The Laurels of Coldwater

Inspectors wroteThis citation pertains to intake #3051218Based on observations, interviews, record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. Findings Include:Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/18/26, reflected R3 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R4 was admitted to the facility on [DATE], with diagnosis that included Vascular dementia, moderate, with agitation and irritability and anger. [...]

Inspectors wroteThis citation pertains to intake #3051218 Based on observation, interview, and record review the facility failed to develop an individualized care plan addressing behaviors and approrpiate ambulatory device for one (Resident #4) out of 6 reviewed for care plans.

Inspectors wroteThis citation pertains to intake 3072680. Based on observation, interview and record review, the facility failed to ensure adequate blood glucose (sugar) monitoring for one (R2) of three reviewed.

Inspectors wroteThis citation pertains to intake 3026546. Based on observation, interview and record review, the facility failed to report an allegation of resident-to-resident sexual abuse to the State Agency timely for two (R3 and R4) of three reviewed.

Inspectors wroteThis citation pertains to intake 3026546. Based on observation, interview and record review, the facility failed to investigate an allegation of resident-to-resident sexual abuse timely for two (R3 and R4) of three reviewed.

Inspectors wroteThis citation pertains to intake 3015141. Based on observation, interview and record review, the facility failed to revise the Care Plan for one (R2) of three reviewed.

Inspectors wroteThis citation pertains to intake 3026546. Based on observation, interview and record review, the facility failed to ensure timely mental and psychosocial evaluation or continued psychosocial support after a resident-to-resident sexual abuse allegation for one (R3) of three reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow up on resident grievances for one (resident 1) of one reviewed.

Inspectors wroteThis citation pertains to intake 2961814. Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for two (R3 & R5) of three reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative therapy as ordered for two (resident 1 and resident 4) of three reviewed.

Inspectors wroteThis citation pertains to intake 2690644. Based on observation, interview and record review, the facility failed to ensure a licensed medical provider (Physician, Nurse Practitioner, Physician Assistant) routinely examined pressure ulcers for one (R4) of three reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure care plans were reviewed and revised for four out of 11 residents (Resident #2, 6, 7, & 9). This citation pertains to intake numbers 2527031, 2669486, and 2656254. Resident #2 (R2):Per the facility electronic medical record (EMR) R2 was admitted to the facility on [DATE]. Record review of a facility incident report revealed that on 9/10/2025 R2 had an altercation with his roommate. R2 began to yell at his roommate to shut the mother f**king door to the bathroom because his roommate had turned the light on. The report revealed R2 yelled to his roommate to come over to him so he could slap him. Review of R2's progress notes dated 9/10/2025 revealed a notation that R2 threatened to physically harm his roommate because he had the bathroom door open. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by staff. Findings Included:This citation pertains to intake number 2622835. Per the facility Electronic Medical Record (EMR) Resident #3 (R3) was admitted to the facility on [DATE]. Diagnoses included post-traumatic stress disorder (PTSD), anxiety, and history of physical abuse. Review of a Minimum Data Set, dated [DATE] revealed R3 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she R3 had no cognitive deficit. Review of a facility incident and investigation report revealed that on 9/5/2025 Certified Nurse Aid (CNA) D used abusive language towards R3 causing R3 emotional distress. The report revealed R3 overheard two CNA's, CNA C and CNA D talking, and she heard CNA C tell CNA D that R3 was faking her incontinence. [...]

Inspectors wroteThis citation pertains to Intake 2604669 Based on observation, interview, and record review, the facility failed to ensure one resident (R1) of three reviewed was free from the use of a physical restraint.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 130 residents, resulting in the increased likelihood for cross contamination and bacterial harborage.

Inspectors wroteBased on observations, interviews, record reviews, and 6 (9, 23, 52, 57, 82, 124) of 26 sampled residents, the facility failed to provide palatable food products effecting 126 residents who consume food, resulting in the increased potential for resident decreased food acceptance and nutritional decline.

Inspectors wroteBased on interview and record review the facility failed to ensure advanced directives were listed correctly on one (R44) of one resident investigated for advanced directives. Findings Include:Resident #44 (R44)Review of the medical record reflected that R44 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of respiratory failure, dementia, lung cancer, chronic obstructive pulmonary disease, anxiety, depression and psychosis. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2025 revealed R44 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R44 is independent for care and needs minimal assistant with set up. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate monitoring for two residents (R7, R82) receiving psychotropic medications.

Inspectors wroteBased on interview, and record review the facility failed to ensure one out of 26 residents (Resident #130) care plan was revised. Findings Included:Per the facility face sheet Resident #130 (R130) was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Physician's orders revealed an order for, [NAME] boot (boots that are puffed up to prevent heels from coming in touch with the bed surface) to bilateral (both) feet while guest is in bed, every shift for Skin integrity., dated 2/11/2025. Review of R130's care plans revealed a care plan in place for, (R130) at risk for impaired skin integrity/pressure injury R/T (related to): decreased mobility, Dx (diagnoses): [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure follow-up on monthly pharmacy medication regimen reviews for one (R82) of five reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six medication carts was locked while unattended. Findings Included:On 07/23/2025 at 11:15 AM, a medication cart on the 100 hall was observed to be left unattended and unlocked. no nurse was observed to be in the area; several residents were in the area wandering around. It was not until 11: 21 AM that License Practical Nurse (LPN) K walked up to med cart. LPN K did not notice the medication cart was unlocked so was then informed that the medication cart was unlocked. LPN K then locked the cart and stated that she went to use the restroom and forgot to lock it. [...]

Inspectors wroteThis is related to MI00148888 Based on observation, interview and record review the facility failed to immediately report abuse allegations for one resident (R203) of two reviewed for abuse, resulting in allegations of abuse that were not reported to the Nursing Home Administrator (NHA) and the State Agency timely and the potential for further allegations of abuse to go unreported.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean equipment, resulting in the potential for an increased risk of foodborne illness, affecting all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment in eight out of 24 resident rooms, a resident lounge, and a resident TV/reading area resulting in un-cleanliness of resident living areas. Findings Included: During a tour on 8/20/2024 at 11:30 AM, R31's room was entered. It was noted that the floor next to bed B had three towels on the floor, and a strong foul smelling odor was noted. R31, who resided in bed B, stated that she had accidents (urinary incontinence) on the floor. R31 said housekeeping had already been in and cleaned her room, but did not pick up the towels or clean the floor. R31 stated she has the accidents frequently. On 8/21/2024 at 11:45 AM, R31's room was observed to have multiple flies, more than a dozen, in the room and several over R31's mattress. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of abuse (bruise of unknown origin) to the State Agency for one Resident (#106) of two Residents reviewed for abuse. Findings Included: Resident #106 (R106) Review of the medical record revealed R106 was admitted to the facility 05/17/2024 with diagnoses that included cerebral vascular accident (stroke), atrial fibrillation, dysphagia (difficulty swallowing), Hemiplegia (paralysis) of the left side, hypertension, hyperlipidemia (high fat content in blood), depression, seizures, and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed R106's Brief Interview of Mental Status (BIMS) was 00 (severe cognitive impairment) out of 15. During observation and attempted interview on 08/20/2024 at 10:28 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate, implement preventive measures, and take corrective action for an allegation of abuse (bruise of unknown origin) for one Resident (#106) out of two Residents reviewed for abuse. Findings Included: Resident #106 (R106) Review of the medical record revealed R106 was admitted to the facility 05/17/2024 with diagnoses that included cerebral vascular accident (stroke), atrial fibrillation, dysphagia (difficulty swallowing), Hemiplegia (paralysis) of the left side, hypertension, hyperlipidemia (high fat content in blood), depression, seizures, and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed R106's Brief Interview of Mental Status (BIMS) was 00 (severe cognitive impairment) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement the care plan, in 1 of 26 residents reviewed for care plans (Resident #24) resulting in unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the Care Plan for two (Resident #68 and #88) of 26 reviewed for Care Plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that hygiene, grooming, and activities of daily living (ADL) needs were met for two of three residents reviewed (Residents #38 and #86). This resulted in the residents not receiving ADL care according to their individual preferences with the potential of feelings of shame or embarrassment and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that two Residents (#24, #102) physician orders were followed and failed to provide an assessment/intervention for bowel constipation for one Resident (#27) out of 26 Residents reviewed for Quality of Care. Findings Included: Resident #27 (R27) Review of the medical record revealed R27 was most recently re-admitted to the facility 08/13/2024 with diagnoses that included bipolar disorder, left knee pain, dysphagia (difficulty swallowing), insomnia, left femur fracture, type 2 diabetes, morbid obesity, low back pain, hypertension, hyperlipidemia (high fat content in blood), gastro-esophageal esophagitis, and schizophrenia. [...]

Inspectors wroteThis citation pertains to MI00138939. Based on observation and interview, the facility failed to maintain a clean, homelike environment, resulting in ceiling tiles with water damage and peeling, water damaged wallpaper.

Inspectors wroteThis citation pertains to MI00138939. Based on observation, interview and record review, the facility failed to report a resident elopement to the State Agency for one (Resident #6) of three reviewed for elopement, resulting in a resident elopement not being reported to the State Agency and the potential for further elopements not being reported.

Inspectors wroteThis citation pertains to MI00138939. Based on observation, interview and record review, the facility failed to ensure a resident elopement was thoroughly investigated for one (Resident #6) of three reviewed for elopement, resulting in the potential for resident elopements not being thoroughly investigated and the potential for further elopements to occur.

Inspectors wroteThis citation pertains to MI00138939. Based on observation, interview and record review, the facility failed to prevent an elopement for one (Resident #6) of three reviewed for elopement, resulting in the resident exiting the facility through an alarmed door, without staff knowledge, and being brought back into the facility by an unknown individual.

Inspectors wroteThis citation pertains to MI00140174 and MI00140241. Based on observation, interview and record review, the facility failed to ensure food was palatable and served at an appetizing temperature, resulting in the potential for decreased food acceptance and nutritional decline for all residents that received food from the facility's kitchen.

Inspectors wroteThis citation pertains to intake MI00137838 and MI00135892. Based on observation, interview, and record review, the facility failed to revise the care plan in 5 of 25 residents reviewed for care plans (Resident #53, #57, #88, #140 & #144), resulting in unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide quality care and treatment services to 4 of 25 reviewed in sample (Resident #7, #19, #32, & #58), resulting in constipation (Resident #32), the potential for delayed wound healing (Resident #7 & 58), and low blood sugars (Resident #19). Resident #58 (R#58) During an observation and interview on 7/10/23 at 11:29 AM, R58 stated she had a sore on the back of her left thigh that was painful and would bleed at times; R58 had an open area that was approximately 4 centimeters in length and 3 cm in width and surface depth. R58's Minimum Data Set (MDS) with assessment reference date of 11/16/22 indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance based cognitive screener of 15 (13-15 Cognitively intact). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate completion of advance directive information for one (Resident #6) of one resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to report allegations of abuse for two residents (#117, #139) of 15 residents in the survey sample for abuse resulting in allegations of abuse not being reported to the State Agency and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings Included: Resident #117 (R117) Review of the medical record revealed R117 was admitted to the facility 02/13/2023 with diagnoses that included multiple sclerosis, depression, protein-calorie deficiency, suicidal behavior, toxic encephalopathy (brain dysfunction caused by toxins), and dysphagia (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2023, revealed R117 had a Brief Interview for Mental Status (BIMS) of 12 (mildly impaired cognition) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to routinely complete thorough pressure ulcer assessments and documentation consistent with professional standards of practice for one resident (Resident #7) of 2 reviewed for pressure ulcer care, resulting in the potential for deterioration in wound and health status.

Inspectors wroteBased on observation and record review, the facility failed to ensure two Licensed Practical Nurses (LPN E and H), and one Registered Nurse (RN G) had specific competencies and skills necessary to meet resident needs, and failed to ensure two Certified Nurse Aides (CNA F, Q) had their required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for nursing staff to lack the necessary qualifications and training to adequately care for the needs of the residents with a facility census of 124.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide treatment and services for mental or psychosocial concerns for one resident (#57) with suicidal ideations of four residents reviewed resulting in the potential for adverse outcomes of a resident with suicidal ideations. Findings Included: Resident #57 (R57) Review of the medical record revealed R57 was admitted to the facility 01/20/2020 with diagnoses that included pain right shoulder, benign prostatic hyperplasia (enlarge prostate), dorsalgia (back pain) , trans ischemic attack, cerebral infarction (stroke), anxiety, type 2 diabetes, morbid obesity, atherosclerotic heart disease, hyperlipidemia (high fat content in blood), sleep apnea, atrial fibrillation, hypertension, gastro-esophageal reflux, and major depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to; (1. label open multi-dose tuberculin vial with open date in 1 of 2 medication rooms; (2. ensure multi-dose insulin pens were dated upon opening in 1 of 3 medication carts and; (3. label open multi-dose prescription eye drops with open date in 1 of 3 medication carts reviewed for labeling, dating and expiration of medications. This deficient practice resulted in the potential for administration of expired medications and decreased therapeutic effects of administered medications, the potential for cross contamination, and medication errors in a current facility census of 124.

Inspectors wroteBased on interview and record review, the facility failed to obtain meet criteria to treat a urinary tract infection, in one of one resident reviewed for diagnosis of urinary tract infection (Resident #90), resulting in the potential for inappropriate antibiotic and treatment.