The Laurels of Salisbury

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident, staff, Urology Nurse, Nurse Practitioner and Medical Director interviews, the facility failed to schedule a urology appointment for follow up of the suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine) placement and infection per the physician order for 1 of 2 residents reviewed for catheters (Resident #7).Findings included:A hospital Discharge summary dated [DATE] revealed Resident #7 was in the hospital from [DATE] through 12/8/2025. During this hospital stay Resident #7 was given an active diagnosis of bilateral hydronephrosis (swelling of both kidneys) status post ureteral stent (a small tube inserted into the ureter to facilitate urine flow from the kidney to the bladder). While in the hospital, Resident #7 had placement of a suprapubic catheter and was discharged with the suprapubic catheter in place. The hospital urology consult documentation dated 12/8/2025 for Resident #7 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and staff interviews, the facility failed to cover facial hair for 2 of 2 dietary staff (Cook #1 and Dietary Aide #1) observed working in food production and failed to have necessary supplies to test the chemical level in the sanitizing sink for 3 of 3 observations. This had the potential to affect food served to all the residents in the facility. The findings included: 1. The kitchen was observed on 1/21/25 at 9:55 AM. [NAME] #1 was observed to be preparing food without a beard cover. [NAME] #1 had facial hair on his chin that measured more than 1 inch in length. The kitchen was observed on 1/23/25 at 11:45 AM. [NAME] #1 was noted to be serving food for residents. [NAME] #1 was asked about the beard cover and he responded that the kitchen was out of beard covers and the Dietary Manager had reordered the beard covers. Dietary Aide #1 was observed preparing resident meal trays 1/23/25 at 11:45 AM. Dietary Aide #1 had facial hair that measured approximately ½ inch on his chin and he did not have a beard cover in place. Dietary Aide #1 reported he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete an admission Minimum Data Set (MDS) assessment within 14 days of admission for 1 of 18 residents reviewed for admission assessments (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE]. The admission MDS was dated 1/22/25 and was listed as in progress. The MDS nurse was interviewed on 1/23/25 at 3:41 PM. The MDS nurse explained she was reviewing assessments for new admissions on 1/22/25 and noticed the admission assessment had not been completed for Resident #16 and she had initiated the assessment. The MDS nurse reported she does not know why the assessment was missed. The Administrator was interviewed on 1/24/25 at 2:23 PM. The Administrator explained the new admissions to the facility were discussed during the morning meeting and checks were completed twice per week to monitor the completion of the MDS assessment. The Administrator reported she was not aware the admission MDS assessment for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Nurse Practitioner interviews, the facility failed to ensure 1 of 3 residents (Resident #163) reviewed for medication errors received medications that were ordered by the physician. Resident #163 received Buspirone (an antianxiety medication) 10 milligrams that was intended for another resident. Medication administration observtions were made during the survey with a sample of residents and no issues were identified. Findings included: Resident #163 was admitted to the facility on [DATE] with diagnoses of heart failure and respiratory failure. A significant change Minimum Data Set assessment dated [DATE] indicated Resident #163 was severely cognitively impaired and did not receive antianxiety medications. Review of Resident #163's Medical Record revealed a Nurse's Progress Note written [DATE] at 3:18 pm by Nurse #1 which stated Nurse Practitioner #1 was notified Resident #163 was administered Buspirone 10 milligrams and orders were received to monitor for 12 hours. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation of the lunch meal tray line observation, staff interviews, and record review the facility failed to provide portions of food per the menu which had the potential to affect all 56 residents in the facility since there were no residents that did not receive a meal tray. Findings included: The menu for Sunday, 8/13/2023, for the lunch meal trays for all regular, Mechanical Soft, and Pureed Diets consisted of: 3 ounces of Salisbury steak; 4 ounces of potatoes; 4 ounces of spinach; 1 dinner roll; and 1 slice of chocolate pie. During a continuous observation of the lunch meal tray line on 8/13/2023 from 11:34 am until 1:07 pm the [NAME] used: a blue handled scoop (2 ounces) in the mechanical soft meat (the menu called for 3 ounces); a blue handled scoop in the creamed potatoes (the menu called for a 4 ounces); a green handled scoop (3 ounces) in the puree meat (the menu called for 3 ounces); a green handled scoop (3 ounces) in the pureed spinach (the menu called for 4 ounces); and a grey handle slotted spoon (1 cup) in the regular texture spinach (the menu called for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation of the lunch tray line; staff interviews, and record review the facility staff failed to ensure the thermometer probe was cleaned in between uses to prevent the potential for cross-contamination and failed to cover and date food stored in the walk-in refrigerator. This practice had the potential to affect food served to residents. Findings included: During an initial observation of the kitchen on 8/13/2023 at 10:00 am the walk-in refrigerator had a tray of serving bowls with 20 peaches and cream desserts that were not covered and did not have a date on them. The [NAME] stated the staff had put them out in the walk-in refrigerator yesterday and should have covered and dated the desserts. On 8/13/2023 at 11:34 am an observation was conducted of the lunch meal tray line. During the observation the [NAME] used a cloth hand towel, that had dark brown stains, to wipe the thermometer after checking each of the foods in the steam table for temperature. During an interview with the [NAME] on 8/13/2023 at 2:31 pm she stated she had worked at the facility for 1.5 years.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of pain medication for 1 of 4 residents reviewed for abuse (Resident #211). The findings included: A physician order dated 11/4/2022 ordered to check the fentanyl patch (a narcotic pain medication that delivers medication through the skin over 72 hours for constant pain control) every shift and report placement to the oncoming shift. A review of the medication administration record (MAR) revealed that the fentanyl patch had been documented on by nursing each shift for the period of 11/4/2022 through 11/30/2022. A physician order dated 11/5/2022 ordered fentanyl patch 100 micrograms (mcg) per hour, apply one patch every 72 hours, remove the old patch prior to reapplying. This order was discontinued on 11/11/2022. A nursing note dated 11/10/2022 written by Nurse #1 documented Resident #211's fentanyl patch was on at shift change and hourly checks were conducted until 6:00 PM and the next time Nurse #1 was able to check Resident #211, it was almost 9:00 PM.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to implement their abuse policy for reporting when the Nurse did not notify the Administrator or Director of Nursing when resident to resident abuse was reported to her by the Nurse Aide. On 4/5/2023 Resident #164 was observed by the Nurse Aide on his knees on Resident #165's bed with his left arm around Resident #165's neck, in a choke hold and his right arm raised like he was going to strike Resident #165 in the face. This deficient practice occurred for 1 of 2 residents reviewed for resident-to-resident abuse. Findings included: The facility's Abuse Prohibition Policy which was last revised on 9/9/2022 stated the staff will report any allegations or suspicions of abuse to the Administrator and Director of Nursing immediately and the Administrator or designee will notify the State agency per state guidelines. Resident #165 was admitted to the facility on [DATE] with diagnoses of traumatic brain injury due to a fall. An admission Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, vascular wound Nurse Practitioner (NP) and Physician interviews, the facility failed to clarify and document surgical wound care and wound vac (a device used to remove pressure and fluids from a wound) orders for 1 of 1residents reviewed for surgical wound care (Resident #217). Findings included: Resident #217 was admitted to the facility on [DATE] with diagnoses that included Peripheral Vascular Disease (PVD), total occlusion of lower leg arteries, total occlusion of arteries of the lower extremities and tobacco use. He was discharged to the hospital on 7/12/23. A review of a hospital Discharge summary dated [DATE] at 12:32 PM revealed in part Resident #217 was admitted to the hospital from the vascular clinic on 6/12/23 when a noninvasive test revealed minimal to no blood flow of both lower legs. On 6/15/23 Resident #217 underwent a left femoral popliteal bypass procedure (a graft is placed in the lower leg to create a new blood flow path to replace a damaged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and staff interviews, the facility failed to store narcotic pain medications in a locked compartment in 1 of 1 medication rooms. The findings included: A facility reported investigation report dated 2/21/2023 documented 5 oxycodone/acetaminophen tablets were missing from the medication room. The medications had been delivered to the facility and were left on the counter of the medication room. The report documented the facility became aware of the missing medications on 2/13/2023 at 1:30 PM. No residents were affected by the missing medications. The report read, in part: On 2/6/2023 an order was placed by the Director of Nursing (DON) #2 to replenish emergency narcotic medications for the automated medication dispensing cabinet, including 5 tablets of oxycodone immediate release 5 milligrams (mg); 10 tablets of hydrocodone/acetaminophen 5/325 mg; and 5 tablets of oxycodone/acetaminophen 5/325 mg. The medications were delivered on 2/7/2023 between 5:00 PM and 6:00 PM and signed for by Nurse #7. The medications were placed on the counter in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor these interventions the committee put into place in February 2022. This was for 1 re-cited deficiency which was originally cited on [DATE] for drug storage (F761), on [DATE] during the follow-up survey (F761), and on the current recertification/complaint survey on [DATE] (F761). The continued failure of the facility during the three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. The findings included: This tag is cross referred to: F761: Based on record reviews, observations, and staff interviews, the facility failed to store narcotic pain medications in a locked compartment in 1 of 1 medication rooms. During the recertification survey conducted [DATE] the facility failed to: 1) Date opened (in use) injectable medications to allow for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.