Laurels Peak Health Care, LLC

In the surveyor’s words

From the most serious findings on record at Laurels Peak Health Care, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 6, 2026

  Based on interview, and record review the facility failed to ensure all staff were competent with transferring and walking residents that required transfer assistance for 1 of 3 residents (R1). This deficient practice resulted in R1 falling and fracturing the facial bone. The facility had put corrective measure in place, prior to the start of the survey and therefore, this was issued at past non-compliance.Findings include:R1's face sheet dated 1/6/26, identified diagnoses of respiratory failure, atrial fibrillation (irregular heart rhythm), osteoporosis, and other variants of Turners Syndrome (condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. […]

• No harm, potential for more than minimal, widespreadF725Sep 29, 2023

  Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance as needed. These deficient practices had the potential to affect all 48 residents who resided in the facility. Findings include: Refer to F561: The facility failed to ensure a resident's morning routine preferences, mealtime and location, and clothing preferences were honored for 1 of 3 residents (R16) who voiced concerns about choices. […]

• No harm, potential for more than minimal, widespreadF867Sep 29, 2023

  Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) committee was effective in implementing appropriate and sustained action plans to correct deficiencies identified during a previous survey. This resulted in repeat deficiencies identified during current survey. This deficient practice had the potential to affect all 48 residents residing in the facility. Findings include: During an interview on 9/29/23 at 1:30 p.m., reviewed findings from previous survey with the regional director of operations (RDO)-A and the assistant director of nursing (ADON) who also facilitated QAPI meetings, and compared them to findings from current survey. […]

• No harm, potential for more than minimal, widespreadF880Sep 29, 2023

  Based on observation, interview, and document review the facility failed to maintain a system to analyze monthly surveillance data for trends and patterns to reduce the spread of illness, infections, control transmission of infections and communicable diseases present in the facility, failed to implement measures to prevent the spread of infection when the facility failed to ensure personal protective equipment (PPE) of N95 masks were worn, and failed to wear appropriate PPE when sorting and handling soiled laundry. This had the potential to affect all 48 residents who resided in the facility. […]

• No harm, potential for more than minimal, widespreadF921Sep 29, 2023

  Based on observation and interview, the facility failed to maintain a clean, safe, and homelike environment when carpet in resident hallways and resident room (R20) were observed to be stained and soiled, and baseboard heat registers in resident rooms (R199, R41, R34) were in disrepair. In addition, facility failed to ensure kitchen ceiling tiles and vents were maintained in a clean and sanitary manner. This had the potential to affect all 48 residents who resided in the facility. Findings include: During an observation on 9/25/23 at 12:38 p.m., in room [ROOM NUMBER], the cover of the metal baseboard heat register was bent forward with metal protruding outward from the register approximately one to two inches. […]