Heritage Hall - Laurel Meadows

In the surveyor’s words

From the most serious findings on record at Heritage Hall - Laurel Meadows, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF580Jun 30, 2026

  Based on staff interview, clinical record review, and facility document review the facility staff failed to notify a Responsible Party (RP) of a change in condition for (1) one of (6) six closed record reviews, Resident #63. Findings included:The facility staff failed to notify the RP of a fall on 12/04/2023. Nursing documentation indicated that the resident sustained a raised area to the side of the forehead from the fall. This was a closed record review. Resident #63's diagnoses included muscle weakness, difficulty in walking, diabetes, dementia with agitation, and repeated falls. […]

• No harm, potential for more than minimal, isolatedF628Jun 30, 2026

  Based on staff interview and clinical record review, the facility staff failed to provide written notification for the reason(s) of transfer/discharge to the resident and the resident's representative for (1) one of (21) twenty-one current sampled residents, Resident #5. Resident #5 was transferred/discharged to a higher level of care on 02/21/2026. Findings included:Resident #5 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included but were not limited to schizophrenia spectrum disorder, depression, cerebral palsy, cerebrovascular disease, and chronic respiratory failure with hypoxia. […]

• No harm, potential for more than minimal, isolatedF656Jun 30, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement the comprehensive person-centered care plan to address weight monitoring for (1) one of (21) twenty-one current sampled residents, Resident #5. Findings included:Resident #5 was admitted to the facility on [DATE] with a diagnosis list that included but was not limited to, morbid obesity due to excess calories. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. […]

• No harm, potential for more than minimal, isolatedF657Jun 30, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to revise a comprehensive person-centered care plan to include appropriate interventions regarding a feeding tube for (1) one of (21) twenty-one sampled residents, Resident #4. Findings included: For Resident #4, the facility staff failed to revise the Comprehensive Person-Centered Care Plan for the proper administration route of Resident#4's tube feeding for nutrition and hydration. An admission Record indicated the facility admitted Resident #4 on 07/14/2020. […]

• No harm, potential for more than minimal, isolatedF658Jun 30, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide care and services to meet professional standards of practice by administering pain medication without a medical provider order for (1) one of (6) six closed record reviews, Resident #61. Findings included:Resident #61 was admitted to the facility on [DATE] with a diagnosis list which indicated diagnoses that included, but were not limited to, acute abdomen intestinal bypass and anastomosis status, dementia, Parkinson's disease, amnestic disorder, cognitive communication deficit, weakness, and difficulty walking. […]