Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laureldale Skilled Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
Improper Food Storage and Dishwashing Sanitation: Surveyors observed multiple improperly stored and labeled food items in the kitchen, including expired prepared meatballs and deli turkey, uncovered milk, undated salad, eggs, cereal, and tea bags stored open in dry storage. Staff also failed to follow the dishwashing policy when the dishwasher did not reach required wash and rinse temperatures, no chemical sanitizer was used, and the sanitation log showed repeated temperature failures.
Unsafe and Unclean Environmental Conditions: Surveyors observed pervasive urine and ammonia odors, debris in a shower stall, rust, peeling and stained wallpaper, loose fixtures, stained mattresses and privacy curtains, sticky floors, a yellow-stained urinal container, a nonworking outlet, and a nonworking bathroom light on the second-floor unit. An LPN reported an unmade bed had remained in the hallway since a resident was moved, and the Administrator confirmed the environmental issues should have been addressed.
Failure to Develop Care Plans for Fall Prevention, Skin Integrity, and Communication Needs: The facility did not develop care plans for three residents with identified needs. One resident with dementia and acute kidney failure had a CAA indicating fall prevention needs, another resident with cellulitis and pressure injuries had a CAA indicating skin/pressure ulcer needs and physician-ordered wound treatments, and a third resident who primarily spoke Spanish had a CAA indicating communication needs and requested interpreter support. The DON confirmed the care areas were not addressed in the current care plans.
Failure to Provide Hygiene and Grooming Assistance for Dependent Residents: Two dependent residents did not receive needed ADL support for hygiene and grooming. One resident with stroke-related hemiplegia, DM2, and polyneuropathy was observed in bed in a hospital gown with dirty, jagged fingernails, no documented shower since the prior week, and no documented nail-care refusal; his contracted hand nails were pressing into his palm. Another resident with severe vascular dementia, gait impairment, urinary retention, and DM2 was repeatedly observed in a wheelchair with food debris on his hat and clothing. The DON confirmed staff failed to assist dependent residents with hygiene and grooming.
The facility failed to follow physician orders for three residents. One resident with severe CKD and HF did not receive ordered weekly weights on multiple occasions, another resident with hypotension and CKD received midodrine when SBP was above the ordered hold parameter, and a third resident with Parkinson’s disease and kidney failure did not have ordered weekly PICC dressing changes documented. The DON confirmed the orders were not followed.
A resident with a stage 3 pressure wound on the left heel, cognitive impairment, and dependence for ADLs did not receive required weekly skin inspections. The care plan called for weekly skin evaluations by an LPN, but records showed two missed inspections, and the DON confirmed the checks were not completed.
Failure to obtain ordered weights for two residents: one resident with diabetes, gastrostomy malfunction, and dysphagia, and another resident with severe protein calorie malnutrition and diabetes. Facility policy required weights on readmission, weekly for 4 weeks, then monthly, but the residents were not weighed as ordered; the DON confirmed there was no evidence the weights were obtained per policy.
Improper Storage of Prepared Medications: On the Third Floor, an LPN poured medications for two residents into uncovered, labeled medication cups and left them in a med cart instead of administering them at the time they were prepared, which was inconsistent with facility policy. The DON confirmed the medications should not have been stored in cups in the cart before administration.
A nurse aide did not complete the required 12 hours of annual in-service training, including dementia care, abuse prevention, and performance-related education. Records showed the aide completed only 9 hours and 29 minutes of in-service education, and the Administrator confirmed the training requirement had not been met.
A deficiency was identified when an exit sign near a resident room in one smoke compartment was found to be unilluminated, as confirmed by the Director of Maintenance.
A corridor door leading to the Patio Lounge failed to positively latch within the door frame, as observed and confirmed by the Director of Maintenance. This deficiency affected one of twelve smoke compartments and did not meet NFPA 101 and CMS requirements for corridor door latching.
An unprotected penetration was found in a smoke barrier wall above double doors near the ADON/Medical Records Office, where blue and red wires passed through without proper protection. This issue, confirmed by the Director of Maintenance, affected two of twelve smoke compartments.
An electrical junction box above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was found without a cover plate, leaving electrical wiring exposed. The Director of Maintenance confirmed the issue during the inspection.
A surge suppressor was used to supply power to a toaster, coffee machine, and microwave in a medical records room, contrary to NFPA requirements. The Director of Maintenance confirmed the improper use of the surge suppressor for these high-draw appliances.
A survey found that the facility is a three-story, Type II (000) unprotected noncombustible building with a basement, which exceeds the maximum allowable story height for this construction type. The Director of Maintenance confirmed that the building's construction type and height are not permitted under current regulations.
The facility did not provide documentation confirming that quarterly inspections of the automatic sprinkler system were completed over the past year. This was confirmed by the Director of Maintenance, and the deficiency impacted the entire sprinkler system component.
Surveyors observed multiple environmental deficiencies across two nursing units, including missing roof shingles, peeling ceiling tiles and wallpaper, damaged walls, stained ceiling tiles, and a crushed dryer vent hose. These issues reflect a failure to maintain a safe, clean, and comfortable environment for residents.
Four residents with significant medical conditions requiring ADL assistance were repeatedly observed with long, dirty fingernails and, in some cases, unshaven, despite care plans specifying the need for grooming and bathing support. Staff did not provide necessary grooming services, and the administrator confirmed these tasks should have been completed during bathing and as needed.
Staff did not follow physician orders for two residents regarding medication administration. One resident received a blood pressure medication despite a low heart rate, and another did not receive an as-needed antihypertensive when their blood pressure was elevated. These failures were confirmed by the Administrator.
A resident with dementia and ventricular tachycardia, who was dependent on staff for care, was found with multiple unexplained bruises by a nurse aide and an LPN. Despite facility policy requiring immediate reporting of such incidents, the Administrator was not notified until nearly two days later, and an investigation was delayed accordingly.
A cognitively impaired female resident, dependent on staff for mobility, was not protected from sexual abuse by another resident with a known history of sexually inappropriate behavior. Despite repeated incidents, including wandering into female residents' rooms, exposing himself, and ultimately groping a peer, the facility did not update the care plan or increase supervision to prevent further abuse.
A resident with a history of falls and requiring maximum assistance for toileting fell and sustained a head injury due to neglect. Despite the care plan's requirement for two staff members to assist, only one nurse aide was present, leading to the resident's fall and subsequent death. The facility's investigation confirmed the aide's awareness of the need for two-person assistance.
A resident with a history of falls and requiring maximum assistance for toileting fell and suffered a head injury when only one nurse aide assisted during a transfer. Despite the care plan requiring two staff members for assistance, this protocol was not followed, resulting in the resident's fall and subsequent death.
A resident with multiple health conditions fell after using the toilet, and the facility failed to notify the responsible party immediately, delaying notification until the next day. This was against the facility's protocol, as confirmed by the DON.
The facility failed to maintain sanitary conditions in the kitchen. Observations revealed three dusty pipes on the floor near the ice machine, two dirty bowls behind it, and water draining onto the floor, creating standing water. Additionally, a vent in the dish room had peeling paint.
The facility failed to follow physician's orders for two residents, leading to improper medication administration. A resident with a history of stroke and high blood pressure received metoprolol without checking required blood pressure and heart rate parameters. Another resident with sepsis and heart failure was given furosemide without confirming blood pressure was above the prescribed threshold. The DON confirmed the oversight.
The facility failed to provide restorative nursing services for three residents, leading to a lack of documented evidence for required passive range of motion exercises. A resident with dementia and hemiplegia, another with dementia and knee pain, and a third with COPD and anxiety were all at risk for loss of range of motion. Despite care plans indicating the need for exercises, there was no documentation to confirm their completion, as confirmed by the DON.
The facility failed to provide adequate supervision and prevent accident hazards on two nursing units. A resident with cognitive impairment was fed by another resident without staff intervention, and a treatment cart with medications was left unlocked near unsupervised, cognitively impaired residents. Additionally, the facility did not properly investigate a fall involving a resident with dementia, implementing an inappropriate intervention and failing to document bed positioning as required.
The facility did not accommodate the meal preferences of two residents, leading to deficiencies. A resident with diabetes and GERD was served a meal with gravy, contrary to her preference. Another resident with dementia and malnutrition received broccoli instead of the specified carrots. These actions did not align with their care plans.
The facility failed to provide written notification to the representatives of nine residents who were transferred to the hospital due to changes in their conditions. The Director of Nursing confirmed that the required documentation was not provided.
The facility failed to develop a comprehensive care plan for a resident with diabetes and an altered mental state. The resident was identified as being at risk for impaired nutrition, but no interventions were included in the care plan. This was confirmed by the Nursing Home Administrator.
The facility failed to timely assess the nutritional status of two residents, leading to significant weight loss without appropriate intervention. One resident lost 12.5% of their weight, and another lost 10.13%, with no evidence of assessment or notification to the physician and responsible party.
Improper Food Storage and Dishwashing Sanitation
Penalty
Summary
The facility failed to store and serve food in a sanitary manner in the kitchen. During a kitchen tour, surveyors observed a container of prepared meatballs in the walk-in refrigerator labeled with a use-by date of June 4, 2026, four two-pound packages of smoked deli turkey breast labeled use or freeze by May 30, 2026, a gallon of chocolate milk without a lid, a Chef’s salad without a name or date, a container of eggs for room [ROOM NUMBER]-B with no date, an uncovered container with garbage near a clean rack of pitchers, an undated container of cereal on a wire rack, and a box of tea bags in an open plastic bag in dry storage. The Dietary Director later confirmed that the items observed were improperly stored and/or labeled. Surveyors also observed that the dishwasher did not reach the required temperatures during the wash and rinse cycles. The facility policy required dishware to be cleaned and sanitized after each use, and if the wash cycle fell below 150 degrees Fahrenheit or the rinse cycle fell below 180 degrees Fahrenheit, dishes were to be sanitized with an approved chemical sanitizer and tested with chemical strips. During observation, staff did not use a chemical sanitizer or test the chemical concentration. Review of the June 2026 Machine Washing Sanitizing Log showed the wash temperature was below 150 degrees Fahrenheit twice and the final rinse temperature was under 180 degrees Fahrenheit ten times. The Dietary Manager and Dietitian confirmed that the dishwashing and sanitation policy was not followed and that the items observed were improperly stored and/or labeled.
Unsafe and Unclean Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on the second-floor unit and third-floor unit. Observation on June 7 through June 9, 2026, identified a pervasive urine odor in the second-floor corridor, debris and a wet washcloth tied around the shower sprayer hose in the left shower stall, rust on the metal ceiling tile separators, peeling wallpaper above the bathroom door, and a brown stain on the wallpaper behind the door. The toilet paper holder screws were loose and hanging down, and there was a rusty outlet cover near the sink. Multiple resident rooms on the second floor had environmental concerns, including strong ammonia-like odors, stained mattresses, stained privacy curtains, stained wallpaper, sticky floors, a yellow-stained urinal container in a bathroom, a brown stain around a sink drain, peeling and marred mattress material, damp and stained wooden molding around an air conditioner, loose and marred wallpaper, a sink with white buildup and a chipped exposed side, a nonworking outlet, and a nonworking overhead bathroom light. An unmade bed was also observed in the hallway between rooms, and an LPN stated the bed had been there since Friday after a resident was moved. The Administrator confirmed on June 9, 2026, that the environmental issues should have been addressed.
Failure to Develop Care Plans for Fall Prevention, Skin Integrity, and Communication Needs
Penalty
Summary
The facility failed to develop comprehensive care plans to meet the needs of three sampled residents. Resident 1 was admitted with diagnoses including acute kidney failure, dementia, and wasting muscles. The MDS CAA section dated [DATE] indicated a care plan was to be developed for fall prevention, but the clinical record contained no evidence of a care plan with interventions to prevent falls. Resident 73 was admitted with diagnoses including cellulitis of the left lower limb, a pressure ulcer of the right ankle, and pressure-induced deep tissue damage. On May 21, 2026, the physician ordered wound treatments for unstageable pressure ulcers on the lower back, right ankle, and left calf. The MDS CAA section dated [DATE] indicated a care plan was to be developed for skin and pressure ulcer/injury, but no care plan was found. Resident 149 was admitted with diagnoses including depression and pain in the right knee. The MDS CAA section dated [DATE] indicated a care plan was to be developed for communication, and the resident primarily spoke Spanish and wanted an interpreter to communicate. A psychology note dated May 29, 2026, documented that the resident requested a call to her daughter for translation, and observations on June 7 and 8, 2026, showed the resident watching Spanish television programs in her room. The clinical record contained no evidence of a care plan for language or communication.
Failure to Provide Hygiene and Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide care and services to maintain activities of daily living, specifically grooming and hygiene, for two residents who were dependent on staff for assistance. Resident 8 had diagnoses including hemiplegia and hemiparesis following a right-side dominant stroke, type 2 diabetes mellitus, polyneuropathy, and need for assistance with personal care. The MDS showed the resident was dependent on staff for personal hygiene, bathing, and dressing, and the care plan directed staff to assist with hygiene, bathing, and dressing. However, on June 7 and June 8, 2026, the resident was observed in bed wearing a hospital gown, with dirty and jagged fingernails on both hands. During interview, the resident stated a preference to be out of bed by 9:00 a.m., wanted his nails trimmed and cleaned, and would not refuse nail care. At that time, the nails on his contracted right hand were observed pressing into his palm. The record also lacked documentation of a shower since June 5, 2026, there was no documented refusal of nail care, and the last daily skin check was documented on April 6, 2026. Resident 10 had diagnoses including severe vascular dementia with agitation, abnormalities of gait and mobility, urinary retention, and type 2 diabetes mellitus. The MDS showed cognitive impairment and dependence on staff for assistance with personal hygiene and dressing. On multiple observations, the resident was sitting in a wheelchair by the unit nurse's station with food debris on his hat and clothing. In interview, the DON confirmed that staff had failed to assist dependent residents with hygiene and grooming to maintain ADLs.
Failure to Follow Physician Orders for Weights, Medication Holds, and PICC Dressing Changes
Penalty
Summary
The facility failed to implement physicians’ orders for three residents. Resident 3 had diagnoses including severe chronic kidney disease and heart failure. A physician ordered weekly weights and instructed staff to call the cardiologist if weight gain was more than three pounds, but review of the MAR showed no evidence that weekly weight checks were completed on five of seven occasions between April 14, 2026, and June 5, 2026. Resident 33 had diagnoses including hypotension and chronic kidney disease. A physician ordered midodrine 10 mg three times daily and directed staff to hold the medication if systolic blood pressure was higher than 130 mm/Hg, but the MAR showed the medication was administered when the resident’s SBP was above that limit on multiple occasions in April, May, and June 2026. Resident 87, who had Parkinson’s disease and kidney failure requiring frequent IV treatments through a PICC, had a physician order for weekly PICC dressing changes, but the treatment record showed no evidence that the dressing was changed on March 4, May 10, and June 6, 2026. The DON confirmed on June 10, 2026, that the physicians’ orders were not followed.
Failure to Complete Weekly Skin Inspections for Resident with Heel Pressure Wound
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not done for Resident 3, who had diagnoses including a muscle disorder and osteoarthritis, was cognitively impaired, and was dependent on staff for activities of daily living. The resident’s MDS showed a stage three pressure wound on the left heel, and the care plan identified actual skin breakdown on the left heel, risk for further skin impairment, and an intervention for a licensed nurse to complete weekly skin evaluations. Review of the skin check evaluations showed no evidence that the required weekly skin inspections were completed on two occasions between May 18, 2026, and June 1, 2026. The DON confirmed in interview that staff did not perform the weekly skin inspections on Resident 3 and that they should have.
Failure to Obtain Ordered Weights for Two Residents
Penalty
Summary
The facility failed to adequately monitor and assess the nutritional status of two sampled residents by not obtaining weights according to policy and physician orders. The facility policy, Weights and Heights, required residents to be weighed on admission or readmission, weekly for four weeks, and monthly thereafter, with weights entered into the electronic health record. The clinical record for Resident 2 showed readmission with diagnoses including diabetes, gastrostomy malfunction, and dysphagia, and a physician order on May 12, 2026, for weekly weights for four weeks and then monthly; however, the resident had not been weighed since May 13, 2026. Resident 2’s care plan identified risk for nutritional problems and dehydration with an intervention to monitor weight per protocol. The clinical record for Resident 80 showed readmission with diagnoses including severe protein calorie malnutrition and diabetes, and a physician order on May 26, 2026, for weekly weights for four weeks and then monthly. Resident 80’s care plan identified risk for a nutritional problem, but the resident was not weighed on readmission or on the ordered Tuesday, May 26, 2026, and was not weighed until June 2, 2026, two weeks after readmission. During an interview on June 10, 2026, at 12:27 p.m., the DON confirmed there was no evidence that the residents’ weights were obtained per policy.
Improper Storage of Prepared Medications
Penalty
Summary
Medications and biologicals were not stored in accordance with facility policy on one of four nursing units, the Third Floor. The facility policy on Medication Administration, last reviewed March 1, 2026, stated that medications were to be administered at the time they were prepared. During a medication pass observation on June 7, 2026, at 9:35 a.m., surveyors observed two uncovered medication cups labeled with black marker in a medication cart on the Third Floor containing medications for two residents. In an interview at that time, an LPN confirmed she had poured the medications into the cups earlier but had not administered them at that time. The DON later confirmed that the medications should not have been stored in cups in the medication cart prior to administration.
Nurse Aide Did Not Complete Required Annual In-Service Training
Penalty
Summary
The facility failed to ensure that one nurse aide received the required 12 hours of annual in-service training, including education in dementia management, resident abuse prevention, and identified performance weaknesses. Review of the nurse aide’s personnel record showed employment with the facility since November 2, 2015. Review of training records for the period from July 1, 2024, to June 8, 2026, showed that the nurse aide completed only 9 hours and 29 minutes of in-service education. During an interview on June 9, 2026, at 10:39 a.m., the Administrator confirmed that the nurse aide had not completed the required annual in-service training.
Failure to Maintain Illuminated Exit Signage
Penalty
Summary
The facility failed to maintain the required illumination of exit signage in accordance with NFPA 101 standards. During an observation, it was found that the exit sign located in Zone 11, near Resident Room 319, was not illuminated. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the exit sign was not functioning as required. The issue affected one of twelve smoke compartments within the component.
Plan Of Correction
The light bulb for the Exit Signage in Zone 11 by Resident room 319 has been replaced. Maintenance staff will be educated on ensuring all exit signage is illuminated moving forward. Maintenance Director/Designee to perform random quarterly audits on exit signage to ensure all exit signage is illuminated. Results of audits will be forwarded to the QAPI Committee.
Failure to Maintain Positive Latching of Corridor Door
Penalty
Summary
The facility failed to maintain the positive latching of a corridor door, specifically the Zone 8 door to the Patio Lounge. During an observation, it was found that this door did not positively latch within the door frame as required by NFPA 101 and CMS regulations. The deficiency was identified during a survey, and the issue was confirmed through an interview with the Director of Maintenance, who acknowledged that the corridor door failed to latch properly. This deficiency affected one of twelve smoke compartments within the facility. The report does not mention any specific residents or patients involved, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the finding is solely on the failure of the door to meet the required positive latching standard, as observed and confirmed by facility staff.
Plan Of Correction
The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee. The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee.
Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls as required by NFPA 101. During an observation, an unprotected penetration was found in the Zone 11 smoke barrier wall, located above the double doors near the ADON/Medical Records Office, where blue and red wires passed through the wall without proper protection. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the unprotected penetration. The issue affected two of twelve smoke compartments within the component. No information about residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The smoke barrier wall was repaired using an approved through-penetration fire stop system. The facility will maintain the rating of the smoke barrier walls moving forward. Maintenance staff will be educated on ensuring penetrations are protected and maintaining the rating within smoke barrier walls. Maintenance Director/Designee to perform random quarterly audits for 1 year on smoke barrier walls. Results of audits will be forwarded to the QAPI Committee.
Exposed Electrical Wiring Due to Missing Junction Box Cover
Penalty
Summary
During an inspection, it was observed that an electrical junction box located above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was missing a cover plate. This resulted in exposed electrical wiring. The Director of Maintenance confirmed the presence of the exposed wiring at the time of the observation. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The electrical junction box cover plate was replaced above the suspended ceiling in Zone 8. Maintenance staff will be educated on ensuring cover plates are in place for junction boxes moving forward. The Maintenance Director/Designee will perform an audit on junction box cover plates when work is completed above the ceiling to ensure the junction boxes have a cover plate in place. Results of audits will be forwarded to the QAPI Committee.
Improper Use of Surge Suppressor for High-Draw Appliances
Penalty
Summary
A deficiency was identified when, during an observation, a surge suppressor was found supplying electrical power to a toaster, coffee machine, and microwave in the Zone 11 Medical Records Room. The use of a surge suppressor for these high-draw appliances does not comply with NFPA 101 and related standards, which restrict the use of power strips and surge suppressors for such equipment. The Director of Maintenance confirmed during an interview that these appliances were indeed plugged into the surge suppressor, indicating a failure to monitor and ensure proper use of electrical equipment within the facility. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The surge suppressor containing the toaster, coffee machine, and microwave has been removed from the Medical Records Office. Staff will be educated on the forbidden use of surge suppressors/mini appliances moving forward. Maintenance Director/Designee to perform a quarterly random audit for 1 year to determine if surge protectors are in use within the facility. Results of audits will be forwarded to the QAPI Committee.
Noncompliance with Building Construction Type and Height Requirements
Penalty
Summary
The facility failed to maintain compliance with building construction requirements as specified by NFPA 101. During an observation, it was found that the building is a three-story, Type II (000) unprotected noncombustible structure with a basement, which exceeds the maximum allowable story height for this construction type. The deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the construction type and height do not meet the permitted standards. No information about specific residents or their conditions was provided in the report. The deficiency centers on the facility's noncompliance with the required building construction type and height limitations, as the structure's number of stories surpasses what is allowed for its construction classification.
Failure to Maintain Documentation of Quarterly Sprinkler System Inspections
Penalty
Summary
The facility failed to provide documentation verifying that quarterly inspections of the automatic sprinkler system were conducted over the previous twelve months. During a document review, it was found that there was no documentation available to confirm that the sprinkler system was inspected between January 23, 2025, and July 3, 2025. This was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of inspection records for the specified period. The deficiency affected the entire sprinkler system component, as required records of inspection and maintenance were not available for review.
Plan Of Correction
Quarterly sprinkler inspections were conducted at Laureldale Skilled Nursing and Rehabilitation Center throughout the previous 12 months. Maintenance staff will be educated on ensuring all sprinkler inspection documentation is maintained moving forward. Maintenance Director/Designee to perform quarterly audits on sprinkler inspection documentation for 1 year to ensure compliance. Results of audits will be forwarded to the QAPI Committee.
Environmental Deficiencies Compromise Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on two of its three nursing units, specifically the second and third floors. Observations conducted over a seven-hour period revealed multiple environmental deficiencies, including missing roof shingles over the Heritage Wing, peeling ceiling tiles and wallpaper in several resident rooms and bathrooms, damaged walls in both resident rooms and common areas, and stained ceiling tiles. Additional issues included a badly crushed vent hose for a resident dryer and discolored areas below molding trim. These findings were directly observed and documented by surveyors, indicating a lack of adequate facility maintenance and oversight in ensuring a homelike and safe environment for residents.
Failure to Provide Adequate Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for four residents who required assistance with activities of daily living (ADLs), specifically grooming and bathing. Clinical record reviews indicated that these residents had significant medical conditions such as paraplegia, congestive heart failure, dementia, polyneuropathy, muscle wasting, diabetes with neuropathy, and hemiplegia due to stroke, all of which necessitated staff support for personal care. Despite care plans outlining the need for assistance, observations on multiple dates revealed that these residents consistently had long and dirty fingernails, and in some cases, were unshaven. Residents who were able to communicate confirmed their need for nail trimming and shaving, while non-verbal residents indicated agreement through gestures. Staff interviews and documentation confirmed that grooming tasks, such as nail trimming and shaving, were not performed as required. The administrator acknowledged that these services should have been provided during bathing and as needed. The repeated observations over several days demonstrated a pattern of inaction in maintaining residents' grooming and hygiene, directly contradicting the care plans and residents' expressed or indicated needs.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for two residents. One resident with Alzheimer's disease and hypertension had a physician's order for Bisoprolol Fumarate to be administered three times daily, with instructions to hold the medication if the systolic blood pressure was below 90 mm/Hg or if the heart rate was less than 60 beats per minute. Despite these parameters, the medication was administered multiple times over several months when the resident's heart rate was below 60. Another resident with epilepsy, dementia, and hypertension had a physician's order for Hydralazine to be given every 8 hours as needed if the systolic blood pressure exceeded 140 mm/Hg. Staff failed to administer the medication on several occasions when the resident's blood pressure was above this threshold. These findings were confirmed by the Administrator during an interview.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator or Abuse Prevention Coordinator as required by facility policy. According to the policy, all incidents and allegations of abuse, including injuries of unknown origin, must be reported immediately to the administrator or designee. In this case, a nurse aide observed multiple bruises on a resident's left arm, breast, and axilla during the evening shift, and an LPN documented the injuries as being of unknown cause or onset. Facility documentation indicated that the injury was identified by the LPN, but there was no evidence that the Administrator was notified within two hours as required. The resident involved had diagnoses including dementia and ventricular tachycardia, was cognitively impaired, and required staff assistance for personal hygiene and transfers. Despite the identification and documentation of the injuries, the Administrator was not notified until nearly two days later, and an investigation was not initiated until that time. Interviews with the Administrator confirmed that staff did not follow the facility's policy for immediate notification regarding the injury of unknown origin.
Failure to Protect Resident from Sexual Abuse by Peer
Penalty
Summary
The facility failed to protect a cognitively impaired female resident, who had dementia and depression and was dependent on staff for mobility, from sexual abuse by another resident with a history of sexually inappropriate behavior. The male resident, who also had dementia and was able to move about the facility independently, had previously exhibited sexually inappropriate behaviors, including being moved to a different room due to such incidents and being monitored by a psychiatrist for these concerns. Despite multiple documented instances of the resident wandering into female residents' rooms without consent, becoming aggressive when discovered, and exposing himself to others, there was no evidence that the facility took action to address or prevent further incidents. The male resident's sexually inappropriate behavior was not included in his care plan, and supervision was not increased, even after repeated incidents. The situation culminated in an incident where the male resident was found groping the female resident while unsupervised in her room. Facility documentation and staff interviews confirmed that no interventions were implemented to protect residents from further abuse, despite a clear pattern of behavior and ongoing risk.
Neglect Leads to Resident's Fall and Head Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. The resident, who had a history of falls and required maximum assistance for toileting, was diagnosed with muscle wasting, hypertension, transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure. The care plan specified that two staff members were needed to assist the resident with transfers. Despite this, on the day of the incident, only one nurse aide assisted the resident, leading to a fall in the bathroom where the resident struck his head. The incident occurred when the resident's knees buckled while being assisted off the toilet, causing him to fall and sustain a head injury, including a hematoma and bleeding. The resident was dazed and had difficulty breathing following the fall. Although the resident refused hospital transport, he stopped breathing shortly after, and staff were unable to revive him. The facility's investigation confirmed that the nurse aide was aware of the requirement for two staff members but failed to comply, contributing to the resident's fall and subsequent injury.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents related to falls for a resident, resulting in actual harm. The resident had a history of falls and required maximum assistance for toileting, as indicated in the care plan. The care plan specified that two staff members were needed to assist the resident with walking and transferring. However, on the day of the incident, only one nurse aide was assisting the resident during a transfer from the toilet, leading to the resident's fall. The resident, who had multiple diagnoses including muscle wasting, hypertension, and chronic respiratory failure, fell and struck his head, resulting in a hematoma and bleeding. Despite being monitored by staff, the resident refused hospital transport and later stopped breathing, with staff unable to revive him. The Director of Nursing confirmed that two staff members should have been assisting the resident at the time of the fall.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party of a change in condition and a fall for one of the sampled residents. The resident, who had diagnoses including muscle wasting, hypertension, history of transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure, experienced a fall on August 6, 2024, at 3:15 p.m. after using the toilet. Despite the facility's protocol to notify the responsible party immediately after a fall, the notification was delayed until the following day at 3:30 p.m. This deficiency was confirmed during an interview with the Director of Nursing on August 16, 2024.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an environmental tour. Three pipes covered in dust were found lying on the floor near the ice machine. Additionally, two dirty bowls were located behind the ice machine, and water was observed draining from the ice machine onto the floor, creating areas of standing water. In the dish room, a vent was noted to have various areas of peeling paint.
Failure to Implement Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to a deficiency in care. Resident 135, with a history of stroke and high blood pressure, was prescribed metoprolol tartrate to be administered twice daily, with specific parameters to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was less than 50 beats per minute. However, the medication was administered over 43 times in June 2024 without checking these parameters. Similarly, Resident 151, diagnosed with sepsis, kidney failure, and heart failure, was ordered to receive furosemide on specific days, with instructions to hold the medication if blood pressure was below 90/60 mmHg. The medication was given ten times in June 2024 without confirming the blood pressure was above the set parameter. The Director of Nursing confirmed that the parameters were not checked prior to administering the medications for both residents.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility for three residents. Resident 4, diagnosed with dementia, congestive heart failure, and hemiplegia, was identified as being at risk for loss of range of motion. Her care plan required staff to perform passive range of motion exercises on her legs during morning and evening care. However, there was no documented evidence that these exercises were being completed. Similarly, Resident 31, who had dementia and knee pain, required passive range of motion exercises for his legs, but again, there was no documentation to confirm these were performed. Resident 83, with chronic obstructive pulmonary disease and anxiety, was supposed to receive passive range of motion exercises for her right arm, but she reported that staff did not complete these exercises. The Director of Nursing confirmed the lack of documentation for the completion of these restorative nursing programs.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards on two of its nursing units. On the Second Floor Unit, Resident 9, who had cognitive impairment and required a mechanically altered texture diet, was observed being fed by another resident without staff intervention. This lack of supervision posed a risk to Resident 9, who had a self-care deficit and required meal support as per her care plan. On the Third Floor Unit, a treatment cart containing various medications was found unlocked and accessible to cognitively impaired residents, including Residents 56 and 88, who were observed moving around the unit unsupervised. Additionally, the facility failed to thoroughly investigate a fall involving Resident 56, who had dementia and was at risk for falls. After a fall, the intervention added was inappropriate, as it involved a toileting program despite the resident having an indwelling urinary catheter. Furthermore, there was no documentation confirming that the resident's bed was in a low position during a subsequent fall, as required by the care plan.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate the meal preferences of two residents, leading to deficiencies in their care. Resident 21, who has diabetes, gastro-esophageal reflux disease (GERD), and intestinal issues, was observed with a meal that included gravy, despite her meal ticket specifying no gravy due to her dislike for it. This occurred while she was alert and oriented, as noted in her care plan. Additionally, Resident 130, who suffers from dementia, underweight, and malnutrition, was served broccoli instead of the carrots specified on her meal ticket. Her care plan highlighted a potential nutritional problem due to poor appetite, yet the meal provided did not align with her documented preferences.
Failure to Notify Residents' Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the residents' representatives regarding the transfer of nine residents to the hospital. These residents were transferred due to changes in their conditions, but there was no evidence that their responsible parties were informed in writing about the transfers and the reasons for these moves. This deficiency was identified through clinical record reviews and confirmed by the Director of Nursing during an interview. The residents involved in this deficiency were transferred to the hospital on various dates between March and June 2024. Despite the requirement to notify the residents' representatives in writing, the facility did not provide such documentation for any of the nine residents. This lack of communication was acknowledged by the Director of Nursing, who confirmed that the necessary written information was not provided to the residents' representatives.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to meet the needs of a resident identified in the comprehensive assessment. Clinical record review revealed that the resident was admitted with diagnoses including diabetes and an altered mental state. The Minimum Data Set Care Area Assessment summary noted that the resident was at risk for impaired nutrition and that this should be addressed in the care plan. However, there was no evidence that interventions to address the resident's nutritional needs were included in the current care plan. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Timely Assess Nutritional Status
Penalty
Summary
The facility failed to timely assess the nutritional status of two residents, leading to significant weight loss without appropriate intervention. Resident 1, who had diagnoses including diabetes and altered mental state, was admitted to the facility and weighed 147 pounds on January 12, 2024. However, no further weights were recorded until March 5, 2024, when the resident weighed 128.65 pounds, indicating a significant 12.5 percent weight loss. During this period, the resident was documented to be eating only about 25 percent of his meals from February 27 to March 8, 2024. There was no evidence that the facility assessed or addressed this significant weight loss or notified the physician and responsible party of the resident's change in condition. Similarly, Resident 6, who had diagnoses including spastic paraplegia and anemia, weighed 122.4 pounds on January 5, 2024. The next recorded weight was on March 8, 2024, showing a weight of 110 pounds, a significant 10.13 percent weight loss. Again, there was no evidence that the facility assessed or addressed this significant weight loss or notified the physician and responsible party. The Nursing Home Administrator confirmed that there was no documented evidence that staff obtained weights according to the facility policy or that they immediately notified the physician and responsible party of the significant weight losses.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 207 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Laureldale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Reading Skilled Nursing And Rehabilitation Ce | 4.3 mi | ★★★★★ | 6 | 0 |
| Spruce Manor Nursing & Rehabilitation Center | 4.6 mi | ★★★★★ | 5 | 0 |
| Transitional Sub-acute Unit | 4.8 mi | ★★★★★ | 0 | 0 |
| Berks Heim Nursing & Rehabilitation | 5.1 mi | ★★★★★ | 1 | 0 |
| Wyomissing Health And Rehabilitation Center | 5.2 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.