Laurel Manor Healthcare and Rehabilitation Center

Inspectors wroteComplaint 2639643Based on medical record review and staff interviews, the facility failed to ensure that a physician order for oxygen was obtained upon a resident's admission. Specifically, the facility implemented and maintained oxygen therapy as part of a resident's Care Plan (CP) without a corresponding physician order to support its use. This deficient practice was identified for 1 of 6 residents reviewed (Resident #5). According to the admission Record (AR), Resident #5 was admitted to the facility with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risk of entrapment, try alternatives, and/or obtain informed consent before initiating side rails for seven (Residents (R)1, R11, R83, and R87) of seven residents reviewed for side rails. These failures could result in serious injury or death to residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one resident (Resident (R) 110 out of 24 sampled residents.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure five of five newly admitted residents (Residents (R)6, R57, R87, R105, and R108) had documentation the Baseline Care Plan had been reviewed with the resident and/or representative within 48 hours, and a copy of the Care Plan had been offered. Findings Include: Review of the facility's policy titled, Care Plans - Comprehensive revised June 2025 indicated: The resident's baseline care plan is developed within 24-48 hours through the admission assessment. There was no procedure of the resident and/or their representative involvement with the baseline care plan. 1. Review of R6's Electronic Medical Record (EMR) under the Clinical Census tab revealed he had been admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow physician orders to hold medication when blood pressure was outside of the parameters for two of two residents (Residents (R)1 and R8) reviewed for medications and ensure the appropriate use of a wander guard device for one of two residents (R11) reviewed for wandering. These failures had the potential to cause residents' conditions to exacerbate and affect quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of four errors occurred out of 25 opportunities for error for two of five residents (Resident (R) 82, and R 108) observed for medication administration. The facility's medication error rate was 16%.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one Resident (R)105 with a tracheostomy, corrugated respiratory tubing which delivered humidified oxygen, and a moisture collection bag had been kept off of the floor. Having the tubing and collection bag on the floor put R105 at risk of infection.

Inspectors wroteComplaint #: NJ171256 Based on observation, interview, record review and pertinent facility documents, it was determined that the facility failed to ensure the accountability of controlled substance inventories were completed in accordance with the facility's policy. This deficient practice was identified on 2 of 5 medication carts reviewed ( Lower [NAME] medication cart #3 and Redwood medication cart #2) during the medication storage and labeling task. The evidence was as followed: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain dignity during meal services for 1 of 3 residents (Resident #89) observed who required assistance with eating. This deficient practice was evidenced by the following: 1. On 04/04/24 at 12:21 PM, the surveyor observed Resident #89 being fed by a Licensed Practical Nurse (LPN) in the main dining room. The LPN stood over Resident #89 who was seated at a dining table. At 12:28 PM, the LPN walked away from Resident #89 to assist another resident. When the LPN returned to Resident #89, she sat next to the resident while she fed him/her. At 12:36 PM, the LPN stood back up and continued to feed Resident #89 while standing over the resident. [...]

Inspectors wroteComplaint NJ #: 169845 Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to address a.) fall prevention interventions and b.) pressure ulcer interventions. This deficient practice was identified for 2 of 19 residents reviewed for resident-centered care plans (Resident #62 and #397) and was evidenced by the following: 1.) According to the admission Record, Resident #62 was admitted to the facility with the diagnoses which included but was not limited to spinal stenosis (condition where spinal column narrows and compresses the spinal cord) and abnormality of gait and mobility. [...]

Inspectors wroteBased on observations, interview, and review of facility documentation it was determined that the facility failed to reconcile a physician order and accurately document on the Medication Administration Record (MAR) for a resident receiving enteral feedings (artificial nutrition given through a tube placed into the stomach). This deficient practice was identified for 1 of 19 resident reviewed for professional standards of nursing practice (Resident #446). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteComplaint NJ #: 169845 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control practices and professional standards during a pressure ulcer treatment for 1 of 2 residents (Resident #447) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 04/05/24 at 1:23 PM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound care treatment on Resident #447. The LPN performed hand hygiene using alcohol-based hand rub (ABHR) and then donned gloves. She wiped down the overbed table with a disinfectant wipe, washed her hands for 40 seconds, and gathered the treatment supplies onto the overbed table, which included a tube of santyl ointment (removes damaged tissue). [...]

Inspectors wroteBased on interview, review of medical records and review of other pertinent facility documentation it was determined that the facility failed to a.) follow the facility policy that was in place for resident identification and b.) to coduct a through/complete investigation for 1 of 4 resident reviewed for incidents and accidents (Resident #62). This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #61 was admitted to the facility with the diagnoses which included but was not limited to hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) an assessment tool which facilitates resident's care dated 02/24/24, indicated that Resident #61 had severe cognitive deficits and required partial to moderate assistance with activities of daily living. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored and maintained in a manner to prevent urinary tract infections for 1 of 3 residents (Resident #40) reviewed for urinary catheters. This deficient practice was evidenced by the following: On 04/04/24 at 11:53 AM, the surveyor observed Resident #40 lying in bed and the resident had a urinary catheter. The privacy cover was secured to the resident's bed, but the drainage bag was on the floor, not in the privacy cover. The drainage bag was empty and had the date 04/03/24 written on it. During an interview with the surveyor on 04/05/24 at 9:55 AM, the Certified Nursing Assistant (CNA) stated that the CNAs were responsible for emptying the urinary catheter drainage bags. [...]

Inspectors wroteComplaint #: NJ169880 and 170054 Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records. This deficient practice was identified for 1 of 22 residents (Resident #398) medical records reviewed and was evidenced by the following: The surveyor reviewed the medical record for Resident #398. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included muscle weakness, difficulty in walking, and cerebral infraction (stroke). A review of the care plan date initiated 11/14/23, reflected a focus of at risk for falls r/t [related to] deconditioning recent hospitalization. 12/2/23 observed on the bathroom floor near wheelchair. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the Nursing Home Resident Care Staffing Report daily. This deficient practice was evidenced by the following: On 04/05/24 at 12:52 PM, the surveyor observed the staffing report posted at the front desk dated 04/04/24 day shift. At that time, a review of the staffing report revealed 04/04/24 evening shift, 04/04/24 night shift, and 04/05/24 day shift was not posted. On 04/10/24 at 10:10 AM, the surveyor observed the staffing report posted at the front desk dated 04/09/24 night shift. At that time, a review of the staffing report revealed 04/10/24 day shift was not posted. On 04/11/24 at 10:40 AM, the surveyor interviewed the Staffing Coordinator (SC) who stated that she was responsible for posting the daily staffing report. [...]

Inspectors wroteComplaint #: NJ#169185 Based on interview, and record review on 11/21/23 and 11/22/23, it was determined that the facility failed to ensure that discontinued medications for Resident #1 were removed from the active inventory. The failure resulted in the Licensed Practical Nurse (LPN) administering Resident #1's medication to Resident #2. This deficient practice was identified for Resident #1 and Resident #2, 2 of 4 residents reviewed and was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to: acute osteomyelitis (an inflammation or swelling of bone tissue caused by an infection), of the left ankle and foot, open wound of the left foot, and local infection of the skin. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to implement personal protective equipment (PPE) according to the New Jersey Department of Health (NJ DOH) and Centers for Disease Control and Prevention (CDC) guidelines to minimize the potential spread of infection to residents on 3 of 3 units (Upper Willow, Lower Willow, and Redwood Terrace), b) ensure that staff wore proper PPE when caring for newly admitted residents who were under observation for sign/symptoms of COVID-19, and c) minimize the potential spread of infection during wound treatment for 1 of 1 nurses observed during wound treatment observation on 1 of 3 units (Redwood Terrace). This deficient practice was evidenced by the following: 1. On 02/02/22 at 11:50 AM, Surveyor #1 observed Certified Nursing Assistant (CNA) #4 making Resident #332's bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to properly store medications within acceptable temperature ranges in accordance with manufacturer's guidelines. This deficient practice was identified for 1 of 2 medication rooms (Lower [NAME] Unit) reviewed as part of the medication storage and labeling task and was evidenced by the following: On 02/08/22 at 10:46 AM, the surveyors observed that the Lower [NAME] Unit medication storage refrigerator had a temperature reading of 42 degrees Fahrenheit (F). During an interview with the surveyors on 02/08/22 at 10:50 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the morning-shift nurse noticed the refrigerator was unplugged earlier today. [...]