Lawrence Rehabilitation Hospital

In the surveyor’s words

From the most serious findings on record at Lawrence Rehabilitation Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF578Jan 30, 2026

  Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to have a system in place to inform and offer written information regarding the option to formulate an Advance Directive. This deficient practice was identified for 2 of 2 residents (Resident #9 and Resident #69) reviewed for AD, and affected all residents who resided in the facility. The evidence was as follows:a. On 1/28/26 at 10:43 AM, Resident #9 was observed in bed, and they were unable to participate in an interview with the surveyor due to confusion. […]

• No harm, potential for more than minimal, widespreadF836Jan 30, 2026

  Based on interview and review of documents it was determined that the facility failed to ensure residents who required Medicaid were admitted to the facility per the facility SNF/NF (Skilled Nursing Facility/Nursing Facility) designation from the Centers for Medicare/Medicaid (CMS) and per the New Jersey Department of Health (DOH). The deficient practice affected all residents admitted to the facility and was evidenced by the following: On 01/27/26 at 11:04 AM, during the facility entrance conference held with the Licensed Nursing Home Administrator (LNHA), and an Executive [NAME] President (EVP) the surveyor asked what the resident population of the facility was. The LNHA confirmed the residents were all short term, and there were no long-term care residents at the facility. […]

• No harm, potential for more than minimal, widespreadF865Jan 30, 2026

  Based on interview and document review, it was determined that the facility failed to implement a comprehensive, effective data driven Quality Assurance Program (QAPI) that included self-identifying areas for improvement and maintaining documentation of QAPI initiatives. The deficient practice affected all residents who resided at the facility and was evidenced by the following:Refer to F620, F627, F881 On 01/30/26 at 9:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding how the facility determines what was reviewed by the QAPI team and how QAPI plans were developed. The LNHA stated skin issues, and fall concerns were reviewed. The LNHA stated trends were reviewed, including the dates and the trends were analyzed. […]

• No harm, potential for more than minimal, widespreadF867Jan 30, 2026

  Based on interview and document review it was determined that the facility failed to investigate, analyze and monitor adverse events and utilize data to develop activities to prevent further adverse events. This deficient practice had the potential to affect all residents who resided at the facility and was evidenced by the following: On 01/30/26 at 9:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding how the facility determines what was reviewed by the QAPI team and how QAPI plans were developed. The surveyor asked if incidents were reviewed, including grievances. The LNHA stated skin issues, and fall concerns were reviewed at QAPI. The LNHA stated trends were reviewed, including the dates and the trends were then analyzed. […]

• No harm, potential for more than minimal, widespreadF881Jan 30, 2026

  Based on observation, interview, and record review of pertinent facility documentation, it was determined that the facility failed to ensure a system was in place to utilize an infection assessment tool prior to prescribing antibiotics and ensure the Antibiotic Stewardship program was implemented consistently. This deficient practice was identified for (2) of two (2) residents reviewed for antibiotic stewardship, (Resident #84 and Resident # 69) and was evidenced by the following: a. […]