Inspection Reports for
Laurel Brook Rehabilitation And Healthcare Center

Complaint #2614619 involved allegations of verbal and physical abuse of Resident #4 by a housekeeping staff member on 12/18/24, which was substantiated. Another complaint involved failure to investigate verbal abuse allegations concerning Resident #2, which was found to be deficient.

The facility was found to have failed to protect a resident from verbal and physical abuse by a housekeeping staff member and failed to follow its abuse prevention policy. Additionally, the facility did not conduct a thorough investigation into an allegation of verbal abuse involving another resident. The abuse was substantiated for one resident, and the facility terminated the employment of the implicated staff member.

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.

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 #: NJ179543. The complaint was substantiated based on observation, interview, and document review confirming failure to follow hand hygiene protocols during wound care.

The facility failed to follow proper hand hygiene protocols during wound care treatment for one resident, which posed a potential risk for infection spread. Observations and interviews confirmed that the Licensed Practical Nurse did not perform hand hygiene before and during wound care, violating facility policy and CDC guidelines.

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.

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#: NJ00176792. The complaint was substantiated based on findings that the facility did not notify the physician of unavailable medications and failed to document such notifications for Resident #3.

The facility failed to notify the physician about unavailable medications for Resident #3, did not follow facility policies regarding unavailable medications, and lacked proper documentation of provider notification. The deficiency was identified through interviews, medical record reviews, and policy review.

Complaint NJ177765 and NJ177069 related to failure to maintain a safe, clean, and homelike environment. Complaint NJ177592 related to failure to provide appropriate treatment and care according to orders and resident preferences.

The facility was found deficient in maintaining a safe, clean, and homelike environment across multiple units, including issues with damaged ceilings, unclean air conditioning units, dust accumulation, and expired medical supplies. Additionally, the facility failed to provide timely diagnostic testing and treatment for residents with changes in condition, failed to ensure proper medication administration including a missed dose of anticoagulant medication, and failed to maintain proper narcotic accountability and medication storage.

The inspection identified multiple deficiencies including environmental safety issues such as damaged ceilings and dust accumulation, failure to timely report abuse allegations, late completion of resident assessments, incomplete PASARR evaluations, inadequate care planning, medication errors, unsafe smoking practices, improper catheter care, expired and improperly stored medications and food, and lapses in infection control practices.

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.

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.

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.

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.

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 #: NJ165714. The complaint was substantiated based on observations, interviews, and review of medical records and facility documents indicating failure to document care and follow CNA job description and ADL policies.

The facility failed to provide documented evidence of care for Resident #2, with multiple blank spaces on ADL documentation sheets indicating tasks were not completed. Interviews with the CNA and Director of Nursing confirmed that ADL sheets should be signed off with no blank spaces, and the blank spaces indicated tasks were not performed. The facility's policies and CNA job description require proper documentation and assistance with ADLs.

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.

Complaint NJ #160150 was substantiated based on interviews, medical record reviews, and facility document reviews showing failure in pain management documentation and administration for Resident #435.

The facility failed to assess and document the resident's pain level, document administration of as-needed pain medication, and re-evaluate and document the effectiveness of pain medication according to professional standards. This deficiency was identified in 1 of 3 residents reviewed for pain management.

The complaint investigation focused on failure to report and investigate a resident-to-resident verbal abuse incident on 5/19/23 involving Residents #72 and #146, and failure to investigate a fecal impaction incident involving Resident #189. The facility did not report the verbal abuse to the NJDOH and did not conduct investigations for either incident until surveyor inquiry.

The facility failed to report and investigate an incident of resident-to-resident verbal abuse between Resident #72 and Resident #146 on 5/19/23, and failed to investigate a fecal impaction incident involving Resident #189. Additionally, medication administration errors and medication storage deficiencies were identified.

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 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.

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.

The facility was found deficient in infection control practices during suprapubic catheter care, medication administration errors exceeding 5%, improper food safety and sanitation practices, and failure to implement proper infection prevention and control measures including PPE use on the COVID-19 PUI unit.

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.

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.