The Laurels of Coldwater

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 10, 2022

  This Citation Pertains to Intake #MI 574 and Intake # MI 791 This citations has two deficient practice statements. DPS 1 and DPS 2. DPS 1) Based on observation, interview and record review, the facility failed to prevent falls for 4 of 7 residents (Resident #62, #121, #117 and #41) reviewed for falls resulting in resident #121 falling from a mechanical lift during staff transfer and sustaining a [CONDITION(S)] and the potential for injuries for Resident #41, #62, and #117 and decreased quality of life. Finding include: Resident #121 (R121) On 06/07/22 at 12:20 PM R121's visitor reported he fell out of the mechanical lift and broke a hip. On 06/08/22 at 4:15 PM, R121's family member stated Of course, I had concerns, they dropped him and fractured his hip, that should have not happened. […]

• Actual harm, isolatedF684Dec 28, 2021

  This Citation Pertains To Intake MI 371 Based on interview and record review the facility failed to ensure one out of six residents (Resident #1) received appropriate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Left facility via Emergency Medical Services for emergency care. Review of R1's medication orders revealed R1 was to receive the following medication to treat Type 2 diabetes mellitus, [MEDICATION(S)] Solution (insulin Glargina) 100 units/milliliter (ml) 110 units subcutaneously two times per day (started 12/10/2021) and Insulin [MEDICATION(S)] Solution 100 units/ml give 10 units subcutaneously… […]

• Actual harm, isolatedF689Dec 28, 2021

  This Citation Pertains To MI 446 Based on observation, interview and record review the facility failed to prevent a fall for 1 resident (#2) of 2 reviewed for falls, resulting in a left nondisplaced fractured femur that required surgical repair and a fractured great left toe. Findings include; According to the clinical record, Resident #2 (R2) was admitted to the facility on [DATE], review of R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/21 revealed R2 required extensive assistance for toileting, bed mobility and hygiene from 2 staff persons. Review of the activity of daily living care plan initiated and currently in place was dated 4/14/20 and reflected R2 required extensive assistance with bed mobility, transfers, and toileting. […]

• Actual harm, isolatedF626Mar 18, 2021

  This citation pertains to MI 5831. Based on interview and record review, the facility failed to readmit one of one residents reviewed for return to facility (involving Resident #5 and Resident #3), resulting in Resident #5 not being allowed to return to his home and being transferred to a facility far away from the residents family and in another state, and the potential for other residents to be denied their right for reentry. Findings include: Upon entrance to the facility on [DATE] at 12:00 PM, Surveyor was informed there were no active Covid-19 cases in the facility. […]

• No harm, potential for more than minimal, widespreadF921Jul 24, 2025

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 130 residents, resulting in the increased likelihood for cross contamination and bacterial harborage.Findings include: On 07/23/2025 at 10:05 A.M., A common area environmental tour was conducted with Environmental Services Director (ESD) M. The following issues were noted: A-Hall Nursing Station: Two 12-inch-wide by 12-inch-long vinyl flooring tiles were observed (etched, scored, particulate). The concrete flooring sub-surface was also observed exposed through the worn vinyl tiles. (ESD) M indicated she would contact maintenance for necessary repairs as soon as possible. Restroom: The hand sink faucet assembly was observed loose-to-mount. […]