The Laurels of Summit Ridge

Inspectors wroteBased on observation and staff interviews, the facility failed to remove expired leftover food and label and date leftover opened foods stored for use in 1 of 1 walk-in refrigerator. The facility failed to discard expired food items stored in 1 of 1 nourishment refrigerator (200 hall). These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, observations, and interviews with resident and staff the facility failed to honor a residents choice to receive a shower instead of a bed bath for 1 of 3 residents reviewed for choices (Resident #28).

Inspectors wroteBased on record review, staff, family, and Nurse Practitioner (NP) interviews, the facility failed to implement effective interventions to prevent a resident (Resident #1) with right side hemiplegia (paralysis on the right side of the body) who took Plavix (antiplatelet medication) and aspirin (antiplatelet medication) from repeatedly falling from an air mattress and sustaining head injuries. Resident #1 sustained falls from her air mattress on 5/29/25, 6/10/25, and 6/13/25. After her fall on 5/29/25 Resident #1 had a raised lump and bruising to her head requiring her to be transferred to the emergency room (ER) for evaluation. After her third fall from the air mattress on 6/13/25, Resident #1 sustained another head injury which included a 3 centimeter (cm) laceration and hematoma. Resident #1 required ER evaluation and staples to treat the laceration to her head. [...]

Inspectors wroteBased on record review, observations, and resident and staff interviews, the facility failed to maximize residents' independence with transfers and bed mobility by not providing assist bars or side rails for 2 of 4 residents reviewed for accommodation of needs (Resident #43 and Resident #28).

Inspectors wroteBased on observations and interviews with staff, the facility failed to date leftover food stored for use in the walk-in refrigerator. The facility also failed to maintain the walk-in refrigerator cooling unit pipe from dripping water onto the wall and floor and maintain the cooling unit pipe and walls of the walk-in refrigerator free from substance build-up. This was for 1 of 2 walk-in refrigerators observed (walk-in refrigerator #2).

Inspectors wroteBased on observation and staff interviews the facility failed to maintain the shower room tile floor in good repair when missing and broken tiles were observed for 1 of 1 shower rooms reviewed for a safe, clean, comfortable and homelike environment.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to perform fingernail care for 1 of 2 residents reviewed for (ADL) care (Resident #8).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication omission and administration of wrong dosage (2 medication errors out of 31 opportunities), resulting in a medication error rate of 6.45% for 1 of 3 residents (Resident #28) observed during medication pass.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their infection control policy when the Floor Technician entered a resident's room (Resident #46) on Enhanced Droplet Precautions without donning an N95 mask, gown, or eye protection. This was for 1 of 6 staff members observed for infection control practices (Floor Technician).

Inspectors wroteBased on record review, staff and Medical Director (MD) interviews the facility failed to follow a physician's order to discontinue a psychotropic medication that resulted in the resident continuing to receive the medication for 1 of 5 residents (Resident #39) reviewed for unnecessary medications.

Inspectors wroteBased on observations and interview with the Dietary Manager (DM) the facility failed to remove expired thickened liquids from 2 of 3 nourishment room refrigerators (the 100 Unit and 300 Unit nourishment rooms). The practice had the potential to affect all residents receiving thickened liquids. The Findings Included: a. An observation of the 100-unit nourishment room refrigerator with the DM on [DATE] at 10:28 AM found 3 unopened 4 oz thickened liquid containers with an expiration date of [DATE]. The DM immediately disposed of the thickened liquids. b. An observation of the 300-unit nourishment room refrigerator on [DATE] at 10:38 AM with the DM found 3 unopened 4 oz thickened liquid containers with expiration date of [DATE] and one unopened 4 oz thickened liquid container with expiration date of [DATE]. [...]

Inspectors wroteBased on an observation and staff interviews the facility failed to ensure all trash was disposed of inside the dumpster for 1 of 1 dumpster. This practice had the potential to attract pests and mice.

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 interventions the committee put into place following the complaint survey conducted on 10/1/21. This was for a repeat deficiency that was originally cited during the complaint survey on 10/1/21 for infection control and recited during the recertification and complaint investigation survey completed on 3/21/24. The continued failure of the facility during a two federal survey of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to implement their infection control policies for laundry services when 1 of 1 staff member (Laundry Staff) failed to follow standard precautions during the infection control observation.

Inspectors wroteBased on observation, record review, and interviews with residents and staff, the facility failed to maintain call bell within reach for 1 out 2 residents reviewed for accommodations of needs. (Resident #1)

Inspectors wroteBased on record reviews and interviews with resident, staff, and the Nurse Practitioner, the facility failed to have accurate advanced directive information documented throughout the medical record for 1 of 3 residents reviewed for code status (Resident #18).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a new mental health diagnosis for 1 of 3 residents reviewed for PASRR (Resident #36).