Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.