Laurel Square Healthcare: Missing Care Plan After Surgery - PA
Nobody wrote a care plan.
That gap is at the center of a November 2025 federal inspection finding against the Oak Lane Avenue facility. Inspectors reviewed the clinical record of the resident, identified in the report as Resident R2, and found no documented goals or interventions tied to the incontinence recommendations the facility's own staff had already made.
The skin and wound team had been thorough. A note from August 11, 2025, spelled out exactly what was needed: moisture barrier creams at every episode of incontinence, appropriate briefs, a chair cushion when the resident used a wheelchair, daily emollient application, attention to bony prominences, heel-floating protocols. A second note from the same morning, following admission wound rounds with an in-house nurse practitioner, found no open wounds and recommended only a podiatry visit for toenail clipping.
The clinical staff had done their jobs. The care plan never followed.
Laurel Square's own policy, revised in March 2022, states that a baseline plan of care must be developed for each resident within 48 hours of admission. The policy exists precisely because newly admitted residents, often arriving in fragile condition from hospitals, need immediate, written, coordinated guidance for staff who may not know their history.
Resident R2's record shows a Braden scale assessment completed on September 10, 2025, rating the resident at moderate risk for pressure ulcer development. The Braden scale is a standard clinical tool; a moderate risk score is not a borderline finding. It is a signal that action is warranted.
Then, according to the inspection record, the resident was hospitalized for surgery on the sacral area due to osteomyelitis, a bone infection. The inspection report does not establish a direct causal link between the missing care plan and the hospitalization. But the sequence is plain: a resident with documented incontinence, documented skin breakdown risk, and documented need for consistent moisture management went without a written care plan, and later required surgery for an infection at a pressure-vulnerable site.
The deficiency was tagged at a level of minimal harm or potential for actual harm, a designation that reflects the lower end of the federal violation scale. It affected a small number of residents in the complaint inspection. Inspectors reviewed six residents' records and found the failure in one.
That framing, though, can obscure what a baseline care plan actually does. It is not paperwork. It is the document that tells the night-shift aide, the weekend nurse, the new float staff, what this particular resident needs and why. Without it, the incontinence recommendations made by the wound care team on August 11 existed in a progress note that any staff member would have to search for, rather than in a care plan they would be expected to follow.
Laurel Square Healthcare and Rehabilitation Center operates at 1020 Oak Lane Avenue in the East Oak Lane neighborhood of Philadelphia. The inspection was completed on November 6, 2025, following a complaint.
The inspection report does not describe when Resident R2 was discharged, whether the bone infection has resolved, or what condition the resident is in now.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Laurel Square Healthcare and Rehabilitation Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
LAUREL SQUARE HEALTHCARE AND REHABILITATION CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on November 6, 2025.
That gap is at the center of a November 2025 federal inspection finding against the Oak Lane Avenue facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.