Laurelbrook Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility document and policy review, the facility failed to report allegations of resident-to-resident abuse and results of the investigations within the required timeframes for 3 allegations that involved 5 residents (Residents #2, #41, #23, #53, and #54) of 5 residents reviewed for abuse. A facility policy titled, Abuse, Neglect and Exploitation, revised 12/29/2025, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy also indicated, VII. A. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is…

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 interview, record review, facility document and policy review, the facility failed to conduct thorough abuse investigations for three allegations that involved 5 (Residents #2, #41, #23, #53, and #54) of 5 residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, revised 12/29/2025, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy also indicated, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. [exempli gratia, 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, interview, record review, facility policy review, and Centers for Medicare and Medicaid Services (CMS) guidelines, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #29) 2 sampled residents reviewed for infection control. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 10/01/2025, indicated, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy specified in the section Initiation of Enhanced Barrier Precautions that, b. A standing order for enhanced barrier precautions will be used for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers) and/or indwelling medical devices (e.g., urinary catheters, feeding tubes, tracheostomy, hemodialysis catheters, [sic]) even if the resident is not known to be infected or colonized with…

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, refrigerator temperature logs review, and interview the facility failed to maintain complete refrigerator temperature logs for 3 of 3 refrigerator temperature logs reviewed which had the potential to affect 43 of 43 residents. The findings include: Review of the facility's policy titled, Refrigerators and Freezers, dated 3/11/2019, revealed .The facility will ensure safe refrigerator and freezer .temperatures .Monthly tracking sheets for all refrigerators .will be posted to record temperatures .Monthly tracking sheets will include time, temperatures, initials . Review of refrigerator temperature logs for 8/1/2024-10/22/2024 revealed there was no documentation the refrigerator temperatures had been obtained as follows: Food Black refrigerator #3 8/2024 - 5 of 31 days (8/1/2024, 8/2/2024, 8/3/2024, 8/4/2024, and 8/5/2024) 9/2024 - 2 of 30 days (9/12/2024 and 9/16/2024) 10/2024 - 3 of 22 days (10/3/2024, 10/7/2024, and 10/11/2024) Medication refrigerator labeled Team 1 9/2024 - 2 of 30 days (9/12/2024 and 9/16/2024) 10/2024 - 3 of 22 days (10/3/2024,…

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 policy review, medical record review, and interview the facility failed to provide information to the resident or resident responsible party regarding their right to formulate an advance directive for 3 residents (Resident #7, #40, and #94) of 16 residents reviewed for advance directives. The findings include: Review of the facility's policy titled, Advance, Directive, Presence of, revised 11/2013, revealed .Advance Care Plan (Living Will) are written instructions stating how you want your future medical decisions made, in the event that you become unable to make or to communicate such decisions for yourself .A patient/resident may have written directions related to treatment choices .in accordance with state law. An advance directive is a means for the resident to communicate his or her wishes, which may include withdrawing or withholding medications . The .Patient Rights & [and] Responsibilities .statement provided to the resident and/or family member when admitted to the facility includes a statement…

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, review of facility documentation and interview, the facility failed to report an allegation of abuse to the State Designated Authority (State Agency) for 1 resident (Resident #321) of 27 residents reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Funds Protocol, undated, revealed .Covered Individual is any owner .employee, manager, agent .of this facility. If a covered individual observes events or becomes aware of information .suspicion of crime has occurred against a resident or individual receiving care from this facility .[the facility] Must notify .The State Survey Agency .Local Law Enforcement .Reports must be within 24 hours (if there is not serious bodily injury) .Within 2 hours (if there is serious bodily injury) .Staff members and persons affiliated with this facility shall not knowingly .Fail to report an incident .withhold information to reporting agencies . Review of the medical record showed Resident #321 was…

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 medical record review and interview the facility failed to submit a Pre-admission Screening and Resident Review (PASARR) to the state-designated authority after a new mental health diagnosis was added for 1 resident (Resident #31) of 27 residents reviewed for PASARR. The findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Homelessness, Post Traumatic Stress Disorder, and Major Depressive Disorder. Continued review revealed a diagnosis of Bipolar Disorder was added on 8/27/2024. Review of the PASARR for Resident #31 dated 6/27/2024, revealed the diagnoses of Anxiety Disorder, Depression, and Post-Traumatic Stress Disorder was noted on the PASARR. Continued review revealed no documentation a new PASARR had been submitted after a new mental health diagnosis of Bipolar disorder was added on 8/27/2024. During an interview on 10/23/2024 at 2:32 PM, the Interim Director of Nursing confirmed a submission for a level II PASARR was…

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 a facility policy, medical record review, and interview, the facility failed to obtain a physician's order for a physical restraint for 1 resident (Resident#1) and monitoring of a physical restraint for 14 of 31 days the restraint was utilized of 4 residents reviewed for physical and chemical restraints. The findings included: Review of a facility policy titled, Restraint Policy, not dated, showed .Definition of a Physical Restraint: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the residents' body that the individual can not remove easily, which restricts freedom of movement or normal access to one's body .8 .a doctor's order must be obtained to implement restraints . Resident #1 was admitted to the facility on [DATE], and discharged on 3/28/2023, with diagnoses including Dementia with Behavioral Disturbance, Suicidal Ideations, Mood [Affective] Disorder, Adjustment Disorder, Vascular Dementia, Delusional Disorders, Anxiety Disorder,…

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 medical record review, facility documentation, and interview, the facility failed to refer 1 resident (Resident #1) of 4 residents reviewed to the state-designated authority for a Level II PASRR (Pre-admission Screening and Resident Review) after the resident was identified with possible serious mental disorder. The findings include: Review of Resident #1's Pre-admission Screening and Resident Review (PASRR) Level 1 Screen Outcome dated 11/30/2022, showed .No mental health diagnosis is known or suspected .Mental Health Symptoms .Physical Violence .current or within the past 30 days .Excessive Tearfulness .current or within the past 30 days .Inpatient Psychiatric Hospital .current or within the past 30 days .Psychotropic Medications .Seroquel 25 mg [milligram] daily . The PASRR showed the resident had no diagnosis of Anxiety Disorder or Suicidal Ideations at the time the Level I PASRR was submitted. Therefore, no Level II evaluation was completed due to a negative Level I PASRR. Resident #1 was admitted…

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 a facility policy, medical record review, and interview, the facility failed to follow a physician's order to apply a back brace daily, for 1 resident (Resident#1) of 4 residents reviewed for physicians' orders. The findings included: Resident #1 was admitted to the facility on [DATE], and discharged on 3/28/2023, with diagnoses including Dementia with Behavioral Disturbance, Suicidal Ideations, Mood [Affective] Disorder, Adjustment Disorder, Vascular Dementia, Delusional Disorders, Anxiety Disorder, Nonalcoholic Steatohepatitis, Transient Cerebral Ischemic Attack, Non-traumatic Intracerebral Hemorrhage, Fatty Liver, Osteoarthritis, and Hepatomegaly. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The resident was independent with walking, dressing, personal hygiene, required supervision with no assistance for bed mobility, toilet use, supervision with 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 review of facility policy, review of Centers for Disease Control (CDC) guidance, medical record review, observation, and interview, the facility failed to ensure staff utilized the proper Personal Protective Equipment (PPE) during a Coronavirus (COVID-19) outbreak for 1 (Resident #31) of 8 COVID-19 positive residents. The findings include: Review of the facility policy titled, Coronavirus 2019 (COVID-19) Response Plan and Facility Policy and Protocol dated 11/23/2020, showed .Isolation Precautions .Residents with suspected or confirmed COVID-19 will be placed in isolation immediately .The type of isolation used is Standard Precautions, Contact Precautions, Airborne Precautions and Eye Protection . Review of CDC guidance, titled Interim Infection Prevention and Control [IPC] Recommendations to Prevent SARS-CoV-2 [COVID-19] Spread in Nursing Homes, updated 9/10/2021 showed .nursing homes .must sustain core IPC practices and remain vigilant for SARS-CoV-2 infection among residents and HCP [health care…

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 CMS's (The Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual CH (chapter) 2: Assessments for the RAI dated October 2018, medical record review, and interview, the facility failed to complete a significant change assessment for 1 resident (#20) of 17 residents reviewed for a decline in activities of daily living. The findings include: Review of CMS's RAI Version 3.0 [NAME] CH 2: Assessments for the RAI revealed A SCSA [significant change of status assessment] is appropriate when .There is a determination that a significant change .in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments .A SCSA is appropriate if there are either two or more areas of decline .Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance .Resident's incontinence…

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 the facility policy, medical record review, and interview, the facility failed to develop a comprehensive care plan for bladder incontinence for 1 resident (#23) of 3 residents reviewed of 14 sampled residents. The findings include: Review of the facility policy Care Plans-Comprehensive undated revealed .An individualized comprehensive care plan that includes measurable objectives .to meet the resident's .needs .The comprehensive care plan is based on a thorough assessment .Each resident's comprehensive care plan is designed to .Identify the professional services that are responsible for each element of care . Medical record review revealed Resident # 23 was admitted to facility on 9/21/12 and readmitted on [DATE] with diagnoses including Heart Failure, Chronic Kidney Disease, Morbid Obesity, Dementia with Behavioral Disturbance, Type II Diabetes, and Delusional Disorder. Medical record review of an Interdisciplinary Care Plan Notes form dated 9/25/18 revealed the resident was incontinent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure a Physician Orders for Scope of Treatment (POST) forms were completed for 2 residents (#31 and #40) of 17 residents reviewed for POST forms. The findings include: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Type 2 Diabetes, Major Depressive Disorder, and Dementia. Medical record review revealed a POST form undated had been prepared and signed by the Assistant Director of Nursing (ADON). Further review revealed the POST form had not been signed or dated by the Physician. Interview with the ADON on 8/19/19 at 2:00 PM, in the conference room, revealed she had completed the Post form for Resident #31. Further interview revealed she had talked with the son and he wanted to make a change to the form. Continued interview revealed the change had been made on 6/12/19 and a new form was to be filled out completely. Further interview revealed she is not sure why 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.