Laurel Brook Rehabilitation And Healthcare Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the housekeeping staff kicked, she said, I don't recall specifically where, but I remembered that he was kicking the resident and yelling. I told him he cannot do that, I told him We are not allowed to yell or kick the residents. I told the housekeeping staff to stop, and he did. I immediately informed my supervisor and the Administrator. She further stated, the housekeeping staff was not seen in the building after the incident occurred that day. On 09/18/2025 at 12:24 P.M., during and interview with the Licensed Nursing Home Administrator (LNHA) in the presence of the Acting Director of Nursing (ADON), the LNHA said the activity aid observed the housekeeping staff kicking and using his foot to slide Resident #4 into their room as the resident was sitting in the hallway. The LNHA stated the activity aid immediately stopped the housekeeping staff and reported the incident to her supervisor and they informed me of the incident. She said, the housekeeping staff had left for the day, he was immediately notified via a phone call about the abuse allegation. The LNHA further stated, yes it was substantiated that abuse occurred after our investigation.

When asked if the facility's policy was followed, the LHNA said; no, the housekeeping staff did not follow the facility's policy on abuse. The expectation is for all staff to follow the facility's Abuse Policy. On 09/18/2025 at 1:00 P.M., the surveyor attempted to interview Resident #4 but was unable to conduct an in-person

interview due to the resident's severe cognitive impairment. A review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with Revision date of April 2021, under Policy Statement reveals: Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Under Policy Interpretation and Implementation reveals: 1.

Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff; . NJAC 8:39-4.1 a(5)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Laurel Brook Rehabilitation and Healthcare Center

3718 Church Road Mount Laurel, NJ 08054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and investigate the allegation and compile documentation of such findings within a reasonable timeframe of receiving the grievance/complaint.7.The administrator or designee will coordinate actions with the appropriate agencies, depending on the nature of the grievance. All alleged cases of resident abuse, neglect, and financial exploitation will be reported and investigated in accordance with facility policy and state law.A review of the facility's policy titled Accidents and Incidents-Investigating and Reporting last revised January 2017, included the following information under Policy Interpretation and Implementation:1.

The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.2. The following data, as applicable, shall be included on

the form:a. The date and time the accident or incident took place;b. The nature of the injury/illness (e.g./ bruise, fall, nausea, etc.);c. The circumstances surrounding the accident or incident;d. Where the accident or incident took place;e. The name(s) of witnesses and their accounts of the accident or incident.NJAC 8:39-4.1(a)5

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