Laurel Bay Health & Rehabilitation Center

Inspectors wroteComplaint #: NJ187696Based on interviews, medical record review, and review of other pertinent facility documentation on 6/30/2025, it was determined that the facility failed to follow their protocol and policy to prevent the elopement of a severely cognitive impaired resident (Resident #1) who had a history of elopement from the facility when a Licensed Practical Nurse (LPN #1) heard the wander guard alarm sound at the front entrance of the facility and failed to respond to the alarm to ensure the safety of its residents. On 6/23/2025 at approximately 8:25PM, LPN #1 was coming down the stairs from the second-floor nursing unit when she heard the wander guard alarm at the front entrance sounding. She stated she called another staff member on the telephone to get the code to the keypad to stop the alarm. [...]

Inspectors wroteComplaint #: NJ187696Based on interviews, review of medical records, and other pertinent facility documentation on 6/30/2025, it was determined that the facility failed to implement care plan interventions for 3 of 3 residents who were identified as an elopement risk. This deficient practice was evidenced by the following:1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Unspecified Convulsions, Unspecified Cerebral Infarction (Stroke), and Hypertension. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 6/5/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. The MDS also indicated that Resident #1 had an elopement alarm in place and was able to ambulate with set-up assistance. [...]

Inspectors wroteComplaint #: NJ187696Based on interviews, medical record review, and review of other pertinent facility documentation on 6/30/2025, it was determined that the facility nursing staff failed to consistently document on the Treatment Administration Record (TAR) the placement of a resident's wander guard bracelet (elopement device) according to the acceptable standards of nursing practice for 1 of 3 residents (Resident #3) reviewed for documentation. The facility also failed to follow its policy titled Documentation, Guidelines. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/30/2024 from 9:25 AM to 10:07 AM, the surveyor, accompanied by the cook and later at 10:07 AM joined by the Dietary Director (DD), observed the following: 1.) In the refrigerator known as the Drink Refrigerator, there was a tray that contained 35 bowls of butterscotch pudding, along with a tray holding 7 cups of applesauce and 1 cup of cottage cheese. None of these items were labeled with preparation or use-by dates. The cook said that all the items should be labeled with both dates to ensure freshness and uphold food safety standards. [...]

Inspectors wroteBased on observation and interview on 12/30/2025 in the presence of the Administrator and the Director of Maintenance (DOM), it was determined that the facility failed to ensure that the resident call bell system was properly functioning by notification of an activation when pressing the call bell button. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation at 12:22 PM revealed that the call bell system did not notify staff of a call bell system activation by visual and or audible notification for bed 1 in room [ROOM NUMBER] when the Administrator pressed the call bell button. In an interview at the time, the DOM confirmed that the call bell system light did not activate outside of the room and that notification at the nurse's station was not received. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to keep all areas clean. The deficient practice was identified for 2 of 2 floors reviewed under the Environmental Task. The deficient practice was evidenced by the following: On 12/30/2024 at 10:31 AM, Surveyor # 1 observed room [ROOM NUMBER]. At that time, Surveyor # 1 observed water on the floor. No wet-floor sign was observed. On the same date at 10:37 AM, Surveyor # 1 observed Resident # 35 in their room. At that time, Surveyor # 1 observed spilled milk on the floor and no bag liner in the trash bin. On 12/31/2024 at 11:03 AM, Surveyor # 1 observed the first floor shower room across from room [ROOM NUMBER]. At that time, Surveyor # 1 observed brown stains on the floor, tile, and caulked areas. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed provide services with reasonable accommodation of resident needs specifically by failing to keep call devices within reach of the resident. The deficient practice was identified 2 of 2 residents (Resident #80 and Resident # 236) reviewed for call devices. On 12/30/2024 at 10:29 AM during the initial tour of the facility, surveyor # 1 observed Resident # 236's call device on the floor next to the night stand. It was connected to the wall input. On 12/31/2024 at 8:58 AM, surveyor # 1 observed Resident # 236's call device on the floor next to the night stand. It appeared to be in the same location as the previous observation. At that time during an interview with surveyor # 1, Resident # 236s said they would use it if he/she could find it. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool used to facilitate care. This deficient practice was identified for 1 of 23 residents (Resident #80) reviewed and was evidenced by the following: Upon initial tour of the facility on 12/30/2024 at 10:44 AM, Resident #80 was observed wandering by the 1st Floor nursing station. The surveyor observed an elopement device on the resident's left ankle. On 12/31/2024 at 11:06 AM, the surveyor observed Resident #80 sitting on their bed in their room. The surveyor asked permission from Resident #80 to enter and was granted permission. Resident #80 acknowledged the presence of the bracelet on the left ankle, but did not know what it was. The surveyor reviewed the medical record for Resident #80. [...]

Inspectors wroteBased on observation interview and record review, it was determined that the facility failed to develop and implement a care plan focus for 1 of 2 residents (Resident #68) reviewed for comprehensive care plans related to indwelling catheter care. This deficient practice was evidenced by the following: During initial tour on 12/30/2024 at 09:48 AM, the surveyor observed Resident # 68 resting in bed with a urinary drainage bag attached to the bed frame. A review of the admission Record located in the Electronic Medical Record, Resident #68 was admitted to the facility with diagnoses including but not limited to: Functional Quadriplegia (the complete inability to move due to severe disability or frailty due to another medical condition, without injury or damage to spinal cord), and Dementia (a group of symptoms affecting memory, thinking, and social abilities). [...]

Inspectors wroteBased on interview, record review and document review it was determined that the facility a) failed to follow a physician's placement order of an elopement device and b) signed the Treatment Administration Record (TAR) that identified correct placement of the elopement device per physician's order. This deficient practice was identified for 1 of 1 Residents (Resident #80) reviewed for elopement and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents it was determined that the facility failed to ensure the resident's environment is free from accident hazards specifically by failing to place a fall mat beside the bed while the resident is in bed. The deficient practice was identified for 1 of 3 residents (Resident # 81) investigated for Falls and 1 of 1 residents (Resident # 75) investigated for Accident Hazards. The deficient practice was evidenced by the following: A review of Resident # 81's quarterly Minimum Data Set (MDS; An assessment tool) dated 11/07/2024 revealed that he/she had a fall without injury upon admission. A review of Resident # 81's physician's orders located in the Electronic Medical Record (EMR) revealed an order for an electric, low bed with a crash mat every shift. [...]

Inspectors wroteComplaint # NJ00177022 Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that there were a.) physicians orders for an indwelling catheter (tube inserted in the bladder to drain urine); b.) ensure urinary drainage bag were secured in manner to prevent contamination and infection control; c.) failed to document the urinary catheter output was collected as ordered by the physician. and that for 2 of 2 resident reviewed for an indwelling catheter. (Resident #68 and Resident #21). The deficient practice was evidenced by the following: 1. During the initial tour on 12/30/2024 at 09:48AM, surveyor #1 observed Resident # 68's urinary drainage bag not in a privacy bag and visable from the hallway. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by leaving respiratory masks uncontained, exposed, open to air. The deficient practice was identified for 3 of 4 residents (Residents # 236, 29, 69) reviewed for Respiratory Care. The deficient practice was evidenced by the following: On 12/30/2024 at 10:30 AM during the initial tour of the facility, Surveyor # 1 observed Resident # 236 in bed. At that time, Resident # 236 was wearing a nasal cannula (tube used to deliver oxygen through the nostrils). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary and comfortable environment regarding Enhanced Barrier Precautions that helped prevent the development and transmission of communicable diseases and infections. The deficient practice was identified on 1 of 2 floors within the facility. The deficient practice was evidenced by the following: 1.) On 12/30/2024 at 9:44 AM, upon initial tour of the second-floor sub-acute unit, surveyor #1 observed room [ROOM NUMBER] with an Enhanced Barrier Precaution (EBP) Sign on the door. Surveyor #1 put on personal protective equipment (PPE) including gloves and gown to enter the room. Surveyor #1 interviewed the two residents inside the room. Prior to exiting the room, surveyor #1took off the PPE but was unable to locate a designated PPE trash can. [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to ensure documentation in the resident's medical record of the information provided regarding the benefits and risks of immunization and the administration or the refusal of the vaccine, specifically the influenza vaccination (vaccine used to prevent influenza). The deficient practice was identified for 2 of 5 resident's reviewed for immunizations, (Resident #34 and Resident # 68). This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #34 was admitted to the facility with diagnoses including but not limited to: Diabetes Mellitus (DM) (a disease of inadequate control of blood levels of glucose) and Metabolic Encephalopathy (a change in the how the brain works due to an underlying condition). [...]

Inspectors wroteComplaint #NJ00164297 Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify a family representative when a resident had a significant change in physical status. This deficient practice was identified for 1 of 18 residents (Resident #192) reviewed. This deficient practice was evidenced by: Review of Resident #192's closed electronic health record (EHR) revealed an admission Record (an admission summary) which indicated that the resident was admitted to the facility with diagnosis which included but were not limited to: vascular dementia (a common form of dementia caused by an impaired blood supply to the brain), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety) and mild protein-calorie malnutrition. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 5 residents reviewed for PASRRs (Resident #80) and was evidenced by the following: On 01/03/24 at 10:55 AM, the surveyor reviewed Resident #80's Electronic Medical Record (EMR) which indicated that the resident had a PASRR level 1 completed on 11/04/22. At the time of the assessment the assessment was marked no for any diagnoses of mental illness. Resident #80 was admitted to the facility with diagnoses which included, but were not limited to dementia, quadriplegia (paralysis of all four limbs), and hypoglycemia (low blood sugar). [...]

Inspectors wroteBased on interviews and review of pertinent facility documentation, it was determined that the facility allowed a Non-Certified Nursing Aide (NA) to continue working as an NA after the specified 120 days from date of hire. This deficient practice was identified for 1 NA, (NA #1) during the NA review. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated April 21, 2023, sent to Nursing Homes included the following: Facilities are advised as follows: II. Nurse Aides Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.1. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to conduct pre and post dialysis assessments for Resident #42, Resident # 44, and Resident # 45, 3 of 3 residents reviewed for dialysis care and services. The deficient practice was evidenced by the following: 1. On 8/31/21 at 12:18 PM, the surveyor observed Resident #42 in the resident's room in their wheelchair watching television. The resident was soft spoken and timid, looking away when spoken to. The resident said they had no complaints. On 9/1/21 at 9:00 AM, the surveyor reviewed the Dialysis Communication Book for Resident #42. It was a notebook that contained only documentation from the dialysis center such as pre and post dialysis weights, vital signs and medication given at the dialysis center. There was no documentation in the communication book by the facility. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide a physician's order for the use of a seat belt which provided support to a resident with poor trunk control. The deficient practice was identified for 1 resident, Resident #7, of 1 reviewed for the use of a restraint and was evidenced by the following. The surveyor observed and interviewed Resident #7 on 8/31/21 at 11:28 AM. The resident was seated in a motorized wheelchair with a seat belt attached to the wheelchair and engaged around the resident's torso. The resident stated the seat belt is needed to stay upright in the wheelchair. The surveyor interviewed the Licensed Practical Nurse (LPN) on 8/31/21 at 11:30 AM. The LPN stated the resident required the seat belt to keep from falling forward. A review of the resident's medical record revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to consistently provide the prescribed flow rate oxygen therapy as ordered by the physician for 2 residents, Resident #20, Resident #10, reviewed for respiratory care. The deficient practice was evidenced by the following. 1. The surveyor observed Resident #20 on 8/31/21 at 10:25 AM. The resident was receiving oxygen through a nasal cannula connected to an oxygen concentrator. The flow rate was set at 3.5 liters per minute (LPM). The resident stated they thought it should be set at 3 LPM. The surveyor observed the resident receiving oxygen therapy on 9/1/21 at 10:13 AM. The flow rate was set at 4 LPM. On 9/1/21 at 10:18 AM the Licensed Practical Nurse (LPN #1) confirmed the flow rate was set at 4 LPM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection during garbage removal and dish handling. The deficient practices were evidenced by the following: On 8/31/21 at 10:47 AM in the presence of the Food Service Director (FSD), the surveyor observed a Food Service Worker (FSW) in the dish washing area with gloved hands who reached into a garbage can and pulled out partial food pieces, placed that food into another garbage can and with the same gloved hands grabbed a tied garbage bag full of garbage from inside that garbage can. The FSW walked toward the exit door and with the soiled gloved hands, touched a keypad to punch in a code and grabbed the door handle. The FSW exited the facility toward the garbage dumpster area to discard the garbage bag. [...]