The Laurels Of Forest Glenn

F-F604: Based on observations, staff, Responsible Party (RP), Medical Director (MD), Nurse Practitioner #1 (NP) and Paramedic #1 interviews and record review, when the facility moved the resident's bed against the wall to prevent her from getting out of the bed, they failed to identify this as a restraint, failed to complete a restraint assessment, failed to obtain a physician order and failed to obtain the RP's consent for the use of a restraint. When the resident fell out of the bed she was wedged between the bed and the wall Resident #1 was assessed by facility staff and found to not have a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE REDACTED]. This was for 1 of 3 residents reviewed for restraints (Resident #1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 345389 Department of Health & Human Services Printed: 09/22/2025 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 345389 B. Wing 06/26/2024

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

The Laurels of Forest Glenn 1101 Hartwell Street Garner, NC 27529

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 0726

F-F689: Based on record review, observations and interviews with staff, Responsible Party (RP), Bed Supplier Manager, Medical Director (MD), Nurse Practitioner #1 (NP), Police Officer #1, Paramedic #1 and Medical Level of Harm - Immediate Examiner (ME) #1 the facility failed to keep Resident #1 free from accident hazards by placing her bed jeopardy to resident health or against the wall and trying to restrict her from getting out of bed and implement fall interventions ensuring safety Resident #1's bed remained in the lowest position. Resident #1 fell out of the right side of her bed in between her bed and the wall where there was approximately two to three inches of space. Resident #1 was Residents Affected - Few discovered by her RP in between the wall and the bed lying face down with the left side of her body slightly leaning against the base board on the wall keeping her from being completely flat on the floor. Resident #1 was assessed by facility staff and found not to have a pulse or respirations so cardiopulmonary resuscitation (CPR) was started by the facility staff and assumed by paramedics. Resident #1 expired on [DATE REDACTED]. This deficient practice was for 1 of 3 residents reviewed for accidents (Resident #1).

Review of the facility's electronic training records indicated the most recent restraint training was on [DATE REDACTED] for the following staff: Nurse #1, Nursing Assistant (NA) #8, Nurse #4, Medication Aide (MA) #1, NA #9, NA #10, Nurse #3, NA #12, Nurse #5, NA #13, NA #2, NA #3, MA #2, UM #1 and Nurse #2. NA #11 received her training on [DATE REDACTED] and review of NA #1's New Employee Facility General Orientation Checklist dated [DATE REDACTED] did not include any specific training on restraints.

An interview was completed on [DATE REDACTED] at 1:12 PM with the Director of Nursing (DON). She stated the facility did not currently have a Staff Development Coordinator (SDC) so she had been filling in with general orientation and ensuring certifications were not expired. She stated the facility utilized an electronic education system that was programmed for different training subjects to be due for the staff at certain times of the year and the previous restraint training was [DATE REDACTED]. The DON stated the training included a review of

the risk associated with implementing a restraint, the different types of restraints, the facility's effort to create

a restraint free environment, alternatives to restraints and the risk associated with the use of side rails. She stated it was not up to the floor nurses to initiate restraints but rather to the nursing management team after

an assessment, obtaining a Physician order and written consent from the resident's RP. She stated the annual training for 2024 was already set up. She stated it was clear that the staff needed re-education and clarification on the definition of restraints and accident hazards. She stated she had all the staff completed retraining on again on [DATE REDACTED] but clearly, there was still work to be done. She stated NA #1 was a new hire

on [DATE REDACTED] and apparently the New Employee Facility General Orientation Checklist that was completed with NA #1 didn't have anything on it regarding restraints and she was unable to find any kind of orientation competency checklist.

The Administrator was notified of Immediate Jeopardy on [DATE REDACTED] at 11:55 AM.

The facility provided the following credible allegation of immediate jeopardy removal with a date of [DATE REDACTED]:

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 345389 Department of Health & Human Services Printed: 09/22/2025 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 345389 B. Wing 06/26/2024

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

The Laurels of Forest Glenn 1101 Hartwell Street Garner, NC 27529

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 0726 The deficient practice resulted when the facility failed to have licensed nurses and nurse aides that were able to demonstrate competency in skills and techniques to address Resident # 1's behavior and attempts to get Level of Harm - Immediate out of bed. Staff restrained Resident #1's movement by pushing the bed against the wall on [DATE REDACTED]. This jeopardy to resident health or staff nor other staff who subsequently provided care for Resident #1 recognized the restraint of the resident's safety movements could create a life-threatening hazard. Resident #1 was found unconscious and wedged between the wall and the bed. Resident #1 expired on [DATE REDACTED]. Residents Affected - Few Other residents in the facility that have a behavior of trying to get out of bed were reviewed and there were no other residents noted that the staff had pushed the bed against the wall to keep the residents in bed. This was completed on [DATE REDACTED] by the Director of Nursing.

Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.

Nurse # 1 received 1:1 education on [DATE REDACTED] by Director of Nursing on the restraint and abuse policy and procedure with a focus on a bed against the wall needing to be evaluated as well as options to address residents that are attempting to get out bed.

On [DATE REDACTED], the Director of Nursing was provided education on the restraint and abuse policy with a focus on

a bed against the wall potentially being a restraint, as well as addressing resident's attempting to get out of bed and options to address this behavior, by the Regional Clinical Coordinator. The education was provided,

in person, verbally with opportunity for discussion and/or clarification.

On [DATE REDACTED], the Director of Nursing and the Nurse Managers initiated education on the restraint, abuse, and behavioral policy for licensed nurses and aides with an emphasis on the potential of pushing a bed against

the wall being a restraint. The education was provided, in person, verbally with opportunity for discussion and/or clarification. Licensed nurses and nursing assistants will continue to receive this education prior to their next scheduled shift until all have been educated. This education will also be provided to new nursing staff during orientation.

The Director of Nursing, Assistant Director of Nursing and Nurse Managers have conducted observational audits of residents in bed, with a focus on whether the bed is pushed against the wall. This was completed

on [DATE REDACTED].

The Director of Nursing, Assistant Director of Nursing and Nurse Managers have conducted staff interviews of five current nursing employees for validation of ability to identify that placing the bed against the wall as a behavior management intervention is a restraint and the required actions to complete prior to initiation of placing a bed against the wall. This was completed on [DATE REDACTED].

The facility alleges credible allegation of immediate jeopardy removal [DATE REDACTED]. The LNHA is responsible to implement the plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 345389 Department of Health & Human Services Printed: 09/22/2025 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 345389 B. Wing 06/26/2024

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

The Laurels of Forest Glenn 1101 Hartwell Street Garner, NC 27529

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 0726 An onsite validation of the immediate jeopardy removal plan was completed on [DATE REDACTED]. A review of Nurse #1's education on the restraint and abuse policy was confirmed to be completed. A review of the DON's Level of Harm - Immediate education on the restraint and abuse policy and addressing resident's attempts to get out of bed was jeopardy to resident health or confirmed as completed. Staff were interviewed to validate in-services were completed on restraint, abuse safety and behavioral policy to include pushing a bed against the wall was a restraint. This education will also be provided to new nursing staff during orientation. A review of the audits of residents in bed with a bed against Residents Affected - Few the wall were confirmed to be completed.

The Immediate Jeopardy removal was validated as removed on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 345389