The Laurels of Walden Park

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 13, 2025

  Based on observation, record review, staff interview, interviews with staff at orthopedic medical office, review of National Pressure Injury Advisory Panel (NPIAP) guidance, and facility policy review, the facility failed to implement interventions to prevent the development of pressure ulcers when wearing a splint device and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. Actual harm occurred on 07/30/25 when Resident #37 developed two avoidable unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcers to the underside of the index finger and to the left side of the palm hand when the facility did not remove… […]

• Actual harm, isolatedF684Nov 26, 2024

  Based on closed medical record review, hospital record review, review of facility policy and interview, the facility failed to ensure Resident #215 received adequate, timely and necessary care and services to prevent an acute change in condition related to hypokalemia (decreased potassium) level. Actual Harm occurred beginning on 10/25/24 at 3:33 P.M. when Resident #215's laboratory results reflected a low potassium level of 3.0 mmol/L (normal range 3.5 -5.0) (indicative of hypokalemia) which went unreviewed and unaddressed by facility staff. On 10/28/24 Resident #215 began to experience shortness of breath and required supplemental oxygen. […]

• Actual harm, isolatedF684Aug 18, 2023

  Based on medical record review, wound notes review, staff interview, hospital paperwork review, and facility policy review, the facility failed to ensure wound care orders were in place, as well as ensure comprehensive wound measurements were completed for Former Resident #300 upon readmission to the facility. Actual Harm occurred when Former Resident #300 was found to have maggots in a pre-existing wound to the left calf/foot area and was admitted to the hospital with a gangrenous left foot with maggot infestation and severe pain. This affected one (Former Resident #300) of three residents reviewed for wound care. The facility census was 201. Findings include: Review of the closed medical record for Former Resident #300 revealed an original admitted [DATE] with a readmitted [DATE]. […]

• Actual harm, isolatedF689Aug 4, 2022

  Based on medical record review, hospital record review, facility policy review and staff interview, the facility failed to ensure Resident #186 was appropriately assisted during a shower resulting in an avoidable fall. This resulted in Actual Harm when State tested Nurse Aide (STNA) #918 failed to utilize two staff to assist during a shower for Resident #186 and the resident rolled off the shower bed, falling onto the tiled shower floor resulting in Resident #186 fracturing her cervical spine and nose. This affected one (Resident #186) of three residents reviewed for accidents. The facility census was 187. Findings include: Review of the closed medical record for Resident #186 revealed an admitted [DATE] and a discharge date of [DATE]. […]

• Actual harm, isolatedF686Nov 16, 2021

  Based on medical record review, staff interview, certified nurse practitioner (CNP) interview, and review of the facility policy and procedure for skin management, the facility failed to implement skin integrity monitoring during the use of Multi-podus boots. In addition, the facility failed to accurately document newly developed skin concerns. This affected one resident (Resident #208) of four residents reviewed for pressure ulcers. The facility census was 201. Actual Harm occurred on 07/07/21 when staff failed to monitor the skin integrity for Resident #208 (who required total dependence of two staff members for all activities of daily living due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]