Laurel Square Healthcare and Rehabilitation Center

Inspectors wroteBased on standards of professional practice, observation, and interview with staff it was determined that the facility failed to store food in accordance with standards for food service safety (main kitchen and first floor nursing unit).

Inspectors wroteBased on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to follow the planned menus for two of four days observed (5/26 and 5/28).

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process. Findings Include: Review of facility documentation Facility Assessment reviewed February 11, 2026, revealed individuals who were involved in completing the review included: Nursing Home Administrator (Employee E1), Director of Nursing (Employee E2), Admissions Director (Employee E3), Business Office Manager (Employee E4), House Keeping Director (Employee E5), Rehabilitation Director (Employee E6), Human Resources (Employee E7), Dietary (Employee E8), and the Medical Director (Employee E9). [...]

Inspectors wroteBased on review of clinical records, review of policy, and interview with staff, it was determined that facility did not develop and implement a baseline care plan for one out of six residents reviewed, related to bladder incontinence (Resident R2)

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with residents and staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispense and administration of medication to meet the needs of a resident according to professional standards of practice relating to medication administration for 1 of 11 residents reviewed (Resident R1)

Inspectors wroteBased on observation, review of facility policies, and staff and resident interviews, it was determined that the facility ensure that refrigerated food items were timely discarded to ensure food safety.

Inspectors wroteBased on observations of the noon meal service, reviews of food committee meeting minutes, reviews of policies and procedures and interviews with residents and staff, it was determined that foods and drinks were not appetizing, palatable and served at safe temperatures that were satisfactory to the residents. Residents: (R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R15 and R16)

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews with residents and staff, it was determined that the facility failed to prepare and serve items as planned on the menu and failed to provide residents with their requested foods of preference for five of 18 residents interviewed (Residents R23, R28, R63, R70, and R289 ). Findings Include: Review of the facility posted Always Available menu posted in the first-floor dining/activities room lists beverages as Apple Juice, Cranberry Juice, Orange Juice, Hot Tea, Coffee, and Decaf Coffee. [...]

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety for three of three floors reviewed. (Ground, First, and Second Floors) Findings Include: Review of facility policy titled, Food Storage: Cold Foods revised April 2018 states, Policy Statement- All Time/Temperature Control For Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines for the FDA Food Code. Further review of the policy revealed, Procedures . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of facility policy titled, Food Storage: Dry Goods, revised September 2017 states, Procedures- . 5. [...]

Inspectors wroteBased on review of facility policies, observations and staff interview, it was determined that the facility failed to maintain a clean and homelike environment for two of two nursing units observed (First Floor and Second Floor Units). Findings Include: Review of facility policy titled, Homelike Environment revised February 21, 2025, states Policy Statement- Residents are provided with safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment; f. pleasant, neutral scents. [...]

Inspectors wroteBased on review of facility policies, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of eighteen residents reviewed (Resident R23 and Resident R80). Findings Include: Review of facility policy titled, Care Planning- Interdisciplinary Team, with a revision date of March 2022 states, Policy Statement- The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation- 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. [...]

Inspectors wroteBased on reviews of staff training and competency sets for nursing assistants, reviews of the facility assessment and interviews with staff, it was determined that, the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for two of four nurse aides personnel records reviewed. (Employees E12 and E13). Findings Include: Employee E12, nursing assistant was hired on July 25, 2025. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant. Employee E13, nursing assistant was hired on October 29, 2010. [...]

Inspectors wroteBased upon interviews with resident and staff, review of clinical records and facility policies, it was determined the facility failed to ensure the rights of a resident were exercised to refuse a room change in accordance with professional standards of practice for one of 18 resident records reviewed (Resident R70). Findings Include: Review of the facility's policy titled, Resident Rights states, basic rights to all residents of the facility include exercising his or her rights and be supported by the facility in exercising those rights. Residents have the right to perform services for the facility if chooses or the right to refuse and the right to refuse a transfer from a distinct part within the institution. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of eighteen residents reviewed (Residents R50). Findings Include: Review of facility policy titled, Care Planning- Interdisciplinary Team, with a revision date of March 2022 states, Policy Statement- The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation- 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. [...]

Inspectors wroteBased on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding Include: Observations were made on the day of arrival to the facility, June 2, 2025 at 9:03 a.m. of the parking lot grass area where there were multiple trash items. Trash items in the grass and in the parking lot included; used paper towels, latex gloves, empty plastic bottles, plastic disposable utensils, and food particles. A tour of the Food Service Department was conducted on June 2, 2025, at 10:23 a.m., with the Food Director, Employee E9. In the area of the loading dock, refuse area one of two dumpsters was so full boxes were preventing the dumpster from completely closing. A toilet was near the dumpster area along with PVC piping that was once used at the facility. [...]

Inspectors wroteThe facility must ensure that residents who require colostomy services, received such care consistent with professional standards of practice and the comprehensive person-centered care plan, and the resident's goals and preferences for one of five residents reviewed. (Resident R1) Findings Include: According to guidelines from American Cancer Society for Caring for colostomy (A colostomy is an opening in the belly abdominal wall that's made during surgery. It's usually needed because a problem is causing the colon to not work properly, or a disease is affecting a part of the colon and it needs to be removed) , The skin around your stoma should always look the same as skin anywhere else on your abdomen. Use the right size pouch and skin barrier opening. An opening that's too small can cut or injure the stoma and may cause it to swell. [...]

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential equipment related to bathroom sink and ice and water dispenser on the first floor were in a safe and working condition for use by residents and nursing staff on one of two nursing units (Second Floor nursing unit).

Inspectors wroteBased on observations and interviews with resident and staff, it was determined that the facility failed to make a process available to allow residents to file a grievance anonymously on two of two nursing units. (First and Second Floor)

Inspectors wroteBased on review of facility policy, review of facility documentation, and review of clinical records, it was determined that the facility did not ensure to develop a person-centered, comprehensive care plan related to bowel obstruction and constipation for one of 19 residents reviewed (Resident R72)

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records and interview with residents, it was determined that facility did not ensure to assist dependent residents with activities of daily living related to hearing aids, nail care and hygiene care (Residents R2, R9)

Inspectors wroteBased on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two of two residents receiving dialysis reviewed (Residents R54 and R7).

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of yearly performance reviews for nurse aides for two out of five employees reviewed (Employee E13, E14)

Inspectors wroteBased on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility did not ensure to post nursing staffing information in a prominent place, readily accessible to residents on three of three floors observed. (Ground, First and Second floors)

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for seven of seven residents in the group meeting (R42, R7, R19, R63, R17, R73 and R11).

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area.

Inspectors wroteBased on observation, staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for one of 18 residents interviewed(Residents R33).

Inspectors wroteBased on observations, review of facility provided documentation and interview with staff, it was determined facility did not ensure to implement resident-directed care and treatment consistent with professional standards of practice, placing the residents at risk for infections or accidents for two residents observed (Resident R4, R5)