THE LAURELS OF UNIVERSITY PARK

Nursing Home Inspector

2420 PEMBERTON RD
RICHMOND, VA 23233
Henrico County
Phone: 804-747-9200
Provider Number: 495109
Last Inspection: 04/13/2017

About the Nursing Home

Number of Beds: 145
Number of Residents: 137
Beds Available: 8
Percent Occupancy: 94%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

56

Facility
30

County
27

VA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

56

2017
58

2016
15

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/13/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 6/23/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 6/1/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 6/23/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/1/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/23/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 6/1/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 6/1/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 6/1/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/1/2017
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 6/1/2017
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 6/1/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Potential 3 6/1/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 6/23/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 6/23/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 6/23/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/23/2017
 
Failed To: Provide a tasty and well-balanced diet that meets the nutritional needs of each resident. Pattern : Potential 3 6/1/2017
 

4/21/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 6/5/2016
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 6/5/2016
 
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 6/5/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 6/5/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/5/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/5/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/5/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 6/5/2016
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 6/5/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 6/5/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 6/5/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/5/2016
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 6/5/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 6/5/2016
 
Failed To: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Isolated : Minimal 3 6/5/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 6/5/2016
 
Failed To: Provide or obtain laboratory services only when ordered by the attending physician. Isolated : Minimal 3 6/5/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/5/2016
 

6/18/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 7/24/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/24/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 7/24/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 7/24/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

1/5/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 2/17/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 2/17/2017
 

8/13/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 9/2/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/2/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 9/2/2015
 

6/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 9/2/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/2/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 9/2/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg VA State Avg
Number of Residents 137 119.33 96.74
Registered Nurses 0.58 0.60 0.75
Licensed Practical / Vocational Nurses 0.95 1.02 1.04
Certified Nursing Assistants 2.09 2.16 2.20
Total Staff Hours 3.63 3.78 3.99

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% VA State Avg%
of high risk long-stay residents with pressure ulcers 7 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 77 96 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 62 94 94
of long-stay residents experiencing one or more falls with major injury 6 2 3
of long-stay residents who have depressive symptoms 2 2 2
of long-stay residents who lose too much weight 12 8 7
of long-stay residents who received an antianxiety or hypnotic medication 16 17 23
of long-stay residents who received an antipsychotic medication 17 12 15
of long-stay residents who self-report moderate to severe pain 8 7 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 28 19 20
of long-stay residents whose need for help with daily activities has increased 24 15 16
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 3 3 4
of low risk long-stay residents who lose control of their bowels or bladder 52 57 53
of short-stay residents assessed and appropriately given the pneumococcal vaccine 60 84 85
of short-stay residents who had an outpatient emergency department visit 15 10 12
of short-stay residents who made improvements in function 54 70 69
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 20 12 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 63 83 83
of short-stay residents who were rehospitalized after a nursing home admission 21 19 21
of short-stay residents who were successfully discharged to the community 56 58 56
of short-stay residents with pressure ulcers that are new or worsened 1 0 0