Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lawrence Rehab & Hcc/the Meadows At Lawrence during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering exited a secure unit despite wearing a wander guard. The resident was found on another floor by an LPN, who returned them to the unit but did not notify other staff. Later, the resident left the facility through a stairwell and exterior door after staff failed to properly investigate an alarm. The resident was not identified as missing for several hours, and the elopement protocol was not enacted promptly. The resident was eventually found outside with injuries requiring hospitalization.
Ice machine drain line was observed extending directly into the floor drain, and the DM confirmed it should not be placed there because an air gap is needed to prevent backflow. When the line was removed, it was coated with a black substance. The facility policy on ice machines did not address maintaining an air gap for the drain line.
The facility failed to provide written transfer notices, appeal rights information, and bed hold notices to resident representatives for multiple residents sent to the hospital, and it also failed to ensure transfer documentation was available for the receiving hospital in several cases. Records and interviews showed that residents with conditions such as respiratory distress, infection, wounds, falls, and acute medical changes were transferred, but families were only called and did not receive the required written information or bed hold discussion.
A resident with cerebral infarct, hemiplegia, hemiparesis, and a cutaneous abscess had a stage III sacral pressure ulcer documented in the record, but the quarterly MDS did not code any pressure ulcers. The MDSC reviewed the wound documentation and acknowledged the MDS did not reflect the resident’s stage III pressure ulcer.
A resident receiving hospice services had a care plan that listed hospice support only for social services and did not include hospice nursing services. The resident had diagnoses including dementia and DM2, was ordered for hospice eval and treat, was accepted for hospice, and was documented on the MDS as being on hospice. An RN acknowledged the care plan did not address hospice nursing services, even though the resident received weekly hospice visits and daily hospice CNA visits.
A resident with CHF and daily diuretic therapy was ordered daily morning weights, but staff did not consistently obtain them. The resident reported not being weighed for 2 weeks because the mechanical lift scale part could not be found, and staff interviews showed that if the scale could not be used or no one knew how to use it, the weight was often not taken or documented.
A resident’s Flonase nasal spray was found on the dresser even though he was not approved for self-administration, and the RN confirmed it should have been stored in the locked medication cabinet. In a separate event, an unlocked treatment cart containing wound care supplies was left unattended on a unit while an LPN and wound care consultant were in a resident’s room; the LPN said she did not have the keys, and the DON stated she had the keys to all medication and treatment carts.
Failure to Offer Influenza Immunization: A resident with severe cognitive deficits and a primary dx of pleural effusion was not documented as being offered the influenza vaccine during the annual vaccination period. The EMR showed no immunization orders, no immunization status in the care plan, and no declination or education indicating the vaccine had been offered, while the IP confirmed the record lacked evidence that the resident was offered the flu shot.
Failure to Offer and Document COVID-19 Vaccine Boosters: The facility did not ensure three residents were offered COVID-19 vaccine boosters or that vaccination education, declination, and status were properly documented. One resident with pleural effusion and severe cognitive deficits had no evidence of being offered the vaccine in 2024 or 2025, another resident with DM and moderate cognitive impairment reported the facility refused the vaccine the prior year, and a third resident with dementia accepted the vaccine on consent but did not receive it after a flu-related hold was documented.
A resident with acute respiratory and kidney conditions was placed on continuous oxygen therapy without a physician's order, contrary to facility policy and professional standards. Staff interviews and record reviews confirmed the absence of the required order, despite the resident's ongoing use of oxygen and the facility's policy mandating physician authorization for such treatment.
The facility staff failed to consistently document ADL care for three residents, leading to incomplete records of bed mobility and repositioning. A resident with severe impairments had multiple days with missing documentation, despite needing frequent repositioning due to skin impairments. Another resident with severe cognitive impairment also had gaps in documentation, and a third resident with moderate impairment experienced similar issues. Staff interviews revealed that documentation was expected to be completed by the end of each shift, but issues such as forgetting or access problems were cited.
The facility did not complete annual performance reviews for CNAs, impacting all five CNAs reviewed. Performance reviews for 2022 and 2023 were missing. The LNHA acknowledged the oversight, attributing it to the recent change in facility ownership.
The facility failed to keep a resident's call bell within reach, despite the resident's history of falls and need for moderate assistance. The call bell was observed on the floor or in the middle of the bed, out of reach, contrary to the care plan and facility policies. Staff acknowledged the oversight during the survey.
The facility failed to report an alleged theft of a wedding ring to the NJDOH. A resident with severe cognitive impairment and dependent on staff for ADLs had a missing ring reported to the facility, but the NJDOH was not notified as required by facility policy. The LNHA acknowledged the oversight.
The facility failed to investigate an alleged theft of a wedding ring belonging to a resident with severe cognitive impairment. The incident was reported a month after it was noticed, and no investigation was conducted due to the time lapse. The facility's policies on investigating theft and misappropriation were not followed.
The facility failed to communicate an electronic pharmacy drug interaction alert to a physician for a resident prescribed Keflex and a multivitamin containing iron. The alert was not documented in the Progress Notes, and the standard procedure to notify the physician was not followed.
The facility failed to provide sufficient nursing staff to ensure ADLs were performed for a resident. The resident was found with an untouched breakfast tray and a saturated incontinent brief, indicating a lack of assistance with meals and incontinence care. The RN assigned as the resident's CNA had fifteen residents to care for, resulting in inadequate care. The DON confirmed that the resident should have been fed and received morning care before noon, and the facility's policies were not followed.
A resident with a fully intact cognition informed the RD that they disliked gravy on their meals because it upset their stomach. Despite this, the resident continued to receive meals with gravy. The RD failed to document and communicate the preference, and the issue persisted even after the resident reiterated their preference at a Food Committee Meeting. The facility's policy on identifying food preferences was not followed, and the LNHA acknowledged the failure.
A resident did not receive scheduled occupational therapy services due to an oversight by the Director of Rehabilitation (DOR) when the Certified Occupational Therapist Aide (COTA) was out sick. The resident had extended their stay for rehabilitation and was paying privately for services, but experienced a lapse in therapy from 3/21/24 to 3/27/24.
A facility failed to maintain infection control standards during wound care treatment for a resident with severe cognitive impairment. The RN did not follow proper hand hygiene protocols and brought a multi-use bottle of wound cleansing solution into the resident's room without disinfecting it before returning it to the treatment cart. These actions were confirmed by the RN, DON, IP, and UM, leading to the identified deficiency.
Failure to Prevent Elopement and Delayed Response to Missing Resident
Penalty
Summary
A cognitively impaired resident with a known history of wandering and a moderate risk for elopement, as documented in their care plan and risk assessments, was able to exit a secure second-floor unit despite wearing a wander guard device. The resident was first found by an LPN on the facility's first floor, asking another resident for directions. The LPN returned the resident to the second-floor common area but did not notify the assigned nurse or other second-floor staff of the incident. This lack of communication meant that staff were unaware of the resident's attempt to leave the secure unit earlier in the day. Later that afternoon, the resident pushed open a stairwell door on the second floor, proceeded down the stairs, and exited the facility through an exterior door. The stairwell door alarm sounded, but the unit secretary silenced the alarm without thoroughly checking the area or confirming the whereabouts of the resident. The unit manager was consulted for the alarm code but also did not investigate the cause of the alarm. As a result, the resident was able to leave the facility unsupervised and was not immediately detected as missing. It was not until several hours later, after staff noticed the resident was missing during rounds, that a search was initiated. The search was initially conducted by a single LPN and later expanded with additional staff, but facility administration and the DON were not notified until much later. The facility's elopement protocol was not enacted until several hours after the resident had left the premises. The resident was eventually found outside on facility grounds, having sustained injuries that required hospitalization. The failure to provide adequate supervision, respond appropriately to alarms, and enact the elopement protocol in a timely manner constituted a deficiency and resulted in an Immediate Jeopardy situation.
Removal Plan
- A headcount was performed to confirm that all residents were accounted for.
- Resident #2 was located and sent to the hospital for evaluation.
- Regional Plant Operations reviewed all doors and locking mechanisms and addressed variances.
- Nursing administration reviewed residents on wanderguard for appropriate orders and care plans.
- Elopement binders were reviewed to ensure that all residents at elopement risk were included.
- All staff were educated on procedures for elopement drill and announcement of Code Yellow.
- All staff were educated on the facility policies on wandering and elopement, and safety checks and supervision.
- Nursing staff were educated on rounding at the start of their shift and every 2 hours.
- Elopement drills were conducted.
Ice Machine Drain Line Placed Into Floor Drain
Penalty
Summary
The facility failed to prevent the potential for cross-contamination by allowing the drain line from the ice machine to extend down into the floor drain. During an observation and interview on 09/01/25 at 12:10 PM, the Dietary Manager confirmed that the ice machine drain line was stuck down into the floor drain. When the drain line was removed from the floor drain, it was observed to be coated with a black substance. Review of the facility policy titled, "Ice Machines and Ice Storage Chests," dated January 2012, showed that ice machines and ice storage/distribution containers were to be used and maintained to assure a safe and sanitary supply of ice, but the policy did not address maintaining an air gap for the machine's drain line to prevent backflow into the ice machine. The report cited the 2017 Food Code provision on backflow prevention, which states that a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
Failure to Provide Transfer, Appeal, and Bed Hold Notices
Penalty
Summary
The facility failed to provide written notice of transfer and bed hold information to the resident representative for multiple residents who were transferred to acute care hospitals, and it also failed to provide transfer documentation to the receiving hospital for several of those residents. The report identified seven residents out of eight sampled for hospitalization: R3, R4, R6, R7, R12, R20, and R84. The missing documentation included notice of transfer, bed hold notice, and information regarding appeal rights, and in some cases the transfer form sent to the hospital could not be located in the record. For R7, the record showed a Universal Transfer Form was completed for the hospital transfer, but there was no notice of transfer or bed hold notice provided to the responsible party, and the appeals process information could not be located. R20’s record similarly showed no notice of transfer or bed hold notice to the responsible party, and no appeal information was found. For R3, the resident was transferred to Capital Health for shortness of breath, and the Notice of Intent to Transfer/Discharge was present in the record; however, the responsible party stated she did not receive any documents or information about bed holds or transfers. R12’s record showed transfer to an emergency room for purulent drainage from an abdominal surgical wound, but no SNF/NF to Hospital Transfer Form or Notice of Intent to Transfer/Discharge was found. R4’s record showed an unplanned discharge to an acute care setting for acute kidney injury, heart failure, and elevated potassium, but there was no documentation discussing the bed hold policy. R6’s spouse agreed to transfer the resident for evaluation and treatment of blackish discoloration and foul-smelling wounds, but the progress notes did not indicate that bed hold was discussed and the transfer form did not show whether required documents were sent. R84’s record showed transfer after the resident was found unresponsive on the floor with injuries, but there was no documentation that the bed hold policy was discussed with the resident or family, and although the responsible party was notified, nothing in writing about the transfer was provided.
MDS Did Not Reflect Stage III Pressure Ulcer
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the presence of a pressure ulcer for one resident, R169. Review of the RAI Manual stated that information used for the MDS must cover the same observation period and be validated for accuracy by the IDT completing the assessment. R169 was admitted with diagnoses including cerebral infarct with hemiplegia and hemiparesis, and cutaneous abscess. The resident’s five-day Medicare MDS with an ARD of 10/08/24 coded the resident as admitted with one stage III pressure ulcer, and a wound assessment dated 10/25/24 documented a stage III pressure ulcer to the sacrum measuring four centimeters by three centimeters. However, the quarterly MDS with an ARD of 10/30/24 did not code any pressure ulcers. During interview, the MDSC reviewed the wound assessments and quarterly MDS and acknowledged that the quarterly MDS did not reflect the resident’s stage III pressure ulcer.
Hospice Services Not Fully Reflected in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for one resident receiving hospice services included hospice nursing services. Resident 13 was admitted with diagnoses including dementia, senile degeneration of the brain, type II diabetes mellitus, and gastroesophageal reflux. A physician order dated 06/17/25 directed hospice to evaluate and treat, and a hospice business office notification form dated 06/18/25 showed the resident was accepted for hospice services. A significant change MDS with an ARD of 06/23/25 documented that the resident was placed on hospice services. Review of the resident’s care plan revised 06/19/25 showed the resident was receiving hospice services due to a terminal diagnosis, but the interventions only reflected services provided by social services and did not include hospice nursing services. During interview on 09/03/25 at 3:10 PM, RN 2 stated the resident received weekly visits from hospice and daily visits from the hospice CNA, and acknowledged that the care plan addressed only hospice social services and did not include hospice nursing services.
Failure to Obtain Ordered Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure quality of care/treatment was provided to one resident, who had multiple sclerosis and a diagnosis of congestive heart failure with daily diuretic use. The resident’s care plan included obtaining weights at ordered intervals, and the physician ordered daily morning weights for CHF. The resident was cognitively intact and reported persistent left leg swelling and that she was supposed to be weighed daily, but stated she had not been weighed in 2 weeks because staff could not find the part needed to weigh her on the mechanical lift scale. Interviews with nursing staff and CNAs showed that weights were supposed to be obtained by CNAs and then documented on a paper weight log and entered into the EMR by nurses, but if the weight was not documented, staff considered it not done. Staff stated that if the mechanical lift scale could not be used, if an aide did not know how to use it, or if the overnight shift could not weigh the resident before she ate or drank, the resident would not be weighed that day. The DON confirmed the resident was supposed to be weighed daily before 7:00 AM and expected that the resident would have been weighed daily per the physician order.
Improper Medication Storage and Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure medications were properly stored for one resident when Flonase nasal spray was observed at the resident’s bedside on the dresser. The resident had been admitted with hemiplegia and hemiparesis following cerebral infarction, had a BIMS score of 14 out of 15 on the quarterly MDS, and the care plan and assessments did not indicate that he was a candidate for self-administration of medications. The resident had an order for fluticasone propionate nasal spray, and during observation the RN administering medications stated the Flonase should have been in the locked medication cabinet on the wall, not on the dresser. The RN then removed the medication and locked it away, and the DON confirmed the resident was not approved for self-administration. The facility also failed to ensure one of two treatment carts was locked. During observation, the treatment cart on the unit was left unlocked while an LPN and the wound care consultant were in a resident’s room, and the cart was out of the LPN’s line of sight. The cart contained wound cleanser, wound care supplies, hydrogen peroxide, alcohol wipes, zinc oxide, and other items. The LPN stated she could not lock the cart because only the medication nurse had the keys, and the DON later stated she had the keys to all medication and treatment carts and there was no reason the LPN could not have come to her to sign out the keys.
Failure to Offer Influenza Immunization
Penalty
Summary
The facility failed to ensure that one of five residents reviewed for immunizations, Resident 11, was offered the influenza immunization in 2024. The facility’s policy titled, Influenza Vaccine, revised 03/2022, stated that all residents and employees without medical contraindications are to be offered the influenza vaccine annually between October 1 and March 31 unless they have already been immunized or the vaccine is medically contraindicated. Resident 11 was admitted to the facility with a primary diagnosis of pleural effusion. Review of the quarterly MDS showed that a BIMS could not be completed due to severe cognitive deficits. Review of the EMR showed no immunization orders in the physician orders, no immunization status in the care plan, and the immunizations record showed the resident had not received the influenza immunization since 10/02/23. There was no declination or education documented to show the resident had been offered the vaccine in 2024. During interview, the Infection Preventionist confirmed the medical record did not include any indication that Resident 11 had been offered the influenza immunization in 2024, but that he should have been.
Failure to Offer and Document COVID-19 Vaccine Boosters
Penalty
Summary
The facility failed to ensure three residents were offered the COVID-19 vaccine boosters and failed to properly document vaccination status, education, and declination information. The facility policy stated that staff members and residents who meet COVID-19 vaccine eligibility criteria will be offered vaccination in accordance with CDC and ACIP recommendations. CDC guidance reviewed by surveyors indicated that eligible adults should receive one or more doses of the 2024-2025 COVID-19 vaccine, and adults older than a specified age should receive two or more doses. One resident, an older male admitted with pleural effusion and severe cognitive deficits, had no COVID-19 immunizations since 04/13/21. His quarterly MDS indicated his COVID-19 immunization was not up to date, but his orders, care plan, and immunization record contained no evidence that he was offered the vaccine in 2024 or 2025, and no declination or education was available. The Infection Preventionist confirmed that the medical record did not show he had been offered the immunization in 2024 or 2025, although he should have been. A second resident, an older female admitted with diabetes mellitus and moderate cognitive impairment, stated during interview that her only concern was receiving the COVID-19 vaccine that year and that the facility had refused to administer it the prior year without explanation. Her record showed a COVID-19 vaccine order dated 12/13/23 and immunizations on 03/03/21, 09/27/22, 12/13/23, and 05/07/25, but no documentation that she was offered the vaccine in 2024. A third resident, an older female admitted with dementia and severe cognitive deficits, had a COVID-19 vaccine order dated 11/09/23 and a consent form showing she was educated and accepted the vaccine on 09/24/24, but the vaccine was not given. Her record also showed a progress note stating to hold COVID vaccine administration until she recovered from flu, and the Infection Preventionist confirmed she was not offered the vaccine after recovering and should have received it in 2024.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to follow professional standards of clinical practice by not obtaining a physician's order for continuous oxygen therapy for a resident who required it. The resident was admitted with diagnoses including acute respiratory failure, obstructive sleep apnea, and acute kidney failure, and was on continuous oxygen via nasal cannula throughout their stay. Despite this, a review of the resident's medical record and order summary report revealed there were no physician's orders for oxygen therapy, either as needed or standing. Multiple staff interviews confirmed that the resident was using continuous oxygen and that a physician's order was required for such therapy, but none was present in the records. Additionally, the facility failed to adhere to its own policy on oxygen administration, which requires verification of a physician's order prior to initiating oxygen therapy. The job description for LPNs at the facility also specifies that obtaining physician orders is part of the admission process. The deficiency was identified through interviews, record reviews, and policy examination, all of which confirmed that the required physician's order for oxygen therapy was not obtained or documented for the resident.
Inconsistent Documentation of ADL Care for Residents
Penalty
Summary
The facility staff failed to consistently document the Activities of Daily Living (ADL) status for three residents, as required by the facility's policy and the Certified Nursing Assistant (CNA) job description. Resident #2, who was admitted with severe impairments and required substantial assistance, had multiple days in July 2024 where there was no documentation of bed mobility, specifically turning and positioning, across all shifts. Despite the care plan indicating the need for frequent repositioning due to skin impairments, the documentation was incomplete, and there were no progress notes indicating any worsening of the resident's skin condition. Similarly, Resident #12, who had severe cognitive impairment and required assistance with ADLs, also had several days in July 2024 with missing documentation for bed mobility. The care plan for Resident #12 highlighted the need for assistance due to deconditioning, yet the documentation did not reflect consistent care. The progress notes for this resident also lacked entries confirming that the necessary repositioning was performed during the shifts with missing documentation. Resident #15, with moderate cognitive impairment and physical limitations, also experienced gaps in documentation for bed mobility. The care plan required assistance with turning and repositioning due to an unsteady gait and impaired balance, but the documentation was incomplete for several days in July 2024. Interviews with facility staff, including a CNA and the Unit Manager/Registered Nurse, revealed that documentation was expected to be completed by the end of each shift, but issues such as forgetting to document or access problems with the electronic system were cited as reasons for the missing entries.
Lack of Timely Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete performance reviews of Certified Nurse Aides (CNAs) at least every twelve months and provide regular in-service education based on the outcome of these reviews. The deficiency was identified for all five CNAs reviewed, as evidenced by the absence of performance reviews for 2022 and 2023 for each CNA. The LNHA acknowledged the lack of performance reviews for 2023 and stated that the facility had recently started conducting reviews due to taking ownership of the building in February 2023.
Failure to Maintain Call Bell Within Resident's Reach
Penalty
Summary
The facility failed to maintain the call bell within reach of a resident, leading to a deficiency in accommodating the needs and preferences of the resident. On multiple occasions, the surveyor observed the resident seated in a wheelchair with the call bell either on the floor or positioned in the middle of the bed, out of the resident's reach. The resident, who had a history of falling and required moderate assistance for transfers and toileting, indicated that they could not reach the call bell when needed. The CNA and LPN acknowledged the issue and repositioned the call bell within reach during the surveyor's visit. The resident's medical record indicated a mild cognitive impairment and a care plan that included keeping the call bell within reach to mitigate fall risks. Despite this, the call bell was repeatedly found out of reach, contrary to the facility's policies and the CNA's job description. The Licensed Nursing Home Administrator, in the presence of the DON and Regional LNHA, confirmed that the call bell should have been within reach and acknowledged the oversight by the staff member who set up the resident's lunch tray.
Failure to Report Alleged Theft to NJDOH
Penalty
Summary
The facility failed to report an alleged theft of a wedding ring to the New Jersey Department of Health (NJDOH). This deficiency was identified for a resident who had severe cognitive impairment and was dependent on staff for activities of daily living. The incident was reported to the facility on 10/26/2023, but the grievance summary indicated that the police report was not filed until December, and the NJDOH was never notified. The Licensed Nursing Home Administrator (LNHA) acknowledged that the incident should have been reported to the NJDOH but was not. The facility's policy on abuse, neglect, exploitation, or misappropriation of resident property requires immediate reporting of such incidents to the administrator and state licensing/certification agency. However, the review of the grievance summaries and interviews revealed that this protocol was not followed. The previous administrator was aware of the missing wedding ring but did not report it to the NJDOH, leading to a failure in compliance with state regulations.
Failure to Investigate Alleged Theft of Resident's Property
Penalty
Summary
The facility failed to complete a thorough investigation for an alleged theft of a wedding ring belonging to a resident with severe cognitive impairment and dependency on staff for activities of daily living. The incident was reported to the facility on 10/26/2023, but the police report was not filed until December. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that the incident should have been investigated, but no investigation was conducted due to the time lapse in reporting. The facility's policy requires the administrator to appoint a staff member to investigate incidents of theft and misappropriation, but this was not done. The resident's representative reported the missing ring a month after it was noticed, making it difficult for the facility to investigate. The DON was unaware if the previous administrator had completed an investigation or if any staff statements were taken. The facility's policy on abuse, neglect, exploitation, or misappropriation mandates that all allegations be thoroughly investigated, but this protocol was not followed in this case. The failure to investigate the alleged theft was a violation of the facility's policies and state regulations.
Failure to Communicate Drug Interaction Alert to Physician
Penalty
Summary
The facility failed to ensure an electronic pharmacy drug interaction alert was communicated to a physician in accordance with professional standards of practice. This deficiency was identified for a resident who was admitted with diagnoses including generalized muscle weakness, complete traumatic amputation, and acute embolism and thrombosis. The resident was prescribed Keflex, an antibiotic, which triggered a drug interaction alert with a multivitamin containing iron. The alert was not communicated to the physician, and the interaction was not documented in the Progress Notes as required by the facility's procedures. The Consultant Pharmacist confirmed that the facility was responsible for addressing drug interaction alerts generated by the pharmacy system. Interviews with the Registered Nurse and Unit Manager/Licensed Practical Nurse revealed that the standard procedure was to notify the physician and document the interaction, which was not done in this case. The Licensed Nursing Home Administrator, in the presence of the Director of Nursing and Regional LNHA, acknowledged the failure to notify the physician and document the interaction. The facility's Medication and Treatment Orders policy did not include a procedure for handling pharmacy drug interaction alerts.
Insufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure activities of daily living (ADLs) were performed for a resident. On the morning of 4/1/24, Resident #57 was observed awake in bed with an untouched breakfast tray. The RN assigned as the resident's CNA confirmed that they had not yet assisted the resident with breakfast or performed incontinence care. The RN had fifteen assigned residents for the day and had not yet provided care for Resident #57. The Unit Manager/LPN confirmed that the resident's incontinent brief was saturated with urine and needed to be changed, and the breakfast tray delivered around 8:30 AM was untouched. The CNA assignment sheet revealed that the RN was assigned as a CNA for the 7-3 shift, with a census of 59 residents and four CNAs assigned to the unit, resulting in an inadequate staff-to-resident ratio. Resident #57's medical record indicated diagnoses including dysphagia, gastrostomy status, and gastro-esophageal reflux disease, with severe cognitive impairment and dependence on staff for eating and toileting. The resident's care plan required hands-on assistance for eating, drinking, and toileting, with specific interventions to monitor intake and provide incontinence care every two hours. The DON acknowledged that the resident should have been fed and received morning care before 12:00 PM, and the facility's policies on ADLs and urinary continence were not followed. The deficiency was confirmed by the DON, LNHA, Regional LNHA, and survey team.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preference of no gravy on meals, which was identified for one resident. The resident, who had a fully intact cognition as indicated by a BIMS score of 15 out of 15, had informed the Registered Dietitian (RD) that they disliked gravy because it upset their stomach. Despite this, the resident continued to receive meals with gravy. The RD acknowledged that she failed to document the resident's preference and did not communicate it to the kitchen. The resident reiterated their preference at a Food Committee Meeting, but the issue persisted, as evidenced by the resident receiving a meal with gravy on a subsequent night. The surveyor's observations and interviews confirmed the resident's ongoing issue with receiving meals containing gravy. The facility's policy on Resident Food Preferences Orders, which requires the dietician and/or nursing staff to identify a resident's food preferences upon admission, was not followed. The Licensed Nursing Home Administrator (LNHA) and other facility leaders acknowledged that the resident's food preferences should have been honored. The deficiency was documented based on the facility's failure to adhere to its own policy and the resident's repeated complaints about receiving meals with gravy.
Failure to Provide Scheduled Occupational Therapy Services
Penalty
Summary
The facility failed to ensure that a resident received occupational therapy services in accordance with their therapy plan. This deficiency was identified for a resident who had extended their stay at the facility for rehabilitation purposes. The resident did not receive therapy from 3/21/24 to 3/27/24 because their Certified Occupational Therapist Aide (COTA) was out sick, and the Director of Rehabilitation (DOR) mistakenly left the resident off the rehab schedule. The resident had decided to continue therapy and pay privately after exhausting their insurance-covered therapy days, but the lapse in therapy occurred due to the DOR's oversight. The resident reported that they did not receive therapy on the promised days, including a missed session on Saturday after the COTA returned to work. Interviews with the COTA, Occupational Therapist (OT), and DOR confirmed the lapse in therapy services. The DOR acknowledged the mistake and admitted that he did not follow up to ensure the resident received their therapy sessions, especially on weekends. The Campus Director of Rehab (CDOR) and the Licensed Nursing Home Administrator (LNHA) also confirmed that the resident should have been scheduled for therapy within twenty-four to forty-eight hours after the discharge plan was made. The resident's medical record indicated diagnoses including a pressure ulcer, muscle weakness, and gout, and the resident had fully intact cognition as per the most recent assessment.
Infection Control Deficiency During Wound Care Treatment
Penalty
Summary
The facility failed to maintain infection control standards and procedures during wound care treatment for a resident with severe cognitive impairment, dementia, diabetes mellitus, and hypertension. The Registered Nurse (RN) did not follow proper hand hygiene protocols, including washing hands for the required 20-30 seconds and performing hand hygiene between glove changes. Additionally, the RN brought a multi-use bottle of wound cleansing solution into the resident's room and did not disinfect it before placing it back into the treatment cart, which is against the facility's policy. During the wound care treatment, the RN placed disposable single-use wound treatment supplies on a clean barrier but placed the multi-use bottle directly on the overbed table. The RN washed her hands for only eleven seconds and did not perform hand hygiene between glove changes. After completing the wound care, the RN washed her hands for only six seconds and did not disinfect the multi-use bottle before returning it to the treatment cart. These actions were observed by the surveyor and confirmed by the RN, Director of Nursing (DON), Infection Preventionist (IP), and Unit Manager (UM). The facility's policies on hand hygiene and wound care were not followed. The handwashing policy requires washing and lathering hands outside the flow of running water for at least 20 seconds, and the wound care policy specifies that only disposable supplies should be brought into the resident's room. The DON, IP, and UM all confirmed that the RN's actions did not comply with these policies, leading to the identified deficiency in infection control standards and procedures.
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Illustrative
What surveyors actually found near you
We read the 746 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Lawrenceville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lawrence Rehabilitation Hospital | 0.2 mi | ★★★★★ | 30 | 0 |
| Clover Meadows Healthcare And Rehabilitation Cente | 1.1 mi | ★★★★★ | 1 | 0 |
| Avant Rehabilitation And Care Center | 3.1 mi | ★★★★★ | 14 | 0 |
| Preferred Care At Mercer | 3.8 mi | ★★★★★ | 10 | 0 |
| Greenwood House Home For The Jewish Aged | 3.8 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.