Laurel Creek Health Center

Inspectors wroteBased on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice and resident's needs for Resident 1 by failing to administer oxygen (a life sustaining gas that travels from lungs to the blood and helps convert food into energy), when Resident 1 was found with critically low oxygen levels in the blood (a dangerous, life-threatening condition when the oxygen not reaching body tissues often causing confusion, rapid breathing, and altered level of consciousness-a change in arousal and responsiveness that ranges from mild to severe e.g. lethargy to coma state). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 39 when the controlled drug (a medication that may be abused or cause addiction) record form was not filled out and signed accurately. This failure has the potential to result in diversion of the residents' unused controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 2 of 4 sampled residents (Resident 23 and 39) for a census of 39.1. For Resident 23, a licensed nurse administered the wrong strength of eye drops, a medication to treat and prevent dry eye, per Physician Orders.2. For Resident 39, a licensed nurse did not educate and instruct the resident per manufacturer guidelines when administering a Metered Dose Inhaler (MDI), (a handheld, pressurized device used to treat breathing issues by delivering a specific amount of medicine directly into the airways). These failures resulted in 2 errors identified out of 34 opportunities for error during the observation of medication administration; the facility medication error rate was 5.88%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly labeled and stored in accordance with accepted standards of practice when:1. Multiple opened and undated multidose containers of glucose test strips (strips that can be used to measure blood sugar levels) were found in the medication carts, which had the potential to result in staff using expired, or ineffective glucose test strips to monitor residents blood glucose levels.2. Two over-the-counter eye drop bottles were found at Resident 55's bedside dresser. These failures may result in medications not being stored and maintained in a manner that will will ensure their safety, integrity and proper use placing the residents at risk for contamination, reduced effectiveness, and medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 39 out of 39 residents when:1. Several various metal sheet pans and lids in clean and ready-to-use storage areas a. Were stacked wet while stored away b. Were dusty and oily2. Three large food storage bins had plastic containers for scoops inside the three food storage bins3. Pantry had four open milk cartons without an opened and use by dates written.4. Breakfast meal cart was left wide open, and unattended. These failures had potential to cause food borne illnesses in a highly susceptible population who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when:Resident 1's nasal cannula tubing was found on the floor,Resident 10 and Resident 56's oxygen tubing were on the floor, Resident 10's nebulizer mask was not stored in a bag, and Resident 56's nasal cannula was not stored in a bag,Resident 25's nebulizer mask was not stored in a bag,Resident 19's CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) mask was not stored in a bag, and;Resident 4's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was on the floor and his CPAP mask was not stored in a bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate meals/diets for 12 out of 39 sampled residents (Residents 3, 4, 16, 22, 23, 25, 26, 27, 28, 37, 39 and 43) when meal trays were being checked by unlicensed staff prior to delivery. This failure had the potential for residents on therapeutic diets to receive the wrong foods; residents with food sensitivities/allergies receiving inappropriate foods; and those on modified texture diets receiving inappropriate food items all of which could lead to complications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for two of eight residents (Residents 4 and Resident 34). This failure resulted in medications not being given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Expired and discontinued medications were not available for resident use; 2. Expired COVID-19 (a highly contagious respiratory disease caused by a virus) Test Kits were not available for resident use; 3. Opened single-use vial was discarded after use; 4. Medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and, 5. Medication refrigerator was maintained in proper working condition. These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) for lunch on 2/12/25 when four residents (Resident 4, 10, 16, 17) who were on Pureed (diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) received 1/4 cup serving of meat instead of 1/2 cup of meat as indicated on the menu. This failure had the potential to result in compromising the medical and nutrition status of the four residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. An ice machine was not clean; 2. Refrigerated food and a nutritional shake were not labeled with open, prepared, use by, or expiration dates; and, 3. The concentration of the sanitizer solution for a sanitation solution (red) bucket was less than 200 ppm. These failures had the potential to cause food-borne illness in a highly susceptible population of 31 of 31 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 33 when: 1. Unlabeled and undated jug of distilled water used for CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) was observed on the floor at Resident 13's bedside; 2. Coffee mug was observed on a commode seat in Resident 31's bathroom; 3. Blood pressure (BP) cuff was not disinfected after use between residents (Resident 139, Resident 2, Resident 188, and Resident 4); 4. BP cuff and BP machine was not disinfected with appropriate disinfectant; 5. Dust particles were observed on the exhaust in the clean linen room in the laundry area; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 8), received sufficient fluids to maintain adequate hydration per resident's care plan and per Registered Dietician's assessment. This failure increased Resident 8's risk for dehydration (not enough fluids in the body to carry out normal functions) that can result in complication of the resident's medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 35) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 35's routine dose of antidepressant was not discontinued after it was changed to PRN (as needed) and the PRN order did not have a specified end date. This failure had the potential to result in unnecessary medication for Resident 35, which had the potential for increased risk and exposure to side effects associated with psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one of 14 sampled residents (Resident 34) when Resident 34's Insulin Lispro (a fast-acting type of insulin - a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered with meals as ordered by the physician. This failure had the potential to result in the drop in Resident 34's blood sugar and the potential for Resident 34 to experience signs and symptoms of low blood sugar.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 16) received nectar thickened liquids as ordered by the physician, when Resident 16 was served thin liquids by Certified Nursing Assistant (CNA 2). This failure had the potential for Resident 16 to experience aspiration (accidental inhalation of food or fluids into the airways or lungs) and choking.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one out of two sampled resident (Resident 1) did not develop a pressure ulcer when the facility did not follow their policy and procedure for prevention of pressure injuries such as inspecting the skin daily when performing or assisting with personal care or activities of daily living (ADL, tasks of everyday life), did not continually evaluate Resident 1 ' s potential for skin breakdown per physician ' s order and request a preventative treatment prescribed by the physician once Resident 1 became incontinent of both bladder (the ability to control on when to empty the urine)and bowel function (the ability to control when to have a bowel movement). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure nursing staff were competent and had skills to provide nursing and related services to assure resident safety when the nurses did not follow the facility ' s policy and procedure on narcotic (drug that causes stupor or insensibility) count reconciliation (physical inventory of all controlled substances), when nurses left the medicine cart (med cart) keys on top of the med cart unattended and the nurses did not know Baza Cream (an incontinent cream that contains zinc oxide, a medicated cream, ointment or paste that treats or prevents skin irritation) requires a Physician Order (PO, the instruction the physician had written for a patients ' treatment ) prior to applying it on a resident skin. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that three of 12 sampled residents (Residents 23, 25, 141) had interdisciplinary (interventions from all departments) and comprehensive person-centered care plans that addressed their preferences (choices), goals (measurable expected outcomes) and interventions (care and services necessary to achieve those goals) when: 1) Resident 23 was on a Regular diet (one that does not include any dietary restrictions). A care plan for food preferences of broth, cheese & crackers, and pineapple to treat weight loss recommended by Registered Dietician (RD) was not developed, implemented and no interventions. 2) Resident 23 was taking Remeron (antidepressant) for depression (A mental health disorder characterized by persistently low mood or loss of interest in activities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six Licensed Staff, which included one Physical Therapist had the appropriate skills and competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles) in providing care included but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs when: 1) A care plan was not developed and implemented for Resident 23, 25, 141 for special diet recommended by Registered Dietician (RD) and medications Remeron & Trazadone and oxygen administration. 2) A Licensed nurse did not clarify order with the Medical Doctor (MD) for medications called Remeron and Trazadone for Depression. Residents 23 & 25 did not have a Depression diagnosis documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1. A medication storage room was left unlocked and unattended, with the potential for access by unlicensed staff or facility residents. 2. Expired medications were not removed and destroyed according to facility policy, with the potential for administration of expired and ineffective medications. 3. Medications requiring storage in the refrigerator were kept at a temperature higher than the recommended temperature range, with the potential for negative impact on effectiveness of the medications stored in the refrigerator. 4. Medications requiring storage at room temperature were kept in a medication room without monitoring the room temperature, a thermometer, or a temperature log with the potential for negative impact on potency of the stored medications. 5. [...]

Inspectors wroteBased on observations, interviews, and records review, the facility failed to implement measures to reduce the risk of disease and infection transmission, when: 1. The Certified Nursing Assistants (CNA) did not perform proper hand hygiene before and after assisting residents with meals and before and after passing individual food trays, for 12 out of 12 residents (Residents 2, 3, 5, 10, 11, 12, 14, 15, 22, 29, 34 and 38). This failure had the potential to result in spread of infections and/or transmission of diseases to the staff and vulnerable residents. 2. The facility failed to ensure staff were not wearing gloves while feeding a resident (Resident 11). This failure had the potential for an issue with resident dignity and/or increased infection transmission. 3. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure they had developed a baseline care plan for one out of seven sampled residents (Resident 240) within the first 48 hours of admission which should have provided instructions for the provision of effective and person-centered care for Resident 240. This failure could adversely affect the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures when Expired E-Kits (Emergency-Kit, storage box containing emergency supplies of medication) medications were not removed and replaced according to facility policy, with the potential for administration of expired and ineffective emergency medications or having medication errors.

Inspectors wroteBased on interviews, and records review, the facility failed to: 1. act on the facility's Consultant Pharmacist's (CP) recommendation for one of three residents (Resident 15) when the physician, the Director of Nursing (DON), and new CP did not follow-through the recommendation to gradually reduce the dose of escitalopram (medication for depression - a mood disorder that causes a persistent feeling of sadness and loss of interest affecting how you feel, think and behave and can lead to a variety of emotional and physical problems) with the addition of buspirone (medication for anxiety - a mental disorder in which a person is often worried or anxious about many things and finds it hard to control this anxiety). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% (percent) for three sampled residents (Resident 142, Resident 190, and Resident 8) when: 1. For Resident 142, a licensed staff did not administer Resident's oxybutin (a medication for overactive bladder), as ordered by the physician. 2. For Resident 190, a licensed staff did not administer Resident's fish oil (a medication for heart health), as ordered by the physician. 3a. For Resident 8, a licensed staff did not administer Resident 8's fish oil as ordered by the physician. 3b. For Resident 3, a licensed staff did not administer Resident 8's glucosamine (a medication for joint health) as ordered by the physician. These failures resulted in four errors identified out of 34 opportunities during the observation of medication administration; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their compliance and ethics policy when a medication temperature monitoring log was falsified with a potential to negatively impact the quality of pharmaceutical products being stored in a medication storage room or a medication refrigerator.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light (a device used by a patient to signal his or her need for assistance from staff) for one out of five sampled residents (Resident 36) was working as indicated by the funtioning of the red light above Resident 36's door. This failure could result in residents not being able to call staff for assistance which had the potential to result in late provision of care, care not rendered, or accidents and falls.