The Laurels of Kettering

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 16, 2025

  Based on medical record review, observations, staff interviews, facility policy reviews, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to timely identify a resident's pressure ulcers until they reached an advanced stage. This resulted in Actual Harm to Resident #35, who developed pressure ulcers while in the facility, which were not identified until they had reached an advanced stage. Resident #35 was noted to have a reddened area on 01/14/25, according to shower sheets, but the area was not assessed, and interventions were not implemented until 01/16/25 when the pressure ulcer was identified as an unstageable pressure ulcer (sloughing and/or eschar) to the coccyx. […]

• Actual harm, isolatedF689Nov 18, 2024

  Based on medical record review, staff interview, resident interview, and policy review the facility failed to ensure a resident was provided with staff assistance at the bedside after toileting which resulted in a fall with injury. This resulted in actual harm when Resident #34 who required substantial/maximal assistance to transfer for toileting, did not have on gripper socks on her feet and was assisted off the bedside commode, became unsteady on her feet, was sat on the side of her bed, and the certified nursing assistant (CNA) left the resident alone and stepped out of the room to get additional staff assistance. […]

• No harm, potential for more than minimal, widespreadF842Jul 8, 2024

  Based on staff interview, record review, and policy review, the facility failed to ensure the resident's medication administration records (MAR) and treatment administration records (TAR) were available during disruption of internet services. This affected five (Residents #12, #13, #20, #26, and #61) of five residents reviewed for medical records and the potential to affect all 87 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE]. Resident #12 had physician orders for medications and treatments on 06/09/24. […]

• No harm, potential for more than minimal, patternF580Jun 16, 2025

  Based on review of the medical record, interviews, and policy review, the facility failed to notify the physician for a change in condition. This affected four (#2, #3, #19, and #53) out of four of residents reviewed for a change in condition. The facility census was 76.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 02/28/25. Diagnoses included multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and type II diabetes mellitus (DM II). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. […]

• No harm, potential for more than minimal, patternF628Jun 16, 2025

  Based on medical record reviews, staff interviews, and policy reviews, the facility failed to complete a discharge summary or recapitulation of a resident's stay, failed to complete a bed hold notice when resident's were transferred to the hospital and failed to notify the Ombudsman of resident's discharges. This affected four (#15, #27, #75, and #134) out of four residents reviewed for discharges. The facility census was 76. Findings include: 1. Review of the medical record for Resident #134 revealed an admission date of 09/12/24 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, hypertensive heart disease, and malignant neoplasm of kidney. Review of the medical record revealed a discharge date of 01/23/25. […]