Inspection Reports for Laurel Manor Healthcare And Rehabilitation Center
18 W Laurel Road, NJ, 08084
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 95
Capacity: 106
Deficiencies: 12
Apr 17, 2024
Visit Reason
A recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident rights, care plan timing and revision, professional standards of care, infection control, accident hazards, incontinence care, nurse staffing, pharmacy services, and resident records. The facility failed to maintain proper feeding etiquette, revise care plans timely, reconcile medication orders, maintain infection control during wound care, ensure resident identification during transport, and post nurse staffing data daily.
Complaint Details
Complaints NJ #: 155752, 168834, 169845, 169880, 170054, and 171256 were investigated during the survey period from 04/03/24 to 04/17/24.
Severity Breakdown
SS=D: 7
SS=B: 1
SS=E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to maintain proper feeding etiquette during meal services for Resident #89. | SS=D |
| Failure to revise comprehensive care plans timely for Residents #62 and #397. | SS=D |
| Failure to meet professional standards of nursing practice related to medication order reconciliation for Resident #446. | SS=D |
| Failure to maintain infection control practices during wound care for Resident #447. | SS=D |
| Failure to ensure resident identification and conduct thorough investigation after misidentification incident for Resident #62. | SS=D |
| Failure to ensure proper handling and dating of Foley catheter drainage bags for Resident #40. | SS=D |
| Failure to post daily nurse staffing information as required. | SS=B |
| Failure to ensure accountability of controlled substance inventories on medication carts. | SS=E |
| Failure to accurately document incidents and notify family timely for Resident #398. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratio as mandated by the State of New Jersey. | — |
| Failure to ensure new employees completed required health history and physical examination within required timeframe. | — |
| Failure to ensure new employees received required two-step Mantoux tuberculin skin test. | — |
Report Facts
Census: 95
Total Capacity: 106
Deficiencies cited: 12
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 14
Medication count discrepancy: 1
Medication count discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Involved in medication cart inventory and resident misidentification incident. |
| LPN #2 | Licensed Practical Nurse | Involved in medication cart inventory and medication administration. |
| IP/SE/ADON | Infection Preventionist/Staff Educator/Assistant Director of Nursing | Provided information on employee health requirements and infection control. |
| DON | Director of Nursing | Provided information on staffing and employee health requirements. |
| SC | Staffing Coordinator | Provided information on staffing ratios and staffing challenges. |
| LNHA | Licensed Nursing Home Administrator | Provided information on staffing ratios and recruitment efforts. |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Nov 21, 2023
Visit Reason
The inspection was conducted based on a complaint visit (Complaint #: NJ#169185) to investigate medication administration errors and staffing deficiencies at Laurel Manor Healthcare and Rehabilitation Center.
Findings
The facility was found not in substantial compliance due to a medication error where a Licensed Practical Nurse administered the wrong resident's medication, and failure to maintain required minimum direct care staff-to-resident ratios on multiple shifts. The facility was deficient in Certified Nurse Aide staffing for 21 out of 21 day shifts and 17 out of 21 evening shifts reviewed.
Complaint Details
The complaint investigation revealed that the facility failed to remove discontinued medications from active inventory, leading to a medication error where Resident #2 received Resident #1's medication. The Licensed Practical Nurse admitted to the error. The facility also failed to maintain required staffing ratios as mandated by New Jersey law.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure discontinued medications were removed from active inventory, resulting in a Licensed Practical Nurse administering Resident #1's medication to Resident #2. | SS=D |
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey for 21 out of 21 day shifts and 17 out of 21 evening shifts reviewed. | — |
Report Facts
Census: 97
Sample Size: 4
Deficient CNA staffing day shifts: 21
Deficient CNA staffing evening shifts: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Identified as the employee who administered the wrong medication to Resident #2. | |
| Licensed Nursing Home Administrator (LNHA) | Conducted investigation and obtained verbal statement from the LPN regarding medication error. | |
| Director of Nursing (DON) | Provided statements regarding medication availability and staffing. | |
| Social Worker (SW) | Attended meetings regarding the medication error and resident concerns. | |
| Unit Manager (UM) | Participated in meetings about resident care and medication error. |
Document
Deficiencies: 0
Feb 9, 2022
Visit Reason
Document is not related to regulatory oversight or inspection; it is a prompt to open the PDF portfolio in specific software.
Findings
No inspection or regulatory content present; only instructions for opening the PDF portfolio.
Inspection Report
Life Safety
Deficiencies: 2
Feb 7, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found noncompliant with life safety requirements, specifically failing to provide at least two remote exits for each floor, and having corridor doors with penetrations that do not resist smoke passage, compromising fire safety.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide at least two exits, remote from each other, for each floor or fire section of the building; only one means of egress from the 2nd floor was available. | SS=F |
| Corridor doors had penetrations (holes drilled) that compromised their ability to resist the passage of smoke, observed in 2 of 65 resident room/office corridor doors. | SS=D |
Report Facts
Number of corridor doors with penetrations: 2
Diameter of holes in therapy room door: 1
Diameter of holes in trash and soiled linen closet door: 1
Number of smoke zones in facility: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding facility layout, waivers, and fire safety findings. | |
| Corporate Director of Facilities (CDOF) | Present during inspection and confirmed findings of deficient exits and door penetrations. | |
| Maintenance Staff (MS) | Present during inspection and confirmed findings of door penetrations. | |
| Maintenance Director | Educated on fire safety requirements and responsible for auditing doors to ensure no penetrations. |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
Sep 25, 2021
Visit Reason
The inspection was conducted based on complaints NJ147948 and NJ146790 regarding the facility's compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility failed to notify the family of a medication change for one resident (Resident #1) reviewed for notification of changes. The resident was their own responsible party, and there was no documentation that the medication change was discussed with the resident or family. The facility policy requires notification and documentation of such changes.
Complaint Details
Complaint Intake: NJ147948. The complaint investigation found the facility failed to notify the family of a medication change for Resident #1. Resident #1 was their own responsible party and was not informed or documented as notified about the medication change.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the resident or responsible party of a medication change for Resident #1. | SS=D |
Report Facts
Census: 95
Sample Size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in relation to failure to notify resident/family of medication change and nurse's notes documentation |
| Director of Nursing | Director of Nursing | Provided expectations regarding notification of medication changes to resident or responsible party |
Inspection Report
Routine
Census: 92
Deficiencies: 0
Aug 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 6
Sample size: 3
Inspection Report
Routine
Census: 86
Deficiencies: 0
Mar 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Routine
Census: 80
Deficiencies: 0
Jan 29, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Routine
Census: 76
Deficiencies: 0
Jan 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Routine
Census: 93
Deficiencies: 0
Dec 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 91
Deficiencies: 0
Nov 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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