Laurel Ridge Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R1).Findings include: Review of the facility policy, Medication Administration dated 3/12/25, indicated medications are administered in accordance with written orders of the prescriber. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/31/26, included diagnoses of hemiplegia (paralysis on one side of the body) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R1's progress notes from admission to discharge (3/24/26 - 5/1/26) documented 14 times that Resident R1 was alert and oriented to person, place, and time. No progress notes were present in the clinical record to indicate 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 facility policy, observation, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for six of seventeen residents as required (Residents R3, R505, R500, R501, R502, and R504) on one of three nursing units and the main dining room. Findings included: Review of the facility policy Accommodation of Needs dated 3/12/25, indicated the resident has the right to a safe, clean comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The maintenance of comfortable sound levels. During an observation on 6/24/25, at 11:32 a.m. Resident R2's room was observed. A large box fan was present, actively blowing toward Resident R2's bed. Large amounts of dust were visible on the fan grill. During a resident group interview (Residents R505, R500, R501, R502, and R504) on 6/24/25, at 1:30 p.m., all five residents in attendance…

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 the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for four of eight residents (Resident R105, R109, R155, and R157). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. Resident R105 had an admission date of 6/9/25, with an MDS completion date of 6/23/25. Resident R109 had an admission date of 6/6/24, with an MDS completion date of 6/24/25. Resident R155 had an admission date of 6/9/25, with an MDS completion date of 6/23/25. Resident R157 had an admission date of 6/9/25, with an MDS completion date of 6/24/25. During an interview on…

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 review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased capillary blood glucose (CBG) levels for one of four residents (R27). Findings: Review of the facility policy, Physician/Advanced Practice Provider Notification dated 3/12/25, indicated, Upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostics, a licensed nurse will: - Perform appropriate clinical observations, - Collect pertinent patient information (e.g., age, diagnoses, prior vital signs, labs, recent changes in medications, previous incidents of a similar nature, code status, etc.), - Report to physician/advanced practice provider (APP). If unable to contact attending physician/APP, the Medical Director will be contacted. Review of the clinical record indicated Resident R27 originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R27's MDS dated [DATE],…

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 review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for two of five residents (Resident R4 and R30). Findings include: Review of the United States Food and Drug Administration prescribing information for potassium chloride (extended release) dated October 2010, indicated, To take this medicine following the frequency and amount prescribed by the physician. This is especially important if the patient is also taking diuretics and/or digitalis preparations. Review of facility policy Medication Administration - Orals dated 3/12/25, indicated that medications are administered in an organized, accurate and safe manner. Review of Resident R30's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 5/2/25, included diagnoses of atrial…

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 review of facility policy and documents, clinical records, and staff interview, it was determined that the facility failed to make certain a resident was free from the use of a physical restraint without a physician's order for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Abuse Prohibition, reviewed 6/3/24, revealed that the facility prohibits abuse, mistreatment, neglect, misappropriation of property, and exploitation. This includes freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Review of the facility policy, Restraints: Use of reviewed 6/3/24, indicated a physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: -Is attached or adjacent to the patient's body, -Cannot be removed easily by the patient, and -Restricts the patient's freedom of movement or normal access…

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 review of state laws, facility documents, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of possible abuse for one of three residents (Resident R1). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of facility policy Abuse Prohibition, reviewed 6/3/24, revealed that the facility prohibits abuse, mistreatment, neglect, misappropriation of property, and exploitation. This includes freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The policy further stated that anyone who witnesses an…

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 review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for three of seven Residents (Residents R5, R30, R37). Findings: Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and anxiety. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/1/24, indicated the diagnoses remain current. Review of a physician order dated 5/29/24, revealed Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin, 7 units once a day, if greater than 350 move to a medium scale two times a day. On 7/1/24, Lantus (long-acting type of insulin…

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 review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of two residents (Resident R12), by failing to follow physicians orders during transfer from a wheelchair into bed. This was identified as past non-compliance. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Abuse Prohibition last reviewed on 6/3/24, with a previous reivew date of 11/1/23, indicated that the center staff are doing all that is within their control to prevent occurrences of abuse, neglect, etc. The center must ensure that all staff are aware of reporting requirements. The investigation will be…

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 review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with hospice services (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care) center for two of two residents receiving hospice (Resident R13 and R49). Findings include: A review of the facility policy Hospice last reviewed 4/26/23, indicated the hospice will provide a communication process, including the method for documenting the communication between the center and the hospice provider to ensure that the patient's needs are met 24 hours per day A review of the clinical record indicated that Resident R13 was admitted to the facility on [DATE], with diagnoses that included iron deficient anemia secondary to chronic blood loss, chronic kidney disease, and failure to thrive. A review of a physician's order dated 11/23/22, indicated Resident R13 was admitted to hospice services. Review of a care plan indicated…

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.