Inspection Reports for Laurel Circle
100 Monroe St, Bridgewater, NJ 08807, United States, NJ, 08807
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Notice
Deficiencies: 0
Date: Nov 20, 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 explains 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 named as contact for privacy practices |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 13, 2024
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to properly review and communicate hospital discharge medication orders and to follow a physician's order for an anti-anxiety medication (Clonazepam) for Resident #152.
Complaint Details
Complaint # NJ 169997 regarding failure to administer anti-anxiety medication as ordered, resulting in resident behavioral changes and lack of communication with physician and family.
Findings
The facility failed to administer the physician-ordered Clonazepam medication to Resident #152 for 14 days, resulting in the resident experiencing agitation, anxiety, insomnia, and wandering at night. There was no documented evidence that the physician or family were notified about the medication omission or the resident's behavioral changes. The medication order was not properly faxed to the pharmacy, and the facility did not follow proper medication administration and communication protocols.
Deficiencies (4)
Failure to thoroughly review hospital discharge summary and communicate anti-anxiety medication recommendations to the physician.
Failure to follow physician's order for Clonazepam, resulting in resident not receiving medication for 14 days.
Lack of documentation regarding notification to physician or family about medication unavailability and resident's agitation.
Medication order was not faxed to pharmacy, causing delay in medication delivery.
Report Facts
Days medication not administered: 14
BIMS score: 12
Medication Error Report Date: Dec 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician | Interviewed and stated she was not notified about the medication omission. | |
| Assistant Director of Nursing (ADON) | Provided medication error report and hospital discharge summary; did not comment on rationale for medication order not being faxed. | |
| Licensed Practical Nurse (LPN) | Admitted the resident and confirmed medication was not administered; unaware of documentation or communication regarding the omission. | |
| Registered Nurse (RN) | Described medication verification process and communication expectations. | |
| Director of Nursing (DON) | Interviewed and stated she was made aware of the issue only the day before the survey; noted no proper investigation was conducted. |
Inspection Report
Routine
Deficiencies: 11
Date: Sep 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility sanitation, medication administration, infection control, pest control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and pest-free healthcare dining room and pantry, failure to revise resident care plans after falls, inadequate activity programming and supervision, inconsistent implementation of fall prevention interventions, improper respiratory care and oxygen equipment handling, improper medication administration techniques and failure to obtain vital signs prior to medication administration, failure to document use of PRN psychotropic medication and non-drug interventions, inadequate infection control practices during meal delivery, and lack of an effective quality assurance performance improvement program.
Deficiencies (11)
Failure to maintain the healthcare dining room and pantry in a clean and homelike manner with presence of ants, flying insects, debris, stains, and worn furniture.
Failure to revise resident-centered ongoing care plan for a resident who sustained multiple falls, missing documentation of recent falls and interventions.
Failure to provide scheduled activities and ensure residents receive identified activity preferences, with no activities occurring as scheduled and lack of activity staff presence.
Failure to ensure fall prevention interventions were consistently implemented, revised after each fall, and supervision was provided for residents at risk for falls.
Failure to ensure oxygen and respiratory related treatments were provided in a manner to prevent infection and injury, including improper storage of oxygen tanks and nebulizer equipment.
Failure to provide pharmaceutical services in accordance with professional standards, including improper insulin pen administration technique and failure to obtain vital signs immediately prior to medication administration for medications with hold parameters.
Failure to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medications, and failure to document non-drug interventions and target behaviors when PRN psychotropic medication was administered.
Failure to procure food from approved sources and maintain the healthcare food service pantry and adjacent storage room in a clean and sanitary manner to prevent food borne illness, with presence of pests, debris, stains, and soiled equipment.
Failure to maintain an effective pest control program for the healthcare dining room, pantry, and food storage area, with documented pest sightings and inadequate exclusion measures.
Failure to have an effective system in place to self-identify concerns and maintain a data-driven Quality Assurance Performance Improvement (QAPI) program addressing adverse events, pest control, kitchen sanitation, and activity programming.
Failure to follow appropriate infection control and hand hygiene practices during meal delivery, including failure to provide residents with opportunities to cleanse their hands prior to meals.
Report Facts
Fall incident reports: 8
Medication doses: 2
Medication doses: 0.5
Medication doses: 12.5
Medication doses: 0.25
Medication doses: 0.125
Medication doses: 50
Medication doses: 0.5
Medication doses: 6.25
Medication doses: 120
Medication doses: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed administering insulin and other medications; interviewed regarding medication administration practices |
| RN #2 | Registered Nurse | Interviewed regarding insulin pen administration technique and medication administration |
| RN #3 | Registered Nurse | Documented psychiatry NP visit and medication renewal |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding resident activity and medication administration |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding resident activity and medication administration |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding resident activity and medication administration |
| Food Service Supervisor | Food Service Supervisor | Present during pantry inspection and discussed pest issues |
| Licensed Nursing Home Administrator | Administrator | Acknowledged cleaning concerns and discussed QAPI program |
| Director of Nursing | Director of Nursing | Interviewed regarding fall prevention, medication administration, infection control, and QAPI |
| Community Life Services Manager | Community Life Services Manager | Interviewed regarding activity programming and resident engagement |
| Community Life Services Director | Community Life Services Director | Interviewed regarding activity programming and resident engagement |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication administration and insulin pen technique |
| Psychiatry Nurse Practitioner | Psychiatry Nurse Practitioner | Interviewed regarding psychotropic medication orders and documentation |
| Psychiatrist | Psychiatrist | Interviewed regarding psychotropic medication orders and documentation |
Inspection Report
Routine
Deficiencies: 6
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, staff performance, food service, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to provide feeding assistance to a visually impaired resident, lack of annual performance evaluations for CNAs, improper use and monitoring of the dish machine, inadequate food handling and sanitation practices, incomplete infection control water management program documentation, and failure to maintain mandatory in-service training hours for CNAs.
Deficiencies (6)
Failure to ensure a visually impaired resident dependent on staff for activities of daily living was physically assisted with meals to prevent weight loss.
Failure to conduct yearly performance reviews of Certified Nursing Aides to provide specific education based on review outcomes.
Failure to ensure dietary staff had appropriate competencies and skill sets to effectively use and maintain the facility's high temperature dish machine.
Failure to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness and maintain kitchen equipment to prevent microbial growth.
Failure to ensure infection control policies were followed and maintained for water management to minimize the risk of legionella and other opportunistic pathogens in building water systems.
Failure to maintain an effective tracking system to ensure Certified Nursing Aides received twelve hours of mandatory in-service training.
Report Facts
Education hours for CNA #1 in 2022: 2.75
Education hours for CNA #2 in 2022: 28
Education hours for CNA #3 in 2022: 28
Education hours for CNA #4 in 2022: 0.75
Education hours for CNA #5 in 2022: 10.05
Dish machine temperature range recorded in July 2023: 145
Dish machine temperature range recorded in July 2023: 165
Dish machine temperature required for final rinse: 180
Dish machine surface temperature measured: 160
Number of days CNA #13 was assigned to resident: 8
BIMS score for Resident #13: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing/Infection Preventionist | ADON/IP | Staff educator responsible for CNA in-service training and reporting |
| Director of Nursing | DON | Provided reports and information regarding resident care and staff performance |
| Licensed Practical Nurse | LPN | Interviewed regarding feeding assistance for Resident #13 |
| Certified Nursing Aide #1 | CNA | Assigned to Resident #13 and involved in feeding assistance discussion |
| Licensed Nursing Home Administrator | LNHA | Provided information on staff performance evaluations and infection control |
| Executive Chef | Food Service Director | Involved in dish machine inspection and temperature monitoring |
| Dish Machine Repair Employee #1 | Conducted dish machine temperature testing and provided technical information | |
| Dish Machine Repair Employee #2 | Provided information on dish machine gauges and temperature requirements | |
| Utility Worker #1 | Responsible for washing dishes and recording dish machine temperatures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 14, 2023
Visit Reason
The inspection was conducted in response to a complaint (NJ Complaint #162847) regarding the facility's failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically related to an allegation of abuse involving Resident #17 on 3/18/2023.
Complaint Details
The complaint involved an allegation of abuse to Resident #17 on 3/18/23. The facility failed to report the allegation immediately to the NJDOH and administration. An investigation was conducted including staff interviews and review of medical records. The resident had a left wrist fracture attributed to osteopenia/osteoporosis. Abuse was not substantiated.
Findings
The facility failed to immediately report an allegation of abuse to the New Jersey Department of Health and to notify administration promptly. An investigation revealed a left wrist fracture in Resident #17, but abuse was ruled out due to the resident's documented osteopenia and osteoporosis. Staff interviews and investigations were completed, and abuse could not be substantiated. However, staff members were written up for failure to report the allegation timely.
Deficiencies (1)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, including failure to report an allegation of abuse immediately or within two hours.
Report Facts
Date of abuse allegation: Mar 18, 2023
Date of fracture X-ray: Mar 22, 2023
Date of survey completion: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in failure to report abuse allegation and assessment of resident |
| LPN #1 | Licensed Practical Nurse | Named in failure to report abuse allegation and assessment of resident |
| CNA #1 | Certified Nursing Aide | Named in statements regarding resident care and abuse allegation |
| CNA #2 | Certified Nursing Aide | Named in statements regarding resident care and abuse allegation |
| Director of Nursing | DON | Interviewed regarding investigation and reporting procedures |
| Licensed Nursing Home Administrator | LNHA | Provided abuse training and statements on reporting procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 10, 2023
Visit Reason
The inspection was conducted based on complaint NJ00163106 to investigate allegations that the facility failed to administer medications according to physician orders and failed to provide the correct diet consistency for Resident #2.
Complaint Details
Complaint NJ00163106 alleged failure to administer medication as ordered and failure to provide the correct diet consistency for Resident #2. The complaint was substantiated with findings confirming these deficiencies.
Findings
The facility failed to administer the prescribed medication Keppra to Resident #2 on 2/23/23 and 2/24/23 due to non-delivery from the pharmacy and did not notify the physician. Additionally, the facility provided the wrong diet consistency to Resident #2, initially delivering a regular diet and thin liquids instead of the physician-ordered puree diet with nectar thickened liquids. The errors were identified and corrected, and the resident did not consume the incorrect diet.
Deficiencies (2)
Failure to administer medications according to physician orders and failure to notify the physician when medication was not administered.
Failure to provide the correct diet consistency according to the physician's order.
Report Facts
Residents reviewed: 4
Residents affected: 1
Dates medication not administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Confirmed medication non-administration and diet order errors during interviews |
| LPN #1 | Licensed Practical Nurse | Confirmed medication non-administration and lack of documentation/notification |
| Director of Nursing | Director of Nursing | Acknowledged medication non-administration and failure to notify physician |
| Dietary Supervisor | Dietary Supervisor | Reported diet tray errors and correction actions |
| Physician | Physician | Stated she was not notified about medication non-administration |
| CNA #1 | Certified Nursing Assistant | Confirmed resident required total care and was not fed the wrong diet |
Inspection Report
Routine
Deficiencies: 4
Date: May 20, 2021
Visit Reason
The inspection was conducted to evaluate compliance with Medicare/Medicaid regulations including beneficiary notice requirements, nursing care standards, dialysis care, and pharmaceutical services.
Findings
The facility was found deficient in multiple areas including failure to provide written notification of potential liability charges to Medicare beneficiaries, failure to follow physician orders for wound care and allergy precautions, improper sequencing of medications for a resident on hemodialysis, failure to maintain left arm precautions for dialysis access, and deficiencies in pharmaceutical services including expired controlled drugs and inaccurate inventory counts.
Deficiencies (4)
Failure to provide written notification to the beneficiary of potential liability charges for services not covered when discharged from Medicare Part A with benefit days remaining.
Failure to follow physician's orders for wound care including applying skin protectant and antifungal powder, accurate documentation, and addressing resident's allergy to adhesive tape.
Failure to sequence medications to accommodate a resident's hemodialysis schedule and failure to follow left arm precautions for dialysis access.
Failure to provide pharmaceutical services including proper administration timing of interacting medications, removal of expired controlled drugs from electronic backup supply, and maintaining accurate accountability for controlled drugs.
Report Facts
Residents reviewed for beneficiary notice: 3
Residents reviewed for nursing practice: 12
Residents reviewed for hemodialysis: 1
Controlled drugs expired: 3
Controlled drugs with inaccurate count: 1
Blood pressure taken in left arm: 14
Tramadol tablets counted: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #2 | Social Worker | Completed Skilled Nursing Facility Beneficiary Protection Notification Review for Resident #59 |
| Social Worker #1 | Social Worker | Interviewed regarding SNF BPNR forms |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding Medicare Part A discharge and notification forms |
| Certified Nursing Aide | CNA | Observed and interviewed regarding wound care and skin protectant application for Resident #17 |
| Registered Nurse | RN | Observed performing wound care and signing electronic Treatment Administration Record |
| Licensed Practical Nurse | LPN | Observed and interviewed regarding wound care and medication administration for Resident #17 |
| Infectious Disease Nurse Practitioner | ID/NP | Interviewed regarding wound care and allergy concerns for Resident #17 |
| Assistant Director of Nursing | ADON | Interviewed regarding wound care, medication reconciliation, and controlled drug inventory |
| Director of Nursing | DON | Interviewed regarding wound care, medication administration, and controlled drug inventory |
| Registered Nurse #1 | RN | Provided information about Resident #377 dialysis schedule |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding left arm precautions and blood pressure measurements for Resident #377 |
| Order Entry Technician | Pharmacy Technician | Interviewed regarding medication bag system |
| Registered Pharmacist | Pharmacist | Interviewed regarding medication administration times and pharmacy procedures |
| Consultant Pharmacist | Pharmacist | Interviewed regarding medication separation and controlled drug accountability |
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