Laurels of Mt Vernon the

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to privacy. This affected one resident (Resident #83) out of three residents reviewed for increased staff supervision. The facility census was 84.

Inspectors wroteBased on observation, schedule review, activity calendar review and interviews, the facility failed to provide comprehensive, resident centered services to ensure dementia care needs were met and promote resident well-being on the specialty unit. This affected two residents (Resident #18 and #24) and had the potential to affect the remaining 20 residents (#1, #2, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #21, #22, #23, #25, and #27) who resided on the specialty care dementia unit. The facility census was 86.

Inspectors wroteBased on record review, review of the abuse policy and Quality Assurance Performance Improvement (QAPI) Committee policy, and interview, the facility failed to implement policies and procedures to communicate and coordinate with the QAPI program regarding situations of abuse, neglect, and misappropriation of resident property, and exploitation. This affected four residents (#1, #2, #14, and #24) and had the potential to affect all 86 residents residing in the facility. The facility census was 86.

Inspectors wroteBased on review of medical records, review of facility investigations, review of the abuse policy, and interview, the facility failed to thoroughly investigate allegations of abuse for Residents #1, #2, #14, and #24. This affected four (Residents #1, #2, #14, and #24) out of six residents reviewed for abuse investigations. The facility census was 86.

Inspectors wroteBased on record review and interview, the facility failed to revise plans to provide comprehensive, resident centered care related to agitation and/or aggression. This affected two (Resident #1 and #24) of six residents reviewed. The facility census was 86.

Inspectors wroteBased on record review and interview, the facility failed to complete neurological checks for Resident #2 after two falls with injuries occurred. This affected one (Resident #2) out of six residents reviewed for incidents with injuries. The facility census was 86.

Inspectors wroteBased on observations and interviews the facility failed to ensure the smoking area was maintained in a clean and safe manner. This had the potential to affect all 89 residents.

Inspectors wroteBased on observation, interview, review of medications manufactures guidelines, and facility policy review the facility failed to ensure medication was dated and discarded properly. This affected six residents (Resident #12, Resident #39, Resident #48, Resident #136, Resident #139, and Resident #290) out of 22 residents reviewed for medication storage and had the potential to affect all 89 residents in the facility.

Inspectors wroteBased on observation and staff interview the facility failed to maintain a clean and sanitary environment for Resident #15, #16, #27, and #73. This four residents (#15, #16, #27, and #73) our of 19 residents reviewed for environment.

Inspectors wroteBased on medical record review, review of fall investigations, staff interview and review of facility policy and procedure, the facility failed to ensure the residents guardian was notified of all falls. This affected two (Resident #39 and #76) of three residents reviewed for falls. The census was 89.

Inspectors wroteBased on medical record review, observation and staff interview, revealed the facility failed to ensure accuracy of assessments. This affected one (Resident #47) of two residents reviewed for dental assessments. The census was 89.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to develop a comprehensive care plan for Resident #47's dental needs. This affected one (Resident #47) of two residents reviewed for dental care.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure pressure reduction interventions were in place at all times for Resident #53. This affected one resident (Resident #53) of three residents reviewed for pressure ulcer prevention.

Inspectors wroteBased on observation, medical record review and interview the facility failed to ensure fall interventions were in place for Resident #60. This affected one resident (Resident #60) of one reviewed for falls. The facility census was 89.

Inspectors wroteBased on observations, medical record review, interview, and facility policy review the facility failed to ensure proper storage of Resident #8 and Resident #78 respiratory equipment, and failed to implement an order for a breathing improvement device for Resident #286. This affected three residents (Resident #8, Resident #78, and Resident #286) out of four residents reviewed for respiratory care. The facility census was 89. Findings Include: 1. Review of the medical record for Resident #8 revealed an admission date 11/30/18 and re-admission date 12/03/24 with the following diagnoses including but not limited to acute respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), sleep apnea, and type two diabetes mellites. Resident #8 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15. [...]

Inspectors wroteBased on medical record review, interview and facility policy review the facility failed to ensure non-pharmacological pain interventions were implemented for one resident. This affected one resident (Resident #237) out of two residents reviewed for pain management. The facility census was 89. Findings Include: A review of Resident #237's medical record revealed admission date of 01/15/23 with the following diagnoses including but not limited to acute kidney failure, pulmonary emboli (clot), alcohol abuse, bipolar disorder, and weakness. Resident #237 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 dated 01/22/25. Resident #237 required assistance from staff to complete Activities of Daily Living (ADL) tasks including transfers and personal hygiene tasks. Resident #237 was non-ambulatory and used a wheelchair for mobility. [...]

Inspectors wroteBased on medical record review and interview the facility failed to ensure laboratory testing was completed for residents. This affected one resident (Resident #237) out of five residents reviewed for use of unnecessary medications. The facility census was 89. Findings Include: A review of Resident #237's medical record revealed admission date of 01/15/23 with the following diagnoses including but not limited to bacteremia, acute kidney failure, pulmonary emboli (clot), alcohol abuse, bipolar disorder, and weakness. Resident #237 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 dated 01/22/25. Resident #237 required assistance from staff to complete Activities of Daily Living (ADL) tasks including transfers and personal hygiene tasks. Resident #237 was non-ambulatory and used a wheelchair for mobility. [...]

Inspectors wroteBased on medical record review, observation and staff interview, revealed the facility failed to ensure routine dental services were in place for Resident #47. This affected one (Resident #47) of two residents reviewed for dental care. The census was 89.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility investigation, review of the facility abuse policy, and interview, the facility failed to protect from abuse Resident #87, who exhibited severe cognitive impairment (with a Brief Interview for Mental Status score of two) and had the diagnoses of unspecified dementia and cognitive communication deficit. This resulted in verbal and physical abuse occurring on 04/12/24 at 7:28 P.M. by Licensed Practical Nurse (LPN) #655 when Resident #87 was yelled at and forcibly placed back into the wheelchair. This affected one resident (#87) of six residents reviewed for dementia care. The facility census was 83. Findings Include: [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure medications were dated and disposed of according to industry standards. This had the potential to affect all 85 residents residing at the facility. The facility census was 88.

Inspectors wroteBased on observation, record review, facility policy review, and interview the facility failed to ensure the use of a lap buddy was assessed to be the least restrictive device for Resident #42 and failed to identify the device as a physical restraint once the resident could no longer independently remove the device on command. This affected one resident (#42) of one resident reviewed for physical restraints. The facility census was 88.

Inspectors wroteBased on record review and interview the facility failed to ensure medications were administered as ordered to treat medical conditions of Resident #59 and/or medications were administered as needed/ordered based on the resident's hemodialysis schedule. This affected one resident (#59) of six residents reviewed for unnecessary medication use. The facility census was 88.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to implement fall interventions for Resident #17. This affected one resident (#17) of two residents reviewed for fall interventions. The facility census was 88.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide timely care and interventions for Resident #183 related to a urinary tract infection (UTI). The facility also failed to provide proper oversight, assessment, and follow up of urinary catheters for Resident #60 and Resident #334. This affected one resident (#183) of four residents reviewed for UTI and two residents (#60 and #334) of two residents reviewed for urinary catheters. The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure weekly weights were obtained for Resident #46 who had significant weight loss. This affected one resident (#46) of two residents reviewed for nutrition. The facility census was 88.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure respiratory equipment was stored in a clean environment. This affected one resident (#17) of one resident reviewed for respiratory care. The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to complete pre and post dialysis assessments for Resident #59. This affected one resident (#59) of one resident reviewed for dialysis. The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to comprehensively assess/provide written description of pain and provide evidence of non-pharmacological interventions prior to administering as needed pain medications for Resident #60. This affected one resident (#60) of five residents reviewed for unnecessary medications. The facility census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to have proper justification for the use of psychotropic medication for Resident #75. This affected one resident (#75) of six residents reviewed for unnecessary medications. The facility census was 88.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain a safe, homelike environment. This affected two residents (#17 and #21) of 88 residents residing in the facility.

Inspectors wroteBased on interviews, record reviews, and document reviews, the facility failed to maintain sufficient levels of nursing staff to ensure resident care needs and preferences were met. This had the potential to affect all 86 residents that resided in the facility.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and facility policy and procedure, the facility failed to complete showers per resident preference and complete nail care as needed. This affected five (#34, #35, #43, #76, and #80) out of five residents reviewed for activities of daily living (ADL's). Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) Assessment, dated 07/12/21, revealed the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toilet use, extensive assistance of one staff for personal hygiene, and limited assistance of one staff for locomotion via wheelchair. [...]

Inspectors wroteBased on resident record review, staff interview, and facility policy review, the facility failed to complete updated Pre-admission Screening and Resident Reviews (PASRR) which included all mental health diagnoses. This affected two residents (Resident #43 and Resident #44) out of two reviewed for PASRR screenings. Findings Include: 1. Review of Resident #43's medical record revealed an admission date of 11/14/12 with medical diagnoses including other osteoporosis without current pathological fracture. On 07/13/17, additional medical diagnoses were added including major depressive disorder, bipolar disorder, delusional disorders, and other schizoaffective disorders. On 01/05/18, the resident was diagnosed with metabolic encephalopathy. Review of the PASRR screening dated 12/04/12 revealed only mood disorder was included on the review. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to properly assess Resident #35 after a fall. In addition, the facility failed to ensure Resident #291 safely smoked based on the individualized smoking assessment. This affected two residents (Resident #35 and Resident #291) of five residents reviewed for accidents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete monthly pharmacy recommendations. This affected three residents (#34, #47 and #69) out of six residents reviewed for unnecessary medications. Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact, and required extensive assistance of two staff for bed mobility, transfers, and toilet use, and limited assistance of one staff for locomotion via wheelchair. [...]