Inspection Reports for Tylers Mill Senior Living
1674 Delsea Dr, Deptford, NJ 08096, United States, NJ, 08096
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Notice
Deficiencies: 0
Nov 19, 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 | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 3
Sep 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation following Complaint #NJ00177021 regarding the facility's compliance with New Jersey Administrative Code standards for assisted living residences.
Findings
The facility was found not in substantial compliance due to failure to implement and enforce policies related to the 'Missing Resident - Elopement Prevention Program,' resulting in an Imminent Danger for Resident #2 due to exit door lock malfunction and inadequate resident assessments and care plans.
Complaint Details
Complaint #NJ00177021 was substantiated with findings of Imminent Danger related to Resident #2's safety due to door lock malfunction and inadequate policy enforcement.
Deficiencies (3)
| Description |
|---|
| Failure to implement and enforce the 'Missing Resident - Elopement Prevention Program' policy, resulting in an Imminent Danger due to exit door lock malfunction affecting Resident #2. |
| Failure to ensure resident rights to live in safe and clean conditions, evidenced by a couch blocking an exit door and door lock malfunction. |
| Failure to complete a health care assessment within 14 days of admission for Resident #2, resulting in an Imminent Danger. |
Report Facts
Census: 45
Sample Size: 3
Date of Survey Completion: Sep 24, 2024
Date of Compliance: Nov 30, 2024
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 7
May 22, 2024
Visit Reason
Complaint investigation triggered by multiple complaints (NJ00169104, NJ00167541, NJ00173456) regarding policy enforcement, resident safety, and abuse allegations at Fox Trail Senior Living at Deptford.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards due to failures in policy implementation related to elopement risk management, visitor sign-in procedures, resident abuse prevention, and notification/reporting requirements. Specific incidents involving residents #1, #2, and #3 were documented, including elopements, abuse allegations, and failure to notify responsible parties and the Department of Health. The facility also failed to notify the NJDOH of a name change and did not maintain complete resident records for review.
Complaint Details
Complaint investigation based on complaints NJ00169104, NJ00167541, and NJ00173456. Imminent Danger identified related to resident #2 abuse and policy enforcement failures. Multiple interviews and document reviews confirmed deficiencies.
Deficiencies (7)
| Description |
|---|
| Failure to implement and enforce policies on elopement, incident reporting, and visitor sign-in, resulting in imminent danger for residents #1, #2, and #3. |
| Failure to ensure resident #2's right to be free from abuse, including lack of visitor identification and notification. |
| Failure to maintain safe and clean conditions and to safely accommodate residents, evidenced by elopements of residents #1 and #3. |
| Failure to notify NJDOH licensing department of facility name change. |
| Failure to notify NJDOH immediately and in writing within 72 hours of resident #3's elopement. |
| Failure to immediately notify resident #3's responsible party of incidents involving the resident. |
| Failure to provide requested medical records and facility documents for residents #2 and #3 during survey. |
Report Facts
Census: 43
Sample Size: 3
Dates of incidents: Multiple dates in May 2024 related to elopements and abuse incidents
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Named in findings related to failure to enforce policies, failure to notify NJDOH and responsible parties, and involvement in incident investigations |
| Health and Wellness Director | Director of Health and Wellness (DHW) | Named in findings related to incident reporting and policy enforcement |
| Certified Medication Assistance | Certified Medication Assistance (CMA) | Interviewed regarding visitor sign-in and awareness of incidents |
| Home Health Aide #1 | Home Health Aide (HHA #1) | Interviewed regarding visitor sign-in and awareness of incidents |
| Home Health Aide #2 | Home Health Aide (HHA #2) | Interviewed regarding visitor sign-in and awareness of incidents |
| Activities Director | Activities Director (AD) | Observed resident elopement incident |
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 1
Sep 13, 2023
Visit Reason
Focused Infection Control Survey due to an outbreak of Covid.
Findings
The facility failed to perform proper hand hygiene technique in accordance with CDC guidelines and the facility's policy for three staff members observed: Food Service Director, certified medication aid, and housekeeper.
Deficiencies (1)
| Description |
|---|
| Failure to perform proper hand hygiene technique according to CDC and facility policy by three staff members. |
Report Facts
Census: 39
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Observed failing to perform proper hand hygiene. | |
| Certified Medication Aid | Observed failing to perform proper hand hygiene. | |
| Housekeeper | Observed failing to perform proper hand hygiene. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 9
Dec 10, 2021
Visit Reason
Complaint investigation conducted due to allegations related to failure to retain completed Universal Transfer Forms, failure to enforce policies and procedures including resident to resident abuse, personal care and assistance, and failure to notify responsible parties and physicians of incidents and changes in condition.
Findings
The facility was found not in substantial compliance with multiple regulatory standards including failure to retain Universal Transfer Forms for transferred residents, failure to conduct investigations of resident to resident abuse, failure to maintain updated General Service Plans and Health Service Plans, failure to notify responsible parties and physicians of falls and changes in condition, and lack of RN coverage for several days. Additionally, controlled substance counts were not properly documented and infectious waste was improperly stored.
Complaint Details
Complaint # NJ 00150473 triggered the investigation of multiple deficiencies including failure to retain transfer forms, failure to investigate resident abuse, failure to maintain care plans, failure to notify responsible parties and physicians, and lack of RN coverage.
Deficiencies (9)
| Description |
|---|
| Facility failed to retain completed Universal Transfer Forms in medical records for transferred residents. |
| Executive Director failed to enforce policies and procedures including investigation of resident to resident abuse and ensuring RN availability. |
| Failure to maintain updated General Service Plans and Health Service Plans reflecting residents' needs and changes. |
| Failure to notify responsible parties of falls and changes in condition. |
| Failure to reassess residents by RN upon return from hospitalization. |
| Failure to notify physicians of incidents of falls and changes in medical condition. |
| Facility failed to ensure RN coverage at all times from 12/6/21 through 12/8/21. |
| Controlled substances shift-to-shift counts lacked proper signatures on multiple occasions. |
| Infectious waste bin was overflowing and lid unsecured, posing risk of exposure. |
Report Facts
Census: 43
Missing narcotic count signatures: 35
Missing narcotic count signatures: 50
RN coverage gap days: 3
Inspection Report
Routine
Census: 47
Capacity: 52
Deficiencies: 4
Sep 15, 2021
Visit Reason
Standard survey of 52 residential units to assess compliance with New Jersey Administrative Code 8:36 for licensure of assisted living residences and related programs.
Findings
The facility was found not in substantial compliance with all standards, with deficiencies in wound care coordination, medication administration, medication aide competency training, and physical plant ventilation systems in resident bathrooms.
Deficiencies (4)
| Description |
|---|
| Failure to coordinate and implement wound care interventions for one resident, including lack of physician orders and incomplete treatment documentation. |
| Failure to administer medications in accordance with prescriber's orders for two residents, including administration without current orders and incorrect dosing. |
| Failure to complete Certified Medication Aide competency training for medication pass delegation for five CMAs, not following facility policy. |
| Failure to ensure mechanical ventilation was operational in 42 out of 48 resident bathrooms without windows, risking moisture buildup and mold growth. |
Report Facts
Census: 47
Total Capacity: 52
Number of resident bathrooms without working ventilation: 42
Number of CMAs lacking medication pass competency training: 5
Number of residents with medication administration deficiencies: 2
Number of residents with wound care deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA #5 | Certified Medication Aide | Observed administering medications incorrectly and without proper physician orders |
| CMA #6 | Certified Medication Aide | Reported lack of medication pass observation by previous DON |
| CMA #14 | Certified Medication Aide | Reported medication passes were observed by other CMAs, not nurses |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound care and medication administration deficiencies; previous DON left unexpectedly |
| Administrator | Administrator (ADM) | Interviewed regarding resident condition, previous DON departure, and facility policies |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding ventilation system failures and lack of preventative maintenance |
| Certified Assisted Living Administrator | Certified Assisted Living Administrator (CALA) | Interviewed regarding lack of policy for ventilation system checks and plans to address deficiencies |
| Registered Nurse #12 | Registered Nurse | Provided care to resident with wound care issues and reported sending resident to hospital |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
May 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00144116.
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.
Complaint Details
Complaint number NJ00144116 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 7
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