Laurelwood Community Living Center

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to prevent the misappropriation of resident property when staff left a controlled substance unattended, resulting in (30) Hydrocodone/Acetaminophen 10-325 milligram tablets prescribed for Resident #1 being unaccounted for and lost for one (1) of four (4) residents reviewed for abuse. (Resident #1).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored and handled in accordance with accepted professional standards when staff failed to immediately secure controlled medications upon receipt for Resident #1 and failed to store medications according to manufacturer's instructions for Resident #3, for two (2) of four (4) sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure adequate supervision and take appropriate actions to prevent an avoidable accident when staff continued transporting a resident after the resident removed his seatbelt and staff failed to stop the transport and request assistance, resulting in the resident falling from his wheelchair inside the facility van, for one (1) of five (5) sampled residents, Resident #1.

Inspectors wroteBased on interviews, record review, and the facility policy review, the facility failed to notify the physician of a resident with no documented bowel movement for six (6) consecutive days, which resulted in the resident being hospitalized on [DATE] for evaluation that included findings consistent with fecal impaction for one (1) of 14 sampled residents.

Inspectors wroteBased on interviews, record review, and the facility policy review, the facility failed to implement comprehensive person-centered care plan interventions for a resident with constipation and no documented bowel movements for consecutive days, which resulted in a Resident being hospitalized on [DATE] for evaluation that included findings consistent with fecal impaction for one (1) of 14 sampled residents.

Inspectors wroteBased on interviews, record review, and the facility policy review, the facility failed to identify or respond to a clinically relevant pattern of constipation, which resulted in a resident being hospitalized on [DATE] for evaluation that included findings consistent with fecal impaction for one (1) of 14 sampled residents.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to maintain a sanitary and pest-free environment in the kitchen by not ensuring effective pest control measures were implemented and sustained for two (2) of three (3) kitchen observations.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate incontinence care was provided, as evidenced by the failure to cleanse the skin during a brief change for one (1) of two (2) residents observed for incontinence care (Resident #13).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were secured when a wound care treatment cart was left unlocked and unattended in a hallway for one (1) of four (4) days of the survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to thaw food at the correct temperature, failed to clean the equipment according to the cleaning schedule, and failed to ensure the three compartment sinks' chemical sanitation was working appropriately to prevent possible foodborne illnesses for two (2) of four (4) dietary observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department. Findings Include: Review of the facility's policy titled, Meat Cookery and Storage, from [NAME] Corporate Dietitians (Copyright ©2020), revealed, the Food and Nutrition Services Department should ensure that meat shall be prepared in a manner to preserve quality, maximize nutrient retention and to obtain maximum yield of product .Procedure: [...]

Inspectors wroteBased on interview, record review and facility policy review the facility failed to ensure the residents were able to obtain funds from their trust accounts on weekends for nine (9) of (12) Resident council members interviewed. (Residents #4, #11, #17, #18, #20, #27, #28, #30 and #31) Findings Include: Review of the facility's policy titled, Resident Trust Fund Policy & Agreement, dated 10/7/07, revealed, .WHEREAS the resident acknowledges that he/she has been informed and understands that he/she has the right to manage his/her own financial affairs . The Facility will give the Resident due receipt for such monetary sums . During an interview on 10/16/23 at 3:30 PM, with the Resident Council members, Residents #4, 11, #17, #18, #20, #27, #28, #30 and #31 complained that they were not able to get their money from their trust fund on weekends. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure Resident Council complaints were resolved in a timely manner regarding transportation to outings. This affected nine (9) of (12) Resident council members who participate in the Resident Council meetings. Residents #4, #11, #17, #18, #20, #27, #28, #30 and #31 Findings Include: Review of the facility's policy titled, Grievances and Complaints, dated 2/14/23, revealed, Social services will act as the grievance officer for the facility and oversee the grievance process. Grievance forms should be kept outside of the office, where residents, and staff members can access them at any time. All grievances will be reported to Social Services and Social Services will follow the following procedure to investigate and work to resolve the grievance . [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a call light was within reach for one (1) of 15 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the Resident's Representative (RR) of a room change for one (1) of 15 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide the Resident, or the Resident Representative (RR), written notification of the bed hold policy at the time of transfer for one (1) of 15 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility's policy review, the facility failed to ensure a resident who was dependent on staff assistance for showering received those services for one (1) of three (3) residents reviewed for Activities of Daily Living (ADL) assistance.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy it was determined that the facility failed to ensure that all parts/entities of the resident call system were functioning properly for 31 of 44 resident call systems observed. The resident call system was not monitored at the nursing station/desk and did not sound with audio signaling at the nursing station panel/board for 31 resident rooms (resident rooms 1-31). There was no facility staff observed at the nursing station/desk from 7:45 A.M. - 11:30 A.M. on 03/18/2021. The facility's failure to provide supervision and to devise appropriate monitoring and surveillance for all residents while the resident call system was malfunctioning was likely to cause serious harm, injury, impairment, or death. [...]

Inspectors wroteBased on observations, staff interviews, record review and facility policy review the facility failed to provide pericare for one (1) of four (4) observations. Resident # 14. The facility policy and procedure titled Perineal Care dated August 25, 2014 revealed, cleanse the perineum to prevent infection and odor . Place call light in place and instruct resident to call for assistance, if needed. Provide privacy. Provide a clean surface. Perform hand hygiene. Put on gloves. Expose perineal area. Avoid unnecessary exposure. Clean perineal area well with soap and warm water or other cleanser taking care to clean from front to back using a clean cloth or clean area of the cloth for each stroke. Rinse perineal area, moving from front to back using a clean area of the washcloth or towelette or use another clean washcloth or towelette for each stroke. (Note: Not all products require rinsing. [...]

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to have a less than five (5) percent med error rate as evidenced by the facility failed to administer oral inhalation medication per manufactures guidelines for two (2) of three (3) medication administration observations Residents # 9 and Resident #11.

Inspectors wroteBased of observation, staff interviews, record review, and facility policy review, the facility failed to remove expired food items from the food pantry and failed to monitor the freezer temperature for one 1 of four 4 observations.