Laurel Park Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Laurel Park Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 10, 2021

  Based on record review, staff interviews, observations, and physician interview the facility failed to provide supervision to prevent a cognitively impaired resident who had been identified as a wandering risk from exiting the facility for one of two residents reviewed for supervision to prevent accidents. Resident #3, who was cognitively impaired, exited the facility without staff knowledge and was found approximately an hour later at a credit union adjacent to a 4-lane highway, 0.2 miles or 1,056 feet away from the facility. After Resident #3 was observed outside by a staff member, he was left unattended outside while confirmation and assistance was sought from other staff members. […]

• Actual harm, isolatedF604May 21, 2025

  Based on record review, and staff, family and Medical Director interviews, the facility failed to protect a severely cognitively resident from physical restraint from a private duty Caregiver and chemical restraint. When Resident #199 refused to take medications from the Nurse the private duty Caregiver offered to assist and forced medications into the Resident's mouth, held her hand over the Resident's mouth, to force her to swallow. When Resident #199 became combative, and kicking and spitting out medications the private Caregiver restrained the Resident by placing her leg over Resident #199 legs to prevent her from kicking. The Nurse asked the Caregiver to stop and left the room to call the on-call provider. […]

• Actual harm, isolatedF686May 10, 2021

  Based on record review, staff interview, physician interview, nurse practitioner interview, and family interview the facility failed to provide necessary services and medical equipment for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to obtain replacement parts for a wound vac, provide an air mattress, provide wound treatments as ordered, and notify the physician of a decline in the wound for Resident #13, resulting in a deterioration of a stage 4 pressure wound with an increase in size and infection. Findings included: Resident #13 was admitted to the facility from the hospital on 3/3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF838May 21, 2025

  Based on staff interview and review of the Facility Assessment the facility failed to identify any cultural considerations for the resident population, failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required, and failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies which had the potential to affect 88 of 88 residents. The findings included: Review of the Facility Assessment revealed it was revised on 3/12/25. The Facility Assessment did not include any cultural considerations to meet the needs of the residents of the facility. […]

• No harm, potential for more than minimal, patternF578May 21, 2025

  Based on record review, resident and staff interviews, the facility failed to provide written information to residents and resident representatives regarding advance directive and/or an opportunity to formulate an advance directive for 19 of 22 residents reviewed for advance directives (Resident #1, #5, #8, #21, #25, #26, #29, #33, #37, #40, #50, #52, #58, #72, #73, #75, #91, #95, and #302). The findings included: a. Review of Resident #1's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, and hypotension. The review revealed a full code Physician order dated 5/18/25. […]