Laurels of Athens, the

Inspectors wroteBased on observation, medical record review, hospital record review, review of information on www.lung.org, review of facility policy, and interview, the facility failed to provide a safe environment, appropriate supervision and implement safe smoking practices for Resident #11, a resident who had been incorrectly identified as a safe/independent smoker despite being noncompliant and unable to manage safe smoking interventions independently. This resulted in Immediate Jeopardy and Actual Harm on 03/21/26 when Resident #11 smoked in the designated smoking area while oxygen was in use via nasal cannula, resulting in ignition caused by smoking in the presence of oxygen. The resident sustained facial burns requiring emergency medical intervention. The resident was subsequently transferred to the hospital where she received treatment for the burns to her face and mouth. [...]

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure residents who required assistance with hygiene received showers/bathing and shaving as per their preference/plan of care/schedule. The affected five (#5, #8, #9, #70, and #76) of 12 residents reviewed for activities of daily living (ADLs). The facility census was 98.

Inspectors wroteBased on observations, medical record review, interview, and policy review the facility failed to ensure a resident's right to privacy and dignity were maintained when a urinary catheter drainage bag was not covered and urine was exposed. This affected one (#92) of one resident reviewed for catheters. The facility census was 98.

Inspectors wroteBased on record review, interview, review of a self-reported incident, review of the facility investigation and policy review, the facility failed to prevent misappropriation of resident narcotics. This affected one resident (Resident #99) of two residents reviewed for misappropriation. The facility census was 98.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident had an active care plan in place to address her diagnosis of anxiety disorder requiring the use of anti-anxiety medications. This affected one (Resident #100) of 30 residents reviewed for care plans.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure care plans were revised to accurately reflect current fall interventions. This affected one (#86) of six residents reviewed for falls. The facility census was 98.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to identify and treat new skin areas. This affected one (#8) of two residents reviewed for skin conditions. Additionally, the facility failed to ensure residents did not go more than three days without a bowel movement without receiving interventions. This affected one (#99) of five residents reviewed for unnecessary medications. The facility census was 98.

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to ensure residents, who had significant weight loss and/ or were at nutritional risk, had their meal consumption amounts recorded to show adequate monitoring of their nutritional status. This affected two (Resident #5 and #12) of three residents reviewed for nutrition/ weight loss.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure a resident with a tracheostomy tube had appropriate medical emergency equipment at her bedside to include an Ambu bag (resuscitation bag). The facility also failed to ensure another resident had a physician's order for the administration of oxygen, prior to its use. This affected two (Resident #9 and #39) of three residents reviewed for respiratory care.

Inspectors wroteBased on Interview, record review, and review of facility policy the facility failed to identify and document trauma triggers on the care plans of residents with post traumatic stress disorder. This affected two residents (#78 and #109) of three sampled for behavioral/emotional concerns. The facility census was 98.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure controlled substances were documented accurately in the medical record. This affected one (#99) of two residents reviewed for misappropriation. The facility census was 98.

Inspectors wroteBased on record review, review of meal times, and staff interview, the facility failed to ensure a medication that was given to a resident for the treatment of osteoporosis was administered in accordance with the physician's orders and on an empty stomach to increase the absorption of the medication. They also failed to ensure a resident receiving a beta-blocker for the treatment of hypertension had her apical pulse checked prior to the administration of the medication as ordered by the physician with parameters in place to hold the medication if the resident's heart rate was less than 60 beats per minute (bpm). This affected two (Resident #12 and #100) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, interview and policy, the facility failed to ensure a urinalysis with culture and sensitivity (UA C&S) was obtained per orders. This affected one resident (Resident #8) of one resident reviewed for urinary tract infection (UTI). The facility census was 98.

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained. This affected four (#9, #12, #76, and #86) of 30 resident records reviewed for a complete and accurate medical record. The facility census was 98.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure hand hygiene was performed in between glove changes during tracheostomy care, failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor, and failed to ensure shared glucometers were properly disinfected between each use. This affected one (Resident #9) of three residents reviewed for respiratory care, one (Resident #92) of two residents reviewed for indwelling urinary catheters, and had the potential to affect three residents (Resident #19, #28, and #79), who the facility identified as having the use of the shared glucometer on the 700 Hall.

Inspectors wroteBased on interview and record review the facility failed to inform and obtain consent from Resident #44's guardian before administration of a COVID-19 vaccination. This affected one resident of six sampled for vaccinations. The facility census was 98.

Inspectors wroteBased on observation, medical record review, hospital record review, interviews and policy review the facility failed to ensure Resident #78 received timely, comprehensive and individualized care following a fall with injury. Actual harm occurred beginning on 12/02/24 at approximately 4:30 A.M. when Resident #78 experienced an unwitnessed fall with evidence of complaints of pain after the incident; however, the resident did not timely receive as needed pain medication until 8:44 A.M. or an x-ray of the area until 12/03/24 at 11:50 A.M. On 12/03/24 at 1:15 P.M. x-ray results revealed the resident had a displaced fracture of the left femoral head and was transferred to the hospital for surgical intervention. This affected one resident (#78) of two residents reviewed for falls.

Inspectors wroteBased on observation, review of meal tickets, review of menus/ spreadsheets to include special diets, and staff interview, the facility failed to ensure menus were followed for residents receiving consistent carbohydrate (CCHO) diets. This affected four residents (Resident #86, #88, #159, and #214) that were observed for tray preparation during tray line for the lunch meal served on 12/11/24. It had the potential to affect 31 other residents (Resident #4, #5, #6, #9, #10, #16, #17, #21, #22, #30, #34, #36, #39, #41, #44, #45, #51, #66, #68, #69, #73, #75, #80, #81, #82, #89, #101, #209, #210, #212, and #215) who were identified by the facility as being on a CCHO diet.

Inspectors wroteBased on record review, review of shower schedules, resident interview, staff interview, and policy review, the facility failed to ensure residents that were dependent on staff for personal care received the assistance needed for scheduled showers. This affected one (Resident #66) of four residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure a resident with the use of supplemental oxygen had a physician's order for the use of oxygen and nebulizer equipment was properly cleaned/ stored when not in use. This affected one (Resident #210) of one residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with a diagnosis of dementia had a comprehensive and individualized treatment plan to ensure behaviors, including inappropriate dress when visible to others, were addressed to promote independence and dignity. This affected one resident (Resident #1) of one residents reviewed for dignity. The census was 101.

Inspectors wroteBased on observation, record review, review of a facility self-reported incident, facility investigation review, interviews, and policy review the facility failed to prevent misappropriation of resident narcotics. This affected one Resident (Resident #28) of one resident reviewed for misappropriation. The facility census was 94.

Inspectors wroteBased on record review, review of a self-reported incident, review of the facilities investigation for the self-reported incident, observation, interviews, and policy review the facility failed to ensure an allegation of misappropriation of controlled medication was thoroughly investigated. This affected one Resident (Resident #28) of one resident reviewed for misappropriation.

Inspectors wroteBased on observation, interview, and policy review revealed the facility failed to ensure controlled medication were signed out when administered and medication were properly labeled and packaged. This had the potential to affect all residents residing on 100, 200, 300, and 400 halls.

Inspectors wroteBased on observation, interview, facility documentation review, and facility policy review, the facility failed to ensure food was stored, prepared and maintained in a safe and sanitary manner. This had the potential to affect 106 residents who were receiving food from the kitchen (a list provided by the facility revealed Resident #95 received nothing by mouth). The facility census was 107.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure equipment was maintained in a safe operating condition. This had the potential to affect 106 residents who were receiving food from the kitchen (a list provided by the facility revealed Resident #95 received nothing by mouth). The facility census was 107.

Inspectors wroteBased on observation, interview, document review, and facility policy review, the facility failed to ensure residents had access to their money on evenings and weekends. This had the potential to affect all 50 residents (#1, #3, #4, #5, #7, #9, #10, #11, #13, #15, #16, #17, #18, #19, #22, #23, #25, #28, #29, #30, #32, #35, #36, #37, #41, #43, #45, #46, #48, #49, #51, #53, #54, #58, #61, #64, #65, #67, #68, #72, #74, #76, #80, #84, #85, #86, #87, #93, #96, and #105) for whom the facility managed resident personal funds accounts. The facility census was 107.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure puree meals were prepared to the correct consistency for consumption. This had the potential to affect five residents (#21, #28, #40, #54, and #69) who were ordered pureed diets. The facility census was 107.

Inspectors wrote2. Review of Resident #26's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, morbid obesity, difficulty in walking and chronic kidney disease, stage two. Review of Resident #26's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/27/23, revealed he was cognitively intact. Review of Resident #26's physician order, dated 08/21/23, identified his advanced directives were do not resuscitate comfort care arrest (DNR-CCA). Review of Resident #26's documentation titled admission Record, dated 07/19/22, and the first form seen in the unit advanced directives binder revealed he was a do not resuscitate comfort care (DNR-CC). [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure a resident's electronic medical record was maintained in a confidential manner. This affected one resident (Resident #7) during a random observation made during the course of the annual survey. The facility census was 107.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure personal hygiene and bathing was completed for dependent residents. This affected two residents (#23 and #37) of three residents reviewed for activities of daily living.

Inspectors wroteBased on record review, interview, policy review, and observations the facility failed to ensure fall prevention interventions were in place for two residents with history of falls. This affected two residents (#51 and #76) of four residents reviewed for falls. The facility census was 107.

Inspectors wroteBased on observation, interview, resident record review, and facility policy review, the facility failed to ensure a resident had the appropriate enabler bars on his bed and failed to ensure the resident's assessment was accurate for the type of devices used on his bed. This affected one resident (#26) of four residents reviewed for accident hazards. The facility census was 107.

Inspectors wroteBased on observation, record review, drug information review, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had four medication errors out of 31 opportunities resulting in a medication error rate of 12%. This affected two residents (#35 and #36) of three residents reviewed for medication administration.

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to properly store medications when not being administered. This affected one resident (#5) that was observed for medication storage at the medication cart. The facility census was 107. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 03/02/22 with the diagnoses of: Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease and Permanent Atrial Fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require extensive assistance with two plus person physical assist with bed mobility, transfers, and extensive assistance with one-person physical assist with toilet use. [...]

Inspectors wroteBased on record reviews, observations, interviews and policy review, the facility failed to demonstrate proper hand washing and proper storage of COVID 19 personal protective equipment (PPE). This affected two residents (#5 and #23) of the two residents reviewed for handwashing and proper storage of equipment. The facility census was 107.