date: Oct 6, 2023
Bruise report date: Oct 8, 2023
Interview dates: Nov 2, 2023
Meeting date: Nov 3, 2023
Survey completion date: Nov 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to bed rail assessment failures and discussions with POA |
| Registered Nurse #1 | Registered Nurse | Signed Side Rail Screen dated 9/14/23 |
| Registered Nurse #2 | Registered Nurse | Signed Side Rail Screen dated 9/20/23 |
| Registered Nurse #3 | Registered Nurse | Reported bruises on Resident #251 on 10/08/23 |
| Registered Nurse/Unit Manager | RN/Unit Manager | Interviewed regarding care plan and resident assistance |
| Physical Therapist/Rehabilitation Director | Physical Therapist (PT)/Rehabilitation Director (RD) | Interviewed regarding lack of referral for bed rail evaluation |
| Licensed Nursing Home Administrator | LNHA | Participated in meeting with survey team discussing deficiencies |
| Clinical Implementation Analyst | CIA | Participated in meeting with survey team discussing deficiencies |
| Regional Nurse Consultant | RNC | Participated in meeting with survey team discussing deficiencies |
| Executive Director | Executive Director (ED) | Participated in meeting with survey team discussing deficiencies |
Inspection Report
Routine
Deficiencies: 10
Date: Nov 8, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with professional standards of quality, medication administration, fall prevention, bed rail safety, pharmaceutical services, infection prevention, staff education, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including improper medication administration, incomplete fall investigations and care plan updates, inadequate assessment and consent for bed rail use, failure to act on pharmacist recommendations timely, improper medication storage and labeling, incomplete hospice documentation, lack of qualified infection preventionist training, and insufficient mandatory staff education on QAPI and other topics.
Deficiencies (10)
Medication was administered without following manufacturer's cautionary to take with meals for Resident #35.
Fall investigation for Resident #35 lacked root cause analysis conclusion and care plan was not updated with new interventions after fall.
Failure to properly assess, obtain physician order, consent, and monitor bed rail use for Resident #251, resulting in bruising and safety concerns.
Consultant pharmacist recommendations regarding sequencing of PRN pain medications for Resident #17 were not acted upon timely.
Discontinued medication for discharged Resident #23 was not removed from active inventory; medication cart left unlocked; expired Lorazepam gel syringe found.
Potentially hazardous foods stored without proper labeling, dating, or expiration information in kitchen and food storage areas.
Incomplete and inaccessible hospice nurse visit notes for Resident #17, with missing documentation from September and October 2023.
Infection Preventionists (IPs) employed without completing required CDC specialized training prior to assuming role; part-time IP coverage issues.
Five Certified Nursing Assistants (CNAs) lacked mandatory annual QAPI training and education.
Certified Nursing Assistant #1 did not receive required 12 hours of annual in-service training for two consecutive years.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
CNAs reviewed: 5
CNA missing education: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| IP#1 | Infection Preventionist | Hired as per diem IP on 6/01/23, assumed IP role prior to completing CDC training |
| IP#2 | Infection Preventionist | Full-time IP hired 4/18/22, completed CDC training after assuming IP role |
| IP#3 | Infection Preventionist | Assumed IP role prior to completing CDC training |
| Director of Nursing | DON | Acknowledged deficiencies and provided explanations during survey |
| Licensed Nursing Home Administrator | LNHA | Provided timelines and documentation related to IPs and education |
| Registered Nurse #1 | RN | Observed medication storage issues and confirmed discontinued medication handling |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding consultant pharmacist reviews and medication cart security |
| Hospice Registered Nurse | HRN | Interviewed about hospice visit notes and documentation |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Date: Sep 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00157842.
Complaint Details
Complaint number NJ00157842 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs.
Report Facts
Sample size: 6
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the applicable infection control regulations and CDC recommended practices for COVID-19.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jul 22, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with professional standards of quality, resident care, medication administration, staff performance, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for blood pressure monitoring, inadequate individualized continence care, incorrect oxygen administration, lack of annual CNA performance evaluations, improper use and documentation of psychotropic medications, failure to honor resident meal preferences, and failure to hold quarterly Quality Assessment and Assurance meetings with required members.
Deficiencies (7)
Failure to follow physician's order to not take blood pressure on Resident #18's left arm.
Failure to provide individualized continence care for Resident #158, including inappropriate use of diapers without formal assessment.
Failure to administer correct oxygen flow rates per physician orders for Residents #50 and #53.
Failure to conduct annual performance evaluations for 3 of 5 CNAs reviewed.
Failure to document non-pharmacological interventions and behaviors prior to administering PRN anti-anxiety medication (Xanax) to Resident #41.
Failure to honor Resident #158's meal preferences regarding portion sizes.
Failure to hold quarterly Quality Assessment and Assurance meetings with required members for the last four quarters.
Report Facts
Blood pressure monitoring on left arm: 130
PRN Xanax administrations: 16
CNA performance reviews missing: 3
QAA meetings missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding care of Resident #18 and Resident #158 | |
| Director of Nursing (DON) | Confirmed failure to follow physician orders and lack of CNA performance reviews; interviewed about QAA meetings | |
| Registered Nurse (RN) | Interviewed regarding Resident #18 and Resident #53 care and oxygen administration | |
| RN Unit Manager (RNUM) | Interviewed about staff compliance with physician orders for Resident #18 | |
| Human Resources Manager (HR) | Interviewed about CNA performance evaluations | |
| Certified Nursing Aide (CNA) for Resident #41 | Interviewed about resident behaviors and care | |
| Licensed Practical Nurse (LPN) | Interviewed about medication administration and documentation for Resident #41 | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed about Resident #41 behaviors, medication administration, and QAA meetings | |
| Food Service Manager (FSM) | Interviewed about portion sizes and meal preparation for Resident #158 | |
| Registered Dietitian (RD) | Interviewed about menus and portion sizes | |
| Temporary Facility Administrator (LHNA) | Interviewed about QAA meetings |
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