Inspection Reports for Lawrence Rehab & Hcc/the Meadows At Lawrence
1 Bishops Drive, Lawrenceville, NJ, 08648
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to staffing levels, documentation, and compliance with oxygen administration policies. Complaint investigations found issues such as failure to maintain adequate staffing, incomplete resident care documentation, and lapses in reporting and investigation procedures, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were substantiated, particularly those involving staffing shortages and care practices. The inspection history suggests some improvement, with the most recent report showing no deficiencies after a period of multiple citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
162 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS, their rights related to this information, and the responsibilities of NJDHSS regarding privacy.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individual rights to access and amend information, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 162
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ185063) to determine compliance with professional standards of care related to oxygen administration for residents.
Complaint Details
Complaint #: NJ185063. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Findings
The facility was found not in substantial compliance due to failure to obtain a physician's order for oxygen administration for one resident (Resident #2) and failure to follow the facility's oxygen administration policy. The deficiency was identified through interviews, medical record review, and facility documentation.
Deficiencies (1)
Failure to obtain a physician's order for oxygen administration for Resident #2 and failure to follow the facility's oxygen administration policy.
Report Facts
Census: 162
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Interviewed and confirmed Resident #2 wore oxygen without a physician's order. | |
| Director of Nursing | Completed visual audit of residents using oxygen and re-educated clinical staff on oxygen policy. | |
| Assistant Director of Nursing | Re-educated clinical staff on oxygen policy and involved in auditing oxygen orders. |
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 2
Date: Sep 17, 2024
Visit Reason
The inspection was conducted based on a complaint visit to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care facilities.
Complaint Details
The complaint investigation determined the facility failed to maintain adequate staffing levels and failed to report a significant cooling unit failure to the state health department.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to inadequate staffing levels for 12 of 14 days and failure to report a cooling unit breakdown to the New Jersey Department of Health. The facility was otherwise in substantial compliance with federal requirements.
Deficiencies (2)
Failure to ensure appropriate licensed and certified staff and/or adequate staffing levels for 12 of 14 days.
Failure to report the breakdown of the cooling unit to the New Jersey Department of Health as required by the facility's heat emergency action plan.
Report Facts
Census: 158
Days with deficient CNA staffing: 12
Date of cooling unit failure: Aug 2, 2024
Order date for replacement unit: Aug 16, 2024
Completion date for corrections: Sep 18, 2024
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
Date: Aug 5, 2024
Visit Reason
The inspection was conducted based on complaint NJ175300 regarding the facility's compliance with resident record documentation and staffing ratios.
Complaint Details
Complaint # NJ175300 triggered the inspection. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Findings
The facility was found not in substantial compliance due to failure to consistently document Activities of Daily Living (ADL) for three residents and failure to meet required staffing ratios for Certified Nursing Assistants (CNAs) on multiple day shifts.
Deficiencies (2)
Failure to consistently document Activities of Daily Living (ADL) status for 3 residents (Resident #2, #12, and #15) in accordance with CNA job description and facility policy.
Failure to ensure staffing ratios were met for 28 of 28 day shifts reviewed, deficient CNA staffing affecting all residents.
Report Facts
Census: 113
Sample Size: 17
Deficient CNA staffing days: 28
Required CNA staffing: 14
Actual CNA staffing: 8
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 10
Date: Apr 9, 2024
Visit Reason
A complaint investigation was conducted based on multiple complaint numbers regarding staffing ratios, resident care, abuse allegations, and other compliance issues at Lawrence Rehab & HCC/The Meadows at Lawrence.
Complaint Details
The complaint investigation was based on multiple complaint numbers (NJ154829; NJ157523; NJ167771; NJ168132; NJ169996; NJ172438) involving staffing shortages, failure to maintain call bells within reach, failure to report abuse and theft allegations, failure to provide therapy services, and infection control issues.
Findings
The facility was found deficient in maintaining required direct care staff-to-resident ratios, failed to ensure call bells were within reach of residents, did not report an alleged theft to the state, failed to complete thorough investigations of abuse allegations, did not communicate pharmacy drug interaction alerts to physicians, failed to provide sufficient nursing staff for resident care, did not complete annual CNA performance reviews, failed to honor resident food preferences, did not provide occupational therapy as ordered, and failed to maintain infection control standards during treatment.
Deficiencies (10)
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for multiple shifts.
Failed to maintain the call bell within reach of the resident (Resident #89).
Failed to report an alleged theft (wedding ring) to the New Jersey Department of Health.
Failed to complete a thorough investigation for an alleged theft for Resident #35.
Failed to ensure an electronic pharmacy drug interaction alert was communicated to a physician in accordance with professional standards of practice (Resident #450).
Failed to provide sufficient nursing staff to ensure activities of daily living care and assistance were performed for Resident #57.
Failed to complete performance review of Certified Nurse Aides at least every twelve months and provide regular in-service education based on the outcome of these reviews.
Failed to ensure a resident's food preference of no gravy on meals was honored (Resident #27).
Failed to ensure that a resident received occupational therapy services in accordance with their therapy plan (Resident #131).
Failed to maintain infection control standards and procedures during care treatment for Resident #16.
Report Facts
CNA staffing deficiencies: 55
CNA staffing deficiencies: 1
CNA staffing deficiencies: 1
Census: 161
Sample size: 34
Sample size: 3
CNA assignments: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #89 | Resident | Named in call bell placement deficiency. |
| Resident #35 | Resident | Named in alleged theft and abuse reporting and investigation deficiencies. |
| Resident #450 | Resident | Named in pharmacy drug interaction alert deficiency. |
| Resident #57 | Resident | Named in insufficient nursing staff and care deficiency. |
| Resident #27 | Resident | Named in food preference deficiency. |
| Resident #131 | Resident | Named in occupational therapy service deficiency. |
| Director of Nursing | Named in multiple findings related to staffing, investigations, and education. | |
| Licensed Nursing Home Administrator | Named in multiple findings related to staffing, investigations, and education. | |
| Staffing Coordinator | Named in staffing deficiency and corrective actions. | |
| Certified Nursing Aide | Named in call bell and performance review deficiencies. | |
| Director of Rehabilitation | Named in occupational therapy service deficiency. | |
| Consultant Pharmacist | Named in pharmacy drug interaction alert deficiency. | |
| Registered Dietitian | Named in food preference deficiency. | |
| Unit Manager/Licensed Practical Nurse | Named in infection control and nursing staff deficiencies. |
Inspection Report
Routine
Census: 154
Deficiencies: 0
Date: Jul 14, 2023
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 CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 9
Inspection Report
Follow-Up
Census: 95
Deficiencies: 1
Date: Dec 21, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code staffing requirements for long term care facilities, specifically to evaluate if the facility maintained the required minimum direct care staff-to-resident ratios.
Findings
The facility was found deficient in maintaining the required minimum Certified Nursing Assistant (CNA) staffing ratios on multiple day shifts in both the main building and Meadows House #2. The facility implemented corrective actions including a bonus structure and partnering with agency staffing to increase coverage. A follow-up revisit report dated 2022-03-30 confirmed correction of the cited deficiency.
Deficiencies (1)
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Residents on day shift: 95
Certified Nursing Assistants (CNAs) required: 12
Certified Nursing Assistants (CNAs) present: 11
Residents on day shift: 9
Certified Nursing Assistants (CNAs) required: 2
Certified Nursing Assistants (CNAs) present: 1
Inspection Report
Life Safety
Census: 94
Capacity: 120
Deficiencies: 2
Date: Dec 21, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/21/21 and 12/22/21 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of NFPA 101, Life Safety Code.
Findings
The facility was found to be in noncompliance with emergency lighting requirements, specifically failing to provide battery backup emergency lighting independent of the building's electrical system and emergency generator above the emergency generator transfer switches in multiple cottages. Additionally, the facility failed to certify that the emergency generator transfers power within the required 10-second timeframe during monthly load tests.
Deficiencies (2)
Failed to provide battery backup emergency lighting independent of the building's electrical system and emergency generator above the emergency generator's transfer switch in multiple cottages.
Failed to certify that the emergency generator transfers power to the building within 10 seconds during monthly load tests.
Report Facts
Certified beds: 120
Census: 94
Deficiencies cited: 2
Monthly generator load tests: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Verified emergency lighting deficiencies and was interviewed during observations | |
| Maintenance Director | Interviewed regarding generator transfer time documentation and emergency lighting deficiencies |
Inspection Report
Routine
Census: 140
Deficiencies: 0
Date: Jan 27, 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 related to 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
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