Laurel Place

Facility failed to assess and determine nurse delegated tasks for 2 of 4 memory care residents, resulting in untrained medication aides administering delegated tasks.

Facility failed to notify resident physicians and monitor residents after medication refusals for 4 of 4 residents and missed medications for 1 of 2 sampled residents.

Facility failed to address and resolve resident grievances for 5 of 5 residents, leaving concerns unresolved.

Facility failed to address and resolve resident grievances for 5 of 5 sampled residents, relating to food quality and customization requests.

Facility failed to ensure background checks were submitted within the first day of employment for 1 of 3 staff and failed to ensure 1 of 3 staff had three positive references before their first day worked.

Facility failed to complete a character, competence, and suitability review for 1 of 3 staff members before allowing them to work unsupervised.

Facility failed to ensure 3 of 3 sampled staff received their first TB skin test within three days of employment.

Facility failed to ensure water temperature in resident rooms met the minimum standard of 105 degrees Fahrenheit.

A sprinkler pipe in the stairwell broke for unknown reasons. The facility implemented a fire watch immediately and the system is now operational. No fire occurred, though the system activated and the fire department responded.

Activities office has multiple penetrations in ceiling and walls.

Facility failed to provide documentation showing fire/smoke damper 4 year inspection.

Facility failed to provide documentation showing fire department connection hydrostatic test; multiple sprinkler heads in kitchen area loaded with debris.

Facility failed to provide documentation showing annual fire alarm inspection.

Facility failed to maintain 2nd floor library doors; doors failed to maintain latched when pushed open.

Fire drills were not conducted once per shift per quarter for the 2nd and 3rd quarter of 2023. Drills during day and swing shift must be audible alarms and cannot be simulated.

Facility unable to provide documentation showing hood cleaning is conducted 2 times a year.

Facility unable to provide documentation of annual fire-resistance-rated construction inspection; 1st floor janitor's closet has penetrations in the ceiling.

Facility missing fire department connection five-year hydrostatic test records and quarterly inspection documentation; sprinkler head in walk-in cooler is loaded with ice.

Fire extinguisher in elevator room was not inspected in the last 2 months.

8 devices failed the 90-minute battery-powered emergency lighting test.

Exit sign/emergency light combo at the back of the dining room did not illuminate when test button pressed.

No documentation for annual fire door inspections; 2nd floor double doors by room 200 and dining room double doors do not latch.

The facility failed to ensure staff monitored a skin injury for a resident after a fall. Despite staff documenting the resident was found on the floor, subsequent notes failed to document the significant bruising discovered on the resident's shoulder.

The facility failed to ensure staff answered a resident's call lights in a timely manner. Review showed response times as high as 99:59 minutes for one resident.

Facility failed to ensure 5 of 5 sampled staff were fit tested for N-95 respirators.

Facility failed to provide an emergency plan book; staff need to be trained on its location and procedures.

Electrical outlet in room 209 had a broken ground.

Failed to provide documentation showing annual inspection of fire-resistance-rated construction and fire walls.

Failed to perform monthly inspections of all fire extinguishers.

Failed to provide documentation showing smoke alarms are being tested and maintained.

Failed to provide documentation showing carbon monoxide alarms/detectors are being tested and maintained.

Failed to provide documentation of fire door annual inspections; double doors by room 200 were not closing.