The Laurels of Salisbury

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 21, 2023

  Based on record review and interviews with Resident, Responsible Party, staff, Nurse Practitioner and Police Department Dispatcher, the facility failed to protect the rights of two residents to be free from resident-to-resident physical abuse. Resident #164 was placed on one-to-one observation prior to the first resident to resident physical abuse incident of 4/5/23 due to aggressive behaviors with staff and exit seeking behaviors. On 4/5/23, Resident #164 went onto Resident #165's bed and put his arm around Resident #165's neck in a chokehold when staff intervened. On 5/4/2023 Resident #164 punched Resident #161 in the left eye and right cheek when Resident #161 asked him to leave his room. […]

• Actual harm, isolatedF689Feb 8, 2024

  Based on record review, observation, and Family Member, staff, and Nurse Practitioner interviews the facility failed to prevent 1 of 1 resident (Resident #1) reviewed for accidents, from being injured during a transfer from a reclining wheelchair to the bed. Resident #1 was admitted to the hospital after she sustained a right proximal femoral fracture on 1/19/2024 when a staff member transferred her without nonskid footwear causing her feet to slide and become twisted. Resident #1 complained of right hip and knee pain, and she could not straighten her right leg due to pain when the Nurse assessed her. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of dementia and right knee contracture. […]

• Actual harm, isolatedF697Feb 8, 2024

  Based on record review, observations, resident, staff, and Nurse Practitioner interviews the facility failed to administer pain medication when a resident complained of right arm and shoulder pain. The delay resulted in the resident experiencing a reported pain of 8 on a scale of 0 to 10 (10 being the worst pain) and the inability to sleep while she waited for the medication. This was for 1 of 1 resident reviewed for pain (Resident #3). Findings included: A Discharge Report from the hospital dated 2/6/2024 indicated Resident #3 was alert and oriented to her name, where she was, why she was there, and the date and time. […]

• No harm, potential for more than minimal, widespreadF803Aug 21, 2023

  Based on observation of the lunch meal tray line observation, staff interviews, and record review the facility failed to provide portions of food per the menu which had the potential to affect all 56 residents in the facility since there were no residents that did not receive a meal tray. Findings included: The menu for Sunday, 8/13/2023, for the lunch meal trays for all regular, Mechanical Soft, and Pureed Diets consisted of: 3 ounces of Salisbury steak; 4 ounces of potatoes; 4 ounces of spinach; 1 dinner roll; and 1 slice of chocolate pie. […]

• No harm, potential for more than minimal, patternF812Jan 24, 2025

  Based on record review, observations, and staff interviews, the facility failed to cover facial hair for 2 of 2 dietary staff (Cook #1 and Dietary Aide #1) observed working in food production and failed to have necessary supplies to test the chemical level in the sanitizing sink for 3 of 3 observations. This had the potential to affect food served to all the residents in the facility. The findings included: 1. The kitchen was observed on 1/21/25 at 9:55 AM. [NAME] #1 was observed to be preparing food without a beard cover. [NAME] #1 had facial hair on his chin that measured more than 1 inch in length. The kitchen was observed on 1/23/25 at 11:45 AM. [NAME] #1 was noted to be serving food for residents. […]