The Laurels of Sandy Creek

Inspectors wroteThis citation pertains to intakes 2738764 and 2707043Based on observation, interview, and record review the facility failed to maintain their roof in a safe, functional, and sanitary manner for 2 (Residents #112 and #113) of 4 residents reviewed for environment, resulting in dissatisfaction with living environment which affected all areas of the facility and an increased potential for contamination.

Inspectors wroteThis citation pertains to intakes 2704281 and 2790806. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse and/or physical abuse by staff for 2 (Residents #107 and 104) of 3 residents reviewed for abuse resulting in feelings of sadness and/or being handled in an undesirable way.

Inspectors wroteThis citation pertains to intake 2790806. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of staff to resident abuse to other state agency according to state law in 1 (Resident #104) of 3 residents reviewed for abuse resulting in the nurse licensing department not being notified and officials being unaware of abuse allegations, and the potential for abuse to reoccur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions for 1 (Resident #111) of 9 residents reviewed for care plan implementation resulting in the potential for further skin breakdown and worsening of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate care for residents who received enteral nutrition (method of delivering nutrients directly into the gastrointestinal (GI) tract via tubes) in 1 (Resident #121) of 1 resident reviewed for enteral nutrition, resulting in the potential for aspiration pneumonia and spoiled tube feeding.

Inspectors wroteThis citation pertains to intake # 2642001Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to an alarming exit door to ensure resident safety in 1 of 3 residents (Resident #101) reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 10/2/25 between 6:15 AM and 6:30 AM, Resident #101, who was an elopement risk, exited the facility, unbeknownst to facility staff, and was found by a Activities Director (AD) E approximately 50 yards away from the facility, in his wheelchair on the sidewalk of the road. This deficient practice placed all residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received care in accordance with professional standards in 1 of 18 residents (Resident #37) reviewed for quality of care when nursing staff administered Lotrel (Medication used to treat hypertension) out of the physician ordered parameters resulting in the potential for adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident food and drink preferences were honored consistently for 8 (Residents #5, 8, 17, 31, 35, 51, 54, 74) of 8 residents reviewed for dining, resulting in feelings of anger and sadness and the potential for weight loss and/or dehydration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adaptive dining equipment was provided for 1 (Resident #5) of 3 residents reviewed for adaptive dining equipment resulting in difficulty eating and the potential for weight loss.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform a resident self-administration assessment and obtain a physician order for the self-administration of medication for 1 (Resident #5) of 18 residents reviewed for self-administration of medication, resulting in the potential for the mismanagement of medication and potential for adverse side effects.

Inspectors wroteBased on interview and record review, the facility to follow advance directive wishes for 1 (Resident #278) of 24 residents reviewed for advance directives, resulting in Resident #278 receiving cardiopulmonary resuscitation (CPR) when Resident #278 had an Do Not Resuscitate (DNR) order in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 resident (Resident #6) of 24 residents received an accurate clinical assessment, reflective of the resident's status at the time of the assessment, resulting in inaccurate diagnosis of schizophrenia documented on MDS (Minimum Data Set) assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of person protective equipment (PPE) (gown and gloves) by staff during high contact care activities for 1 (Resident #27) of 18 residents reviewed for enhanced barrier precautions (EBP) resulting in the potential for the spread of infection, cross contamination, and disease transmission.

Inspectors wroteBased on interview and record review the facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to provide an oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, foodborne illness, or inadequate assessment of high-risk residents.

Inspectors wroteThis citation pertains to intake number MI00148293. Based on interview and record review, the facility failed to ensure staff had appropriate competencies and skills needed to provide care in a manner that supported their psychosocial wellness in 1 (Resident #102) of 6 residents reviewed for behavioral competency, resulting in inappropriate staff to resident interactions, inability of staff to appropriately address the psychological distress, unmet care needs, and resident not maintaining or achieving highest practical psycho-social well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent involuntary seclusion in 1 of 6 residents (Resident #102) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an infection control surveillance plan was in place and included an ongoing collection and interpretation of data for 4 (Resident #109, #112, #113, and #114) of 15 residents with the potential to affect all 78 residents who reside at the facility, resulting in the potential for the spread of infection without timely identification and response, and the development and spread of infection to a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration and documentation in 6 of 10 residents (Resident #7, #14, #22, #38, #39, and #50) reviewed for medication administration, resulting in the potential for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted and resident dignity in 1 (Resident #4) of 3 residents reviewed for dignity, resulting in the potential of feelings of humiliation, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life.

Inspectors wroteThis citation pertains to intake #MI00142698 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 (Resident #105) of 5 residents reviewed for abuse, resulting in Resident #105 being physically assaulted by Resident #100.

Inspectors wroteThis citation pertains to intake # MI00141124 Based on interview and record review, the facility failed to immediately report an injury of unknown origin (hematoma of neck) to the State Agency for 1 of 5 residents (Resident #100) reviewed for abuse, resulting in the potential for neglect and/or abuse going undetected, unreported, or without thorough investigation.

Inspectors wroteThis citation pertains to intake MI00142698 Based on interview and record review, the facility failed to provide adequate supervision and implement interventions to prevent resident to resident physical altercations in 2 (Resident #100 and Resident #105 ) of 5 residents reviewed for abuse, resulting in the potential for further resident to resident altercations, physical injury, unmet care needs, fear, anxiety, and a decline in psychosocial well being. Resident #100 Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #100 was severely cognitively impaired. [...]

Inspectors wroteThis citation pertains to intake #MI00138742. Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) with a valid nursing license was on duty eight consecutive hours a day, seven days a week resulting in the potential for negative clinical outcomes affecting all residents at the facility.

Inspectors wroteThis citation pertains to intake #MI00138742 Based on interview and record review, the facility failed to implement policies and procedures related to screening procedures for work eligibility in a nursing home prior to employment for 1 (Unlicensed Staff (US) C) of 5 employees reviewed, resulting in Unlicensed Staff C working falsely under the authority of a licensed nurse in the facility for approximately 7 months.

Inspectors wroteThis citation pertains to intake #MI00138742. Based on interview and record review, the facility failed to ensure 2 of 6 facility staff members (Unlicensed Staff (US) C and Registered Nurse (RN) F) reviewed for competency, were annually evaluated and had a valid nursing license, resulting in Unlicensed Staff (US) C, falsely acting with the authority of a licensed nurse, provided nursing care to residents, administered medications in error and falsely documented the administration of treatments for 4 residents (Resident #106, #107, #108, and #109), RN F not being annually evaluated for competency, and the potential for serious negative outcomes for all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the dignity for five Residents (#4, #27, #36, #45 and #264) from a total sample of 16 Residents reviewed for dignity, resulting in feelings of frustration, decreased self-worth and concern for their own well-being.

Inspectors wroteThis citation pertains to Intakes: MI00130667, MI00130673, MI00130677 Based on interview and record review, the facility failed to adequately supervise a resident (Resident #31) with known behaviors to prevent resident to resident incidents for 4 (Resident #31, Resident #56, Resident #214, Resident #215) of 4 residents reviewed for adequate supervision, resulting in continued resident to resident incidents and injuries to Resident #31 and Resident #215.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a clean and sanitary environment, sanitize resident equipment (IV-intravenous poles, wound vacuums) for 1 resident (Resident #44) reviewed for infections, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with their preferred practice to maintain hygiene for 1 of 3 residents (Resident #41) reviewed for self-determination, resulting in feelings of frustration and the potential for the residents to not meet their highest practicable well-being.

Inspectors wroteThis citation pertains to intake number MI00135896. Based on observation, interview, and record review the facility failed to protect the resident's right to be free from staff to resident verbal abuse toward 1 Resident (R#53) out of 4 Residents reviewed for abuse/neglect, resulting potential feelings of dehumanization based on the reasonable person concept. Findings Include: Review of an admission Record revealed Resident #53 was admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #53 dated 4/8/23, revealed pertinent diagnoses that included unspecified dementia without behavioral disturbances, muscle weakness, adjustment disorder with mixed anxiety and depressed mood. Further review of the MDS revealed a Brief Interview of Mental Status (BIMS) score of 3/15 which indicated Resident #53 was severely cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to complete PICC (peripherally inserted central catheter- long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) line dressing changes according to professional standards for 1 resident (Resident #44) out of 4 resident reviewed for infections, resulting in the potential for Resident #44 inability to properly heal his infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was a trauma survivor received care and services that accounted for experiences, and addressed their needs in 1 of 1resident (Resident #56) reviewed for trauma informed care, resulting in the potential for re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma, and the lack of care plan interventions in place.