The Laurels of Forest Glenn

Inspectors wroteBased on record reviews and interviews with facility staff and the Pharmacist, the facility failed to have effective systems in place for the return of discontinued narcotic medications to prevent the diversion of controlled medications (Percocet 5/325 milligrams 4 tablets and six (6) 1/2 tablets of Oxycodone 5 milligrams) for 2 of 2 discharged residents reviewed for pharmacy services (Resident #106 and Resident #107).

Inspectors wroteBased on observation and staff interviews, the facility failed to post the daily nurse staffing information for 1 of 4 days of the survey (7/12/26).

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to provide services in a safe manner when the Certified Occupational Therapy Assistant (COTA) utilized a rollator (a four wheeled walker with a seat) during a therapy session which had been deemed unsafe for Resident #313. During a therapy session with COTA #1 on 11/9/24 Resident #313 stood up from the locked rollator, unlocked brakes, and while turning herself around to walk forward, she fell to her left against the counter/lower kitchen cabinets and slid down to the floor. Resident #313 was sent to the emergency department (ED) on 11/9/24 for evaluation after reporting pain in her left shoulder and hip. A computerized tomography (CT) scan of the pelvis revealed a nondisplaced left greater trochanter fracture (break at the top of the thigh bone near the hip). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of hospice care for 2 of 21 residents reviewed for MDS accuracy (Resident #17 and Resident #87).

Inspectors wroteBased on observations and staff interviews, the facility failed to discard an opened canned drink in 100-hall nourishment room refrigerator and label and date food items stored in the 200-hall nourishment room refrigerator for 2 of 2 nourishment room refrigerators (100-hall and 200-hall nourishment room refrigerators).

Inspectors wroteBased on observations and staff, Responsible Party (RP), Medical Director (MD), Nurse Practitioner #1 (NP) and Paramedic #1 interviews and record review, when the facility moved the resident's bed against the wall to prevent her from getting out of the bed, they failed to identify this as a restraint, failed to complete a restraint assessment, failed to obtain a physician order and failed to obtain the RP's consent for the use of a restraint. When the resident fell out of the bed she was wedged between the bed and the wall. Resident #1 was assessed by facility staff and found to not have a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE]. This was for 1 of 3 residents reviewed for restraints (Resident #1). [...]

Inspectors wroteBased on record review, observations and interviews with staff, Responsible Party (RP), Bed Supplier Manager, Medical Director (MD), Nurse Practitioner #1 (NP), Police Officer #1, Paramedic #1 and Medical Examiner (ME) #1 the facility failed to keep Resident #1 free from accident hazards by placing her bed against the wall and trying to restrict her from getting out of bed and implement fall interventions ensuring Resident #1's bed remained in the lowest position. Resident #1 fell out of the right side of her bed in between her bed and the wall where there was approximately two to three inches of space. Resident #1 was discovered by her RP in between the wall and the bed lying face down with the left side of her body slightly leaning against the base board on the wall keeping her from being completely flat on the floor. [...]

Inspectors wroteBased on record review, observations and interviews with staff, Responsible Party (RP), Medical Director (MD), Nurse Practitioner #1 (NP), Police Officer #1, Paramedic #1 and Medical Examiner (ME) #1, psychiatric NP and the Bed Supplier Manager, the facility failed to demonstrate competency by not recognizing that putting the bed against the wall for a severely cognitively impaired resident with anxiety, agitation and restlessness was a restraint and an accident hazard. Nurse #1 positioned Resident #1's right side of her bed up against a wall to prevent her from getting out of the bed. Resident #1 fell out of the right side of her bed in between the bed and the wall where she was discovered by her RP on the floor with the left side of her body slightly leaning against the base board keeping her from being completely flat on the floor. She was found to not have a pulse or respirations. [...]

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure medications were not left unattended on top of the medication cart (100 Hall medication cart) and failed to dispose or discard out of date medications stored in 2 of 5 medication carts (100 Hall middle A/B medication cart).

Inspectors wroteBased on observations, record review and staff interview the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 6/21/21 recertification and complaint investigation. This was for 1 recited deficiency on the current recertification and complaint survey of 2/23/24 in the area of label/store drugs and biologicals (F761). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on observations, record review, staff interviews, and Medical Director interview, the facility failed to provide care in a safe manner for 1 of 3 residents reviewed for accidents (Resident #1). On 1/21/24 Resident #1 was positioned on her left side with the bed raised to waist height by Nurse Aide (NA) #1 to perform incontinence care and bathing. NA #1 left the resident unattended on her left side to obtain supplies on the other side of the bed, and Resident #1 fell from the bed onto her right side on the floor and sustained a laceration to her head and a skin tear to her right elbow. Resident #1 was transferred to the emergency room for evaluation where she received a computerized tomography (CT) head and cervical spine imaging which was notable for small hemorrhagic contusions (bleeding inside the brain) to bilateral temporal lobes (area of the brain behind the ears). [...]

Inspectors wroteBased on observations, record review, staff interviews, and Medical Director interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the [DATE] recertification and complaint investigation. This was for 1 recited deficiency on the current complaint investigation survey of [DATE] in the area of Provide Supervision to Prevent Accidents (F689). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.