Laurel Brook Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure recommendations made by the Consultant Pharmacist were acted upon in a timely manner. This deficient practice was identified for 1 of 5 residents (Resident #17) reviewed for unnecessary medications and was evidenced by the following:On 1/15/26, the surveyor observed Resident #17 sitting in the dining room eating lunch. The surveyor reviewed the medical record for Resident #17. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, vascular dementia. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 10/10/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. [...]

Inspectors wroteComplaint # 2671178Based on observation, interview, and review of facility documentation it was determined that the facility failed to follow the wound care consultant's treatment recommendations for a resident with pressure ulcers (skin damage caused by pressure). This deficient practice was identified for 1 of 2 residents (Resident # 6) reviewed for pressure ulcers. On 1/14/26 at 10:40 AM, during the initial tour of the facility, Resident #6 was observed in a reclining chair in the dayroom with eyes closed. On 1/15/26 at 11:15 AM, the surveyor entered Resident #6's room and noted a malodorous odor. The surveyor asked the nurse caring for the resident if the resident had any wounds. The nurse stated the resident had multiple wounds and that wound care was completed on the 3:00 PM-11:00 PM shift. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to consistently follow medication hold parameters according to the physician's order and Consultant Pharmacist's recommendations. This deficient practice was identified for 1 of 5 residents (Resident #17) reviewed for unnecessary medications and was evidenced by the following:On 1/15/26, the surveyor observed Resident #17 sitting in the dining room eating lunch. The surveyor reviewed the medical record for Resident #17. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, vascular dementia and hypertension (high blood pressure). [...]

Inspectors wroteComplaint #: 2614619 Based on interviews, record review and review of pertinent facility documents 09/18/2025 and 09/23/2025, it was determined that the facility failed to ensure a resident was protected from verbal and physical abuse on 12/18/24 when a house keeping staff was observed yelling and kicking a resident (Resident #4). The facility also failed to follow its policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Resident. This deficient practice was identified for 1 of 9 residents and was evidenced as follows:According to the admission Record (AR), Resident #4 was admitted to the facility with diagnoses that include but not limited to: Unspecified Dementia (loss of cognitive function, thinking), Depression (feeling of severe despondency and dejection), and History of Falling. [...]

Inspectors wroteBased on interviews, medical record reviews, and review of other pertinent facility documents, it was determined that the facility failed to conduct a thorough investigation for an allegation of verbal abuse. This deficient practice was identified for 1 of 9 residents reviewed for abuse (Resident #2), and was evidenced by the following:A review of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) dated 8/01/24, included an allegation of rough handling of Resident #2. According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint #: NJ179543 Based on observation, interview, and review of pertinent facility documents on 1/16/2025, it was determined that the facility failed to follow appropriate hand hygiene during an observation of a resident's wound treatment for 1 of 3 residents ( Resident #1). This deficient practice has the potential spread of infection in accordance wiht the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice and facility policy as evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . [...]

Inspectors wroteComplaint#: NJ00176792 Based on interviews, medical record review, and review of other pertinent facility documents on 11/19/2024, it was determined that the facility failed to notify a resident's physician of unavailable medication, follow facility policies regarding unavailable medication, and charting and documentation. This deficient practice was identified for 1 of 1 resident (Resident # 3) reviewed for physician notification. This deficient practice was evidence by the following: According to the admission Record (AR), Resident #3 was admitted to facility with diagnoses which included but were not limited to aftercare following joint replacement, unspecified atrial fibrillation (an irregular, rapid heart rhythm that can lead to blood clots in the heart and increase the risk of stroke), and anxiety. [...]

Inspectors wrotePart B. The facility further failed to: complete a safe smoking evaluation immediately upon the identification of a change in resident's smoking status. This deficient practice was identified for 1 of 7 residents (Resident #191) reviewed for smoking. This deficient practice was evidenced by the following: 2. ) On 10/9/24 at 1:44 PM, the surveyor attempted to meet with Resident #191 who was not in their room. Licensed Practical Nurse (LPN) #10 was present outside of the resident's room and stated that the resident was outside smoking. The surveyor went to the courtyard and observed Resident #191 seated at a table with another resident in the designated smoking area. When interviewed, the resident stated that they only smoked now and then. [...]

Inspectors wrote4.) During the initial tour on 10/8/24 from 10:55 AM to 1:11 PM of Central Unit, the surveyor observed the following: -room [ROOM NUMBER]-A: There was a hole in the ceiling that was covered with clear plastic surrounded by black electrical tape. There was a dried substance noted in the center of the plastic that covered the hole in the ceiling. A PTAC (packaged terminal air conditioner unit) had a visibly dented and damaged front cover, and a portable air conditioner unit that was vented out of the resident's window were both in the room. Resident #81 and his/her spouse were present and stated, the ceiling should not be that way, and it has been that way since around Christmas. They put the plastic up in the early part of the year. I would think it would have been fixed by now. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was identified in the facility's kitchen and 5 of 5 refrigerators designated for resident food, and was evidenced by the following: On 10/08/24 from 9:30 AM to 10:45 AM, the surveyor, accompanied by the Food Service Director (FSD) toured the kitchen and observed the following: In the refrigerator identified as the Korean Refrigerator: 1. Two sealed bags of cooked rice with a use-by date of 10/02/24. The FSD removed the two bags from refrigerator and discarded them. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff implemented facility policies and procedures to ensure a.) residents were provided with care and services to achieve their highest practical wellbeing, and b.) maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for and 5 out of 5 nursing units, and was evidenced by the following: Refer to F584, F645, F657, F689, F758, and F812 A review of the Administrator's job description provided by the facility revealed the following: [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of 1 resident (Resident #97) reviewed for level II PASARR and was evidenced by the following: On 10/15/24 at 10:08 AM, the surveyor reviewed the electronic medical record for Resident #97. A review of the admission Record face sheet (an admission summary) reflected that the resident had diagnosis that included, intellectual disability, schizophrenia and generalized anxiety. A review of the PASARR level I Screening Tool dated 2/7/24 and signed by the facility's social worker (SW), indicated the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's individualized comprehensive care plan (ICCP) related to smoking for 3 of 6 residents (Resident #73, #102 and #198) reviewed for accidents. This deficient practice was evidenced by the following: 1.) On 10/9/24 at 1:52 PM, the surveyor observed Resident #102, awake and alert, sitting in a chair at a table in the outside smoking patio. The surveyor observed a red pack of cigarettes with a black lighter on top of the pack of cigarettes on the patio table. The resident confirmed the cigarettes and lighter were his/hers and that he/she did not use a smoking apron anymore. Resident #102 further stated that he/she can come out to smoke anytime between 8:00 AM and 8:00 PM, and there was no supervision by the staff. [...]

Inspectors wrote2.) On 10/08/24 at 9:31 AM, the surveyor observed Resident #167 in his/her room. A review of the admission Record (admission summary) reflected the resident had diagnoses which included, but were not limited to, anxiety disorder, depression, and bipolar disorder (mental illness that causes unusual shifts in mood). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 9/4/24, revealed the resident had a Brief Interview for Mental Status score of 15 which indicated that the resident's cognition was intact. A review of Resident #167's Physician's orders located in the Electronic Medical Record (EMR) revealed an order for Lorazepam (medication used for anxiety) 0.5 milligram tablet to by given by mouth every 6 hours as needed for anxiety disorder, with a start date of 08/29/24. The active order did not include a duration for use or stop date. [...]

Inspectors wroteBased on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to provide necessary dental care services in a timely manner for 1 of 1 resident (Resident #143) reviewed for dental care services. This deficient practice was evidenced by the following: On 10/8/24 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #143 lying in bed awake with a visitor present at the bedside. The resident stated that he/she was ordered a mechanical soft diet (designed for people who have trouble chewing/swallowing). The resident further stated, I lost my bottom denture a year ago and thought that the facility was going to replace them, but it never happened. [...]

Inspectors wroteBased on interviews, record review and review of other pertinent documentation, it was determined that the facility failed to report timely an allegation of staff to resident abuse to the facility administrator and the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 residents (Resident #173) reviewed for an allegation of abuse. This deficient practice was evidenced by the following: During the initial tour of the facility on 10/08/24 at 1:36 PM, Resident #173 was observed seated on the side of their bed. When interviewed, the resident was tearful at times as they described how they were spoken to by the Nurse Practitioner (NP). The resident stated that the NP told them that they would die if they did not take their potassium. The resident stated that he/she did not want care forced upon them. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a Tracking Record (Discharge) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, for 2 of 38 residents (Resident #108 and Resident #406) reviewed for resident assessments. The deficient practice was evidenced by the following: 1. On 10/11/24 at 1:00 PM, the surveyor completed record review of Resident #108 specific to MDS assessment. Resident #108 was discharged to home on 9/10/24. The Discharge Return Not Anticipated/End of PPS Part A Stay MDS was completed on 10/11/24. The discharge MDS was 17 days overdue. 2. On 10/11/24 at 3:00 PM, the surveyor completed record review of Resident #406 specific to MDS assessment. Resident #406 was discharged to the hospital on 7/9/24. The Discharge Return Anticipated MDS was completed on 8/2/24. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's psychological needs specifically by failing to implement a care plan for a resident diagnosed with anxiety on admission. The deficient practice was identified for 1 of 6 residents (Resident #167) reviewed for unnecessary medication. This deficient practice was evidenced by the following: On 10/8/2024 at 9:31 AM, during the initial tour, the surveyor observed Resident #167 in their room. A review of Resident 167's admission Record face sheet (an admission summary) revealed that they had a diagnosis that included but not limited to; major depressive disorder, bipolar disorder, and generalized anxiety disorder. [...]

Inspectors wroteComplaint #: NJ176224 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) a resident was assessed by a Registered Nurse (RN) after sustaining a fall and b.) a resident was evaluated by a physical therapist as per a physician's order. This deficient practice was evidenced for 1 of 6 residents (Resident #305) reviewed for accidents and 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 wroteComplaint #: NJ177592 Based on interview, record review, and a review of other pertinent documentation, it was determined that the facility failed to ensure that the appropriate care was provided with no delay in treatment for a.) a resident who had a change in condition, with left lower extremity swelling and bruising, suspected DeepVein Thrombosis (DVT, blood clot) received a STAT (immediate) venous doppler (diagnostic test to rule out DVT) in a timely manner before being transferred to the hospital with emergency services, and b.) a resident who had a change in condition and experienced nausea, weight loss, and indigestion was rescheduled for an outpatient CT scan (x-ray image) in a timely manner in accordance with professional standards of nursing practice. [...]

Inspectors wroteBased on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to perform and document a skin assessment, obtain a treatment order, and implement timely interventions to prevent the development of a pressure ulcer upon the identification of an alteration in skin integrity for a resident previously identified to be at risk for the development of pressure ulcers. This deficient practice was identified for 1 of 2 residents (Resident #101) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 10/8/24 at 10:18 AM, during the initial tour of the facility the surveyor observed Resident #101 lying awake in bed with an air mattress motor noted at the foot of the bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure an indwelling urinary catheter drainage bag and tubing did not touch the floor and b.) ensure the urinary catheter drainage bag was changed as ordered by the physician for 2 of 2 residents (Resident #174 and #188) reviewed for urinary catheter. This deficient practice was evidenced by the following: 1.) On 10/8/24 at 11:27 AM, the surveyor observed Resident #188 sitting in a wheelchair with a urinary catheter drainage bag (a collection device attached to a tube placed in the body to empty urine) secured to the wheelchair. The drainage bag was touching the floor. On 10/9/24 at 09:03 AM, the surveyor observed Resident #188 sitting in a wheelchair with a urinary catheter drainage bag secured to the wheelchair. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) provide fortified foods as prescribed by the physician, b.) obtain weekly weights as recommended by the Registered Dietician, and c.) obtain re-weights according to the facility's policy for 2 of 5 residents (Resident #91 and #7) reviewed for nutrition. This deficient practice was evidenced by the following: 1.) On 10/11/24 at 12:12 PM, the surveyor observed Resident #91 receive his/her lunch tray which included a sealed pudding pack without a label. According to the resident's meal ticket, the resident was supposed to receive fortified pudding (pudding that contains extra nutrients). The surveyor took a picture of the lunch tray. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to store respiratory equipment in a safe and sanitary manner when not in use to reduce the incidence of infection for 1 of 3 residents (Resident #123) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/8/24 at 1:11 PM, during the initial tour of the facility, the surveyor entered Resident #123's room with permission and observed a nebulizer machine (an electrically powered machine that turns liquid medication into a mist so that it can be inhaled directly into the lungs through a mask or mouthpiece) that was stored on top of a crowded table with the resident's personal belongings. The mask was not stored in a bag and condensation (moisture) was noted in the clear, plastic chamber. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of all Certified Nurse Aides (CNA) at least every twelve months and provide regular in-service education based on the outcome of employee job performance reviews. The deficient practice was identified for 2 of 6 CNAs (CNA # 12 and #8) reviewed for the completion of annual performance evaluations and was evidenced by the following: 1.) On 10/11/24 at 11:09 AM, the surveyor reviewed the personnel files of five Certified Nursing Assistants and noted that the Annual Staff Performance Appraisal of CNA #12 dated 12/20/23, was not signed by the employee, Supervisor or Department Head in the spaced provided. [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent documentation, it was determined that the facility failed to ensure that the current resident census was accurately reflected and recorded on the Nursing Home Resident Care Staffing Report prior to posting the notice in prominent areas for residents and the general public to view. This deficient practice was identified on three of six survey dates was evidenced by the following: On 10/8/24 at 9:11 AM, the Licensed Nursing Home Administrator (LNHA) stated that the facility census was 207. A review of the facility daily staffing sheet indicated that the resident census was 208. A review of the Nursing Home Resident Care Staffing Report dated 10/8/24-Day Shift, reflected that the Current Resident Census was 203. [...]

Inspectors wroteComplaint #: NJ177069 Based on observation, interview, and pertinent record review, it was determined that the facility failed to a.) ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy, b.) ensure that narcotics were properly secured under two secured locks per facility policy, and c.) obtain and administer a medication per physicians order. This deficient practice was observed in 1 of 5 medication carts reviewed for medication storage and 1 of 5 residents (Resident # 355) reviewed for medication adminsitration, and was evidenced by the following: 1.) On 10/10/24 10:45 AM, the surveyor, in the presence of Registered Nurse #1 (RN #1), reviewed the North 1 Unit's medication B Cart shift to shift narcotic count logs which indicated the following missing documentation: [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure that all medications were administered without an error rate of 5% or less. During the medication pass observation on 10/9/24 at 8:21 AM, the surveyor observed four nurses administer medications to four residents. There were 32 opportunities and 2 errors which calculated to a medication administration error rate of 6.25%. This deficient practice was identified for 1 of 4 residents (Resident #92) and was evidenced by the following: On 10/9/24 at 8:21 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 obtain a bottle labeled probiotic from the supply of house stock medications (medication that can be obtained over the counter without a prescription). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly dispose of expired medical equipment and maintain clean and sanitary medication storage areas. This deficient practice was observed in 2 of 3 medication storage rooms and 1 of 5 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 10/10/24 at 9:31 AM, the surveyor, in the presence of the Registered Nurse Unit Manager (RN/UM) observed the East Medication Storage Room, which contained one (1) box of Shiley inner cannulas (a plastic medical tube which is inserted into a resident's tracheostomy (an opening in the neck into the windpipe to help a person breathe) containing 10 expired cannulas with an expiration date of 3/25/24. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to A.) perform hand hygiene before preparing and administering medications. B.) failed to maintain a non-touch technique when returning excess medication to the original bottle. and C. failed to disinfect the blood pressure equipment after each use. This breach in infection control practice occurred during 2 of 4 medication administration observation. This deficient practice was evidenced by the following: 1.) On 10/09/2024 at 08:21 AM during the Medication Administration task, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare and administer Resident #92's medication. He/She did not perform hand hygiene prior to preparing the resident's medication and after administration. [...]

Inspectors wroteComplaint #: NJ165714 Based on observations, interviews, a review of the medical record, and other pertinent facility documents on 10/3/23, it was determined that the facility failed to provide documented evidence of care provided to a resident (Resident #2). The facility also failed to follow the Certified Nursing Assistant's job description and its policies titled, Activities of Daily Living (ADL), Supporting for 1of 4 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the AR Resident #2 was admitted to the facility on 7/2//23 with diagnoses which included but were not limited to Obstructive Sleep Apnea, Difficulty Walking, Major Depressive Disorder, Hypertension, and Muscle Wasting. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of resident-to-resident verbal abuse between Resident #72 and #146 that occurred on 5/19/23. This deficient practice was identified for 1 of 2 reportable investigations reviewed, and was evidenced by the following: On 5/22/23 at 12:28 PM, the surveyor observed Resident #72 sitting in their room. Resident #72 informed the surveyor that on Friday (5/19/23), he/she was involved in a verbal screaming match and cursing with their roommate (Resident #146). Resident #72 reported that Resident #146 was speaking with their Nurse Practitioner (NP), and the NP asked Resident #146 a question, which the resident did not respond so he/she (Resident #72) answered the NP's question. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to investigate a.) an incident of resident-to-resident verbal abuse for Resident #72 and #146 on 5/19/23, and b.) an incident with a resident sent to the emergency department with a diagnosis of fecal impaction to rule out neglect on 3/3/23. This deficient practice was identified for 2 of 3 residents reviewed for abuse and neglect (Resident #72 and #189), and was evidenced by the following: 1. On 5/22/23 at 12:28 PM, the surveyor observed Resident #72 sitting in their room. Resident #72 informed the surveyor that on Friday (5/19/23), he/she was involved in a verbal screaming match and cursing with their roommate (Resident #146). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) administer medications according to physician's orders; b.) clarify a physician's order; and c.) contact the pharmacy and physician for a medication (vitamin E) that was unavailable in accordance with professional standards of practice. This deficient practice was identified for 1 of 3 residents observed for medication administration (Resident #282), and was evidenced as follows: 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 ensure all medications were administered without an error of 5% or more. During the medication observation on 5/18/23, the surveyor observed three (3) nurses administer medications to three (3) residents. There were 30 opportunities, and two (2) errors were observed which calculated a medication administration error rate of 6.6%. This deficient practice was identified for one (1) of three (3) residents (Resident #282) that were administered medications by one (1) of three (3) nurses. The deficient practice was evidenced as follows: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to a.) maintain medication storage rooms free of expired nutritional formula (Jevity 1.5 calorie) for 1 of 3 medication storage rooms inspected (North 1), and b.) ensure the required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate reconciliation for 2 of 8 forms reviewed. The deficient practice was evidenced by the following: 1. On [DATE] at 12:13 PM, in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN), the surveyor inspected the inventory and medications in North 1 Medication Room. The surveyor observed twenty-three (23) eight-ounce (8 oz) cartons of Jevity 1.5 calorie with the expiration date of [DATE]. [...]