Laurel Lakes Rehabilitation And Wellness Center

Based on observations, review of facility temperature logs, and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.Findings include:Observation of the dish machine in the main kitchen on July 28, 2025, at 1:22 PM, revealed kitchen staff were washing dishes from lunch, and the wash temperature of the dish machine read 138 degrees Fahrenheit (F).During an interview with Employee 3 (Certified Dietary Manager) on July 28, 2025, at 1:23 PM, he revealed the dish machine should be running at a minimum wash temperature of 150 degrees F. The surveyor questioned if he could link a sanitizing solution to the machine for safe use at a lower temperature and if he could have maintenance staff service the machine. Employee 3 revealed he could link the sanitizer to the machine as well as contact maintenance staff. Observation of the dish machine in the main kitchen on July 29, 2025, at 1:21 PM, revealed kitchen staff were washing dishes from lunch, and the wash temperature of…

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 review of facility policy, review of grievances, and interviews with staff and residents, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 34 residents reviewed (Resident 130). Findings include:Review of the facility policy, titled Dignity, with a last reviewed and revised date of February 2021, revealed, Each resident shall be cared for in a manner promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Review of Resident 130's clinical record revealed diagnoses of morbid obesity (a body mass greater than 40) and acute respiratory failure (when lungs cannot adequately exchange gases, leading to insufficient oxygen in the blood). Interview with Resident 130 on August 28, 2025, at 1:15 PM, revealed that Resident 130 had filed a complaint in June 2025, with the facility after Employee 1 had helped Resident 130 clean up and used disposable paper towels to dry Resident 130 because she said that she didn't have…

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 clinical record review and staff interviews, it was determined that the facility failed to convey resident's funds within 30 days, and a final accounting of those funds to the resident upon discharge for one of three resident closed records reviewed (Resident 179).Findings include: Clinical record review revealed Resident 179 was admitted to the facility on [DATE], discharged from the facility on February 27, 2025, and did not return. Review of Resident 179's final billing statement revealed she had a credit of $638.00 that was issued in the form of a check on May 30, 2025.Interview with Employee 4 (Business Office Manager) on July 30, 2025, at 1:40 PM, revealed the transaction history report for Resident 179 indicated that she was issued a refund check on May 30, 2025, and that a third party billing system messed up transaction so she had to reverse it, but the process for issuing resident refunds typically would occur within 30 days. During an interview with the Director of Nursing on July 31, 2025,…

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 policy review, facility documentation review, as well as resident and staff interviews, it was determined that the facility failed to ensure that a timely response was provided to a resident following submission of a grievance for one of two residents reviewed for grievances (Resident 168).Findings include: Review of facility policy, Grievance Process Procedure, dated October 2021, revealed, Upon the completion of the facility investigation, the administrator will ensure that the investigation results and resolution steps are communicated to the individual who originally submitted the grievance, complaint and/or suggestion. Resolution of the concern is desired within five (5) working days from the date the concern was filed. Routine follow up on concerns that are outstanding will be completed through the morning meeting process. During an interview with Resident 168 on July 29, 2025, at 11:05 AM, she revealed that she submitted a grievance regarding food concerns about a month ago, but never heard a thing about it. Review of a grievance form dated July 4, 2025, 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 facility policy review, clinical record review, observation, and interviews with staff and residents, it was determined that the facility failed to protect the resident's right to be free from mental abuse and neglect for two of 34 residents (Residents 21 and 54). Findings include: Review of facility policy, Abuse and Neglect- Clinical Protocol, revised March 2018, revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including the caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Instances of abuse of all residents, irrespective or any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Resident 21's clinical record revealed diagnoses of dementia (a decline in…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed (Resident 4). Findings include: Review of facility policy, titled Psychotropic Medication Use, dated July 2022, with a last review date of June 20, 2025, revealed the following: 1. A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics. 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e.…

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 clinical record reviews and resident and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 34 residents reviewed (Residents 3, 4, and 171). Findings include: Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting the right side and hypertension (high blood pressure). Review of Resident 3's Medicare 5 Day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of July 3, 2025, revealed in Section GG. Functional Abilities at Question GG0115. Functional Limitation in Range of Motion that she was coded as having no impairment in her upper extremities. During a staff interview with 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 facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for range of motion (Resident 46). Findings include: Review of facility policy, titled Restorative Nursing Services, with a last revision date of July 2017, and a last review date of June 20, 2025, indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Review of Resident 46's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included muscle weakness, chronic obstructive pulmonary disorder (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations), and chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and…

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 clinical record review, medication information review, and staff interview, it was determined that the facility failed to ensure that was free form unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 4).Findings include: Review of diclofenac dosage guidelines in the Physician's Desk Reference (a comprehensive resource for drug information, providing healthcare professionals with trusted prescribing information and patient adherence resources) revealed the following: Diclofenac gel is only indicated for the relief of the pain of osteoarthritis of joints amenable to topical treatment such as the knees and hands. The gel was not evaluated for use on joints of the spine, hip, or shoulder with dosage guidelines of 4 g (4.5 inches) topically per knee, ankle, or foot joint 4 times daily (Max: 16 g/day per lower extremity joint) and/or 2 g (2.25 inches) topically per elbow, wrist, or hand joint 4 times daily (Max: 8 g/day per upper extremity joint). Do not exceed a…

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 review of select facility grievances, review of the menu, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable and at an appetizing temperatures at one of one meal observed.Findings include:Review of facility grievance filed on January 9, 2025, read, in part, cold food.Review of facility grievance filed on January 24, 2025, read, in part, food is cold.Review of facility grievance filed on July 1, 2025, read, in part, food is served cold all the time.Review of facility grievance filed on July 4, 2025, read, in part, after waiting 20 minutes, lunch was served and the cheeseburger was cold.Interview with Resident 25 on July 28, 2025, at 11:43 AM, she revealed the temperature of the food is poor when it is served.Interview with Resident 124 on July 28, 2025, at 11:50 AM, she revealed the food is always cold. During a group interview on July 29, 2025, at 11:05 AM, Resident 60 stated that food is always cold by the time it is served at the end of her hallway. Resident 168 revealed she…

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, review of select facility documentation, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents received food that accommodated their preferences for two of two residents reviewed for meal accuracy (Residents 102 and 104).Findings include:During an interview with Resident 104 on July 29, 2025, at 11:05 AM, he revealed that he frequently does not receive the meal he has selected.Review of the lunch menu for July 29, 2025, revealed the main entree was honey dijon chicken, and the alternate entree was a salmon patty.Observation of Resident 102 on July 29, 2025, at 12:10 PM, revealed he was eating his lunch in his room, and he was scraping the sauce off of his chicken. During an immediate interview with Resident 102, he revealed that he did not receive what he had requested for lunch, and that he did not like what he was served.At the time of the observation, Resident 146, Resident 102's roommate, stated that he had put a timely request in the book for himself and Resident 102 to receive the alternate entree…

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 review of facility policy, closed clinical record, resident account statement and staff interview it was determined that the facility failed to convey resident account balance in accordance with State law and closed accounts upon discharge in a timely manner for one of 2 closed resident records, Resident 12. Findings include: A review of the facility policy titled, Account Receivable Refunds, last revised May 5, 2023, states, Credit balances to be refunded after researching for validity. Private pay credit balances/overpayment are to be refunded within 30 days. The facility confirmed that on May 17, 2024, complainant paid on the Resident 12's account to cover May 1, 2024, through May 31, 2024. Review of the closed clinical record for Resident 12, revealed resident was dischaarged from the facility on May 24, 2024. Complainant states that she has contacted the facility several times to request a refund, without success of receiving the refund. Review of Resident 12's account indicated that the complainant should have received a refund in the amount of $2,424.00 (two…

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 observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 37 residents reviewed (Residents 17, 100, 117, and 131). Findings include: Review of Resident 17's clinical record revealed diagnoses that included diabetes mellitus (DM- a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and atrial fibrillation (irregular and rapid heartbeat). A review of Resident 17's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date of June 29, 2024, revealed in Section P. Restraints and Alarms, that Resident 17 was coded to use a restraint less than daily. Resident has a BIMS (brief interview of mental status) of 15, indicating she is cognitively intact. During…

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 clinical record review and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 37 residents reviewed (Residents 3, 45, 88, and 131). Findings include: Review of Resident 3's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs) and hypertension (high blood pressure). Review Resident 3's current physician orders revealed no orders for weights. Review of Resident 3's care plan revealed a focus for at nutritional risk with an intervention for weights as ordered dated January 31, 2024, and an intervention for weekly weights on Monday mornings, with a revision date of August 6, 2024. Review of Resident 3's weight records on August 21, 2024, revealed that their last weight was documented as being obtained on August 8, 2024. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 22, 2024, at 11:21 AM, the NHA indicated that Resident 3's weekly weights were…

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, policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 37 residents reviewed (Residents 11, 117, and 326). Findings Include: Review of Resident 11's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), muscle weakness, and obstructive sleep apnea (a sleep-related breathing disorder that causes repeated disruptions in breathing during sleep). Review of Resident 11's physician orders revealed an order for Dialysis Precautions: No blood draws/ injections/ blood pressure from right arm. Emergency kit at bedside containing appropriate equipment, with a start date of July 4, 2024. Review of Resident 11's clinical record revealed she has been receiving hemodialysis (a treatment to filter wastes and water from your blood when your kidneys are not working well) since her original admission to 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 clinical record review, policy review, and staff interview, it was determined that the facility failed ensure failed to ensure effects and side effects of psychotropic medications was being monitored for three of five residents reviewed (Resident 67, 100, and 131). Findings include: Review of facility policy, Antipsychotic Medication Use, revised July 2022, revealed, The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications and Nursing staff shall monitor for and report . side effects and adverse consequences of antipsychotic medications to the attending physician. Review of Resident 67's clinical record revealed diagnoses that included psychotic disorder (a condition that causes people to lose touch with reality) and depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine). Review of Resident 67's physician's orders dated August 20, 2024, revealed a current order for Seroquel…

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 observations, review of select facility documentation, and staff interviews, it was determined that the facility failed to utilize equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Observation of the dish machine on August 19, 2024, at 9:50 AM, revealed the wash cycle temperature was reading 132 degrees Fahrenheit (degrees F- unit of measure), below the minimum standard for safety of 150 F. Return observation of the dish machine during lunchtime on August 19, 2024, at 1:11 PM, revealed the wash cycle temperature was reading 125 F and the dishes that came out of the cycle still had food particles on them. Employee 5 (Dietary Employee) took the rack of dishes and returned them to the front of the dish machine to be rewashed. Interview with Employee 4 (Dietary Manager) on August 19, 2024, at 1:26 PM, revealed when the dish machine is not functioning properly, the process is to move to paper products or use the three-compartment sink to wash dishes, and that he does have a work order in for the dish machine.…

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 staff interviews and facility policy review, it was determined the facility failed to maintain a data collection system of surveillance for three of 12 months reviewed (October 2023; November 2023; and December 2023). Findings include: Review of the facility policy, titled Surveillance for Infections, last reviewed January 19, 2024, revealed the facility will maintain a monthly line list of residents with infections for trending and outbreak potential to include the following data; identifying information i.e., name, age, room number, unit, and attending physician; admission date, date of onset, symptoms if known, and date of positive diagnostic test; site; pathogen and invasive procedures or risk factors (i.e., surgery, indwelling tubes, fractured hip, malnutrition, altered mental status). During an interview with the Employee 3 (Infection Control Preventionist [ICP]) on August 20, 2024, at approximately 11:00 AM, the ICP revealed the facility was unable to find any data collection system of surveillance from the previous full health survey through June of 2024. The ICP…

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 observations, clinical record review, policy review, and resident and staff interviews, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for one of 34 residents reviewed (Resident 4). Findings include: Review of facility policy, titled Answering the call light, last revised September 2022, read, in part, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Review of Resident 4's clinical record revealed diagnoses that included left above the knee amputation (AKA- removing the leg from the body), muscle weakness, and seizure disorder (a condition where brain cells malfunction and send electrical signals uncontrollably) Observation in Resident 4's room on August 20, 2024, at 9:34 AM, revealed her call bell was out of reach, wrapped up around her left enabler bar. During an interview with Resident 4 on August 20,…

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 clinical record review, state regulation, and staff interview, it was determined that the facility failed to conduct a Significant Change Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental and psychosocial needs) for one of two residents reviewed for Hospice (Resident 23). Findings include: Review of Centers for Medicare and Medicaid Services' Resident Assessment Instrument Version 3.0 Manual (instructions for completing the resident Minimum Data Set assessment) revealed instructions in Chapter 2 that included the direction of, An [Significant Change Minimum Data Set] is required to be preformed when a terminally ill resident enrolls in hospice program . Review of Resident 23's clinical record revealed diagnoses that included Alzheimer's disease (irreversible, progressive degenerative disease of the brain the results in decreased contact with reality and decreased ability to perform activities of daily living) and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring of fluid restrictions for two of eight residents reviewed for nutrition/hydration needs (Residents 3 and 117). Findings include: Review of facility policy, titled Encouraging and Restricting Fluids, with a last revised date of October 2010, indicated in section titled General Guidelines to 1. Follow specific instructions concerning fluid intake or restrictions; and in section titled Reporting to 1. Notify the supervisor if the resident refuses the procedure and 2. Report other information in accordance with facility policy and professional standards of practice. Review of Resident 3's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs) and hypertension (high blood pressure). Review of Resident 3's physician orders revealed an order for 1800 cc (cubic centimeters) fluid restriction in 24-hour period, with an original order date of January…

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, resident and staff interviews, policy review, and clinical record review, it was determined that the facility failed to document completely and accurately on the clinical records for one of three residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Charting and Documentation, last revised July 2017, revealed the medical record should facilitate communication between the interdisciplinary team. Review of the clinical record for Resident 1 on July 29, 2024, revealed diagnoses that included congestive obstructive pulmonary disease (COPD-disease process that causes decreased ability of the lungs to perform) and anemia (a reduction in red blood cells). Observation of Resident 1 on July 29, 2024, at 1:00 PM, revealed the Resident resting in his bed. The Resident had no complaints regarding his care and services. On July 17, 2024, Resident 1 left the faciity on a leave of absence (LOA). Resident's family member signed Resident 1 out in the sign out log at the main desk, but entered the wrong date. Resident 1's niece confirmed 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 a closed record review, staff interviews, and policy review, the facility failed to assist the resident in obtaining and emergency dental services for one of 15 residents reviewed (Resident 13). Findings include: Review of the facility's policy, titled Emergency Dental Care, last reviewed April 2007, stated emergency dental care is available on a 24 hour basis. Emergency dental services include services to treat broken, or otherwise damaged teeth. Review of Resident 13's closed clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and dysphagia (difficulty swallowing). Resident 13 was admitted to the facility on [DATE], and discharged to home on February 8, 2024. A review of the closed clinical record nursing note dated September 22, 2023, statesd, lower dentures broken. Resident stated last night staff was cleaning them and accidentally dropped dentures on to the floor causing them to…

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 clinical record review and staff interview, it was determined that the facility failed to ensure a significant change assessment was completed for one of four residents reviewed (Resident 8). Findings include: A review of Resident 8's clinical record on April 1, 2024, revealed diagnoses that included Paraplegia (the inability to voluntarily move the lower parts of the body) and Atrial Fibrillation (irregular and rapid heartbeat). A review of Resident 8's usual weight range prior to January 1, 2024, was documented as 168.3 to 172.0 pounds. A review of the clinical record for Resident 8 on April 1, 2024, revealed Resident 8 had a significant weight loss of 15 % in February 2024. Resident 8's weight on January 1, 2024, was 168.3 pounds, and on February 7, 2024, weighed 143.0 pounds. Resident 8 was diagnosed with a stage 2 pressure ulcer (ulcer involving loss of the top layers of the skin) on February 21, 2024. Resident 8 was weighed again on March 4, 2024, and weighed 134 pounds, an additional 9-pound weight loss. A review of the clinical record on April 1, 2024, revealed no…

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 staff interview, policy review, and facility investigation, it was determined that the facility failed to prevent potential accidents/hazards for controlled substances for one nursing unit (B Wing) and a wandering resident (Resident 11). Findings include: A review of the facility policy, titled Controlled Substances, last revised April 2019, Line 4, stated, Access to controlled medications remains locked at all times; and Line 12, C. stated, Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing immediately. A review of the event investigation dated March 25, 2024, revealed that Employee 1 (Licensed Practical Nurse) delivered and reconciled with Employee 2 (Licensed Practical Nurse) a card containing 30 tablets, 15 milligrams each tablet, of morphine (a non-synthetic narcotic with a high potential abuse and is derived from opium and is used for the treatment of pain). The delivery of the medication occurred on March 24, 2024, at approximately 7:30 PM. Based on Employee 2's statement, the medication bag was placed on 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 review of facility policy, facility investigation, and staff interview, it was determined that the facility failed to follow procedures to secure controlled medications on one of five nursing units (B Wing). Finding include: A review of the facility policy on April 2, 2024, titled, Controlled Substances, last revised April 2019, stated that any discrepancies in the controlled substance count are documented and reported to the director of nursing (DON) services immediately; controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications; and the DON services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator. A review of the facility's event investigation dated March 25, 2024, revealed that Employee 1 (Licensed Practical Nurse) was delivered and reconciled with Employee 2 (Licensed Practical Nurse) a card containing 30 tablets with 15 milligrams each of morphine (a…

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) for one of 3 residents reviewed (Resident 1). Findings Include: Review of the facility policy titled, COVID-19 Infection Control Protocols to Minimize Exposure, with an annual review in 2023, For residents going to medical appointments, regular communication between the medical facility and the nursing home (in both directions) is essential to help identify residents with potential exposures or symptoms of COVID-19 before they enter the facility so that proper precautions can be implemented. Review of the closed clinical record on December 26, 2023, revealed Resident 1 with diagnoses that included end stage renal disease (kidneys lose the ability to remove waste and balance fluids) and hypertension (elevated blood pressure). Further review of the closed clinical record on December revealed that Resident 1 attended dialysis on December 1,…

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.