Landmark of Laurel Creek Rehabilitation and Nursin

In the surveyor’s words

From the most serious findings on record at Landmark of Laurel Creek Rehabilitation and Nursin, in the surveyor’s own words.

• Immediate jeopardy, patternF657Dec 8, 2022

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to revise the person-centered Comprehensive Care Plan (CCP) to include measurable objectives and timeframes to provide services that met standards as related to care plan revision by the Interdisciplinary Team (IDT) after each assessment for five (5) of nine (9) residents, Residents #1, #2, #3, #7, and #8. 1. Review of Resident #1's Comprehensive Care Plan (CCP), initiated [DATE], revealed the facility assessed the resident as at risk for falls with interventions noting the resident required staff support and assistance for toileting. […]

• Immediate jeopardy, patternF689Dec 8, 2022

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices necessary to prevent accidents for five (5) of nine (9) sampled residents (Residents #1, #2, #3, #7 and #8). 1. The facility assessed Resident #1 as at risk for falls and care planned the resident to require physical assistance of two (2) staff with his/her Activities of Daily Living (ADLs) to include transfers and walking in his/her room. […]

• Immediate jeopardy, patternF835Dec 8, 2022

  Based on interview, record review, review of the facility's policy and Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration's failure to follow its policies in preventing falls and ensure the safety of residents assessed as at high risk for falls resulted in injury for five (5) of nine (9) sampled residents, Residents #1, #2, #3, #7 and #8. Interviews with the Administrator, Director of Nursing (DON), and Minimum Data Set (MDS) Coordinator revealed they participated in the facility's Interdisciplinary Team (IDT) meetings. […]

• Immediate jeopardy, patternF865Dec 8, 2022

  Based on observation, interview, record review, and review of the facility's policy, investigations, and documentation, it was determined the facility failed to implement their Quality Assurance Performance Improvement (QAPI) program to ensure the identification of opportunities for improvement in the care and services provided to residents. The facility's QAPI process failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards of quality of care regarding performance improvement measures were sustained. As a result the facility's QAPI program failed to develop, implement, and monitor to identify issues with supervision of residents in prevention of falls. […]

• No harm, potential for more than minimal, widespreadF812Jun 24, 2021

  Based on observation, interview, and a review of the facility policy, it was determined the facility failed to store serve and prepare food under sanitary conditions. A trash can was observed uncovered in the kitchen next to the hand sink, an egg carton was observed contaminated with egg shells and egg residue stored in the walk-in refrigerator, bags of bologna, packs of ground beef and ham was stored in the refrigerator not labeled and/or dated. Dented cans were stored available for use. Butter was observed stored uncovered and had food debris on it in the refrigerator. […]