Laurels of Defiance the

In the surveyor’s words

From the most serious findings on record at Laurels of Defiance the, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Apr 1, 2022

  Based on open and closed medical record review, staff interviews, physician interview, review of an emergency services run report, review of hospital documentation, review of a death certificate, review of a facility investigation, review of a facility facsimile (fax) transmittal binder, and review of facility policy regarding a change in a resident ' s condition, the facility failed to timely notify the physician of a significant change in condition for one resident (Resident #12). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #12 was complaining of abdominal pain and distention, difficulty breathing, and signs of gastrointestinal (GI) bleeding, and pleading to be sent to the hospital or be seen by a physician with no notification to the physician. […]

• Immediate jeopardy, isolatedF600Apr 1, 2022

  Based on open and closed medical record reviews, staff interviews, physician interview, review of an emergency services run report, review of hospital documentation, review of a death certificate, review of a facility investigation, review of a facility facsimile (fax) transmittal binder, and review of facility policies regarding abuse, managing emergencies, and standards of nursing practice, the facility failed to ensure residents were free from neglect by providing on-going and timely assessments when there was an identified significant change in condition for one resident (Resident #12). […]

• Actual harm, isolatedF689Mar 5, 2021

  Based on medical record review, staff interview, review of the facility incident log, review of the facility incident report, review of the facility investigation, and policy review, the facility failed to ensure one resident's (#82) fall interventions were in place. This resulted in actual harm when Resident #82 fell from the bed, when she was left unattended, while the bed was in the highest position which resulted in a [MEDICAL CONDITION]. This affected one resident (#82) out of four reviewed for falls. The facility census was 81. Findings included: Review of the medical record revealed Resident #82 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 12/29/20 revealed the resident was at risk for falls. […]

• No harm, potential for more than minimal, widespreadF606Nov 8, 2023

  Based on record review, interview and policy review, the facility failed to terminate employment for a State tested Nursing Assistant (STNA) who had a finding entered in the State Nurse Aide Registry concerning abuse, neglect, or misappropriation. This resulted in one employee, STNA #101, working at the facility while he was not eligible to work in a long-term care facility. This had the potential to affect all residents in the facility. The facility census was 85. Findings include: Review of the personnel file for STNA #101 revealed a hire date of 12/01/22. Review of the background check log revealed STNA #101's background check was submitted 11/22/22, completed 12/07/22 and received at the facility on 12/14/22. […]

• No harm, potential for more than minimal, patternF761Jun 12, 2025

  Based on observation, staff interview, facility policy, and pharmacy documentation, the facility failed to store resident insulin in a safe and sanitary manner. This affected six of 17 residents (#14, #24, #25, #31, #34 #51) identified by the facility to receive insulin administration in a facility census of 93. Findings include: 1. Observation on [DATE] at 10:55 A.M. with Licensed Practical Nurse (LPN) #402 during observation of the 100 hall medication cart storage noted three open insulin pens. Resident #25 Fiasp insulin pen, Resident #14 Lantus insulin pen, and Resident #34 Basaglar insulin pen. No date was marked on the insulin pens indicated when they were opened. […]