Below average — CMS composite of the measures below.
The next survey window likely opens 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 Rehabilitation Hospital during CMS and state inspections, most recent first.
Failure to Inform Residents About ADs: The facility did not have a process to inform residents or their representatives about the right to formulate an AD or provide written information about it. Two residents reviewed had POLSTs in the record, but there was no documentation that ADs were discussed or offered; one resident with severe cognitive impairment had DNR status, and another cognitively intact resident later said the facility never offered anything related to an AD. SWs stated they asked about existing ADs and used POLST forms, but did not review ADs or provide educational materials.
The facility failed to admit residents requiring Medicaid in accordance with its CMS SNF/NF designation. The LNHA, VPO, LPN UM, and SWs all stated the building operated as a sub-acute/rehab facility only, with no LTC residents, no resident council, and no Medicaid residents staying long term. Surveyors also reviewed facility documents and the website, which described the facility as subacute and included materials reflecting 0 Medicaid residents on the LTC facility application.
The facility failed to maintain a comprehensive, data-driven QAPI program with documented initiatives and supporting data. The LNHA could only describe a few isolated QAPI items, including a resident with an incorrect name band, therapy changing urinary catheter leg bags too often, psychotropic med consent forms, and incomplete employee education, but could not provide goals, root-cause information, or data for the concerns. The LNHA also stated there were no QAPI plans for admission/discharge, social services, or infection control, despite prior and current concerns related to Antibiotic Stewardship. The facility’s QAPI plan was undated and unsigned.
QAPI Failed to Review and Analyze Adverse Events: The LNHA stated QAPI reviewed skin issues and falls, but could not provide information on systematic analysis of falls, root causes, or specific corrective actions tied to adverse events. A falls PIP showed falls were trending up, with 9 total falls, 3 injuries, and 1 hospitalization, yet grievances and reportable events were not reviewed at QAPI and internal risk management information was kept separate from QAPI.
The facility failed to consistently use its antibiotic stewardship process for two residents. One resident received Macrobid for a presumed UTI, but the McGeer infection assessment tool was not completed and the antibiotic was given for fewer days than ordered. Another resident was treated with IV cefepime for a wound infection, but the IP could not provide documentation that McGeer criteria were being used or explain how antibiotic data were tracked and trended. The IP also stated there was no policy identifying who completed the infection screening form before antibiotics were started.
A resident who was cognitively intact and received dialysis three times per week was not afforded their stated preference to eat breakfast after returning to the unit. Staff left the breakfast tray in the room for hours while the resident was at dialysis, and when the resident returned, an LPN initially offered lunch instead of the requested breakfast tray. The resident’s meal preference was not documented in the care plan, and the DON stated the information had not been communicated to dietary services.
Incomplete pre-employment screening was identified when one employee worked before the background check was completed, and a dietary vendor employee file contained multiple criminal convictions without reference checks or supporting documentation about work ethics or circumstances since the last arrest. Interviews showed the LNHA and HR manager were unclear about the vendor employee screening process, and the facility’s records did not consistently show that required background checks were completed before hire.
Incomplete Investigation of Resident Fall and Alleged Rough Handling: A resident with intact cognition and multiple medical diagnoses fell after an unanswered call bell and reported that an LPN handled them roughly while lifting them from the floor to a wheelchair. The EMR and incident report showed the resident was found on the floor, but the facility did not promptly obtain or document statements and did not fully investigate the allegation of abuse or neglect at the time of the event.
A resident with severe cognitive impairment had a newly identified skin tear on the upper arm that was dressed without an individual physician order, and the wound order was entered for the wrong body location. In a separate issue, another resident’s milk allergy and multiple hospital-documented allergies were not transcribed into the admission record, allergy roster, care plan, or meal selection sheets, despite the resident later confirming the milk allergy to the RD.
A resident with CVA, DM, hemiplegia, and hemiparesis was assessed as high risk for pressure injuries and had a right heel DTI with an order to offload both heels on pillows while in bed. Surveyors repeatedly observed the resident’s feet resting directly on the mattress instead of being offloaded, including after dialysis returns, and MAR entries showed the heels were not offloaded on multiple days. Staff stated they were unaware the heels were not in place or expected them to be applied later, and the right heel wound was later found to have worsened with necrotic tissue.
A resident with dementia, urinary retention, and BPH had a physician order for bladder scans every 6 hours after Foley removal, with straight cath for PVR over 350 mL. The MAR showed multiple missed or undocumented PVR checks, and a nursing note stated the bladder scanner was not available while the resident was wet and voiding on the toilet. Interviews showed the UM was unaware the scanner was broken, the LPN said she had been told it was already broken, and the RNS and MD confirmed the scan was intended to check for urinary retention after voiding.
Failure to provide and document ordered trach humidification for a resident with a trach and altered respiratory status. An LPN checked only the O2 flow rate and was unaware of the aerosol humidity order, while the eMAR/eTAR lacked documentation that the humidification was verified or monitored. The resident was observed asleep with a loose trach mask and gurgling sounds, and the CDSP stated floor nurses handled the ongoing monitoring.
A resident with ESRD on hemodialysis had a dialysis communication form that included an order to stop Calcium Acetate based on lab results, but staff did not transcribe the order or notify the MD, and the medication continued to be given. The resident also had a right chest wall permcath, but the care plan incorrectly addressed bruit and thrill instead of the ordered access-site checks for infection, drainage, bruising, and bleeding.
The facility failed to complete annual performance appraisals for all CNAs. Review of five CNA personnel files showed three with the most recent appraisal completed more than a year earlier. When questioned, the LNHA stated the 2025 evaluations would not be completed until 2026, and no further information was provided by the facility.
An LPN administered Lokelma and Questran to a resident without following the manufacturer cautionary timing instructions, and the eMAR did not reflect added cautions. Surveyors also found two unlabeled glucometers on each of two med carts with only one device per cart documented as calibrated, and they identified narcotic accountability problems when one resident’s oxycodone inventory lacked the corresponding bingo card and multiple DEA Form-222 records were missing.
Consultant Pharmacist Failed to Identify Medication Timing Irregularities: A resident’s med regimen included Lokelma for hyperkalemia and Questran for hyperlipidemia, both of which have administration timing requirements relative to other meds. During med pass, an LPN prepared both meds for the resident, but the CP’s MRR did not identify the irregularity or recommend changes to the administration times. The CP later acknowledged she had access to the eMR and did not identify the issue.
Failure to Perform Hand Hygiene and Disinfect Shared Equipment: An LPN and an LPN/UM were observed entering a resident's room on Enhanced Barrier Precaution without performing hand hygiene before donning PPE and providing care. The LPN used a BP machine during assessment, then exited without hand hygiene and left the machine undisinfected in the hallway. The LPN/UM later entered the same room, donned gloves without hand hygiene, and assessed a DTI wound without first cleaning hands.
CNA in-service training and abuse education deficiencies: The facility failed to ensure that CNAs received the required annual in-service hours and that CNA education files included abuse training. Review of CNA education records showed one CNA with only 3.4 hours of annual education and another with 4.98 hours, while three CNA files lacked current abuse training documentation. The LNHA stated abuse training should be completed annually, and the facility policy required staff training on abuse prevention, identification and reporting, stress management, and managing aggressive behavior.
A resident with hemiplegia/hemiparesis and intact cognition was admitted under Medicare A, but the facility's admission packet included language requiring a waiver of the 30-day written discharge notice for post-acute care. Surveyors found the resident was transferred when Medicare payment ended, and staff stated the resident was not offered the option to remain at the facility because Medicaid was needed. The resident and spouse said they would have stayed if that option had been offered.
A resident with hemiplegia and hemiparesis, who was cognitively intact and admitted under Medicare A, was transferred when skilled benefits ended and the payor source changed. Staff described the facility as sub-acute or rehab only and said residents needing LTC were sent to other company facilities, while social work staff stated they did not assist with Medicaid transfers. The record showed the resident was moved to another facility for LTC, but there was no specific discharge plan documented for remaining at the facility under Medicaid pending status, and the resident and spouse stated they would have preferred to stay if offered.
Inaccurate MDS discharge coding: The facility incorrectly coded the DCRNA MDS for three residents as unplanned discharges even though the records showed planned transitions, including transfer to another facility and discharge home with arranged services, transportation, DME, meals, and pharmacy support. The MDSC said the coding was based on whether residents met goals, while the DON stated she would not consider these discharges unplanned.
A resident admitted for rehab with intact cognition and an indwelling catheter was observed with a urinary catheter leg bag, but the EHR showed no Foley catheter order and no catheter care plan was initiated on admission. The existing CP only addressed urinary incontinence related to weakness and impaired mobility, and staff acknowledged that a CP for the Foley catheter should have been in place.
Failure to Post Nursing Staffing Report Daily: Surveyors repeatedly did not observe the nursing staffing report posted in visible areas of the facility. The LNHA stated it was posted on the 2nd and 5th floors, but it was not found at the time clock on the 2nd floor. The staffing coordinator said supervisors were responsible for posting it, and the staffing was later observed behind the nurse's station on the 2nd and 5th floors, not readily visible to residents and visitors.
The facility failed to conduct thorough contact tracing during a COVID-19 outbreak, as required by policy and health guidelines. The Infection Preventionist did not complete or document contact tracing efforts, and the line listing was incomplete, missing entries for some positive cases. The facility's policies for contact tracing and testing were not fully implemented, leading to a deficiency in managing the outbreak.
The facility failed to properly label and date opened food items in the walk-in meat freezer, as observed by a surveyor. An opened slab of roast beef and a bag of Salisbury patties were found without labels or dates. The Food Service Directors acknowledged the oversight, and the items were discarded. The facility's policy requires all refrigerated or frozen foods to be covered, labeled, and dated, which was not adhered to in this instance.
The facility failed to complete required audits for the two-step TB skin test for active employees as part of their QAPI program. While audits were conducted for newly hired employees in January, no audits were completed for active employees from January to August, contrary to the QAPI plan. The LNHA and IP acknowledged the oversight during interviews.
The facility failed to implement its antibiotic stewardship program effectively, as the IP could not provide documentation or demonstrate the use of surveillance criteria. The LNHA and DON acknowledged the program's review during QAPI meetings but noted the lack of evidence. A resident received antibiotics without proper documentation, highlighting the deficiency in monitoring and prescribing practices.
A facility failed to consistently document the administration of a resident's enteral tube feeding on the MAR. The resident, who had a PEG tube due to dysphagia, was present in the facility during the dates when the MAR entries were left blank. The LPN/UM acknowledged the lack of documentation, and the DON confirmed that such omissions were unacceptable. Facility policies emphasized the importance of proper documentation, which was not adhered to in this case.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to have a system in place to inform residents and, when appropriate, their representatives about the option to formulate an Advance Directive (AD), and failed to provide written information regarding that right. This deficiency was identified for 2 of 2 residents reviewed for AD and was stated to affect all residents in the facility. The facility policy required residents to be informed upon admission and to be provided written information concerning the right to formulate an AD, or for that information to be provided to a legal representative if the resident was not competent. One resident reviewed was admitted with diagnoses including prostate cancer, dementia, and peripheral vascular disease, and had a BIMS score of 4/15 indicating severe cognitive impairment. The record showed the resident was listed as DNR and had a POLST signed by the resident representative, but there was no documented evidence in the medical record, including Progress Notes or Social Service notes, showing whether the resident had an AD or, if not, whether the resident or representative was offered the opportunity to formulate one. The social service assessment also indicated that advanced directives had not been reviewed. A second resident reviewed was cognitively intact with a BIMS score of 15/15 and was documented as Full Code with a POLST in the record. The medical record contained no documentation regarding an AD, and the resident later stated that the former facility never offered anything related to an AD. Interviews with social workers showed they asked residents and families if they had an AD and would place it in the EMR if provided, but they did not inform or provide educational material about ADs and instead told residents and representatives they could look online. The DON and LNHA confirmed the facility did not have a process in place for AD.
Failure to Admit Medicaid Residents Consistent with CMS Designation
Penalty
Summary
The facility failed to ensure residents who required Medicaid were admitted in accordance with the facility’s SNF/NF designation from CMS and the NJ DOH. During the entrance conference, the LNHA stated that all residents were short term, that there were no long-term care residents at the facility, and that there was no resident council meeting because there were no LTC residents. The LNHA also stated that when residents needed LTC placement, they could be transferred next door or referred to a separate SNF/NF facility with a different CMS provider number. The surveyor reviewed the facility website, which described the building as a physical rehabilitation hospital offering acute and sub-acute rehabilitation services and identified 56 subacute rehab beds. The VPO stated the facility was a sub-acute facility and said that if residents had a need and were on Medicaid, there were no Medicaid residents who had requested to stay at the facility for LTC. The VPO further stated the company had other buildings where skilled nursing/sub-acute residents could go if they wanted to stay long term. The surveyor also reviewed the facility entrance binder, which included a resident council document stating the facility is a subacute facility and does not have a resident council president, a facility assessment titled Subacute Facility Assessment, and a 44-page welcome packet. The packet’s Medicaid section described Medicaid as available to Virginia residents and referenced the New Jersey Department of Human Services, Division of Medical Assistance and Health Services. The LNHA later provided the Long-Term Care Facility Application for Medicare and Medicaid, which indicated 0 for Medicaid under F8b. Staff interviews confirmed the facility was strictly sub-acute, that no residents were staying long-term, that no LTC care conferences had occurred, and that social workers would not assist a resident with transferring to Medicaid for payment.
Incomplete QAPI Program and Missing Documentation
Penalty
Summary
The facility failed to implement a comprehensive, effective, data-driven QAPI program that included self-identifying areas for improvement and maintaining documentation of QAPI initiatives. During interview, the LNHA stated that QAPI review focused on skin issues and falls, and that trends were reviewed by date, but when asked about the facility’s current QAPI initiatives, the LNHA could only identify a resident with an incorrect name band, therapy changing leg bags for urinary catheters too frequently, psychotropic medication consent forms, and employee education not completed. For these items, the LNHA was unable to provide supporting data, goals, or additional information, and stated that the name band issue and leg bag issue were related to one resident each, with no further data available. The LNHA also stated there were no QAPI plans for admission or discharge processes, social services, or infection control. When asked about infection control, the LNHA confirmed there were no QAPIs related to that area despite prior survey concerns regarding Antibiotic Stewardship and concerns raised again during the current survey. The survey team reviewed the facility’s QAPI plan, which was undated and unsigned, and found it only generally described using data to monitor performance, establish goals and thresholds, identify and prioritize problems, analyze causes, and develop corrective actions. The LNHA, DON, Executive President, and Corporate Nurse met with the survey team at exit and confirmed there was no additional information to provide.
QAPI Failed to Review and Analyze Adverse Events
Penalty
Summary
The facility failed to investigate, analyze, and monitor adverse events and failed to use data to develop activities to prevent further adverse events. During interview, the LNHA stated that QAPI reviewed skin issues and fall concerns, and that trends were reviewed by date and analyzed. However, when asked for the data and information related to the Falls QAPI, the LNHA provided a March 2025 falls performance improvement project showing that falls were trending up in the facility, with the root cause analysis listing that 27.3% of falls occurred on Tuesday, 54.5% occurred on the second floor, 36% occurred on the 3-11 shift mainly between 8:00 PM and 11:00 PM, and 46% occurred on the 11:00 PM to 7:00 AM shift mainly between 1:00 AM and 7:00 AM. The monthly trend for March 2025 showed 9 total falls, 3 falls with injury, and 1 person sent to the hospital. When the surveyor asked for the specific corrective actions related to the causes of falls and other adverse events, the LNHA stated that would have been done independently for each fall and had no information to provide. The LNHA also stated that the hospitalization related to the fall would have been discussed in an internal risk meeting and that none of the internal risk management information would be discussed at QAPI. When asked about grievances and reportable events, the LNHA stated that grievances were not reviewed at QAPI and that reportable events were not part of the QAPI process. The facility provided an undated and unsigned QAPI plan stating that QAPI includes identifying and using data to monitor performance, establishing goals and thresholds, prioritizing problems and opportunities for improvement, systematically analyzing underlying causes of systemic problems and adverse events, and developing corrective action or performance improvement activities.
Antibiotic stewardship monitoring was not consistently completed
Penalty
Summary
The facility failed to ensure a system was in place to use an infection assessment tool before prescribing antibiotics and failed to implement its Antibiotic Stewardship program consistently for two residents reviewed. For one resident with dementia, urinary retention, and benign prostatic hyperplasia, a nurse practitioner note documented discomfort at the Foley catheter insertion area, UA results were discussed, and Macrobid was started while cultures were pending. The physician order was for nitrofurantoin 100 mg every 6 hours for 10 days, but the MAR showed the antibiotic was administered for only 4 days. The Infection Preventionist stated the McGeer tool was embedded in the EMR and should typically be completed within 24 hours of an antibiotic order, but acknowledged it was not completed for this resident and could not provide documentation of the antibiotic stewardship process at that time. For the second resident, who was re-admitted with diagnoses including type 2 diabetes, pain in the left foot, and difficulty walking, progress notes documented a wound infection and that the resident was started on cefepime after the hospital culture was positive for MSSA and Pseudomonas. The resident was receiving cefepime 2 grams IV every 12 hours for 2 weeks. During interview, the Infection Preventionist stated the facility used McGeer Criteria, conducted weekly antibiotic risk meetings, and reviewed criteria with the physician, but could not provide documentation that the criteria were being used for this resident. The Infection Preventionist also could not explain how the data were analyzed or how trending and tracking were completed, stating only that the facility had a computer-generated tool and that she entered data into the computer. The facility policy required antibiotic usage and outcome data to be collected and documented on a facility-approved antibiotic surveillance tracking form, and stated that all resident antibiotic regimens would be documented on that form. The Infection Preventionist stated there was no policy identifying who was responsible for completing the infection screening form for antibiotic usage and confirmed that the review should be completed prior to initiation of antibiotics.
Failure to Honor Resident Meal Preference After Dialysis
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to self-determination regarding mealtimes after dialysis. The resident, who had diagnoses including hemiplegia, hemiparesis, peripheral vascular disease, multiple rib fractures, and diabetes mellitus, received dialysis three times per week and required extensive assistance with activities of daily living and all meals. The resident stated that staff were aware of the preference to have breakfast after returning from dialysis, but the breakfast tray was left in the room and the resident reported that the food was cold. On the day of the event, the resident left the facility at 5:00 AM for dialysis and returned at 11:30 AM. The breakfast cart arrived on the unit at 7:45 AM, confirming that the breakfast tray remained in the room for almost four hours. The resident stated that staff never offered to warm the food and that they wanted their breakfast tray, not lunch, upon return. When the LPN caring for the resident was informed of the situation, she initially told the resident it was lunch time and that she would order a lunch tray, which upset the resident. The LPN later stated she would call the kitchen and request a breakfast tray. Review of the care plan showed a dialysis focus and interventions for dialysis on Tuesday, Thursday, and Saturday with a 6:00 AM chair time, but the resident’s meal preference to receive breakfast after dialysis was not documented. The CNA interviewed on the unit stated the resident preferred to eat breakfast after dialysis regardless of the time of return. The DON stated the issue had not been communicated to dietary services and that the resident had been given the same breakfast tray served in the morning and left in the room. The facility admission agreement stated residents have the right to reasonable accommodation of needs and preferences and to self-determination through support of resident choice.
Incomplete Pre-Employment Background Screening and Documentation
Penalty
Summary
The facility failed to consistently follow its system for pre-employment screening to prevent abuse, neglect, and theft. Based on interviews and record review, surveyors found that prior to hire, all employees were not consistently pre-screened to confirm they had not been found guilty in court of abuse, neglect, or misappropriation, and that documentation was not consistently maintained to show appropriate pre-screening for contracted employees, including dietary and housekeeping staff. One employee file showed that Employee #1, hired on 10/1/25, had a background check ordered and completed on 10/3/25, while the timecard showed the employee worked on 10/1/25, 10/2/25, and 10/3/25. This indicated the employee worked before the background check was completed. The surveyors reviewed 34 employee files provided by the facility and identified concerns or missing items in 2 of 39 files reviewed. The survey team later reviewed additional files for dietary vendor employees after being told the kitchen was outsourced through a vendor contract dated 10/30/25. Employee #28, a dietary vendor employee hired on 1/3/26, had multiple positive criminal background findings, including controlled dangerous substance offenses, aggravated assault with firearm, and obstruction-related offenses. The file did not contain reference checks or other documentation regarding the employee's work ethics or circumstances since the last arrest. The LNHA stated she was not familiar with the employee's background and later said the dietary vendor regional manager made the hiring decision. The HR manager stated she was unaware of the kitchen vendor employees' background checks and said the vendor should have a similar process. The facility provided policies describing background screening and positive background check review, and the dietary contract stated the service provider was responsible for background checks for its employees, but no further information was provided by the facility.
Incomplete Investigation of Resident Fall and Alleged Rough Handling
Penalty
Summary
The facility failed to complete a thorough investigation to determine whether abuse or neglect occurred after a resident fell while trying to get to the bathroom. Resident #55, who had a BIMS score of 15 and diagnoses including malignant ascites, anxiety, depression, DM, CVA, and heart failure, reported that the call bell was unanswered for about 45 minutes, that they attempted to get out of bed on their own, fell, and hit their head. The resident also stated that an LPN grabbed them from behind, threw them into the wheelchair, and hurt their back. The EMR documented that the resident was found on the floor by a CNA, that the call light was not on, and that staff were notified, but the facility’s incident report was limited and the facility could not provide additional information or statements until after survey inquiry. Statements obtained after the surveyor’s inquiry were dated three days after the incident and described the resident being on the floor, yelling for help, and being transferred from the floor to the wheelchair by the nurse. The resident’s account of rough handling was not documented in the initial incident investigation materials reviewed by the surveyor. Interviews with the DON, LNHA, LPN, and supervisory LPN showed that the allegation was not fully investigated at the time of the event. The DON stated she learned of the allegation later and had no documentation of the interaction, while the Administrator stated that when a resident is found on the floor, it should be investigated at that time and statements should be obtained then. Facility policies required prompt initiation and documentation of investigations for accidents and incidents and required investigation of all possible incidents of abuse, neglect, or mistreatment.
Missing wound order and incomplete allergy documentation
Penalty
Summary
A newly identified skin tear on a resident’s left upper arm did not have an individual physician treatment order in place when the wound was observed covered by a large bloody gauze dressing. The resident was confused and unable to participate in an interview, and the medical record showed severe cognitive impairment with a BIMS score of 4/15. Review of the physician orders showed no treatment order for the left upper arm wound. An LPN stated the resident had sustained a skin tear after sliding out of bed and falling, and that she had dressed the wound that morning but forgot to date the dressing. She also stated that the order to cleanse and dress a skin tear had been entered for the wrong body location, and acknowledged that she should have contacted the MD to update the order. The DON confirmed that each wound should have its own individual treatment order. A second deficiency involved a resident whose allergy information from the hospital discharge summary was not transcribed into the facility record on admission. The resident was observed seated in a wheelchair, appropriately dressed, and conversant, and stated they were allergic to milk, which caused vomiting. The admission record listed allergies as “to be determined,” and the allergy roster did not include the resident. The nutritional assessment left food intolerance and allergy sections blank, and the resident’s care plan and meal selection sheets did not reflect a milk allergy or other food allergy prior to surveyor inquiry. The hospital record contained multiple documented medication allergies, and the resident’s milk allergy was not identified in the facility record until the RD later interviewed the resident and confirmed the allergy. The RD stated that during the initial nutritional assessment the resident had not reported the milk allergy or other food-related allergy. An LPN stated that admission staff were expected to obtain allergy information from the resident and family, review the hospital record, and inform the prescriber of any allergies, but the resident’s medical record did not reflect the allergies found in the hospital record.
Failure to Offload Heels for Resident with High Pressure Injury Risk
Penalty
Summary
The facility failed to follow a physician order to offload a resident’s bilateral heels while in bed. Resident #4 was admitted with diagnoses including cerebrovascular accident, diabetes mellitus, hemiplegia, and hemiparesis, and was assessed as being at high risk for pressure ulcers. The resident also had a deep tissue injury to the right heel on admission, with the wound care plan documenting the need to float the heels and other preventive measures. A physician order dated 12/25/25 directed staff to offload both heels on pillows when the resident was in bed every shift. Survey observations showed the resident repeatedly lying in bed with the feet resting directly on the mattress rather than being offloaded. This was observed during the initial tour on 1/27/26, again on 1/28/26, on 1/29/26, and on 1/30/26. The record review showed nurses initialed the MAR indicating the heels were not offloaded on 1/3/26, 1/8/26, 1/10/26, 1/13/26, and 1/27/26. Staff told the surveyor the resident had been out of the facility for dialysis on some of those occasions, and there were no measures in place to ensure the heels were offloaded when the resident returned. Interviews with staff showed the CNA planned to apply the heel protectors after incontinence care and was unsure about the heel DTI or treatment, while the LPN/UM stated she was not aware the heels were not offloaded and expected staff to ensure interventions were in place when leaving the room. On 1/30/26, the right heel DTI was measured again and was covered with necrotic tissue, measuring 7 cm x 5 cm. The physician assistant note also documented heel pain with DTI and floating heels, with wound care following.
Missed Bladder Scan Monitoring After Foley Removal
Penalty
Summary
The facility failed to ensure appropriate care was provided for a resident with diagnoses including dementia, urinary retention, and benign prostatic hyperplasia after a physician ordered a void trial with bladder scans every 6 hours for 3 days following removal of an indwelling urinary catheter. The order also required straight catheterization for post-void residuals greater than 350 mL. The record showed multiple missed or undocumented post-void residual checks on the MAR, with entries coded as treatment not administered, treatment refused, or absent from the facility, and no documented PVR values in the required time periods. A nursing note documented that the bladder scanner was not available, and the resident was wet and voiding on the toilet, with monitoring for retention noted, but there was no change to the order or indication that the physician was notified. During interviews, the UM stated she was unaware the bladder scanner was broken and should have been notified, while the LPN stated she had been told in shift report that the scanner was already broken and that the resident was urinating, so it was okay. The RNS stated the bladder scanner was important to determine whether the resident was retaining urine after voiding and that staff should have contacted a supervisor and the physician if the machine was broken. The physician stated the purpose of the bladder scan was to ensure the resident was not retaining urine after voiding.
Failure to Provide and Document Ordered Tracheostomy Humidification
Penalty
Summary
The facility failed to ensure necessary respiratory care and services for a resident with a tracheostomy and altered respiratory status. Resident #77 was admitted with diagnoses including cognitive communication deficit and tracheostomy placement, and the care plan included interventions for altered respiratory status related to respiratory failure and tracheostomy placement. A physician order dated 1/21/26 directed aerosol humidity 35% at 5 liters via trach mask as needed, along with trach downsizing and use of a speaking valve. However, the eMAR and eTAR did not show documentation that the aerosolized humidification was checked for accuracy or monitored for effectiveness as part of the care plan interventions. During observation, the resident was asleep in bed receiving oxygen via tracheostomy tube, and later the trach mask was observed loose while a gurgling sound was heard from the resident. The LPN stated she checked only that the oxygen was set between 5 and 6 lpm and did not document the humidity settings in the eMAR, eTAR, or progress notes. The CDSP stated she provided trach care that morning, but the remaining care and monitoring were completed by floor nurses, and also stated the nurse could not correct the humidity setting if it was incorrect. The LPN stated she was unaware of the aerosolized humidification setting and that the humidification setting was not in the physician order or care plan as she understood it.
Dialysis Communication Orders Not Reviewed and Access Site Care Plan Incorrect
Penalty
Summary
The facility failed to thoroughly review dialysis communication sheets after a resident returned from dialysis and failed to act on a dialysis center recommendation reflected on the communication form. The resident had end-stage renal disease, dependence on renal dialysis, hemiplegia and hemiparesis, and diabetes mellitus, and was cognitively intact with a BIMS score of 13 out of 15. The resident was scheduled for dialysis three times weekly and returned to the facility after treatment with a dialysis communication form dated 1/24/26 that included an order to discontinue Calcium Acetate 667 mg because the resident’s phosphate was 2.9. The medication was not discontinued when the communication form was reviewed, and the resident continued to receive Calcium Acetate on multiple occasions after the dialysis treatment. There was no documented evidence that the physician was informed of the recommendation. During interviews, the unit manager stated she was not aware of the order and could not describe a system for reviewing dialysis communication forms, and the nurse stated she reviewed the form only to confirm weights, vital signs, and signatures, not for orders. The DON later stated the oversight occurred because staff should have reviewed the communication log and transcribed the order, and the physician should have been made aware. The facility also failed to ensure the care plan accurately addressed the resident’s dialysis access site. The resident had a permcath on the right chest wall for hemodialysis, and the order summary required the access site to be checked every shift for signs and symptoms of infection, drainage, bruising, and bleeding. However, the comprehensive care plan listed an intervention to check for bruit and thrill, which applies to a fistula rather than the resident’s permcath. The DON acknowledged the care plan should reflect the appropriate site and stated the care plan was revised to match the right access site.
Annual CNA Performance Appraisals Not Completed
Penalty
Summary
The facility failed to evaluate the performance of all Certified Nursing Aides (CNAs) on an annual basis. During review of five randomly selected CNA personnel records, three records showed that the most recent Annual Staff Performance Appraisal had been completed more than a year earlier: CNA #1, hired 5/24/23, had an appraisal signed as completed on 3/20/24; CNA #2, hired 9/8/20, had an appraisal signed as completed on 4/8/24; and CNA #3, hired 3/27/23, had an appraisal signed as completed on 8/24/24. When the survey team met with the LNHA and DON, the LNHA stated that the 2025 evaluations would not be completed until 2026 and said she would check on this. At a later meeting with the LNHA, DON, and a corporate nurse, no further information was provided by the facility.
Medication administration, glucometer calibration, and controlled substance recordkeeping deficiencies
Penalty
Summary
Pharmaceutical services were not provided in accordance with manufacturer specifications during a medication pass for one resident who was ordered Lokelma for hyperkalemia and Questran for hyperlipidemia. During observation, an LPN prepared both medications along with other oral medications, and later administered the resident’s oral medications. Review of the Lokelma package showed a caution that it should be taken at least 2 hours before or 2 hours after other medications, and the Questran package showed that other drugs should be taken at least 1 hour before or 4 to 6 hours after Questran. The eMAR did not show that either cautionary instruction had been added to the physician orders, and the physician progress notes did not show awareness of the drug interactions. The facility also failed to ensure blood glucose monitors on two medication carts were consistently calibrated and identified. On both carts, surveyors observed two unlabeled glucometers, but only one of the two glucometers on each cart had documentation showing calibration within the reviewed period. The nurses inspecting the carts could not identify which glucometer had been calibrated, and both confirmed that the devices should have been calibrated, checked for functionality, and checked for accuracy before use. In addition, the facility did not maintain consistent accountability for controlled substances and DEA Form-222 records. During narcotic inspection, one resident’s oxycodone inventory showed one tablet remaining, but the corresponding bingo card was not available, and the unit manager could not provide documented evidence of the reported conversation with the nurse on duty about the missing documentation. Review of DEA Form-222 records also identified multiple missing forms, and the DON stated she would reorganize the records to locate them. The facility policy stated that controlled substances are to be monitored and reconciled to identify loss or potential diversion, and that completed DEA Form-222 copies and invoices are to be retained and readily available for inspection.
Consultant Pharmacist Failed to Identify Medication Timing Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist identified irregularities during the monthly drug regimen review for a newly admitted resident. Resident #55 had physician orders dated 1/9/26 for Lokelma 10 grams by mouth daily for hyperkalemia and Questran 4 grams by mouth at bedtime for hyperlipidemia. During a medication pass observation on 1/29/26 at 9:19 AM, an LPN was observed preparing 14 medications for this resident, including Lokelma and Questran. A review of the 1/12/26 Consultant Pharmacist medication regimen review did not show any recommendation regarding the administration times for Lokelma and Questran. The manufacturer’s instructions cited in the report stated that Lokelma should be given at least 2 hours before or after other medications, and Questran should be separated from other drugs by at least 1 hour before or 4 to 6 hours after. During interview, the LNHA and DON stated that newly admitted residents’ drug regimens were reviewed by the Consultant Pharmacist, and the CP confirmed she had access to the eMR and could review the medication list the same day of admission, but acknowledged she did not identify the irregularities or make recommendations to change the administration times.
Failure to Perform Hand Hygiene and Disinfect Shared Equipment
Penalty
Summary
The facility failed to perform appropriate hand hygiene and to disinfect shared medical equipment during care provided to a resident on Enhanced Barrier Precaution. On 1/27/26, an LPN approached the resident's room with a medication cart and blood pressure machine, donned gloves and a gown, and entered the room without first performing hand hygiene. While in the room, the LPN removed the resident's blanket, located the dialysis access site on the resident's chest, palpated the dressing, replaced the blanket, and used the blood pressure machine to obtain vital signs. The LPN then removed the gloves and gown and exited the room without performing hand hygiene, and left the blood pressure machine in the hallway without disinfecting it after use. On 1/29/26, a second staff member, the LPN/UM, was observed entering the same resident's room for a wound evaluation. The LPN/UM reached for a gown at the entrance, donned gloves without first performing hand hygiene, and entered the room. The LPN/UM removed the sheet from the resident and assessed the resident's deep tissue injury wound without first performing hand hygiene. During interview, the LPN confirmed not washing hands before or after the room entry and not disinfecting the blood pressure machine, and stated that hand hygiene and disinfection should have been performed to prevent cross contamination. The IP later acknowledged the infection control breaches.
CNA in-service training and abuse education deficiencies
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received the required 12 hours of annual in-service training for 2 of 5 CNAs reviewed, and failed to ensure that CNA education files included abuse training for 3 of 5 CNAs reviewed. During review of the in-service education hours for five randomly selected CNAs, the surveyor found that CNA #1, hired 5/24/23, had only 3.4 hours of education during the 5/24/24 to 5/24/25 period, and that this education did not include abuse training; the last documented abuse training for this CNA was 7/3/24. CNA #2, hired 9/8/20, had 4.98 hours of education during the 9/8/24 to 9/8/25 period. The surveyor also found that CNA #4, hired 5/8/24, had a most recent abuse training dated 5/8/24, and CNA #5, hired 5/6/24, had a most recent abuse training dated 8/1/24. The facility provided an education calendar showing that Elder Abuse: The Elder Justice Act self-paced training was scheduled for September. When interviewed, the LNHA stated that abuse training should be completed annually. The facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated October 2022, stated that staff orientation and training should include abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.
Admission Agreement Included Waiver of 30-Day Discharge Notice
Penalty
Summary
The facility failed to ensure its admission agreement did not require residents to waive their right to receive 30-day written notice of discharge. During review of the entrance binder, the surveyor found a 44-page Welcome Packet used as the admission agreement. In the section titled Notice of Resident's Rights Regarding Transfer or discharge, the packet stated that residents generally cannot be transferred or discharged until 30 days after receiving facility notice unless they agree to an earlier date. The surveyor also reviewed Resident #71's closed EMR. The resident had diagnoses including hemiplegia and hemiparesis, and the admission MDS showed a BIMS score of 15/15, indicating the resident was cognitively intact. The resident was admitted with Medicare A, and payment ended on 12/4/25. A nursing progress note documented that the resident was transferred to another facility on 12/4/25, and a social service note also reflected the transfer. Two social workers stated the facility was dually certified but confirmed there were no current Medicaid residents and that they would not assist someone who required Medicaid. One social worker stated Resident #71 was never offered the option to stay at the facility because the resident needed Medicaid and that this was not documented in the record. The resident and spouse later stated they were told the transfer occurred because the payment source was ending and that the resident could only go to the receiving facility because it accepted pending Medicaid; they said they would have stayed at the prior facility if offered the option. The admission packet in the EMR, electronically signed by the resident, included an addendum for short-term post-acute rehabilitation care stating the resident and representative waived the right to a 30-day written notice of discharge when admitted for post-acute services.
Failure to Ensure Appropriate Discharge Planning When Payor Source Changed
Penalty
Summary
The facility failed to ensure an appropriate discharge process was in place for a resident whose payor source changed. Survey interviews with the LNHA, EVP, VPO, LPN unit manager, social workers, RN educator, and MDS coordinator showed the facility described itself as a short-term or sub-acute facility and stated that residents needing LTC were sent to other facilities owned by the same company. Staff also stated there were no current LTC residents and that they did not assist residents with transferring to Medicaid for payment. The LNHA later stated that discharge planning should be documented in the chart and by social workers. Resident #71 was admitted with diagnoses including hemiplegia and hemiparesis and was cognitively intact, scoring 15/15 on the BIMS. The resident was admitted under Medicare A, and the payment ended when the resident reached day 99. A nursing progress note documented that the resident was transferred to another facility, and a social service note stated the resident had been approved to transition into LTC at another named facility and would be picked up by wheelchair-accessible van. The resident and spouse later stated the transfer occurred because the payment source was ending and that the receiving facility was the only one that accepted pending Medicaid. During record review, the admission packet and agreement showed the resident initialed an addendum stating the sub-acute unit was for short-term rehabilitation only and that residents agreed to discharge when medically appropriate. The agreement also included a waiver of the 30-day discharge notice for post-acute services and an ABN for exhausted Medicare Part A skilled days. However, the record did not contain specific documentation of a discharge plan allowing the resident to remain at the facility under Medicaid pending status, and the resident stated they would have preferred to stay at the facility if offered. Therapy records showed the resident was discharged from OT, PT, and SLP because benefits were exhausted, and the resident was transferred the next day.
Inaccurate MDS discharge coding
Penalty
Summary
The facility failed to accurately complete the MDS for 3 of 19 residents reviewed, involving discharge coding for Residents #71, #72, and #74. Resident #71 had diagnoses including hemiplegia and hemiparesis following CVA affecting the right dominant side and dysphagia. The record showed a discharge plan to transition to another long-term care facility, with social services arranging transportation and documenting the move as approved and planned, yet the DCRNA MDS dated 12/4/25 was coded as an unplanned discharge to a nursing home. Resident #72 had diagnoses including benign prostatic hypertrophy and obstructive uropathy. The care plan addressed discharge potential and discharge preparation, and social service documentation showed the family was informed of the last covered day, the anticipated discharge date, and that homecare services were already in place. The discharge summary documented transportation home, a homecare referral, and orders for a wheelchair and commode, but the DCRNA MDS was coded as an unplanned discharge to home. Resident #74 had a diagnosis of adult failure to thrive. Social service notes documented discharge planning with Meals on Wheels, pharmacy coordination for medications, food delivery arrangements, and transportation home, all tied to the resident’s anticipated discharge and expressed preference to go home sooner. Despite these planned discharge arrangements, the DCRNA dated 9/20/25 was coded as an unplanned discharge to home under the care of a home health service organization. When questioned, the MDS Coordinator stated the facility coded unplanned discharge based on whether the resident met goals, while the DON stated she would not consider these discharges unplanned.
Missing Care Plan for Foley Catheter
Penalty
Summary
A comprehensive, person-centered care plan was not developed or initiated for Resident #80 to address Foley catheter care. The resident was admitted for rehabilitation with diagnoses including diabetes mellitus, hypertension, and atherosclerotic heart disease, and the admission MDS indicated intact cognition with a BIMS score of 14 out of 15. Section H0100 of the MDS was coded yes for the presence of an indwelling catheter, and the surveyor observed the resident sitting in a wheelchair with a urinary catheter leg bag in place. The EHR showed that the OSR with a start order date of 1/16/26 did not include an order for a Foley catheter. The comprehensive care plan review showed no catheter care plan was initiated on admission, and the existing care plan addressed urinary incontinence related to weakness and impaired mobility, with goals for incontinence care and moisture barriers as needed. There was no care plan for the urinary catheter or leg bag. The LPN/UM stated there should be a care plan for the Foley catheter, and the IP agreed that the resident should have had a care plan in place.
Failure to Post Nursing Staffing Report Daily
Penalty
Summary
The facility failed to post the nursing staffing report daily. On 1/27/26, during the entrance and initial tour, the survey team did not observe the nursing staffing report posted in the facility. On 1/28/26 at 12:56 PM, the surveyor again did not observe nursing staffing posted in the lobby, on the second floor, or on the fifth floor. When interviewed at 1:06 PM, the LNHA stated the staffing was posted on floors two and five by the time clock, but when she walked with the surveyor to the second-floor time clock, staffing was not observed there, and she acknowledged it should be posted there. On 1/29/26 at 9:56 AM, the staffing coordinator stated supervisors were responsible for posting the staffing and that a new supervisor had been educated after it was noted by the surveyor that it was not posted. At 10:11 AM, the surveyor observed staffing for the prior day posted on the fifth floor behind the nurse's station with a print date and time of 1/28/26 at 1:14 PM, and staffing for 1/29/26 posted on the medication room door behind the nurse's station, not readily visible to residents and visitors. The second-floor staffing was also posted on the medication room door behind the nurse's station, not readily visible to residents and visitors.
Deficiency in COVID-19 Contact Tracing and Documentation
Penalty
Summary
The facility was found to have a deficiency in its infection prevention and control program during an active COVID-19 outbreak. The surveyor noted that the facility failed to conduct complete and thorough contact tracing upon the identification of a new COVID-19 case, as required by the facility policy and guidelines from the CDC and health departments. This deficiency was identified in the case of a resident who had tested positive for COVID-19 and was expected to complete isolation precautions. Despite the outbreak status, there was no signage or PPE indicating isolation precautions for the resident, and the LPN assigned to the resident was unaware of the COVID-19 status. The Infection Preventionist (IP) admitted to not having completed contact tracing for the outbreak, stating that documentation was only partially done in the comment section of the line listing. The IP had not used the CDC checklist for contact tracing and had not documented interviews with staff or residents to determine close contacts. The IP also stated that no specific education related to COVID-19 was provided to staff during the outbreak. The facility's line listing was incomplete, missing entries for some positive cases, and lacked comprehensive documentation of contact tracing efforts. The facility's policies required contact tracing and testing of close contacts, but these procedures were not fully implemented. The IP's failure to document contact tracing and the lack of comprehensive information on the line list were noted by the Licensed Nursing Home Administrator and the Director of Nursing as issues. The facility's policy outlined specific steps for contact tracing, including identifying the infectious period and potential exposures, but these were not followed, leading to the deficiency in managing the COVID-19 outbreak effectively.
Failure to Properly Label and Date Opened Food Items
Penalty
Summary
The facility failed to handle potentially hazardous food properly, which could lead to foodborne illness. During an initial tour of the kitchen, a surveyor observed an opened slab of roast beef and an opened bag containing six Salisbury patties in the walk-in meat freezer. Both items were not labeled or dated. This observation was made in the presence of two Food Service Directors (FSD #1 and FSD #2). FSD #1 acknowledged that all items in the freezer should be dated once opened, and FSD #2 discarded the unlabeled items. The Licensed Nursing Home Administrator confirmed in an interview that opened food packages should be labeled and dated with a use-by date. A review of the facility's policy on Food Receiving and Storage, revised in November 2022, indicated that all foods stored in the refrigerator or freezer must be covered, labeled, and dated with a use-by date. This practice was not followed, leading to the deficiency.
Failure to Complete QAPI Audits for Employee Health
Penalty
Summary
The facility failed to ensure that their Quality Assurance and Performance Improvement Program (QAPI) effectively analyzed quantitative data to evaluate program effectiveness and implement new processes. This deficiency was identified during a standard survey. The surveyor requested the facility's QAPI book during the entrance conference, which was provided three days later. The review of the QAPI book revealed that the facility initiated a QAPI project in January 2024 concerning the two-step tuberculosis (TB) skin test for employee health. The Infection Preventionist (IP) and Human Resources (HR) were responsible for auditing active employee files, but the process was ongoing without completion. By April 2024, the QAPI project was still ongoing, and there was no documented evidence of audits for active employees from January to August 2024. During interviews, the Licensed Nursing Home Administrator (LNHA) acknowledged that audits were only completed for newly hired employees in January 2024, not for active employees as required by the QAPI plan. The LNHA confirmed that audits from February to August 2024 were not completed and should have been presented at QAPI meetings. The Infection Preventionist (IP) admitted that the audits for active employees fell by the wayside, although the plan was to review all active employees. The facility's undated QAPI Program policy outlined the process for identifying and correcting quality deficiencies, including tracking and measuring performance, but these steps were not followed as required.
Deficiency in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to fully implement its antibiotic stewardship program, as evidenced by the lack of ongoing monitoring and use of nationally recognized surveillance criteria before consulting the prescriber. This deficiency was identified during a survey when the Infection Preventionist (IP) was unable to provide documentation of the antibiotic stewardship program or demonstrate the use of the McGeer Criteria tool. The IP admitted to monitoring residents on antibiotics but could not produce a report or identify a resident currently being monitored for antibiotic stewardship. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) both acknowledged that the antibiotic stewardship program was reviewed during Quality Assurance Performance Improvement (QAPI) meetings. However, they also noted that the IP should have been able to provide evidence of the program when requested. The LNHA eventually provided a binder used for antibiotic stewardship, but it only contained laboratory data and reports from the electronic health record, lacking documented evidence of McGeer Criteria Assessments. Resident #27 was identified as a case where the antibiotic stewardship program was not properly implemented. The resident was ordered and received Amoxicillin-Pot Clavulanate for a bacterial infection, but the Medication Administration Record (MAR) showed blanks for several administration times, indicating a lack of documentation. Additionally, the facility's policy on antibiotic stewardship emphasized the importance of monitoring antibiotic use and ensuring appropriate prescribing practices, which were not adhered to in this case.
Failure to Document Enteral Tube Feeding Administration
Penalty
Summary
The facility failed to ensure consistent documentation of the administration of a resident's enteral tube feeding on the Medication Administration Record (MAR). This deficiency was identified for a resident who was fully cognitively intact and had a percutaneous endoscopic gastrostomy (PEG) tube due to dysphagia and other medical conditions. The resident's care plan included specific goals and interventions related to enteral nutrition, but there were instances where the MAR was left blank, indicating a lack of documentation for whether the tube feeding was administered or held. During the survey, it was observed that the MAR entries for the resident's tube feeding were not signed out on several occasions, specifically on 08/25/24, 08/27/24, 08/28/24, and 08/29/24. The Licensed Practical Nurse Unit Manager (LPN/UM) acknowledged that the resident was present in the facility during these dates and that the nurse did not properly document the administration of the tube feeding. The LPN/UM admitted there was no excuse for the lack of documentation and confirmed that there were no orders to hold the tube feeding. The Director of Nursing (DON) also confirmed that blanks on the MAR were unacceptable and highlighted the importance of documentation in nursing practice. The facility's policy on enteral tube feeding and medication administration emphasized the need for proper documentation, including the date, time, and signature of the person performing the procedure. The lack of documentation was identified as a problem, as it was unclear whether the care was provided, despite the resident being in the facility.
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What surveyors actually found near you
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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.
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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 Rehab & Hcc/the Meadows At Lawrence | 0.2 mi | ★★★★★ | 13 | 1 |
| Clover Meadows Healthcare And Rehabilitation Cente | 1 mi | ★★★★★ | 1 | 0 |
| Avant Rehabilitation And Care Center | 3.2 mi | ★★★★★ | 14 | 0 |
| Preferred Care At Mercer | 3.9 mi | ★★★★★ | 10 | 0 |
| Greenwood House Home For The Jewish Aged | 4 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.