The Leland of Laurel Run.

“The facility had confirmed bed bug infestation identified by Orkin pest control inspection. Evidence of infestation of insects was found in the home.”

“Residents were placed on involuntary 'isolation' for seven days, confined to their rooms with meals brought to them, after bed bugs were found in their room. This practice of seclusion is prohibited under the regulations.”

“Two residents had significant behavioral changes documented with emergency room visits for behavioral disturbances, but no additional assessments were completed or updated to identify these significant changes in condition prior to the annual assessment.”

“Two residents had medical evaluations identifying mental health diagnoses, but their resident assessment and support plans (RASP) did not indicate or document these identified mental health needs.”

“The facility failed to provide immediate access to documents requested by a Department agent. Documentation of 15-minute checks requested at 9:15am was not submitted until 1:30pm, and resident records requested at 9:15am were submitted at various times between 10:00am and 1:15pm.”

“The Omnicare Controlled Medication Utilization Record for Tramadol showed inaccurate counts. On 07/18/24, one dose was given at 1:00pm (remaining 19), another dose at 8:03pm with 1 wasted (remaining 18), but the record failed to reflect the actual remaining amount of 17.”

“The facility did not consistently follow the prescriber's orders for Tramadol 50mg. While the physician's order stated medication should be given by mouth 3 times daily, staff were administering it inconsistently—sometimes crushed in applesauce and sometimes whole in applesauce, depending on what the Med Tech felt comfortable doing.”

“The resident's support plan documentation contained conflicting dietary information. The annual medical evaluation stated the resident required a Pureed Drinkable diet, but the resident assessment dated later stated the resident required a Regular Texture diet with Thin Liquids.”

“A box of generic brand denture cleaner labeled 'call poison control center if ingested' was unlocked, unattended, and accessible to residents in room #406. Not all residents, including those in the Secure Dementia Care Unit, have been assessed as capable of safely using or avoiding poisonous materials. This is a repeated violation.”

“The refrigerator in the SDCU kitchenette measured 48 degrees Fahrenheit at 10:15 AM and 50 degrees Fahrenheit at 2:10 PM on 7/18/24, exceeding the required maximum temperature of 40°F for refrigerated food.”

“An unlocked tube of Phytoplex Z-Guard Paste was found in an unlocked drawer in the 2nd floor bathroom vanity on 7/17/24. On 7/18/24, four unlabeled or improperly stored medications were found on the floor of resident bedroom #409, including an orange pill marked HH 222, a yellow pill marked H125, and two unlabeled pink pills.”

“A Victoza insulin pen prescribed to resident #3 was found in the medication cart with an opening date of 1/12/24, exceeding the manufacturer's requirement to discard 30 days after opening. Additionally, four loose medications were found on the floor of the 2nd floor medication room: an oval white pill marked 'Z', a round pink pill labeled 262, a large round white pill marked '44' and '104', and a round pink pill marked 'lupin' and '10'.”

“Resident engaged in inappropriate sexual behaviors toward other residents, including entering shower rooms during bathing, entering resident rooms and lifting covers while making sexual statements, and touching another resident's inner thighs and private areas without consent. These incidents caused discomfort and upset to multiple residents.”

“Resident was prescribed medications (capsules twice daily and later increased dosage) with the diagnosis of 'Behaviors' rather than a specific mental, emotional, or behavioral condition, constituting chemical restraint use prohibited under regulations.”

“Staff member A was hired without completion of criminal history check until after the required date of 9/6/2022. Background check was eventually completed and showed no criminal record.”

“Staff person B did not receive required annual training in emergency preparedness procedures and recognition and response to crises and emergency situations during training year 2022. Training was completed on 1/17/2023.”

“Herbal essence hairspray and Medic choice antiperspirant deodorant, both labeled as potentially harmful or fatal if swallowed, were unlocked, unattended, and accessible to residents in the secured dementia unit. All residents in this unit are incapable of safely recognizing and using poisonous materials.”

“Lint trap accumulation of approximately 1-2 inches found in both dryers, creating fire hazard. Lint was not removed after each use as required.”

“Written emergency procedures were not reviewed and submitted to local emergency management agency within the past year.”

“Resident 1's glucometer was not calibrated with correct date (behind one day), and blood sugar readings were incorrectly entered in the medication administration record. Resident 2's glucometer reading was also incorrectly entered in the medication administration record.”