The Laurels of Heath

Inspectors wroteBased on interviews and record review, the facility failed to protect a resident's right to privacy when staff took a picture of the resident without consent. This affected one (Resident #42) of three residents reviewed for privacy. The facility census was 107.

Inspectors wroteBased on record review and interviews, the facility failed to report an allegation of abuse to the State Agency (SA). This affected one (Resident #42) of three residents reviewed for abuse. The facility census was 107.

Inspectors wroteBased on interviews and record review, the facility failed to complete a thorough investigation when informed of staff taking a photo of a resident without consent. This affected one (Resident #42) of three residents reviewed for abuse. The facility census was 107.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure an allegation of verbal/ emotional abuse was reported to the State survey agency as required. This affected one (Resident #14) of two residents reviewed for abuse. The facility census was 104.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure an allegation of potential verbal/ emotional abuse was investigated by the facility when reported to management staff. This affected one (Resident #14) of two residents reviewed for abuse.

Inspectors wroteBased on closed resident record review, review of a facility medication error report, review of pharmacy labels, staff interview, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one (#105) of three residents reviewed for medication errors. Actual Harm occurred on 09/30/25 for Resident #105, when a nurse crushed and administered an extended release Morphine (narcotic pain medication) tablet to the resident, while also administering double the ordered dose of prescribed Lyrica (anticonvulsant analgesic) to the resident, resulting in the need to administer Narcan (opioid reversal agent) to the resident to reverse the effects of a drug overdose and to be evaluated at the local emergency department (ED), after the overdose occurred.

Inspectors wroteBased on observation, staff interview, and review of manufacturer guidelines, the facility failed to label Tuberculin (TB) solution (Tubersol) multi-use vials with a date when opened for use. This deficient practice had the potential to affect all 112 residents residing in the facility. The facility census was 112. Findings Include:1. An observation on 09/11/25 at 7:45 A.M. in the medication refrigerator in the Unit Three medication storage room revealed an opened multi-use vial of Tuberculin solution. There was no date on the vial or on the packaging box to reflect when the vial had been opened for use. The vial expiration was 04/2026. An interview on 09/11/25 at 7:47 A.M. with Medication Technician (MT) #339 confirmed the opened vial of Tuberculin solution without a date reflecting when the vial was opened for use. MT #339 stated the vial should be removed from use and discarded.2. [...]

Inspectors wroteBased on facility infection tracking and monitoring records, and staff interview, the facility failed to properly monitor and address patterns and trends of known infections. This had the potential to affect all 112 residents in the facility. The census was 112. Findings Include:Review of the facility infection control log, dated June 2025, revealed there were two urinary tract infections on one hallway and 12 total skin infections throughout the facility, including three in one unit and three on a separate unit. Review of facility infection control log, dated July 2025, revealed two fungal infections on one unit, two osteomyelitis infections on another unit, three skin infections on a third unit, and two more fungal infections on a fourth unit. [...]

Inspectors wroteBased on observation, staff interview, review of cleaning schedules, and facility policy review, the facility failed to maintain an clean and homelike environment. This deficient practice affected four (#3, #60, #93, and #105) of 112 residents observed for homelike environment. The facility census was 112. Findings Include:An observation on 09/08/25 at 10:30 A.M. revealed Resident #3 lying in bed with the bed covers pulled up to cover lower body. There were several dark brown stains noted on the white window blinds which were in the half-open position. An observation on 09/08/25 at 2:21 P.M. revealed Resident #93's room had cobwebs located in the corners where the wall met the ceiling and in the windowsill. The floor was dirty with noted stains along the baseboard under the heating and cooling unit and under the three-drawer dresser beside the bed. [...]

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to allow a resident to choose to eat a diet texture of their preference when the resident's diet was downgraded without appropriate tests or evaluations completed. This affected one (#49) of one residents reviewed for choices. The census was 112. Findings Include:Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 07/02/25, revealed he was cognitively intact. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure residents had an appropriate diagnosis for use of an antipsychotic medication and failed to provide proper justification for not attempting a gradual dose reduction for a resident's psychotropic medication. This affected two (#118 and #4) of six residents reviewed for psychotropic medications. The facility census was 112.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to provide assistance with personal hygiene for a resident who was dependent for care. This deficient practice affected one (#63) of eight residents reviewed for activities of daily living. The census was 112. Findings Include:Review of the medical record for Resident #63 revealed an admission date of 07/11/23 with diagnoses including but not limited to heart disease, depression, seizures, and intellectual disabilities. Review of Resident #63 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of seven out possible 15, and required moderate to dependent assistance from staff to complete activities of daily living (ADLs) tasks including personal hygiene and shaving of facial hair. [...]

Inspectors wroteBased on observation, medical record review, review of census information, resident interview, and staff interview, the facility failed to provide meaningful activities per resident preference. This affected one (#86) of four residents reviewed for activities. The census was 112.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to implement splint/brace program for a resident with bilateral hand contractures. This deficient practice affected one (#47) of two residents reviewed for positioning and mobility. The facility census was 112. Findings Include:Review of the medical record for Resident #47 revealed an initial admission date 02/08/23 and a re-admission date 03/14/23. Diagnoses included but were not limited to bipolar disorder, anxiety, depression, suicidal behavior, and contractures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of two out of possible 15. Resident #47 was dependent on staff for care, bathing, and transfers. [...]

Inspectors wroteBased on record review, review of fall investigations, staff interview, and facility policy review, the facility failed to implement appropriate interventions and properly address repeated non-compliance with interventions to prevent resident falls. This deficient practice affected one (#14) of four residents reviewed for falls and accidents. The facility census was 112. Findings Include:Review of the medical record for the Resident #14 revealed an admission date of 06/12/06. Diagnoses included dementia, diabetes, anxiety disorder, and glaucoma. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, revealed the resident had impaired cognition. Review of the plan of care dated 07/31/25 revealed Resident #14 was at risk for fall related injury and falls due to a history of falls and his requirements for assistance with activities of daily living (ADLs). [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed to properly assess a resident prior to making a diet order change, and failed to properly, accurately, and timely obtain resident weights and notify the physician of weight changes as ordered. This affected three (#49, #2, and #9) of eight residents reviewed for nutrition. The census was 112. Findings Include:1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. [...]

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to provide/offer timely dental services to residents as needed. This affected two (#49 and #6) of four residents reviewed for dental services. The census was 112. Findings Include:1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 07/02/25, revealed he was cognitively intact. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to implement restorative programs following completion of therapy services as recommended. This affected one (#11) of two residents reviewed for therapy services. The facility census was 112. Findings Include:Review of Resident #11's medical record revealed an initial admission date of 08/19/24 with a re-admission date 05/24/25. Diagnoses including but were not limited to orthopedic care, fracture of the left femur, high blood pressure, spinal stenosis, and dementia. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15, and was independent with ambulation, transfers, and personal hygiene. Resident #11 had a history of falls. [...]

Inspectors wroteBased on observation, resident and staff interview, review of pest control records, and facility policy review, the facility failed to maintain an effective pest control program. This deficient practice affected three (#3, #52, and #93) of 112 residents observed for environment and pest control. The facility census was 112. Findings Include:An observation on 09/08/25 at 10:15 A.M. revealed Resident #105 sitting at edge of the bed looking out the window. There were multiple house flies noted on the windowsill and bed covers. An observation on 09/08/25 at 11:25 A.M. revealed Resident #52 sitting in a wheelchair in her room awaiting lunch meal service. There were several house flies observed in the room. Resident #52 would occasionally swat at one house fly as it flew around her face. An observation on 09/08/25 at 2:21 P.M. [...]

Inspectors wroteBased on observation, and interview, the facility failed to maintain toilet rails, thresholds, walls, floors and dressers. This affected six (Resident's #2, #3, #4, #5 #8, and #9) of 117 residents in the facility.

Inspectors wroteBased on observation, policy review, record review and interview, the facility failed to ensure call bells were within reach. This affected three (Resident's #1, #3 and #4) of six residents observed. The census was 117.

Inspectors wroteBased on interview, record review, and review of job description the facility failed to ensure the social worker assisted the resident to address his preferences of transferring to a different facility. This affected one resident (#2) of one residents reviewed for transfers. The facility census was 117.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were provided drinking water. This affected three (Resident's #1, #3 and #4) of five residents observed for water availability. The census was 117.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, observation medical record review, review of facility policy, and review of facility investigation, the facility failed to ensure Resident #127 did not elope from the facility for an extended period of time. This affected one resident (#127) of three residents reviewed for elopement. The facility census was 122.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on a Facility-Reported Incident (FRI) review, medical record review, facility investigation review, observation, staff interviews, and facility policy review, the facility failed to ensure money was timely returned to the resident or resident representative to prevent misappropriation. This affected one resident (Resident #135) of two residents reviewed for misappropriation. The facility census was 128. Findings Include: Review of Resident #135's medical record revealed admission date of [DATE] and discharge date [DATE] with diagnoses including but not limited to metabolic encephalopathy, heart attack, kidney failure, chronic obstructive pulmonary disease (COPD), and adult failure to thrive. [...]

Inspectors wroteBased on medical record review, interviews and facility policy review the facility failed to ensure respiratory equipment used for sleep apnea, continuous positive airway pressure (CPAP), mask and tubing were cleaned routinely. This affected one resident (Resident #133) of three residents reviewed for use of respiratory care. The facility census was 128. Findings Include: Review of Resident #133's medical record revealed admission date 09/15/22 and discharge date [DATE] with diagnoses including but not limited to unspecified dementia, spina bifida, sleep apnea, depression and anxiety. Resident #133 required staff assistance to complete activities of daily living (ADL) tasks related to having bilateral lower extremity impairment and used a wheelchair for mobility. [...]

Inspectors wroteBased on observations, staff interviews and facility policy, the facility failed to store resident food properly in the unit refrigerator on Unit 3. This had the potential to affect all of the residents on Unit 3 (17 residents on J Hall and 23 residents on K Hall). The facility census was 116.

Inspectors wroteBased on medical record review, observation, interview, the facility failed to provide dignity in dining for Resident #37 while being assisted with her lunch meal. This affected one resident (Resident #37) out of three residents reviewed for meal assistance. The facility census was 116.

Inspectors wroteBased on closed medical record review, review of the wound nurse practitioner (NP) progress notes, and interviews the facility failed to ensure wound notes were accurately documented to reflect current treatment orders for skin alterations. This affected one resident (#1) of three record reviewed.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to implement a comprehensive and effective water management program to identify areas in facility at risk for Legionella growth. This affected one resident (#122), who contracted Legionella while residing in the facility and had the potential to affect all 120 residents residing in the facility. The facility census was 120. Findings Include: [...]

Inspectors wroteBased on record review, resident interview, staff interview and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance they needed to be bathed/ showered as scheduled and as per their preference. This affected three residents (#4, #15, and #64) of three residents reviewed for activities of daily living (ADL) assistance.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a rationale was provided when the physician declined the pharmacist's recommendation. This affected four (#14, #39, #51, and #114) out of five residents reviewed for unnecessary medications. The facility census was 122.

Inspectors wroteBased on review of menu spreadsheets, observation, staff interview, and review of a diet list, the facility failed to ensure residents on a mechanical soft diet and no added salt diet received meals according to the menu. This affected 34 (Residents #1, #2, #4, #6, #14, #19, #22, #27, #31, #32, #33, #37, #38, #39, #49, #50, #52, #54, #58, #60, #61, #64, #66, #68, #70, #71, #75, #88, #97, #105, #109, #227, #275, #328) of 34 residents who were on a mechanical soft diet and/or no added salt diet. The facility census was 122.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure staff practiced proper infection prevention precautions to prevent the spread of respiratory syncytial virus (RSV). This had the potential to affect all 32 residents (#3, #4, #6, #23, #25, #29, #31, #35, #39, #42, #43, #45, #50, #53, #55, #56, #59, #60, #65, #70, #72, #74, #81, #82, #85, #87, #92, #94, #96, #101, #113, #324) who were negative for RSV and resided on the K hall and C hall. The facility census was 122.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 19 (#9, #10, #23, #27, #43, #64, #66, #71, #72, #74, #84, #87, #92, #103, #110, #116, #118, #326, and #475) residents who the facility identified as independently mobile and able to use the pool table in the K hallway. The facility census was 122.

Inspectors wroteBased on medical record review, family interview, and staff interview, the facility failed to ensure Resident #102's primary language of Spanish was addressed in the comprehensive care plan. This affected one (Resident #102) out of one resident reviewed for communication. The facility census was 122.

Inspectors wroteBased on medical record review, observation, interview, and review of facility policy, the facility failed to ensure activities were provided as care planned and preferred in order to meet the needs of the residents. This affected two residents (#24 and #108) of three residents reviewed for activities. The facility census was 122.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure fall interventions were implemented as ordered. This affected one resident (#104) of four residents reviewed for falls. The facility census was 122.

Inspectors wroteBased on medical record review and staff interview, the facility failed to adequately obtain/monitor resident blood pressures in order to ensure antihypertensive medication was administered as ordered. This affected one resident (#114) of five residents who were reviewed for unnecessary medications. The facility census was 122.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure residents were provided adaptive equipment at meals as needed. This affected one (Resident #39) out of six residents reviewed for nutrition. The facility census was 122.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview and record review the facility failed to initiate antibiotic treatment orders when Resident #132's diabetic ulcer became infected. This affected one resident (Resident #132) of three residents reviewed for infections. The facility census was 117.

Inspectors wroteBased on interview and record review the facility failed to obtain ordered lab work for Resident #132. This affected one resident (#132) of three residents reviewed for laboratory testing The facility census was 117.

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure antibiotic stewardship procedures were followed regarding wound cultures obtained during consultation appointments. This affected one resident (Resident #132) of three residents reviewed for antibiotic stewardship. The facility census was 117.

Inspectors wroteBased on observation, review of shower documentation, and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received assistance with grooming and personal hygiene. This affected four of four residents reviewed for ADL's (Residents #16, #49, #105, and #368). The census was 125.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident (Resident #57) received tracheotomy care in a manner to prevent potential infection. Additionally, the facility failed to ensure three resident's (Residents #24, #39, #115) oxygen equipment was stored in a sanitary manner. This affected one of one resident reviewed for tracheotomy/ventilator use and three of four residents reviewed for oxygen use. Findings Included: 1. Review of Resident #57's medical record revealed an original admission date of 12/19/20 with the latest readmission of 04/07/20. [...]

Inspectors wroteBased on observations, medical record review, staff interview, and facility policy review, the facility failed to follow infection control and COVID-19 policies and procedures. This affected eight (Residents #10, #27, #38, #58, #61 #67, #99, and #109) of nine residents reviewed for infection control procedures. The census was 125.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide beneficiary notices for skilled services being discontinued in a timely manner. This affected two (Residents #47 and #58) of three resident beneficiary notices reviewed. The census was 125. Findings Include: Review of Resident #47 beneficiary notice letter revealed his skilled services started on 10/20/21. The end date of his skilled services was scheduled to be 11/27/21. In review of his medical records, the facility did not have evidence that Resident #47's responsible party signed the beneficiary notice form. There was evidence that it was sent to Resident #47 responsible party via mail, but they never received a signed copy. [...]

Inspectors wroteBased on observation, medical record review, staff interview the facility failed to provide a resident personal privacy during a medical treatment. This affected one of 125 residents (Resident #57). Findings Included: Review of Resident #57's medical record revealed the latest readmission of 04/07/20. Diagnoses included chronic respiratory failure with hypoxia, status tracheotomy, dependence on ventilator, chronic obstructive pulmonary disease, metabolic encephalopathy, diabetes mellitus, dysphagia, status gastrostomy, hypertension, anemia, mood disorder, insomnia, chronic pain, anxiety, carcinoma of skin of face, basal cell carcinoma of skin of face, dependence on supplement oxygen and constipation. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a homelike environment for residents. This was observed in two of ten hallways (L and M hallways) and affected 43 residents residing on the affected hallways. The census was 125.

Inspectors wroteBased on medical record review and staff interview, the facility failed to update resident Pre-admission Screening and Resident Review (PASRR) records after a significant change. This affected two (Resident #16 and Resident #46) of six resident PASRR forms reviewed. The census was 125. Findings Include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE]. His diagnoses were unspecified dementia with behavioral disturbances, hypertensive heart disease, congestive heart disease, type II diabetes, atrial fibrillation, peripheral vascular disease, adjustment disorder (05/03/21), unspecified psychosis, major depressive disorder, dysphagia, vitamin D deficiency, dry eye syndrome, osteoarthritis, hypokalemia, and personal history of transient ischemic attack. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to maintain an updated and accurate Pre-admission Screening and Resident Review (PASRR) for residents when they are first admitted to the facility. This affected two (Resident #6 and Resident #73) of six residents PASRR forms reviewed. The census was 125. Findings Include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE]. His diagnoses were dementia with behavioral disturbances, chronic obstructive pulmonary disease, type II diabetes, chronic kidney disease, anemia, dysphagia, chronic respiratory failure, schizoaffective disorder, schizophrenia, anxiety disorder, major depressive disorder, bipolar disorder, osteoarthritis, vitamin D deficiency, peripheral vascular disease, hyperlipidemia, type II diabetes, and shortness of breath. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to report a significant change of a resident Pre-admission Screening and Resident Review (PASRR) records to the state mental health agency. This affected two (Resident #16 and Resident #46) of six resident PASRR forms reviewed. The census was 125. Findings Include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE]. His diagnoses were unspecified dementia with behavioral disturbances, hypertensive heart disease, congestive heart disease, type II diabetes, atrial fibrillation, peripheral vascular disease, adjustment disorder (05/03/21), unspecified psychosis, major depressive disorder, dysphagia, vitamin D deficiency, dry eye syndrome, osteoarthritis, hypokalemia, and personal history of transient ischemic attack. [...]

Inspectors wroteBased on activity record documentation and staff interview, the facility failed to provide on-going activities. This affected one of two residents reviewed for activities (Resident #24). The census was 125.

Inspectors wroteBased on observations, staff and resident interviews, facility failed to ensure Resident #46 had eyeglasses in functional working condition when her glasses were broken. This affected one resident of one reviewed for assistive devices. Facility census was 125.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure pressure ulcer interventions were maintained. This affected one (Resident #109) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure one resident (Resident #57) physician ordered contracture prevention device was in place as ordered. This affected one of one resident reviewed for limited range of motion. Findings Include: Review of Resident #57's medical record revealed an original admission date of 12/19/20 with the latest readmission of 04/07/20. Diagnoses included chronic respiratory failure with hypoxia, status tracheotomy, dependence on ventilator, chronic obstructive pulmonary disease, metabolic encephalopathy, diabetes mellitus, dysphagia, status gastrostomy, hypertension, anemia, mood disorder, insomnia, chronic pain, anxiety, carcinoma of skin of face, basal cell carcinoma of skin of face, dependence on supplement oxygen and constipation. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately monitor and treat one resident (Resident #81) constipation with known history of small bowel obstruction. This affected one of one resident reviewed for bowel and bladder incontinence. Findings Included: Review of Resident #81's medical record revealed an original admission date of 10/30/20 with the latest readmission of 11/17/21. [...]

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure one resident's (Resident #57) enteral feeding formula was labeled and not spoiled. This affected one of one resident reviewed for enteral feeding. Findings Included: Review of Resident #57's medical record revealed an original admission date of 12/19/20 with the latest readmission of 04/07/20. Diagnoses included chronic respiratory failure with hypoxia, status tracheotomy, dependence on ventilator, chronic obstructive pulmonary disease, metabolic encephalopathy, diabetes mellitus, dysphagia, status gastrostomy, hypertension, anemia, mood disorder, insomnia, chronic pain, anxiety, carcinoma of skin of face, basal cell carcinoma of skin of face, dependence on supplement oxygen and constipation. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were stored properly. Multiple stock medications were expired in Unit 3's Medication Room. This affected one of two medication storage rooms observed for medication storage and had the potential to affect all residents in the facility. The facility census is 125.

Inspectors wroteBased on record review and interviews of staff, residents, and the certified nurse practitioner, the facility failed to obtain laboratory services according to physician orders. This affected two residents (Residents #46 and #105) of two reviewed for laboratory orders. Facility census was 125.