Laurelwood Health Care Center

Inspectors wroteBased on policy review, Maintenance Director Job Description review, https://weather.com review, National Library of Medicine website review, invoice review, medical record review, observation, and interview, the facility failed to ensure residents resided in a safe, clean, homelike, and comfortable environment with temperatures ranging from 71 degrees Fahrenheit (F) to 81 degrees F when resident room temperatures were measured ranging from 53 degrees F to 65 degrees F in 8 of 35 (Resident #11, #13, #14, #20, #27, #34, #40, #42, #45, #47, and #51) resident rooms observed during initial tour. The facility's failure to prevent dangerously cold room temperatures placed Residents #11, #13, #45, and #47, who were vulnerable and cognitively impaired residents, at an immediate jeopardy risk for weather induced complications. The census was 47. [...]

Inspectors wroteBased on policy review, invoice review, medical record review, a list of residents who use the 100 Hall communal bathrooms, observation, and interview, the facility failed to promote and ensure dignity and quality of life was met for 3 of 4 residents (Resident #14, #29, and #34) sampled for activities of daily living.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 4 of 4 communal bathrooms (100 Hall women's, 100 Hall men's, 200 Hall women's and 200 Hall men's) were observed with unsecured personal items, and without hand hygiene supplies, and when 2 of 2 nurses (Licensed Practical Nurse (LPN) A and LPN B) failed to use proper infection control measures during medication administration.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide a safe, functional, and sanitary environment for 4 of 4 (100 Hall men's and women's and 200 Hall men's and women's) communal bathrooms.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when carbon covered cookware was used in the kitchen, the dishwasher thermometer failed to reach 120 degrees during the wash cycle, sanitation solution did not measure appropriately, when residents were served with unsanitary plates and silverware, when expired foods were found in the dry storage area and in the Emergency Food Supply. The facility had a census of 53, with 51 of those resident's receiving a lunch tray from the kitchen on 1/23/2025, and 49 receiving a breakfast tray on 1/24/2025.

Inspectors wroteBased on policy review, record review, and interview the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 6 of 24 (Resident #34, #40, #41, #42, #47 and #49) residents reviewed for Advance Directives.

Inspectors wroteBased on policy review, medical record review, and interview, it was determined the facility failed to have physician orders and failed to provide pressure ulcer/injury treatments for 1 of 4 (Resident #258) sampled residents reviewed for pressure ulcer/injuries.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to take appropriate actions in accordance with the facility's policy when a fall occurred for 1 of 3 (Resident #5) reviewed for falls.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter (a tube in the bladder that drains the urine) for 1 of 1 (Resident #258) sampled residents reviewed for indwelling catheters.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to follow the facility's policy for monitoring weekly weights for 1 of 3 (Resident #1) sampled residents reviewed for nutritional status.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices were followed during medication administration when 1 of 3 Licensed Practical Nurse (LPN) A nurses failed to follow Enhanced Barrier Precautions (EBP) when administering PEG (percutaneous endoscopic gastrostomy) tube medications and failed to perform appropriate hand hygiene.

Inspectors wroteAMENDED 6.10.24 Based on policy review, Occupational Safety and Health Administration (OSHA) review, medical record review, observations, and interview, the facility failed to ensure the residents' environment was free of accidents and hazards when the facility failed to develop and implement care plan interventions to prevent falls for a resident with high risk of falls, supervise a cognitively impaired Resident, failed to monitor the Resident's condition post fall, and failed to provide care and services for 1 of 10 (Resident #42) sampled residents reviewed for falls. Resident #42 is a moderately cognitively impaired Resident who was ambulatory with a walker, fell on [DATE], and had complaints of right hip pain documented on 10/19/2023. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 8 of 35 resident's rooms (Resident #1, #2, #37, #43, #22, #39, #46, and #50), 1 of 4 communal bathrooms (200 Hall), and 1 of 3 scales (Standing Life Scale) observed.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by the paper towel dispenser not working, dirty trash cans, vent fans are coated with a thick grayish brown substance, large utensil holder dirty with package of crackers inside, greasy ice cream scoop, spice and condiment holder dirty with food crumbs, dirty kitchen floors, carbon build up on pots and pans, wet pans stacked on top of other pans, fryer baskets coated in yellow sticky substance; [...]

Inspectors wroteBased on CDC (Centers for Disease Control and Prevention) guidelines, observation, and interview, the facility failed to ensure proper infection control practices were followed when 2 of 3 (Licensed Practical Nurse (LPN L and M) nurses failed to clean reusable equipment before use on residents during medication administration.

Inspectors wroteBased on policy review, job description review, medical record review, and interview, the facility failed to report injuries of unknown source to the state agency, adult protective services, law enforcement, and Ombudsman for 1 of 13 (Resident #42) sampled residents reviewed for abuse.

Inspectors wroteBased on policy review, job description review, medical record review, facility investigation, observation and interview, the facility failed to thoroughly investigate an unwitnessed fall with injury and bruises of unknown source in order to identify possible factors of abuse and/or neglect for 1 of 13 sampled residents (Resident #42) reviewed for abuse/neglect.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings for 1 of 14 (Resident #356) sampled residents and failed to update the care plan for 1 of 14 (Resident #42) sampled residents reviewed for care planning.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide podiatry care and services for 1 of 1 (Resident #46) sampled residents reviewed for podiatry services.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain adequate nutritional status via enteral feeding (nutrition provided via use of a gastric feeding tube) for 1 of 3 (Resident #11) sampled residents reviewed for enteral feeding.