Inspection Reports for Lawrence Rehabilitation Hospital
2381 Lawrenceville Road, 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 range of deficiencies including medication documentation, food safety, infection control, staffing ratios, and life safety code issues such as fire sprinkler maintenance and emergency lighting. Complaint investigations mostly found staffing ratio issues, with some substantiated deficiencies related to insufficient Certified Nurse Aide coverage, though no enforcement actions or fines were listed in the available reports. Prior reports also noted challenges with resident care practices, environmental maintenance, and communication, but no immediate jeopardy or license actions were reported. The facility’s record suggests some ongoing areas for improvement, particularly in staffing and safety systems, but the absence of deficiencies in the latest report indicates progress.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
48 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, including how personal health information may be used and disclosed, and the rights individuals have regarding their health 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 department's legal duties and responsibilities 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
Annual Inspection
Census: 48
Deficiencies: 14
Date: Sep 6, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint #: NJ169579, 170062, 170190, 171246, 171258. The survey was a recertification survey with complaint investigations included.
Findings
Deficiencies were cited related to medication administration documentation, food safety, quality assurance and performance improvement (QAPI), infection prevention and control, antibiotic stewardship, staffing ratios, tuberculosis screening, and life safety code violations including stairway markings, sprinkler system maintenance, corridor door smoke resistance, HVAC ventilation, elevator emergency communication, electrical system maintenance, and electrical equipment testing.
Deficiencies (14)
Failed to ensure consistent documentation of administration, hold, or refusal of enteral feedings for Resident #27.
Failed to handle potentially hazardous food properly; unlabeled and undated opened food items found in walk-in meat freezer.
Failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program with ongoing data analysis and corrective actions.
Failed to conduct complete and thorough contact tracing during an active COVID-19 outbreak.
Failed to fully implement an antibiotic stewardship program including monitoring and documentation of antibiotic use.
Failed to maintain required minimum direct care staff to resident ratio for 6 of 6 weeks prior to survey.
Failed to ensure new employees received required two-step Mantoux tuberculin skin test (PPD).
Exit stair landings and handrails were not marked with safety yellow as required by NFPA 101.
Failed to conduct 5-year internal obstruction investigation for fire sprinkler system within required timeframe.
Corridor doors were not able to resist passage of smoke; doors stuck or had gaps preventing proper closure.
Resident bathroom ventilation systems were not functioning in 12 of 54 units.
Elevator emergency communication telephone did not function for elevator #2.
Electrical system maintenance deficiencies including poor electrical connections and lack of repair documentation.
Failed to provide electrical policy, maintenance, and documentation for patient care related electrical equipment (PCREE).
Report Facts
Census: 48
Sample size: 15
Deficiency counts: 14
Staffing deficiency weeks: 6
Resident rooms with ventilation issues: 12
Resident rooms with corridor door issues: 4
Resident beds without inspection stickers: 54
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Apr 11, 2024
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ00171422) to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint #: NJ00171422. The facility was found deficient in CNA staffing for 1 of 14 day shifts during the weeks of 03/24/2024 to 04/06/2024. No residents were identified as having been affected. All residents have the potential to be affected.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements for 1 of 14 day shifts due to insufficient Certified Nurse Aide (CNA) staffing. No residents were identified as affected, but all residents had the potential to be affected. The facility implemented multiple corrective actions to address staffing shortages and improve employee retention.
Deficiencies (1)
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 1 of 14 day shifts.
Report Facts
Census: 51
Sample Size: 5
Deficient CNA staffing: 4
Day shifts reviewed: 14
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 10
Date: Jun 2, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations NJ161372 and NJ163759.
Complaint Details
Complaint investigation related to NJ161372 and NJ163759.
Findings
Deficiencies were cited related to resident self-determination, meal delivery timeliness, resident hygiene and laundry services, environmental maintenance, transfer/discharge notice requirements, respiratory care, pharmacy services, medication management, food temperature and preferences, staffing ratios, and infection prevention and control practices.
Deficiencies (10)
Facility failed to ensure meals were consistently delivered on time and accommodate resident dietary preferences for 7 of 21 residents reviewed.
Facility failed to maintain a clean, homelike, and sanitary environment; multiple rooms had walls with open holes, scrape marks, and white substance.
Facility failed to provide written notification of emergency transfer to resident, representative, and Ombudsman for one resident.
Facility failed to maintain respiratory care consistent with professional standards and failed to obtain physician's order for residents receiving respiratory treatments.
Facility failed to provide pharmaceutical services in accordance with professional standards including accurate transcription of physician orders, medication availability, and documentation of medical indications for medications.
Facility failed to properly secure medications in emergency crash cart; crash cart handle was not a secure lock.
Facility failed to ensure safe and appetizing temperatures of hot and cold food served to residents; multiple test tray audits showed food temperatures below acceptable ranges.
Facility failed to ensure resident dietary preferences were consistently identified and implemented for 8 of 8 residents reviewed.
Facility failed to ensure call bells were answered timely for 4 of 21 residents and failed to maintain required minimum direct care staff-to-resident ratios for multiple shifts.
Facility failed to maintain proper infection control practices including appropriate PPE use, glove use by housekeeping, containment of disposable PPE, and timely testing of exposed resident.
Report Facts
Residents reviewed for meal delivery: 21
Residents reviewed for call bell response: 21
Staffing ratio deficiencies: 34
Residents interviewed at council meeting: 5
Residents with dietary preference issues: 8
Medication orders lacking medical indication: 10
Medication cart missing medication dose: 1
Emergency crash carts inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed medication administration errors and acknowledged transcription error. |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Observed unsecured emergency crash cart and acknowledged lack of proper locking. |
| CNA #1 | Certified Nurse's Aide | Reported meal tray delivery issues and resident complaints about food. |
| Food Service Director | Food Service Director | Discussed meal delivery issues, new software implementation, and QAPI plan. |
| IPN #1 | Infection Preventionist Nurse | Discussed infection control rounds and PPE requirements. |
| IPN #2 | Infection Preventionist Nurse | Assisted in transition and discussed infection control practices. |
| Director of Nursing | Director of Nursing | Provided re-education on medication policies and call bell response. |
| Vice President of Growth and Transitions | Vice President | Acknowledged food service QAPI plan and staffing concerns. |
| Licensed Nursing Home Administrator | Administrator | Acknowledged staffing ratios and infection control concerns. |
Inspection Report
Life Safety
Census: 53
Capacity: 56
Deficiencies: 3
Date: May 25, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 05/25/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including emergency lighting at the emergency generator transfer switch, fire alarm system testing and maintenance, and annual inspection of fire doors. These deficiencies had the potential to affect all 53 residents.
Deficiencies (3)
Emergency lighting was not provided at the emergency generator transfer switch in accordance with NFPA 110 Standard for Emergency and Standby Power Systems.
The fire alarm system was not tested and maintained in accordance with NFPA 70 and NFPA 72; specifically, smoke detection sensitivity was not checked every alternate year.
Fire doors were not inspected annually in accordance with NFPA 101 Life Safety Code; inspections and required tags were missing.
Report Facts
Occupied beds: 53
Total licensed capacity: 56
Deficiency correction completion date: Jun 15, 2023
Deficiency correction completion date: Jul 14, 2023
Deficiency correction completion date: Jun 15, 2023
Post-certification revisit date: Jul 21, 2023
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: May 9, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to complaints NJ00162351 and NJ00162754, focusing on staffing ratios and compliance with state regulations.
Complaint Details
Complaint #: NJ00162351 and NJ00162754. The facility failed to meet minimum staffing ratios on 17 of 63 shifts reviewed, potentially affecting all residents. The facility was required to submit a plan of correction.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios on multiple shifts. The facility was in substantial compliance with federal long term care requirements but deficient in state staffing standards.
Deficiencies (1)
Failed to ensure staffing ratios were met to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 17 of 63 shifts reviewed.
Report Facts
Survey Census: 52
Sample Size: 7
Deficient Shifts: 17
Staffing Deficiencies: 5
Staffing Deficiencies: 10
Staffing Deficiencies: 2
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Sep 28, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ144380.
Complaint Details
Complaint #: NJ144380. The facility was found compliant based on this complaint survey.
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.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 1
Date: May 20, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility failed to identify and evaluate a resident's ability to swallow medications, notify the physician of a resident who did not consistently swallow medications, and implement appropriate communication strategies for a resident. The nurse was overheard speaking loudly and harshly to a resident, which caused distress. Corrective actions included revising nursing policies, re-educating staff, and monitoring compliance.
Deficiencies (1)
Failure to identify and evaluate a resident's ability to swallow medications, notify the physician of inconsistent swallowing, and implement appropriate communication strategies.
Report Facts
Sample Size: 15
Deficiency Completion Date: May 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration and communication deficiency |
| Director of Nursing | DON | Interviewed regarding communication and medication procedures |
| Chief Nursing Officer | CNO | Interviewed regarding communication and medication procedures |
| Administrator | LHNA | Interviewed regarding medication administration procedures |
| Primary Physician | MD | Interviewed regarding resident's medication and notification |
| Director of Professional Services | DOPS | Interviewed regarding resident's communication and assessment |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 18, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/18/2021 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be in noncompliance due to failure to maintain the piped-in Oxygen system in accordance with NFPA 99, evidenced by repeated deficiencies in the oxygen switch low alarm and delayed corrective actions.
Deficiencies (1)
Failure to maintain the piped-in Oxygen system in accordance with NFPA 99, including unresolved oxygen switch low alarm drift issues noted in annual inspection reports from 03/04/2020 and 03/22/2021.
Report Facts
Date of survey: May 18, 2021
Date of survey completion: May 20, 2021
Dates of oxygen system inspection reports: 2
Building stories: 5
Smoke zones: 6
Generator coverage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding oxygen system deficiency and aware of vendor inspection report deficiency | |
| Administrator | Notified of the finding at the Life Safety Code exit conference | |
| Director of Facilities | Responsible for submitting reports and ensuring corrective actions and monitoring | |
| Safety Chairman | Receives reports and oversees plan review and remedies | |
| Safety Chair | Submits Safety Committee minutes to Administrative Council (QAPI Committee) |
Inspection Report
Routine
Census: 39
Deficiencies: 0
Date: Nov 16, 2020
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: 3
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