Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews, and interviews, the facility failed to ensure that a care plan was developed
related to behaviors for one resident (Resident #41) out of the sampled twenty-five residents.
Findings included:
On 07/27/21 at 10:55 a.m., Resident #41 was observed sitting at the table in the main dining room. The
resident appeared calm. He was dressed for the day. Resident #41 replied yes when asked if he was ok.
Resident #26 was observed in the main dining room sitting at a table during this time also. When asked was
everything ok, he stated yes except for that nasty man while pointing at Resident #41 and he proceeded to
use profanity related to the behaviors of Resident #41. Resident #26 stated Resident #41 was nasty and
was always messing with his private parts in the front of everyone.
A review of the admission Record for Resident #26 revealed that he was admitted into the facility on [DATE]
with a primary diagnosis of unspecified dementia with behavioral disturbance. Section C Cognitive Patterns
of the Minimum Data Set (MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental
Status (BIMS) score of 12 out of 15 indicating moderately impaired.
Resident #38 was seated at the table with Resident #26. She stated, Yes he is always doing that. He shows
his vagina. I mean . You know what I mean.
A review of the admission Record for Resident #38 revealed that she was admitted into the facility on
[DATE] with a primary diagnosis of schizophrenia. Section C Cognitive Patterns of the MDS dated [DATE]
indicated that the resident had a BIMS score of 15 out of 15 indicating cognitively intact.
The Activities Director was in the main dining room at this time also and confirmed the accusations. He
stated that they redirect him as much as they can and take him to his room if it gets too out of hand.
On 07/27/21 at 12:55 p.m., Staff D, Certified Nursing Assistant (CNA), stated that the resident was always
digging in his backside, and he touches his private area. Staff D reported when the resident displays this
type of behavior, she walks away. If you leave him and go back to check on him, most times he would be
calm. She stated that they try to redirect him and let him know that the behavior was not appropriate. She
had observed this behavior at least two times a day.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
105228
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105228
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurellwood Post- Acute and Rehabilitation Center
3127 57th Ave N
Saint Petersburg, FL 33714
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 07/27/21 at 3:12 p.m., Staff C, Licensed Practical Nurse (LPN), stated Resident #41 was a lot calmer
now. She stated when he ambulates, he touches a lot. At one point he would come out in the hall and
urinate instead of going into the bathroom. Staff C reported that she has gotten report that he takes his
pants down, but she had not seen him do it.
On 07/28/21 at 11:30 a.m., Resident #41 was observed sitting in the main dining room at the table with
three other residents. The resident was observed spitting on the floor.
On 07/28/21 at 11:35 a.m., the Activities Director reported that the resident displayed these behaviors all
over the facility. He stated that the resident had his hands in his pants today in the main dining room and
multiple residents were in the dining room at that time. The Activities Director stated Resident #41 did not
expose himself, but he was digging in the front and the back with his hands in his pants causing an uproar
with the other residents. He stated that the resident said he was fixing his pants when he tried to redirect
him.
On 07/28/21 at 2:53 p.m., Staff J, LPN Unit Manager, reported that she was not aware of Resident #41
displaying any inappropriate behaviors.
A review of the admission Record reflected that Resident #41 was admitted into the facility on [DATE] with
an admitting diagnosis of Alzheimer's Disease.
Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that
Resident #41 had a BIMS score of 99 indicating that the resident was unable to complete the interview.
This section also indicated that the resident had short term and long-term memory problems.
Section E Behaviors indicated that Resident #41 displayed only verbal behavioral symptoms directed
towards others 1 to 3 days.
The resident had the following active orders as of 07/29/21:
Target Behavior Monitoring for Depakote: Monitor resident for pacing and agitation;
Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG- Give 1 capsule po (by mouth) two times a
day for mood.
A review of the Behavior Monitoring Charts for May, June, and July 2021 indicated that the resident did not
display any of the mentioned behaviors.
A review of the Point of Care Responses for Behavior Symptoms reflected that Resident #41 had a
behavior of wandering and grabbing on three days in the last 30 days.
Section 13 AIMS/Mood/Behavior of the Quarterly Nursing Comprehensive Evaluation dated 06/26/21
indicated that the resident was calm and did not have any behaviors.
A review of the Progress Notes from May 2021 to current did not reflect any documentation related to the
behaviors displayed by the resident.
A review of the care plans revealed that Resident #41 did not have a care plan in place for behaviors.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105228
If continuation sheet
Page 2 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105228
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurellwood Post- Acute and Rehabilitation Center
3127 57th Ave N
Saint Petersburg, FL 33714
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 07/28/21 at 2:07 p.m., the Director of Nursing (DON) stated that Resident #41 likes to pick in his
clothing, touches his bowel, and act as if he's finger painting with it. The DON reported that he also urinates
in the corner of his room, and he spits. She stated that she cannot explain why it was not on the care plan
or documented in the record, but it was reported to psych, and he made a medication adjustment.
On 07/29/21 at 11:55 a.m., an interview via the phone with the psych Advanced Practice Register Nurse
(APRN) revealed that he was familiar with Resident #41. He stated that Resident #41 needed redirection
and he was incontinent. The psych APRN stated that Resident #41 was up at night, so he started him on
Depakote. He reported that he was not aware of any inappropriate behaviors, and he was not aware of the
resident urinating on the floor or digging in his pants in the front of others. The psych APRN stated that he
would expect the behaviors to be documented in the medical record.
Event ID:
Facility ID:
105228
If continuation sheet
Page 3 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105228
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurellwood Post- Acute and Rehabilitation Center
3127 57th Ave N
Saint Petersburg, FL 33714
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility did not ensure that the medication error rate
was below 5.00%. A total of twenty-five medications were observed administered and four errors were
identified for three (3) (Resident #10, #23 and #46) of six (6) residents observed. These errors constituted a
medication error rate of 16 percent.
Residents Affected - Few
Findings included:
A facility provided policy titled, Administering Medications, revision date April 2019, Policy and Procedure,
Medications are administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation:
4. Medications are administered in accordance with prescriber orders, including any required time frame.
10. The individual administering medication checks the label three (3) times to verify the right resident, right
medication, right dosage, right time, and right method (route) before giving the medication.
On 07/28/21 at 09:25 a.m., and observation was conducted of Staff A, Licensed Practical Nurses (LPN)
administering medication to Resident #10. During the observation Staff A, (LPN) was seen administering
Isosorbide Mononitrate ER Extended Release (ER) Tablet and Potassium Chloride Extended Release (ER)
Tablet 10 MEQ. Both medication labels had written instructions of Do Not Crush. Staff A, (LPN) was
observed to place the tablets in a clear packet and crushed the Extended Release (ER) medications and
then place them in chocolate pudding in a clear medication cup with the other 9:00 am medications and
administered them to Resident #10. An immediate interview was conducted with Staff A, (LPN), who
revealed that she did realize they were extended Release (ER) medications and should not be crushed.
On 07/28/2021 at 11:06 a.m., an observation of medication administration with Staff B, (LPN) was
conducted with Resident #23. Staff B, (LPN) had obtained a Blood sugar reading of 278 at 10:45 a.m., prior
to the observation. Staff B, (LPN), administered KwikPen U-100 Insulin (Lispro) 1-Unit Dial Insulin Pen; 100
units/milliliter (mL); six (6) units to Resident #23's in his right upper arm. Staff B, (LPN) was not observed
priming the KWIKPEN with two (2) units prior to administering the insulin injection.
According to manufacture instructions for Insulin Lispro Injection KwikPen
http://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, Priming Your Pen: Priming your pen means removing the
air from the Needle and Cartridge that may collect during normal use and ensures that the pen is working
correctly. If you do not prime before each injection, you may get too much or too little insulin.
A second observation was conducted of Staff B, (LPN) performing insulin administration on Resident #46.
Staff B, (LPN) indicated that she did not need to perform a Blood Sugar value before administering insulin
to the resident. She administered twenty (20) Units Levemir FlexTouch Solution Pen Injector 100 Unit/ML
(Insulin Detemir) to the resident. After medication administration, an immediate interview was conducted
with Staff B, (LPN), and she was asked why she did not prime the insulin pen for both Resident #23 and
#46 insulin injectors. Staff B, (LPN) stated You do not have to prime the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105228
If continuation sheet
Page 4 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105228
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurellwood Post- Acute and Rehabilitation Center
3127 57th Ave N
Saint Petersburg, FL 33714
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 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
pen, because when you put the top on and dial it up it retracts, so there is no need to prime the pens before
dialing the insulin up.
Review of manufacturer Novo Nordisk manufacturer instructions of usage and safety guidelines:
https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/LevemirIFU.pdf,
FlexTouch prefilled insulin pens, Priming our Levemir FlexTouch Pen:
Step 7: Turn the dose selector to 2 Units
Step 8: Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air
bubbles rise to the top,
Step 9: Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter
shows 0. The 0 must line up with the dose pointer.
-A drop of insulin should be seen at the needle tip.
-If you do not see a drop of insulin repeat Steps 7 to 9, no more than six times,
-If you still do not see a drop of insulin change the needle and repeat steps 7 to 9.
Record review of active physician orders for the Resident #46 revealed Levemir FlexTouch Solution Pen
Injector 100 Unit/ML (Insulin Detemir) Inject 20 units subcutaneously in afternoon for Diagnosis of Type 2
Diabetes, date 4/20/2021.
An interview was conducted with the Director of Nursing (DON) on 07/28/2021 at 12:17 p.m. The DON was
notified of the medication administration observations made of Staff A, (LPN) and Staff B, (LPN). The DON
revealed that all flex pens/insulin pens need to be primed with two (2) units before each use. She further
stated that the nurse should have not crushed medications not be crushed.
On 07/29/20211 at 12:08 p.m., a telephone interview was conducted with the Pharm-D, Pharmacy
Consultant. The Pharmacy Consultant was informed of observations made of Staff A (LPN) and Staff B
(LPN) during medication administration. The Pharmacist stated
As far as crushing Extended-Release Medications, it damages the tablets and is not acceptable to crush
and administer. She further revealed and stated, The insulin dose may not have been accurate without
priming with two (2) units, because insulin fills the pen needle and old insulin that may have remained in the
pen is gone, for a clean dose to be administered to the residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105228
If continuation sheet
Page 5 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105228
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurellwood Post- Acute and Rehabilitation Center
3127 57th Ave N
Saint Petersburg, FL 33714
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, record review, and interview the facility failed to store, prepare, distribute and serve
food in accordance with professional standards for food service safety regarding not dating pre-made
sandwiches on one of one tray observed in the walk-in refrigerator, not documenting food temperatures
prior to serving for one out of eleven meals on the temperature log, and not ensuring food from an outside
source was stored with a use-by date and labeled with the owners name in one of one nursing station
refrigerator.
Findings included:
On 7/27/21 at 9:15 a.m., an initial tour of the kitchen was conducted with the Kitchen Manager (KM). A
three-quarter filled tray of pre- made turkey and cheese half sandwiches was observed in the walk-in
refrigerator. The observation identified that none of the sandwiches or the tray was dated as to when they
were assembled. The KM confirmed that the sandwiches were undated, he picked up the tray, looked at it
and stated there isn't a sticker. The KM left the walk-in refrigerator and placed a sticker with a date on the
tray.
An observation was conducted, on 7/28/21 at 11:30 a.m., with Staff Member I, cook, obtaining the
temperatures of the food that was to be served to residents for the lunch meal. Neither the staff member
nor the KM documented the temperatures of food on the log as they were obtained. Approximately half way
through the process the KM started filling out the log with temperatures. As he wrote down the temperature
readings for the lunch meal, it was observed that the breakfast temperatures for 7/28/21 were not
documented. The KM confirmed those findings. The cook stated she had taken the temperatures but had
written on a piece of paper that had been thrown away. The cook stated it's on me.
On 7/29/21 at 10:56 a.m., an observation was conducted with the Director of Nursing (DON) of one of one
unit refrigerator reserved for residents. A bag of green grapes were observed in grocery store plastic bag
and an opened bottle of water that was not labeled with a name or date. The grapes were identified by a
resident name and the date of 7/18 (eleven days prior to the observation). The items were returned to the
refrigerator and the DON stated that the items should be labeled with a resident name and a date.
The policy, Food Preparation, revised October 2019, indicated that all foods are prepared in accordance
with the guidelines of the FDA Food Code. The policy identified that Temperature for Time/Temperature
Control for Safety (TCS) foods recorded at time of service, and monitored periodically during meal service
periods as indicated.
The policy, Food brought by Family/Visitors, undated, indicated that Perishable foods must be stored in
re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's
name, the item, current date/time, and the use by date. The policy identified that the nursing staff was
responsible for disposing of perishable foods on or before the use by date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105228
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the July 30, 2021 survey of LAURELLWOOD POST- ACUTE AND REHABILITATION CENTER?
This was a inspection survey of LAURELLWOOD POST- ACUTE AND REHABILITATION CENTER on July 30, 2021. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LAURELLWOOD POST- ACUTE AND REHABILITATION CENTER on July 30, 2021?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep aisles, corridors, and exits free of obstruction in case of emergency."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.