Laurel Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Laurel Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF755Apr 12, 2022

  Based on observation, interview, and record review, the facility failed to provide routine and emergent necessary pharmaceutical services to residents; failed to have a functioning system in place to accurately manage the ordering, administering, monitoring, and reconciliation of medications, including controlled substances, for 6 (#s 1, 2, 3, 4, 5, 6) of 8 sampled residents. This failure resulted in harm and potential for more harm to residents receiving medications from the facility. An Immediate Jeopardy was called on [DATE] at 4:59 p.m., in the presence of the facility administrator, administrator in training, the RN, DDCO, and the facility AGACNP-BC, MSN, Chief Nursing Officer. The IJ pertained to F755 - Pharmacy services. […]

• Actual harm, isolatedF757Jul 30, 2026

  Based on interview and record review, the facility failed to ensure medications were free from unnecessary use by administering Narcan (naloxone) without a physician order or documented clinical indication for 1 (#4) of 1 resident reviewed for unnecessary medications. The failure resulted in precipitated opioid withdrawal symptoms, increased resident distress, and hospitalization, and the resident received additional medical treatment. Findings include: Review of a facility-reported incident submitted to the State Survey Agency on 5/18/26 showed resident #4, a hospice resident receiving comfort-focused treatment, was found unresponsive, and a staff member administered Narcan (naloxone). […]

• Actual harm, isolatedF760Oct 12, 2023

  Based on interview and record review, the facility failed to ensure 1 (#3) of 14 sampled residents was free from a significant medication error requiring hospitalization . Resident #3 was given 22.5 mls of Methadone instead of the ordered 10 mls. Findings include: Review of a facility reported incident, dated 3/8/23, showed a medication error resulted in resident #3 being transferred to the emergency room from the wound clinic. Investigation for the incident showed the resident was to receive 10 mls of Methadone, but received 22.5 mls. Review of the incident showed the dosage of Methadone had been changed from 22.5 mls to 10 mls on 3/6/23 upon return from a hospital stay. […]

• Actual harm, isolatedF684Dec 9, 2021

  Based on interview and record review, the facility failed to comprehensively assess accurately and identify and assess non-pressure wounds present on admission, and failed to implement wound care and regular ongoing monitoring necessary to promote healing, and prevent worsening of venous stasis ulcers, and other non-pressure wounds for 2 (#s 31 and 197) of 4 sampled residents. The deficient practice had the potential to negatively affect wound healing. Resident #197's eventually required an amputation of his right lower leg. Findings include: A list of new admissions, and a list of all wound care orders since 7/1/21, showed resident #31 and resident #197 had venous or other non-pressure related wounds present on admission. 1. […]

• Actual harm, isolatedF686Dec 9, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents admitted with pressure ulcers received the necessary care and services, consistent with professional standards of practice, to promote healing and prevent infections of pressure ulcers, for 2 (#s 10 and 197) of 3 sampled residents. These deficient practices resulted in the delay in identification, assessment, and initiation of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A list of new admissions with wounds was reviewed. The residents were sampled from this list. 1. Resident #197 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]