Laurel Hill Nursing Center

In the surveyor’s words

From the most serious findings on record at Laurel Hill Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 24, 2026

  Based on interview and record review it was determined the facility failed to ensure bed brakes were engaged during resident care for fall prevention for 1 of 3 sampled residents (#8) reviewed for accidents. Resident 8 experienced a fall from bed and sustained a skin abrasion, increased lower extremity pain, and a decline in mobility status. Findings include:Resident 8 was admitted to the facility in 10/2024 with diagnoses including hemiparesis (one-sided weakness) following a stroke.An 11/18/25 Quarterly MDS Assessment for Resident 8 demonstrated a BIMS Score of 14, indicating intact cognitive function.An undated fall investigation document revealed Resident 8 suffered a fall to the floor between her/his bed and the wall which occurred while Staff 9 (CNA) was providing personal care and… […]

• Actual harm, isolatedF689Dec 15, 2023

  Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision, follow care plans, complete thorough investigations and timely assess smoking for 4 of 4 sampled residents (#s 6,15, 23, and 134) reviewed for accidents. Resident 15 and Resident 134 experienced falls resulting in fractures. Findings include: 1. Resident 15 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease and stroke. A 7/13/22 Admission MDS and CAAs indicated Resident 15 was impaired on both sides, at risk for falls due to weakness, required increased ADL support and her/his care plan was to include interventions to reduce the risk of falls. a. […]

• Actual harm, isolatedF684Sep 16, 2022

  Based on interview and record review it was determined the facility failed to ensure a surgical wound was monitored and assessed for 1 of 1 sampled resident (#177) reviewed for non-pressure skin. This resulted in Resident 177's surgical wound becoming infected, and the resident being hospitalized . Findings include: The facility's 4/2018 Skin at Risk Program Overview indicated: 16. Skin conditions other than pressure ulcers, etc. will be documented on the resident's treatment record. Other skin conditions (rashes, skin tears, excoriations, abrasions, bruises or surgical wounds) would be addressed with appropriate treatment orders. 17. […]

• No harm, potential for more than minimal, widespreadF812Mar 28, 2025

  Based on observation, interview, and record review it was determined the facility failed to properly follow dish sanitation practices for 1 of 1 kitchen. This placed residents at risk for food borne illnesses. Findings include: Instructions for the facility dish machine revealed the dish machine required 50 parts per million of chlorine rinse to santize. On 3/27/25 at 12:40 PM Staff 26 was observed to use the dish machine to wash dishes. Staff 26 stated she started the dish machine in the mornings when she worked and ensured chemicals were visually flowing into the dish machine to verify the chemical concentration was adequate in the dish machine. […]

• No harm, potential for more than minimal, widespreadF801Dec 15, 2023

  Based on interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: A 9/19/19 Nutrition and Food Service Training Program indicated Staff 4 (Dietary Manager) completed 270 contact hours of the program. On 12/12/23 at 11:05 AM Staff 4 indicated he did not yet pass the test for the nutrition program certification. On 12/13/23 at 1:35 PM Staff 1 (Administrator) stated she was only recently aware that Staff 4 did not possess the required certification as required.