The Landing at Laurel Lake

• Service and Service Coordination Requirements - Emergency Response
• AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.
• During the months of December 2023, August 2024, and June 2025, there were 16 e-call response times over the eight-minute limit in accordance with the Resident's policy.
• Quality Assurance and Performance Improvement
• AGE reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Safety Assurances, and Medication Quality from last quarter of calendar year 2023, through the date of the Compliance Review.

Service Planning

• Documentation that the Residence identified the date the audit was conducted, name of the person who conducted each audit, a target date for follow-up action, staff responsible for follow-up and documented clear outcomes were missing for calendar year 2024.

Resident Safety Assurances

• Documentation of an Evidenced Informed Falls Prevention Program review being included in the annual safety review process was missing for the 2023 and 2024 calendar years reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from the last quarter of calendar year 2023 through the date of the Compliance Review to ensure compliance with SAMM and LMA Residence policies.
• Documentation of a quarterly medication review summary was missing for the last quarter of the 2023 calendar year.
• Documentation that the Residence identified a target date for follow-up action, staff responsible for follow-up and documented clear outcomes were missing for calendar year 2024 and second quarter of calendar year 2025.

Medication administration observation

• AGE observed two Resident Assistant (R/A) staff and one Nurse providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM / LMA.

SAMM

• AGE observed one Resident's medication storage unit that contained multiple loose pills, multiple over the counter medications in resident's room and a loose pill from the previous evening SAMM medication bubble pack on resident's counter.
• AGE observed one Resident's family filled medication planners without the required label.

LMA

• AGE observed the Nurse perform medication administration in the common dining area.
• AGE observed one Resident's medication storage unit contained Exemption C without a noted opening date.
• Residents shared rooms are missing the required proper labels of resident's names on medication storage units.
• Record Requirements - Correspondence log
• AGE reviewed the documentation maintained in the correspondence logs required every twenty-four hours to communicate information necessary to maintain the continuity of care for Residents.
• The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• The Residence did not maintain the Correspondence Log for at least 90 days.
• General Requirements for an Assisted Living Residence (ALR)
• AGE reviewed five Resident Records reviewing documentation from November 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Service Plan Development and Requirements

• Two records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Two records were missing signatures of the Resident or the Legal Representative.
• Controlled Substances
• AGE reviewed the Controlled Substance policy and procedure to provide safeguards to prevent theft and dispose of controlled substances prescribed to Residents who participate in SAMM and LMA.
• Upon review of the controlled substance practices of the Residence, it was discovered that the Residence was inconsistent in documenting a controlled substance count for all Residents prescribed a controlled substance(s) in accordance with the Residence policy for all years reviewed.
• Record Requirements- Personnel Record Requirements
• AGE reviewed the personnel records of five staff members to determine compliance with personnel record requirements.
• Two records were missing documentation of a signed job description.
• Documentation that the required training had been met in accordance with the regulations was missing in two records.
• Resident Rights and Required Disclosures - Additional Disclosures
• AGE reviewed five Resident records to confirm compliance with the Additional Disclosure requirements.
• The informational cover sheet required by AGE for each Residency Agreement was missing in two records.
• The required Disclosure forms and notification of the right to bring a Representative prior to the first meeting, were not signed by the Resident, Resident Legal Representative and/or Residence in two records.
• The Residence's documentation of the receipt of a consumer guide, developed by AGE, during its first formal meeting with a prospective Resident was missing in two records.
• Training Requirements - Introductory Visit and Review
• AGE reviewed the records of five Residents to determine compliance with the requirements that a nurse reviews the Resident's service plan with all relevant personal care workers within 48 hours after the provision of service or with any change of condition for the Resident:
• Three records were without documentation to support the fact that Introductory Visits were consistently conducted with all applicable staff.

LBGTQ Inservice

• AGE reviewed five personnel records to determine compliance with training requirements.
• Two records were missing documentation to confirm completion of required LGBTQ Inservice.
• Resident Records- Progress Notes
• AGE reviewed five Residents' records to determine compliance with record requirements.
• Inconsistent documentation of significant occurrences in the Progress Notes for two Residents.
• Staffing Requirements- Staffing Levels
• AGE reviewed the Residence records to determine compliance with Staffing Level requirements.
• Documentation to confirm the Residence conducted quarterly staffing level assessments was missing for the third and fourth quarter of calendar year 2023 and second quarter of calendar year 2025.
• Special Care
• AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the SCR is complying with all the required safeguards.
• Documentation to support that the required SCR operations review was conducted for the second half of the 2023 calendar year was missing.
• Deficiencies with operational safeguards related to secure SCR entry and exit doors and procedures to reduce the risk of potential hazards in the physical environment:
• AGE noted chemicals not secured in the common kitchen area.
• The laundry door was unlocked and opened when AGE entered the unit.
• Entry and exit door alarms were not responded to by a staff member on duty as required by Residence policy when triggered by AGE during door alarm testing.
• Propane tank attached to the outside Grill on SCR unit.