Laurelbrook Nursing Home

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on facility policy review, review of The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to identify a severe weight loss and decline in 1 or more Activities of Daily Living (ADL) as a significant change in a resident's condition and failed to complete a significant change assessment after a severe weight loss for 1 Resident (#30) of 4 residents reviewed for assessments. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to revise the care plan for an unplanned weight loss for 1 resident (Resident #30) of 4 residents reviewed. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. The Immediate Jeopardy was effective 12/2/2021 - 2/17/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/18/2022. [...]

Inspectors wroteBased on facility policy review, medical record review, review of physician logs, interviews, and observations, the facility failed to identify a significant weight loss and implement interventions to prevent further weight loss for 1 resident (Resident #30) of 4 residents reviewed for nutrition and hydration status. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the IJ in the Administrator's office on 2/15/2022 at 6:48 PM. [...]

Inspectors wroteBased on review of staff job descriptions, review of facility policy, medical record review, review of facility documentation, review of staffing schedules, review of staff time punches, and interview, the facility failed to employ a Registered Nurse (RN) acting as the Director of Nursing (DON) for 18 of 52 weeks and failed to provide RN coverage for 8 consecutive hours, 7 days per week in the facility for 4 of 30 days. The failure of the facility to provide an RN as a DON from 9/1/2021-2/18/2022 resulted in a failure to identify and implement interventions to prevent a severe weight loss for Resident #30, who experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. [...]

Inspectors wroteBased on review of facility policy, medical record review, review of facility documentation, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency by failing to identify and implement interventions to prevent a severe weight loss for Resident #30. Resident #30 experienced a significant weight loss of 11.4% in 90 days on 12/2/2021, and then went on to have a severe weight loss of 41.3 lbs. (20.6%) in 5 months. The facility's failure placed Resident #30 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the Administrator's office on 2/15/2022 at 6:48 PM. [...]

Inspectors wroteBased 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.