Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Laurel Manor Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with COPD and emphysema received continuous oxygen therapy at 3 LPM via nasal cannula as documented in the care plan, but no corresponding physician order was found in the medical record. Staff, including an LPN, UM, RN, and DON, all acknowledged that a physician order should have been obtained and that existing chart-check processes should have identified the omission. Review of the facility’s physician order policy showed procedures for transcribing and verifying orders, yet these were not effectively applied to ensure a documented oxygen order for the resident.
Failure to assess entrapment risk and obtain informed consent before side rail use. The facility used side rails for multiple residents, including residents with severe or moderate cognitive impairment and histories of falls, but records did not show that alternatives were explored or that risks and benefits were documented before use. Staff and the DON stated residents were asked if they wanted side rails and that only verbal consent was obtained, while assessments and care plans often lacked documentation of entrapment risk, risk-versus-benefit review, or valid consent.
A resident admitted with bipolar disorder and anxiety disorder had an inaccurate PASARR Level I screen that did not identify mental illness. The SSD said staff were usually looking for diagnoses like bipolar and schizophrenia, but agreed any mental illness diagnosis should be listed on the Level I; the DON stated she expected assessments to be completed accurately and correctly.
Failure to document review and offer of baseline care plans for newly admitted residents. Five residents, including some with severe cognitive impairment and others needing substantial/maximal assistance with ADLs, had no EMR documentation that their initial care plans were reviewed with them or their representatives within 48 hours of admission, and one representative stated she was not offered a copy. The DON confirmed there was no documentation showing the resident and/or representative reviewed the initial care plan and was offered a copy within the required timeframe.
The facility failed to follow physician hold parameters for two residents’ medications and used a wander guard for a resident who was not assessed as an elopement risk. One resident received Midodrine when SBP was above the ordered limit, and another received Hydralazine when SBP was below the ordered limit. The resident with the wander guard had no documented wandering or exit-seeking behavior, and staff stated the resident was not a wanderer.
Medication administration errors exceeded the allowed rate when an LPN made four errors in 25 opportunities, resulting in a 16% error rate. One resident with COPD and HTN received Amox-Clav and Metoprolol ER before breakfast and without food, despite orders to give them with meals or food. Another resident with DM2 received Metformin and Insulin Lispro after breakfast was already completed, even though the orders required Metformin with meals and Insulin Lispro before meals. The LPN confirmed the timing errors, and the DON stated meds are expected to be given as prescribed.
A resident with a tracheostomy and humidified O2 had corrugated tubing with a moisture collection bag repeatedly observed laying on the floor beside the bed while she was in bed. The facility policy required oxygen tubing to be stored to prevent infection, and the DON and an LPN acknowledged the tubing on the floor created an opportunity for infection and had frequently been found there.
The facility failed to ensure the accountability of controlled substance inventories as per its policy. An LPN admitted to not signing the Controlled Substance Inventory Record immediately after dispensing medications, leading to discrepancies in the counts of Tramadol HCL 50 mg tablets and Pregabalin capsules. The DON confirmed that the inventory documents should not be missing signatures.
The facility failed to maintain dignity during meal services for a resident who required assistance with eating. An LPN was observed standing over the resident while feeding, and the resident was left with an uncovered meal tray for an extended period before being assisted. The resident had dementia and Alzheimer's Disease and was on hospice services. Interviews with the ADON and DON confirmed that staff should be seated at eye level when feeding residents and that meal trays should not be left uncovered if the resident is not ready to be fed.
The facility failed to revise care plans for two residents to include necessary fall prevention and pressure ulcer interventions. One resident, with moderate cognitive impairment, had fall prevention measures like a geri-chair and alarms that were not documented in the care plan. Another resident, with severe cognitive impairment and a stage 4 sacral pressure ulcer, did not have an air mattress or ROHO cushion documented in the care plan, despite recommendations. Staff confirmed these omissions, which violated the facility's care plan policy.
A facility failed to reconcile a physician order and accurately document on the MAR for a resident receiving enteral feedings. Despite being NPO, the MAR indicated the resident accepted an HS snack on multiple occasions. Interviews with staff and policy reviews confirmed the resident should not have been offered an HS snack, and the order should have been discontinued earlier.
A facility failed to maintain infection control practices during a pressure ulcer treatment for a resident with diabetes, sepsis, and cellulitis. The LPN did not perform hand hygiene between glove changes and did not label the wound dressing before application. The facility's policies on wound care and hand hygiene were not followed.
A resident with moderate cognitive impairment was mistakenly transported to a medical appointment meant for another resident due to a failure in following identification procedures. The incident report lacked details and did not include statements from all involved staff members, resulting in a deficiency in ensuring resident safety and proper identification.
A facility failed to ensure proper storage and maintenance of a urinary catheter drainage bag, which was observed on the floor instead of in a privacy cover. The CNA responsible for emptying the bag demonstrated improper handwashing techniques. The resident had a history of urinary tract infections, and the care plan lacked specific interventions to prevent infections. Interviews with staff confirmed the deficiency.
A resident with a history of falls experienced an unwitnessed fall, but the incident was not documented in the EMR on the day it occurred, and the resident's representative was not notified until two days later. Interviews with staff revealed that the facility's policies for documentation and notification were not followed.
The facility failed to post the Nursing Home Resident Care Staffing Report daily as required. Observations on multiple occasions revealed missing reports for specific shifts, which was confirmed by the Staffing Coordinator and the Licensed Nursing Home Administrator.
Oxygen Therapy Implemented Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician order for oxygen therapy upon a resident’s admission, despite implementing and maintaining oxygen as part of the resident’s care. The resident was admitted with diagnoses including an upper right humerus fracture with routine healing, fall, emphysema, and COPD. The discharge MDS showed the resident was cognitively intact with a BIMS score of 15/15. The resident’s Care Plan documented oxygen therapy at 3 LPM via nasal cannula continuously for COPD, with detailed interventions to monitor for signs and symptoms of respiratory distress and related complications. However, review of the resident’s Order Summary Report revealed no corresponding physician order for oxygen. During interviews, an LPN stated that residents admitted from the hospital should have their orders transcribed and reviewed with the physician, and that a resident on oxygen should have a physician order. A Unit Manager confirmed that residents on oxygen should have both an order and a care plan, and acknowledged that there was no oxygen order for this resident despite the care plan indicating its use. The RN described a three-step chart check process involving the admission nurse, UM, and DON, plus night shift checks, and stated that someone should have identified the missing oxygen order. The DON confirmed there was no physician order for the resident’s oxygen and stated there should be, and that the oxygen order should match the care plan. The facility’s policy on physician orders outlined processes for transcribing and verifying verbal orders, and required all orders to be signed monthly, but this process did not result in a documented oxygen order for the resident.
Failure to assess entrapment risk and obtain informed consent before side rail use
Penalty
Summary
The facility failed to assess the risk of entrapment, try alternatives, and/or obtain informed consent before initiating side rails for seven residents reviewed for side rail use. The report states that the facility policy required a side rail assessment on admission, quarterly re-evaluation, and discussion of risks and alternatives with the resident and family when side rails were requested by family, but the records reviewed did not show that these steps were completed for the residents identified in the survey. For one resident with diagnoses including muscle weakness and abnormalities of gait and mobility, the significant change MDS showed severe cognitive impairment with a BIMS score of 5 out of 15. The care plan and physician orders showed bilateral quarter side rails used as an enabler, but the resident evaluation/bedrail assist device records dated in January, April, and July did not show evidence that alternatives were explored or that risks versus benefits were reviewed. Staff interviews indicated that residents were assessed for side rails on admission and asked if they wanted them, but staff were unsure where signed consents were kept and acknowledged that alternatives were not being explored prior to use. Another resident was observed in bed with both half side rails raised on multiple occasions. That resident’s admission MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The admission/readmission evaluation documented altered safety awareness, a history of falls, poor bed mobility, difficulty with balance or trunk control, medications requiring increased safety precautions, current use of side rails for positioning or support, and the resident’s desire for siderails. The interventions included lower bed to the floor, restorative care, frequent night monitoring, assisted toileting, and reminders to use the call bell, with a recommendation for bilateral half side rails. A third resident was also observed with bilateral half side rails raised. That resident’s admission MDS showed a BIMS score of 0 out of 15, and the admission/readmission evaluation documented altered safety awareness, a history of falls, poor bed mobility, difficulty with balance or trunk control, medications requiring increased safety precautions, and current use of side rails for positioning or support. The interventions included restorative care, frequent night monitoring, assisted toileting, and reminders to use the call bell, with a recommendation for bilateral half side rails. For another resident with diagnoses including seizure, gastrostomy status, and acute respiratory failure with hypoxia, the quarterly MDS showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The care plan stated the resident used side rails as an enabler and included interventions to discuss and record risks and benefits with the resident/family, ensure valid consent before initiating siderails, and evaluate ongoing need. However, the admission evaluation contained no side rail assessment or consent, and the later siderail assessment identified the resident as high risk for falls but did not include the risk of entrapment or whether informed consent was obtained. Interviews with staff and the DON confirmed that only verbal consent was obtained, that there were no written consents, and that the facility’s side rail policy did not include risk of entrapment, risk versus benefits, or informed consent.
Inaccurate PASARR Level I Assessment
Penalty
Summary
The facility failed to ensure that an accurate PASARR Level I assessment was completed after admission for one resident who was admitted with diagnoses including bipolar disorder and anxiety disorder. Review of the resident’s admission record showed the diagnoses in the EMR, and review of the NJ Department of Human Services PASRR Level I screen dated 08/21/25 showed no indication of mental illness identified. During interview, the Social Services Director stated she was not aware the PASARR Level I was not completed correctly and said staff are usually looking for diagnoses like bipolar and schizophrenia, but agreed that any mental illness diagnosis should be listed on the Level I. The DON stated she expected staff to complete all assessments accurately and correctly.
Failure to Document Review and Offer of Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that five newly admitted residents had documentation that their Baseline Care Plans were reviewed with the resident and/or representative within 48 hours of admission, and that a copy of the Care Plan had been offered. The facility policy titled, Care Plans - Comprehensive revised June 2025, stated the resident's baseline care plan is developed within 24-48 hours through the admission assessment, but it did not include a procedure for resident and/or representative involvement with the baseline care plan. The deficiency was identified through record review, interviews, and policy review. Resident 6 had severe cognitive impairment with a BIMS score of 0/15, and the Baseline Care Plan was completed on 06/04/25, but there was no documentation that it was reviewed with the representative; the resident's representative also did not participate in the social services admission/readmission evaluation and later stated she was not offered a copy of the care plan. Resident 87 also had a BIMS score of 0/15, and although the Baseline Care Plan was completed on 08/11/25, there was no documentation it was reviewed with the representative. Resident 105 had severe cognitive impairment with a BIMS score of 5/15, and the Baseline Care Plan was completed on 06/04/25 with no documentation of review with the representative. Resident 57 had a BIMS score of 11/15 and required substantial/maximal assistance with toileting hygiene, bathing, and lower body dressing; the record contained no documentation that the baseline care plan was provided or reviewed, and the resident stated she had not attended a care planning meeting or discussed her care with staff. Resident 108 had intact cognition with a BIMS score of 15/15 and required substantial/maximal assistance with toileting hygiene, bathing, and lower body dressing; the EMR contained no documentation that the initial baseline care plan was provided or reviewed, and the resident stated he had not attended a care planning meeting or discussed his care with staff. The DON stated that when a resident is admitted, the admission assessment is completed by the nurse and an initial care plan is generated, but there was no documentation that the resident and/or representative reviewed the initial care plan and was offered a copy within 48 hours of admission.
Failure to follow medication hold parameters and inappropriate wander guard use
Penalty
Summary
The facility failed to follow physician orders for medication hold parameters for two residents and failed to use a wander guard device appropriately for one resident. The report states that these issues were identified through observation, interview, record review, and policy review, and that the failures had the potential to affect the residents’ quality of care. For one resident with diagnoses including orthostatic hypotension, gastrostomy status, and acute respiratory failure with hypoxia, the physician ordered Midodrine 5 mg via PEG tube three times daily for hypotension and to hold the medication when systolic blood pressure was greater than 120. Review of the MAR showed Midodrine was administered on multiple occasions when the resident’s systolic blood pressure was above that parameter, including readings of 122/78, 139/69, 134/78, 124/82, 128/79, 134/79, 130/76, 122/74, and 124/76. The facility’s pharmacist also documented that Midodrine was not always held as required by the physician’s order. For a second resident with diagnoses including hypertension, heart failure, and diabetes mellitus, the physician ordered Hydralazine 25 mg every 8 hours and to hold it for systolic blood pressure less than 120. Review of the MAR showed Hydralazine was administered on several occasions when the resident’s systolic blood pressure was below that parameter, including readings of 108/55, 115/66, 104/42, 116/51, 116/73, 118/72, and 110/50. The pharmacist likewise noted that Hydralazine was not always held as required by the physician’s order. The report also found that a resident was care planned for risk for elopement and wore a wander guard, but the resident’s assessments and staff interviews did not support wandering or elopement risk. The resident’s significant change MDS showed severe cognitive impairment, but the elopement risk assessments dated in January, April, and July indicated the resident was not at risk for elopement, and notes from March through August contained no documentation of wandering or exit-seeking behavior. Staff interviews stated the resident was not a wanderer and should not have a wander guard if not assessed as an elopement risk, yet the order and care plan still directed use of the device.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. Surveyors identified four medication errors out of 25 opportunities for error, resulting in a 16% error rate for two residents observed during medication administration. The facility’s medication administration policy stated that medications ordered with food may be given with milk and graham crackers or similar items, medications ordered with meals should be given with the meal, and medications ordered before a meal should be administered prior to the start of the meal. One resident was admitted with chronic obstructive pulmonary disease and hypertension and had moderately impaired cognition with a BIMS score of 11 out of 15. During observation, an LPN administered Amox-Clav and Metoprolol Succinate ER before breakfast and without offering food, even though the physician’s orders required Amoxicillin/Potassium Clavulanate to be given with food or meals and Metoprolol Succinate ER to be given with meals. A second resident was admitted with type 2 diabetes mellitus and had intact cognition with a BIMS score of 15 out of 15. During observation, an LPN administered Metformin after breakfast had already been eaten and gave Insulin Lispro after the resident finished breakfast, although the physician’s orders required Metformin to be given with meals and Insulin Lispro to be administered before meals. The LPN confirmed the timing errors during observation. The consulting pharmacist stated medications should be administered as ordered by the prescribing physician, and the DON stated the facility expectation was that medications are to be administered as prescribed.
Respiratory Tubing Left on Floor
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured for one resident with a tracheostomy. The resident was admitted with a fracture of the base of the skull, epidural hemorrhage, chronic obstructive pulmonary disease, and previous acute respiratory failure that resulted in a tracheostomy. Her care plan included tracheostomy care every shift and humidified oxygen as prescribed, and her cognitive assessment showed severe impairment. Observations on multiple occasions showed the resident’s corrugated humidified oxygen tubing with a moisture collection bag between two pieces of tubing laying on the floor beside her bed while she was in bed. The facility policy stated oxygen tubing should be properly stored to prevent transmission of infection and that tubing that falls on the floor should be immediately discarded and replaced. The DON stated the tubing was changed daily on the night shift and later acknowledged she had not been aware the tubing was on the floor and that there was a chance for transmission of an infectious process. An LPN also stated the tubing being on the floor was an opportunity for infection and that they had not found a way to keep it off the floor because it was frequently found laying there.
Controlled Substance Inventory Accountability Failure
Penalty
Summary
The facility failed to ensure the accountability of controlled substance inventories in accordance with its policy. During an interview, an LPN stated that both incoming and outgoing nurses should sign the Controlled Substance Inventory Record (CSIR) and count the actual medication cards. However, a review of the Lower [NAME] medication cart #3 revealed a missing signature in the section labeled '7PM OUT' on 04/03/2024. Additionally, discrepancies were found in the Redwood medication cart #2, where the count of Tramadol HCL 50 mg tablets and Pregabalin capsules did not match the documented counts. The LPNs admitted to administering the medications but forgetting to sign the respective records immediately after dispensing the medications, as required by the facility's policy. The Director of Nursing (DON) confirmed that the unit manager and herself monitored the controlled substances to ensure correct counts and no missing items. The DON acknowledged that the controlled substance inventory documents should not be missing signatures and that the nurses should have signed the declining inventory logs as soon as the medication was dispensed. The facility's policy, dated 01/2024, required a narcotic count to be completed by two licensed nurses prior to the end of each shift and for the nurse to sign out the narcotic from the declining sheet immediately after taking it out of the card. The failure to adhere to these procedures led to the identified deficiencies.
Failure to Maintain Dignity During Meal Services
Penalty
Summary
The facility failed to maintain dignity during meal services for a resident who required assistance with eating. On multiple occasions, a Licensed Practical Nurse (LPN) was observed standing over the resident while feeding, which is against proper etiquette. The LPN admitted to standing due to back pain but acknowledged that staff should be seated in front of the resident for better etiquette. Additionally, the resident was left with an uncovered meal tray for an extended period before being assisted, which is contrary to the facility's policy of keeping trays covered until staff are ready to feed the resident. The resident involved had diagnoses including dementia and Alzheimer's Disease and was on hospice services. The resident's care plan indicated a risk for weight loss due to sporadic food and fluid intake, with an intervention for staff to feed and encourage the resident to complete all food and fluids. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that staff should be seated at eye level when feeding residents and that meal trays should not be left uncovered if the resident is not ready to be fed. The facility's Meal Pass policy did not include specific instructions on how staff should feed residents.
Failure to Revise Care Plans for Fall Prevention and Pressure Ulcer Interventions
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to address fall prevention and pressure ulcer interventions. This deficiency was identified for two residents. Resident #62, who had moderate cognitive impairment and was at moderate risk for falls, was observed using a geri-chair with a chair alarm and a bed alarm. However, these fall prevention interventions were not documented in the resident's care plan. Multiple staff members, including the Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA), Director of Rehabilitation (DOR), and Registered Nurse/Unit Manager (RN/UM), confirmed that these interventions should have been included in the care plan but were not. The facility's policy indicated that care plans should be revised as the resident's condition changes, but this was not done for Resident #62's fall prevention measures. Resident #397, who had severe cognitive impairment and a stage 4 sacral pressure ulcer, also had deficiencies in their care plan. The resident's care plan did not include the use of an air mattress or a ROHO cushion, which were recommended by the wound care consultant to prevent worsening of the pressure ulcer. The Director of Rehabilitation (DOR) confirmed that the resident had received a ROHO cushion from the therapy department, but there was no documentation to support this. Interviews with various staff members, including the CNA, LPN, RN/UM, Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed that these pressure ulcer preventative measures should have been included in the care plan but were not. The facility's policy on comprehensive care plans, revised in June 2023, stated that care plans should reflect treatment goals and be revised as the resident's condition changes. However, the facility failed to adhere to this policy for both Resident #62 and Resident #397. The lack of documentation and updates in the care plans for these residents' fall prevention and pressure ulcer interventions led to the identified deficiencies.
Failure to Reconcile Physician Order and Document Accurately for NPO Resident
Penalty
Summary
The facility failed to reconcile a physician order and accurately document on the Medication Administration Record (MAR) for a resident receiving enteral feedings. The resident, who was diagnosed with dysphagia, dysarthria, and had a gastrotomy, was observed receiving nutritional supplements via a tube feeding pump. Despite being NPO (nothing by mouth), the MAR indicated that the resident accepted an HS (bedtime) snack on multiple occasions, which was inconsistent with the resident's NPO status and physician orders. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) revealed that the resident should not have been offered an HS snack due to their NPO status. The LPN confirmed that the HS snack order was mistakenly entered and should have been discontinued. The Director of Nursing (DON) acknowledged that the resident's MAR incorrectly documented the acceptance of HS snacks and confirmed that the order should have been reconciled and discontinued earlier. The facility's policies on Admission/Readmission Order Reconciliation, NPO diet, and HS snacks were reviewed, indicating that the resident's NPO status should have been properly documented and reconciled. The deficiency was identified when the surveyor observed discrepancies in the MAR and confirmed through interviews and policy reviews that the resident, who was NPO, was incorrectly documented as accepting HS snacks.
Failure to Maintain Infection Control During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to maintain infection control practices and professional standards during a pressure ulcer treatment for a resident. The Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes multiple times during the wound care procedure. Specifically, after removing the old wound dressing, the LPN donned new gloves without washing hands, cleansed the wound, and repeated the same mistake when applying the new dressing. Additionally, the LPN did not label the wound dressing with the date and time before applying it, which is against the facility's protocol. The resident involved had a history of diabetes, sepsis, and cellulitis, and was admitted with a Stage 4 pressure ulcer and two Unstageable pressure ulcers. The facility's policies on wound care and hand hygiene were not followed, as confirmed by the Infection Preventionist/Assistant Director of Nursing (IP/ADON) and the Director of Nursing (DON). The IP/ADON also noted that multidose containers like the tube of santyl ointment should not be brought into the resident's room to prevent contamination, which the LPN failed to adhere to during the treatment.
Resident Misidentification and Incomplete Investigation
Penalty
Summary
The facility failed to follow its policy for resident identification and did not conduct a thorough investigation into an incident involving Resident #62. Resident #62, who had moderate cognitive impairment, was mistakenly transported to a medical appointment meant for Resident #61. The error occurred because the Registered Nurse (RN) on duty misidentified Resident #62 and sent them out without verifying their identity through the required procedures such as checking the name band or picture on the face sheet. The Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) confirmed that the resident was sent out without an escort, which was against the facility's policy for cognitively impaired residents. The incident report lacked details on how the misidentification occurred and did not include statements from the involved staff members, including the RN who made the error and the Licensed Practical Nurse (LPN) who identified the mistake later in the day. The facility's policies on transportation and patient identification were not followed, leading to the incident. The investigation was incomplete as it did not identify the root cause of the error or include statements from all involved staff members. The facility's failure to adhere to its policies and conduct a thorough investigation resulted in a deficiency in ensuring resident safety and proper identification.
Improper Catheter Care and Hand Hygiene
Penalty
Summary
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 one resident. The surveyor observed the resident's drainage bag on the floor, not in the privacy cover, which is against the facility's policy. The CNA responsible for emptying the drainage bags confirmed that the bag should not touch the floor and demonstrated the emptying process, which included improper handwashing techniques by lathering hands under the stream of water instead of outside it as required by the facility's policy and CDC guidelines. The resident involved had a history of urinary tract infection, sepsis, cystitis, retention of urine, and hematuria. The resident's care plan did not include specific interventions on how to maintain the urinary catheter to prevent infections. Interviews with the LPN, IP/ADON, and DON confirmed that the drainage bag should be kept off the floor and that proper handwashing techniques should be followed to prevent the spread of germs. The facility's policies on catheter care and hand hygiene were reviewed and found to be consistent with best practices, but the observed practices did not align with these policies. The failure to adhere to these protocols was identified as a deficiency in the care provided to the resident, potentially increasing the risk of infection.
Failure to Accurately Document and Notify After Resident Fall
Penalty
Summary
The facility failed to accurately document in the medical records for one resident, leading to a deficiency. The resident, who had a history of falls and was admitted with diagnoses including muscle weakness, difficulty in walking, and cerebral infarction, experienced an unwitnessed fall. The incident occurred in the bathroom, and the resident was found sitting on the floor next to their wheelchair. Although the fall was documented in the Incident/Accident Report, there was no corresponding progress note in the electronic medical record (EMR) on the day of the fall. The progress note was only entered the following day, indicating that no injury was noted and that neurological checks were in progress. Additionally, the resident's representative was not notified until two days after the fall, despite the facility's policy requiring immediate notification of the responsible party in such events. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that the staff did not follow the facility's policies for documenting falls and notifying the resident's representative. The LPN stated that it was important to document falls in the EMR and notify the family immediately, but this was not done in this case. The DON acknowledged that a progress note should have been included with the incident report and that the resident's representative should have been notified right after the incident. The facility's policies on Incident/Accident, Notification of Change, and Nursing Documentation all emphasize the importance of timely and accurate documentation and communication, which were not adhered to in this instance.
Failure to Post Daily Staffing Report
Penalty
Summary
The facility failed to post the Nursing Home Resident Care Staffing Report daily as required. On multiple occasions, the surveyor observed that the staffing report was not updated for the current shifts. Specifically, on 04/05/24, the staffing report for the evening and night shifts of 04/04/24 and the day shift of 04/05/24 were not posted. Similarly, on 04/10/24, the day shift report for 04/10/24 was missing. These observations were confirmed through interviews with the Staffing Coordinator (SC) and the Licensed Nursing Home Administrator (LNHA), who both acknowledged the responsibility of updating and posting the staffing report daily. The SC explained that she edited and printed the staffing reports daily and for the weekends, ensuring they were posted at a table across from the front receptionist desk. However, the surveyor's observations indicated lapses in this process. The LNHA, in the presence of the Director of Nursing (DON) and the survey team, reiterated that the staffing report should be updated daily and posted in front of the receptionist desk. The facility's policy also mandated daily updates of the staffing ratios for each shift, which was not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,444 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stratford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Voorhees | 2.1 mi | ★★★★★ | 3 | 1 |
| Lions Gate | 2.4 mi | ★★★★★ | 0 | 0 |
| Echelon Care & Rehab | 2.8 mi | ★★★★★ | 0 | 0 |
| Voorhees Pediatric Facility | 2.8 mi | ★★★★★ | 2 | 0 |
| The Subacute At Autumn Lake Healthcare | 3 mi | ★★★★★ | 19 | 3 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Laurel Manor Healthcare And Rehabilitation Center.
100% money-back within 48 hours.
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.