Inspection Reports for
Laurel Manor Healthcare And Rehabilitation Center

The visit was complaint-related, triggered by concerns about PASARR screening, care plan review, medication administration errors, use of wander guard devices, side rail assessments and consents, medication error rates, and infection control practices. Substantiation status is not explicitly stated.

The facility failed to ensure accurate PASARR Level I assessments, timely review and offering of baseline care plans to residents or their representatives, adherence to physician medication hold orders, appropriate use of wander guard devices, proper assessment and consent for side rail use, maintaining medication error rates below 5%, and infection control practices related to oxygen tubing placement. These deficiencies were associated with minimal harm or potential for actual harm to residents.

Complaint NJ#: 169845 related to care plan revisions and infection control; Complaint NJ#: NJ171256 related to controlled substance inventory; Complaint NJ#: NJ169880 and 170054 related to medical record documentation.

The facility failed to revise comprehensive care plans for fall prevention and pressure ulcer interventions for residents #62 and #397, failed to maintain proper infection control during wound care for resident #447, failed to ensure accurate controlled substance inventory documentation on medication carts, and failed to properly document a resident's fall and family notification in the medical record for resident #398.

The complaint investigation included issues related to dignity during feeding, care plan revisions, medication administration, infection control during wound care, resident misidentification and transport errors, catheter care, staffing report posting, controlled substance inventory accountability, and medical record documentation.

The facility was found deficient in multiple areas including dignity during feeding assistance, incomplete care plans for fall and pressure ulcer interventions, medication administration errors, infection control lapses during wound care, resident misidentification leading to transport errors, improper urinary catheter maintenance, failure to post staffing reports daily, incomplete controlled substance inventory documentation, and incomplete medical record documentation related to a resident fall.

Complaints NJ #: 155752, 168834, 169845, 169880, 170054, and 171256 were investigated during the survey period from 04/03/24 to 04/17/24.

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 #NJ#169185 involved a medication error where discontinued medication for Resident #1 was administered to Resident #2. The complaint was substantiated by interviews and record reviews, including statements from the LPN, Licensed Nursing Home Administrator, Director of Nursing, and Social Worker.

The facility failed to ensure discontinued medications were removed from active inventory, resulting in an LPN administering the wrong resident's medication. The investigation confirmed the medication was correct but labeled with the wrong patient's name, and the LPN did not verify before administration.

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.

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.

The facility failed to properly store medications within acceptable temperature ranges, failed to implement proper personal protective equipment (PPE) usage according to guidelines to minimize infection spread, and failed to follow proper hand hygiene and wound care procedures.

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.

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.

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.