Laurelwoods

The facility failed to ensure water was served to all residents during the lunch meal in the special care unit. While preferred beverages like tea and juice were provided, staff did not offer or serve water to any of the 10 residents present. Interviews with staff and management confirmed that water was not consistently provided and some staff were unaware of the requirement.

The facility failed to ensure water was served to all residents in the special care unit during the lunch meal. While preferred beverages like tea and juice were provided, staff did not offer or serve water in addition to these beverages.

The facility failed to ensure a resident had a physician's order to self-administer a topical medication (Voltaren gel). There was no documentation in the resident's record or eMAR authorizing the use of this medication or the resident's ability to self-administer medications.

The facility failed to ensure follow-up care for a resident by not contacting the primary care provider (PCP) when vital signs fell outside of prescribed parameters. Specifically, there was no documentation that the PCP was notified regarding multiple instances of systolic blood pressure greater than 170, diastolic blood pressure greater than 90, or pulse rates outside the 60-90 range during January, February, and March 2025.

The facility failed to follow physician orders regarding monitoring and notifying the primary care provider for specific vital sign parameters. Specifically, for one resident, the facility did not contact the physician despite blood pressure and pulse readings falling outside the prescribed limits, such as systolic pressure over 170 and pulse rates below 60.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit. Observations on 11/19/24 showed water temperatures ranging from 120 to 124 degrees F in a resident room and the special care unit common shower room.

The facility failed to maintain water temperatures at all resident-used fixtures between 100 and 116 degrees Fahrenheit. Observations revealed temperatures as high as 124 degrees Fahrenheit in a resident room bathroom sink and the SCU common spa sink/shower.

The facility failed to obtain written therapeutic diet orders from a physician for 2 of 4 sampled residents. Specifically, for Resident #1, there were conflicting diet orders and a lack of a complete, current order from the Nurse Practitioner regarding pureed diet requirements.

The facility failed to obtain written therapeutic diet orders for 2 of 4 sampled residents. Specifically, the FL2 forms for Resident #1 and Resident #4 did not accurately reflect the required diet orders, such as pureed or finger food consistencies, despite the residents receiving the correct food types.