Laurel Heights Community Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary condition was met for food storage in the kitchen when there was a slight dent on a can of Hunt's Tomato Sauce in the storage room. This failure was likely to result in putting residents at risk for foodborne illness (diseases caused by consuming contaminated food or drink). During a concurrent observation and interview on 7/27/25 at 11:52 AM with Dietary Service Supervisor (DSS) in the storage room in the kitchen, there was a dent on the can of Hunt's Tomato Sauce on a shelf. The can indicated, . BEST BY OCT (October) 17 2026 . NET WT (Weight) 15 OZ (an abbreviation for ounce, a unit of weight or fluid volume) (425g (gram, a unit of mass in the metric system, equal to one thousandth of a kilogram)) . DSS stated, the can should not have the dent and he needed to throw it away. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan within 7 days after completion of the comprehensive assessment in collaboration with the Interdisciplinary (professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident) Team (IDT) and hospice provider for 1 of 3 residents (Resident 29) receiving hospice services. The deficient practice resulted in the potential for unmet physical, emotional and psychosocial needs, and lack of coordination between the facility and hospice. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to provide a written agreement with the hospice that defined the services to be provided, respective responsibilities, and established a process for communication and collaboration for one of three sampled residents (Resident 29). This deficient practice resulted in the potential for compromised quality of care due to lack of defined roles, responsibilities and communication between the facility and hospice provider for all residents receiving hospice services. During a review of facility's clinical document titled admission Record, dated 7/24/2025, admission record, indicated, resident 29 was admitted on [DATE], and is a Medicare and Medi-Cal beneficiary. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in two (resident rooms [ROOM NUMBERS]) of 14 residents' rooms met the required minimum of 80 square feet (sq ft) per resident. This failure has the potential for residents to not to have enough appropriate space for the provision of care or daily living. During an observation on 7/27/2025 at 10:00 AM, in the course of the initial tour of the facility conducted on the first-floor room [ROOM NUMBER] were occupied by three beds divided by curtains two residents, room [ROOM NUMBER] were occupied by three beds with three residents, with curtains to divide each bed. During an interview on 7/28/25 at 10:20 AM, Resident 24 in Room14, Resident was asked how the space was in their room. Resident 24 stated, I am okay staying with this room, I don't have any issue sharing it to my two neighbors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an avoidable fall for one of four sampled residents (Resident 1) when Resident 1 fell from the mechanical lift device (also known as Hoyer lift, a device that helps caregivers lift and transfer residents from one place to another) while being transferred by Certified Nursing Assistant (CNA) 1 from his bed to recliner. This failure resulted in Resident 1 sustaining a head trauma (injury that occurs when there is a direct or indirect blow to the head), which led to hospitalization and subsequent death.

Inspectors wroteBased on observation, staff interviews, and review of facility documents, the facility failed to: 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. 2. Ensure the Registered Dietitian (RD) provided sufficient consultation to the Food and Nutrition Services department. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure kitchen staff competency for: 1. Calibrating food thermometers; 2. Cooldown procedures for Time/Temperature Control for Safety (TCS) food (food which requires time and temperature monitoring to prevent the growth of harmful bacteria); 3. Procedures for monitoring dishmachine temperature and sanitizer strength; 4. Temperature monitoring for trayline food; 5. Temperature monitoring for food storage coolers; 6. Manual dishwashing using the two-compartment sink; and 7. Testing sanitizer strength used for food contact surfaces. The failure to ensure staff competency regarding required and/or performed tasks had the potential to result in contamination of food and/or utensils and equipment leading to illness caused by pathogens (harmful organisms) for 27 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to follow the planned menu. This failure had the potential to result in inadequate and/or inappropriate nutrients served to residents leading to nutrient related medical complications for 27 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to serve food that was flavorful and at a palatable temperature. This failure had the potential for decreased food intake leading to nutrient related complications for 27 residents who received food from the kitchen.

Inspectors wroteThe facility failed to serve food in a safe and sanitary manner when: 1. Time/Temperature Control for Safety (TCS; food which requires time and temperature monitoring to prevent the growth of harmful bacteria) foods were not monitored for cool down; 2. Raw meat was stored directly next to produce; 3. Different types of thawing meat were commingled; 4. Stored and ready to use utensils and equipment were not clean and/or in poor condition; a. Two of two food processors; b. Seven of seven cutting boards; c. A variety of cooking tools and equipment stored in drawers and on shelving; 5. Wood shelving, cabinets, and drawers had peeling paint and/or built-up residue and grime; 6. TCS food was not discarded by storage recommendations; 7. A storage container holding coffee was not cleaned before refilling; and 8. A freezer gasket was not maintained clean. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) that require dialysis (mechanical removal of wastes and excess fluids from the body) receive services as consistent with professional standards of practice when there was no ongoing communication between the nursing home and the dialysis facility. This failure had the potential to result in misinformation that may negatively affect patient care.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the appropriate texture of pureed food was served to residents. This failure had the potential for residents to aspirate (breath in fluid into the lungs which can cause choking, aspiration pneumonia, and/or death) while consuming food for 10 residents with a prescribed a pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures when: 1. The urine drainage bag of Resident 131 was touching the floor. 2. Staff did not perform hand hygiene (a way of cleaning one's hands that substantially reduces harmful microorganisms on the hands) in between clean and dirty tasks. 3. Staff did not sanitize Resident 9's call light after picking it up from the floor and prior to placing it on Resident 9's bed. 4. Staff did not perform hand hygiene after handling dirty linens. These failures placed Resident 131 at risk for transmission of infectious organisms from the floor to the urinary tract and had the potential for spread of germs in the facility.

Inspectors wroteBased on observation and record review, the facility failed to provide 80 square feet of living space for each resident, in two of 14 resident rooms (resident rooms [ROOM NUMBERS]). This failure had the potential to prevent staff from providing the necessary care and services to the residents, and it could potentially prevent the residents from having enough space for their personal belongings.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs when: On 4/15/24 at 10:15 AM Resident 9's call light was found on the floor and was not plugged in the wall socket. This failure created an un-individualized care and an environment that promotes neglect. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) require but the facility fails to provide them to the resident(s) resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress.

Inspectors wroteBased on record review and interview, the facility failed to complete a comprehensive assessment and failed to monitor weight weekly for one of two sampled residents (Resident 26) after Resident 26 had an unplanned, significant weight gain of 9.4% in February 2024. This failure had the potential for Resident 26 to not receive necessary treatment and care to related to the unplanned, significant weight variance, leading to medical related complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan (CP) for one of 12 sampled residents (Resident 26) when Resident 26's care plan did not include the physician's order to use heel protectors (devices designed for the heel of the foot that help remove the pressure from the heels and prevent and treat pressure ulcers [breakdown of skin integrity due to pressure]). This failure resulted in the care plan not accurately reflecting individualized, person-centered intervention necessary to meet the care needs of Resident 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to prevent pressure ulcer for one of 12 sampled residents (Resident 26) when the physician's order to apply bilateral heel protectors was not carried out. This failure placed Resident 26 at risk to develop pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 131) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when there was no side effect (also known as adverse reactions, are unwanted undesirable effects that are possibly related to a drug) monitoring for the use of Trazodone (a medication used to treat depression [a constant feeling of sadness and loss of interest, which stops a person from doing normal activities] or help with sleep problems). This failure had the potential to place Resident 131 at risk for unrecognized side effects associated with the use of Trazodone that could cause harm to resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Aspart insulin bottle was dated when first opened when: On 4/15/24, an Aspart insulin bottle was found not dated when first opened for use. This practice of either advertently or inadvertently not dating the insulin bottle or vial when first opened will put the resident's health at risk by receiving an expired medication or an insulin that is not potent. It can potentially cause more elevation of the resident's blood sugar resulting to organ damage and/or death.

Inspectors wroteBased on observation and interview, the facility failed to maintain one of three food refrigerators free of significant ice build-up. This failure had the potential to affect the quality and safety of food stored inside the refrigerator.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide six of 31 residents with 80 square feet of usable space in two resident rooms, rooms [ROOM NUMBERS]. This failure had a potential to result in residents tripping and falling while trying to move throughout the rooms, and prevent staff from providing the necessary care and services to the residents. It could also potentially prevent the residents from having enough space for their belongings. During the meeting on 12/08/21, at 11: 30 a. m.,with Resident 2, Resident 2 stated, she attended the Resident Council meetings every month. She stated, No resident raised issues regarding lack of enough space in their rooms, during the last three Resident Council meetings. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to honor the rights and dignity of one of 14 sampled residents (Resident 16), when the resident, who required assistance to eat, was fed her lunch by a standing CNA 1 (Certified Nurse Assistant). The facility's failure to treat the resident with dignity decreased the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu plan for the designated week, 12/5/21. This failure had the potential to cause loss of appetite and boredom with food repetition.