Inspection Reports for Laurel Brook Rehabilitation And Healthcare Center
3718 Church Road, NJ, 08054
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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 outlines the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health 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 and contact person for the notice |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 1
Jan 16, 2025
Visit Reason
The inspection was conducted based on a complaint visit (Complaint #: NJ179543) to assess compliance with infection prevention and control requirements.
Findings
The facility was found not in substantial compliance with infection prevention and control regulations due to failure to follow appropriate hand hygiene during a resident's treatment, posing a potential risk for infection spread. The facility implemented re-education and auditing measures to address the deficiency.
Complaint Details
Complaint #: NJ179543. The facility was found not in substantial compliance based on this complaint visit. The deficiency involved failure to perform hand hygiene during care treatment of Resident #1, confirmed by observation and interviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow appropriate hand hygiene during an observation of a resident's treatment, risking the spread of infection. | SS=D |
Report Facts
Sample size: 3
Audit frequency: 4
Audit frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Re-educated on infection prevention policy including hand hygiene before care treatments |
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 1
Nov 19, 2024
Visit Reason
The inspection was conducted based on complaint NJ00176792 to investigate the facility's compliance with notification requirements regarding unavailable medications and related policies.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to notify a resident's physician of unavailable medication and to follow facility policies regarding medication notification and documentation. This deficient practice was identified for one resident.
Complaint Details
Complaint number NJ00176792 was investigated and found substantiated based on interviews, medical record review, and facility document review indicating failure to notify the resident's physician of unavailable medication.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify a resident's physician of unavailable medication and failure to follow facility policies regarding unavailable medications, medication notification, and documentation. | Level D |
Report Facts
Census: 156
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 204
Deficiencies: 1
Sep 19, 2024
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ00177093) to investigate allegations related to staffing ratios and compliance with state minimum staffing requirements.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding minimum staffing ratios, failing to meet required CNA staffing levels on 28 of 28 day shifts and total staff on 1 of 28 evening shifts during the review period. No residents were found to have been affected by these staffing deficiencies.
Complaint Details
Complaint #: NJ00177093. The complaint investigation found the facility deficient in meeting minimum staffing requirements but no residents were found to have been affected. The facility was required to submit a Plan of Correction.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 28 day shifts and 1 evening shift. |
Report Facts
Census: 204
Deficient day shifts: 28
Deficient evening shifts: 1
Required CNA staffing: 24
Actual CNA staffing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Named in corrective action plan to conduct staffing reviews and recruitment efforts. | |
| Director of Nursing | Named in corrective action plan to conduct staffing reviews and recruitment efforts. | |
| Staffing Coordinator | Named in corrective action plan to conduct staffing reviews and recruitment efforts. | |
| Medical Director | Member of QAPI Committee reviewing staffing compliance. |
Inspection Report
Life Safety
Census: 210
Deficiencies: 2
May 21, 2024
Visit Reason
The inspection was conducted as a Life Safety Code Survey related to a renovation project including Long Term Care Unit #1, a new large dining room, and exit access corridor.
Findings
The facility was found non-compliant with NFPA 101, 2012 Edition Life Safety Code requirements due to missing illuminated exit signage and lack of smoke detection in the newly renovated dining room area. These deficiencies had the potential to affect all 210 residents.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide one illuminated exit sign to clearly identify the exit access path to reach an exit discharge door. | SS=D |
| Failed to ensure that areas open to the corridor were provided with smoke detection as required. | SS=D |
Report Facts
Residents affected: 210
Number of smoke detectors to be installed: 6
Inspection Report
Complaint Investigation
Census: 206
Deficiencies: 2
Oct 3, 2023
Visit Reason
The inspection was conducted based on a complaint (NJ165714) alleging deficiencies in resident care documentation and staffing ratios at Laurel Brook Rehabilitation and Healthcare Center.
Findings
The facility was found not in substantial compliance due to failure to provide documented evidence of care for a resident and failure to meet minimum staffing ratios for Certified Nursing Assistants (CNAs) on multiple day shifts. Deficiencies included incomplete documentation of Activities of Daily Living (ADLs) and insufficient CNA staffing levels over several weeks.
Complaint Details
Complaint #: NJ165714. The complaint investigation found the facility failed to provide documented evidence of care for Resident #2 and failed to meet minimum staffing requirements for CNAs on multiple shifts. The facility was not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide documented evidence of care provided to a resident, including incomplete documentation of Activities of Daily Living (ADLs) by Certified Nursing Assistants. | SS=D |
| Failure to ensure staffing ratios were met for 28 of 28-day shifts reviewed, including deficient CNA staffing and total staff on some shifts. | — |
Report Facts
Census: 206
Deficient CNA staffing day shifts: 28
CNA staffing counts: 14
Overnight shifts deficient total staff: 1
CNA staffing counts: 14
Inspection Report
Annual Inspection
Census: 196
Capacity: 220
Deficiencies: 13
Jun 1, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to report and investigate alleged abuse, medication administration errors, pain management, medication storage, staffing ratios, employee health physicals, and life safety code violations including egress door locking, hazardous area enclosure, fire alarm system installation, smoke barrier doors, HVAC ventilation, and electrical system reliability.
Severity Breakdown
SS=D: 8
SS=E: 4
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to report to the New Jersey Department of Health an allegation of abuse between residents and failure to investigate the incident. | SS=D |
| Failure to administer medications according to physician's orders, clarify physician's orders, and contact pharmacy for unavailable medication. | SS=D |
| Failure to assess, document, and re-evaluate pain management and medication effectiveness. | SS=D |
| Medication administration error rate exceeded 5% due to incorrect medication administration. | SS=D |
| Failure to maintain medication storage free of expired nutritional formula and incomplete DEA 222 forms. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | — |
| Failure to ensure newly hired employees received a health physical examination by a physician or advanced practice nurse within two weeks prior to the first day of employment or upon employment. | — |
| Egress doors equipped with hook-type deadbolt locks that restrict emergency use of the exit. | SS=E |
| Failure to provide fire barrier with two-hour fire resistance rating in boiler room due to missing wallboard exposing insulation and wood. | SS=E |
| Failure to provide fire alarm notification by audible and visible signals for enclosed courtyard. | SS=D |
| Smoke barrier doors not fully smoke resistant due to gaps between doors. | SS=E |
| Resident bathroom ventilation systems not functioning properly due to faulty motor. | SS=E |
| Failure to demonstrate reliability regarding fuel supply for two natural gas generators due to lack of documented reliability letter. | SS=D |
Report Facts
Census: 196
Total Capacity: 220
Medication Administration Error Rate: 6.6
Expired Nutritional Formula Count: 23
Staffing Shifts with Deficient CNA Ratios: 12
Resident Bathrooms with Ventilation Issues: 32
Inspection Report
Original Licensing
Census: 29
Deficiencies: 0
Jan 18, 2023
Visit Reason
State Licensure Certification survey for a Dementia/Alzheimer's Unit to determine compliance with New Jersey administrative code standards for licensure of long term care facilities.
Findings
The facility was found to be in compliance with the applicable New Jersey Administrative Code standards for Alzheimer's/Dementia programs. The facility is not to advertise the certified dementia unit until final approval of certification is provided.
Document
Deficiencies: 0
Jul 21, 2022
Visit Reason
Document is a PDF portfolio container page prompting user to open with specific Adobe software.
Findings
No inspection or regulatory content present; only software usage instructions.
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 0
Nov 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ 149769.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities. A COVID-19 Focused Infection Control Survey found the facility compliant with CMS and CDC recommended practices for COVID-19.
Complaint Details
Complaint # NJ 149769 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 6
COVID+ In House: 11
Inspection Report
Complaint Investigation
Census: 206
Deficiencies: 0
Oct 9, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ146756, NJ146534, NJ146783, NJ147791, and NJ146830.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ146756, NJ146534, NJ146783, NJ147791, and NJ146830 were investigated and found to be in compliance.
Report Facts
Sample Size: 9
Inspection Report
Plan of Correction
Census: 185
Deficiencies: 1
Sep 30, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing requirements.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios for 21 of 21 shifts reviewed, potentially affecting all residents. The facility implemented corrective actions including re-education of key staff, weekly staffing reviews, recruitment efforts, and contracting with staffing agencies.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 21 of 21 shifts reviewed. |
Report Facts
Residents on day shift: 185
Certified Nurse Aides (CNAs) on day shift: 15
Certified Nurse Aides (CNAs) on day shift: 20
Number of shifts reviewed: 21
Number of staffing agencies contracted: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding staffing requirements and recruitment efforts |
| Administrator | Administrator | Re-educated on minimum staffing requirements and involved in staffing review meetings |
| Human Resources Director | Human Resources Director | Re-educated on minimum staffing requirements and involved in staffing review meetings |
| Staffing Coordinator | Staffing Coordinator | Re-educated on minimum staffing requirements and involved in staffing review meetings |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
May 29, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ131588, NJ138557, NJ139723, NJ140296, and NJ140298.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ131588, NJ138557, NJ139723, NJ140296, and NJ140298 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 16
Inspection Report
Annual Inspection
Census: 161
Deficiencies: 4
Apr 28, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to infection control practices during catheter care, medication administration errors exceeding 5%, food safety and sanitation issues, and failure to properly don PPE and perform hand hygiene on a COVID-19 PUI unit.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to follow appropriate infection control practices during catheter care for Resident #103. | SS=D |
| Medication error rate exceeded 5% with 2 errors in 30 medication administrations observed. | SS=D |
| Failed to ensure food procurement, storage, preparation and serving in a sanitary manner including exposed facial hair and wet pans. | SS=D |
| Failed to establish and maintain an infection prevention and control program including failure to don PPE and perform hand hygiene on COVID-19 PUI unit. | SS=D |
Report Facts
Census: 161
Sample Size: 55
Medication administrations observed: 30
Medication errors observed: 2
Deficiency completion date: May 13, 2021
Deficiency completion date: May 18, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Failed to don PPE gown and perform hand hygiene on PUI unit |
| CNA #2 | Certified Nurse Aide | Interviewed about PPE process on PUI unit |
| Social Worker | Social Worker | Failed to don PPE gown on PUI unit due to PPE fatigue |
| LPN identified in medication error | Licensed Practical Nurse | Observed medication administration errors and improper catheter care |
| Director of Nursing | Director of Nursing | Provided interviews regarding infection control and medication administration |
| Infection Preventionist | Registered Nurse Infection Preventionist | Provided interviews and education on infection control and PPE use |
| Dietary Worker #1 | Dietary Staff Member | Observed with exposed facial hair during food preparation |
| Dietary Director | Dietary Director | Interviewed regarding food safety and sanitation deficiencies |
Inspection Report
Life Safety
Census: 161
Capacity: 220
Deficiencies: 5
Apr 28, 2021
Visit Reason
The inspection was conducted to assess compliance with Life Safety Code requirements and emergency preparedness during a routine survey visit.
Findings
The facility was found not in substantial compliance with minimum Life Safety Code requirements, including deficiencies in illumination of means of egress, exit signage, hazardous area enclosures, sprinkler system maintenance, and essential electrical system testing.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide 2 sources of illumination at exit discharges to the common way for evacuation. | SS=D |
| Failed to properly identify doors with appropriate 'No Exit' signage. | SS=E |
| Hazardous storage areas were not equipped with self-closing hardware on doors. | SS=F |
| Automatic sprinkler heads were not free of foreign materials such as lint and paint, and ceiling tile missing near sprinkler head. | SS=D |
| Failed to certify that the emergency generator transfers power to the building within the required 10 seconds. | SS=E |
Report Facts
Certified beds: 220
Census: 161
Deficiency completion dates: 5
Number of sprinkler heads observed with lint: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies; unaware of some requirements. | |
| Regional Director of Plant Operations | Responsible for conducting in-service training and overseeing corrective actions. |
Inspection Report
Routine
Census: 164
Deficiencies: 0
Feb 16, 2021
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 and recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 168
Deficiencies: 0
Jan 19, 2021
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 the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 172
Deficiencies: 1
Dec 10, 2020
Visit Reason
The inspection was conducted based on complaint NJ 141624 to investigate compliance with food safety requirements related to food procurement, storage, preparation, and serving.
Findings
The facility failed to store potentially hazardous foods properly, as several cases of meat were found without proper labeling or dating, posing a risk of food borne illness. The meats in question were discarded and corrective actions including staff in-service and regular audits were implemented.
Complaint Details
Complaint NJ 141624 triggered the visit. The facility was found not in compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to store potentially hazardous foods in a manner to prevent food borne illness, including lack of proper labeling and dating of meats. | SS=D |
Report Facts
Census: 172
Sample Size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vice President of Dining Services | VPDS | Provided statements regarding food labeling and storage practices, participated in corrective action |
| Food Service Director | FSD | Discarded contaminated food items and conducted audits of food storage |
| Dietary Director | DD | Accompanied surveyor during refrigerator tour and provided information on food storage |
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