Laurels Of Sandy Creek (the)

F 0554 Review of the facility's Medication Administration policy, revised 10/17/2023, stated, Authorized Personnel - Medications are .administered .only by licensed nursing, medical, pharmacy, or other personnel authorized Level of Harm - Minimal harm or by state laws and regulations to administer medications .Self-Administration - residents are allowed to potential for actual harm self-administer medications when specifically authorized by the attending physician and in accordance with

the guideline for self-administration of medication. A self-administration evaluation will be completed prior to Residents Affected - Few the resident starting the self-administering process. Self-administration of medication will be reflected in the resident care plan along with any special considerations .Observe that the resident swallows the oral medications. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 In an interview on [DATE REDACTED] at 1:11 PM, DON B reported that she was working on the evening of [DATE REDACTED] and

she ran to Resident #278's room when she heard staff yelling for help. DON B reported that when she went Level of Harm - Minimal harm or to Resident #278's room, she observed CNA H, CNA N, and LPN I' in Resident #278's room, and that potential for actual harm Resident #278 was already beginning to wake up as she entered his room, and LPN I had already stopped performing CPR compressions on Resident #278. DON B confirmed that Resident #278 was unresponsive, Residents Affected - Few did not have a pulse, and LPN I performed CPR on him, which did result in Resident #278 regaining a heartbeat. DON B reported that it was her expectation that staff would begin CPR on a resident until they verified the resident's code status. DON B confirmed that the facility did not complete an incident report, or initiate any further education after the incident with Resident #278 to improve the process of staff ensuring correct code status of residents in the event of emergencies.

In an interview on [DATE REDACTED] at 1:40 PM, Nursing Home Administrator (NHA) A reported that she was working

on [DATE REDACTED] when she had overheard a code blue being called for Resident #278. NHA A reported that she ran down to Resident #278's room and she saw LPN I, CNA N, and CNA H in Resident #278's room. NHA A reported that she ran to the nurses station and confirmed that Resident #278 had a DNR, and went back to Resident #278's room to report that he had a DNR, but that other staff were already there reporting his code status. NHA A reported that she had found out after the event that LPN I performed CPR on Resident #278 when he had an active DNR order in place. NHA A reported that the facility did not do an incident report after

the event, but she thought that DON B had completed follow up education with staff. NHA A reported that

she expected staff to confirm a resident's code status prior to initiating CPR. NHA A confirmed that Resident #278 was unresponsive, did not have a pulse, and LPN I performed CPR on him, which did result in Resident #278 regaining a heartbeat.

Review of the Facility's CPR policy last reviewed [DATE REDACTED] revealed, . Staff must maintain a current CPR certification for healthcare providers through a CPR provider whose training includes a hands on session in a physical instructor-led setting or a virtual instructor-led setting with hands-on demonstration in accordance with accepted national standards . 1. Validate the resident is full code and there is no DNR order .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 In an interview on 05/21/25 at 10:34 AM, Minimum Data Set-Registered Nurse (MDS-RN) V reported that Resident #6 had never received treatment for schizophrenia or behaviors. MDS-RN V reported that the Level of Harm - Minimal harm or diagnosis of schizophrenia was documented in error on multiple MDS assessments; MDS-RN V will modify potential for actual harm the assessments and resubmit them.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47659 potential for actual harm Based on interview and record review the facility failed to ensure residents received care in accordance with Residents Affected - Some professional standards in 1 of 18 residents (Resident #37) reviewed for quality of care when nursing staff administered Lotrel (Medication used to treat hypertension) out of the physician ordered parameters resulting

in the potential for adverse side effects.

Findings include:

Resident #37

Review of an Admission Record revealed Resident #37 was originally admitted to the facility on [DATE REDACTED] with pertinent diagnoses which included hypertension (high blood pressure).

Review of Resident #37's Orders revealed, Lotrel Oral Capsule 10-40 MG (Amlodipine Besylate-Benazepril HCl) Give 1 capsule by mouth one time a day for HTN Hold if Systolic (systolic blood pressure) <110/ HR (heart rate)<60 .

Review of Resident #37's Pharmacy Consultation Report dated 3/6/25 revealed, (Resident #37) has an order for Lotrel that was administered outside of the parameters for which it was ordered. Specifically, on 3/3, 3/4 when SBP (systolic blood pressure) was below 110. Recommendation: Please remind staff of the importance of administering/holding medication within the parameters ordered . This recommendation was signed by Director of Nursing (DON) B on 3/18/25.

Review of Resident #37's Medication Administration Record for March, April, and May 2025 revealed that staff had documented administering Lotrel to Resident #37 when his systolic blood pressure was below 110

on 3/3/25, 3/4/25, 3/15/25, 3/19/25, 5/9/25 and 5/11/25. It was noted that Licensed Practical Nurse (LPN) G had documented the administration of the medication for each date except for 5/11/25.

In an interview on 5/21/25 at 12:22 PM, DON B reported that she did not recall the pharmacy recommendation that she had signed for Resident #37 on 3/18/25. DON B confirmed that she had not completed any follow up education with nursing staff on ensuring that they were administering medications within the parameter orders.

This writer attempted to reach LPN G on 5/21/25 at 12:50 PM for an interview. LPN G was unable to be reached prior to survey exit.

Review of the facility's Medication Administration policy dated 10/17/23 revealed, Resident medications are administered in an accurate, safe, timely, and sanitary matter . Physician's orders: Medications are administered in accordance with written orders of the attending physician . Procedure: .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Potential for minimal harm 38905

Residents Affected - Many Based on interview and record review the facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to provide an oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, foodborne illness, or inadequate assessment of high-risk residents.

Findings include:

During the initial tour of the kitchen, starting at 7:50 AM on 5/19/25, it was found that Dietary Manager T still has a few more months to go until he completes his Certified Dietary Manger certification. When asked if he has been in the position for longer than a year, Dietary Manager T stated yes. When asked how often the dietitian comes to the facility, Dietary Manager T stated that the dietitian comes two days a week. When asked if he was aware that only one year was granted upon hire in the Dietary Manager / Food and Nutrition Supervisor role to obtain the Certified Dietary Manager certification, Dietary Manager T stated he thought he was allowed the length of the Certified Dietary Manager course, which is 18 months.

A staff record review found no documentation that facility had a full time Certified Dietary Manager or full time Dietitian on staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Review of a Meal Ticket for Resident #54 with a reference date of 5/20/25 revealed Allergies .pickles and cucumbers. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/20/25 at 12:33pm, Certified Nursing Assistant (CNA) J delivered Resident #54's lunch tray to him in his room. Residents Affected - Some

In an interview on 5/20/25 at 12:35pm, CNA J reported she regularly cared for Resident #54, and delivered his meals. CNA J reported was not aware the resident had any food allergies.

In an interview on 5/20/25 at 1:59pm, CNA M reported Resident #54 watched his food very carefully because

he was worried about mistakenly being served food that contained pickles or cucumbers again.

Review of a Nurses Note for Resident #54 with a reference date of 4/19/25 revealed Resident has allergies to cucumbers/pickles. Resident (sic) reported that he noticed after a few bites of potato salad from dinner that there were pickles in it and immediately stopped eating and notified the nurse. Resident reported that mouth was slightly itchy .on call provider notified and ordered PRN (as needed) (name of antihistamine medication) and Ondansetron (anti-nausea) medication for 3 days. DON (Director of Nursing) and kitchen manager notified as well .

Review of a Medication and Treatment Incident Report for Resident #54 with a reference date of 4/21/25 revealed Date of Incident: 4/19/25 .Route of Administration Involved: Pickles in potato salad .Description of Event: .resident took a couple of bites of potato salad .it had pickles .Resident c/o (complained of) itching in mouth . (antihistamine and anti-nausea medication) ordered. 2. Failure to Follow Procedure: allergy checking for meal ingredients .Corrective Action: Spoke with dietary manager .

Efforts to contact the nurse who authored the Nurses Note and Medication and Treatment Incident Report where not successful at the time of the completion of the survey.

In an interview on 5/21/25 at 9:30am, Dietary Manager (DM) T reported Resident #54 was mistakenly served potato salad that contained a known food allergen in April 2025. DM T reported the resident's food allergy was listed on his meal ticket at the time and the kitchen staff were expected to review the resident's food allergens as selected foods for the resident's meal tray. DM T reported the staff did not cross reference the ingredients list on the pre-made potato salad with Resident #54's food allergens on 4/19/25 when he was served food that contained pickles. DM T could not provide verification of any corrective action that was taken following the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Review of Resident #5's physician's orders included a diet order, revised 1/29/2025, that stated, Regular diet, chopped meat texture .built up utensils. Level of Harm - Minimal harm or potential for actual harm Review of Resident #5's Nutritional Re-evaluation, dated 4/29/25, stated, .Adaptive Devices .foam built up utensils. Residents Affected - Some

Review of Resident #5's nutrition care plan included an intervention, revised 1/31/2025, that stated, Regular diet, Chopped Meat texture .built up utensils.

Review of Resident #5's cognition care plan, revised 8/1/2024, stated, (Resident #5) is at risk for decline in cognition and has impaired cognitive function or impaired thought processes R/T: (related to) History of Stroke.

Review of the facility's Adaptive Equipment (adaptive dining equipment) policy, revised 3/6/2024, stated, It is

the policy of this facility to provide adaptive eating (dining) equipment for those residents who would benefit from their use .Culinary staff will place the adaptive equipment on each meal tray .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR Level of Harm - Minimal harm or 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations potential for actual harm (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of an Enhanced Barrier Precautions policy with a reference date of 3/5/25 revealed Enhanced Barrier Precautions are indicated for residents with any of the following .a wound or indwelling device .Health care Level of Harm - Minimal harm or personnel caring for residents on Enhanced Barrier Precautions should wear gloves and gowns during high potential for actual harm contact resident care. Examples of high contact resident care activities requiring gown and glove use: . transferring .providing hygiene .changing briefs . Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 235313 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235313 B. Wing 05/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Sandy Creek (the) 425 E Elm St Wayland, MI 49348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 38905

Residents Affected - Some Based on observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease

in satisfaction of living.

Findings include:

During a tour of the East Day room, at 9:43 AM on 5/19/25, it was observed that food crumbs, paper trash, and debris were found under and on the sides of seat cushions of two chairs and a love seat.

During a tour of the East Hall Spa, at 9:53 AM on 5/19/25, it was observed that dried bowel movement was found stuck on the front bowl and seat of the commode. Further observation found an accumulation of dirt and debris behind the toilet in the back corner of the commode area and four wash cloths found stored on top of the paper towel holder next to the sink.

During a tour of the [NAME] Hall spa room, at 10:42 AM on 5/19/25, it was observed that 12 wash cloths, four towels, and a box of gloves were stored on a shower chair next to the shower. Observation of the spa cabinet found a spray bottle of disinfectant stored over and next to clean and sanitary linens.

During a revisit of the East Day room, at 9:04 AM on 5/20/25, observation of the chairs and love seat in this area found an accumulation of food crumbs, paper trash, and debris in the sides of the seat cushions. An

interview with Laundry Director (LD) Q found that these areas should be cleaned daily.

During a tour of the East side shower, at 9:09 AM on 5/20/25, observation of the commode found dried bowel movement on the front of the bowl and seat of the commode. Further observation found a stack of wash cloths stored on the paper towel holder. Observation of the cabinet found personal hygiene products stored with a bottle of cleaning disinfectant. When asked about items being stored together, LD Q stated that personal hygiene products should be stored in residents' rooms.

During a tour of the [NAME] Shower room, at 9:21 AM on 5/20/25, it was observed that 14 towels and 12 wash cloths were found stored on a shower chair next to a shower. When asked if this is where clean linens are usually stored, LD Q stated no and that they should be stored in the cabinet to not get contaminated from residents showering.

During a tour of the facility, starting at 1:35 PM on 5/20/25, observation of the following exit doors found gaps and spaces between the door, the door frame, and the installed weatherstripping. Doors noted with concern were the [NAME] hall North door (bottom), the [NAME] center South door (side), Center hall North courtyard door (bottom right), Dining Room exit door (left side), and the East hall North door (weatherstrip bent). These areas were found to allow the visible presence of light, air, and easy pest entry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 235313