Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurens Care Center during CMS and state inspections, most recent first.
QAA Meeting Attendance Deficiency: The facility failed to ensure all required QAA members attended quarterly meetings. Review of QAPI attendance records showed the required team had not all attended a quarterly meeting since 5/27/25. The DON acknowledged that staff turnover, leadership changes, and the Infection Preventionist being pulled to work as a charge nurse affected attendance. The QAPI plan listed the required participants, including the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director, Activity Director, Social Worker, and Dietary Manager.
Failure to Follow Medication Administration Standards: A CMA administered a nebulizer treatment and handed a resident an inhaler at the same time, allowing the resident to take two puffs immediately without being told to wait until the nebulizer treatment was complete or to wait between puffs. The CMA also did not offer a mouth rinse after the inhaler, despite the manufacturer’s instructions to rinse after use. The DON stated she had no prior knowledge of the action and confirmed the expectation to wait between medications and offer an oral rinse.
Failure to Provide Scheduled Restorative ROM Program: A resident with quadriplegia, depression, bipolar disorder, and CVA had a care plan for restorative ROM and stretching 5-7 times per week, but restorative therapy was missed on multiple occasions. The resident stated therapy was not provided when the restorative aide was off duty, while the restorative aide said floor staff were supposed to complete it. CNAs said they were not aware they were expected to provide the restorative program, and the DON stated staff should complete the same routine when the restorative aide was absent. The facility had no policy for restorative therapy.
Failure to document pneumococcal vaccine screening, education, and consent for 3 residents. Residents with intact cognition had prior pneumococcal immunizations on record, but the chart lacked documentation that they were educated about, offered, or consented to or refused PCV20 or PCV21. The IP stated the facility relied on physicians to track vaccine due dates and had no internal process for managing these immunizations.
A male resident with severe cognitive impairment and a history of inappropriate sexual behaviors was able to inappropriately touch the breasts of two female residents with cognitive impairments on multiple occasions. Despite interventions such as 15-minute checks and environmental modifications, staff were unable to consistently prevent these incidents, resulting in repeated episodes of resident-to-resident sexual abuse.
A resident with multiple diagnoses and no cognitive impairment was not assisted in obtaining medications through the VA pharmacy, despite being eligible and having documentation indicating veteran status. The facility did not complete the necessary steps to transition the resident's medications to the VA, resulting in the resident paying full price for medications. Staff interviews and record review confirmed the process was not completed due to miscommunication and staff turnover.
A facility failed to include a resident's antidepressant medication in their care plan, despite the resident having moderate cognitive impairment and receiving Mirtazapine for failure to thrive. The DON confirmed the omission, and the facility lacked a specific care plan policy, relying on federal regulations instead.
The facility failed to update care plans for two residents with changing needs. A resident with Alzheimer's required assistance with eating, contrary to their care plan stating independence. Another resident, documented as independent, needed limited assistance with eating, which was not reflected in their care plan. The facility did not revise care plans as required by regulations.
A facility failed to document oxygen therapy for a resident with moderate cognitive impairment and pneumonia. The resident was observed using oxygen at 2 liters per minute on several occasions, but the Treatment Administration Record only noted its use once without specifying the amount. The DON confirmed the absence of a policy for as-needed oxygen, relying instead on physician's orders, which should have been documented.
The facility failed to verify that a student CNA became certified and registered after completing the CNA course and taking the written exam. Discrepancies in test results led to the CNA working without proper credentials.
The facility failed to provide timely and correct Medicare Non-Coverage notices to two residents. One resident received the notice two days late, and both residents were given the incorrect SNF ABN form. Staff acknowledged the errors, and the facility lacked a specific policy for administering ABNs.
The facility failed to ensure bed hold notices were signed by the resident or the resident's responsible person when two residents were transferred out of the facility. Both residents' clinical records lacked the required bed hold forms, and the Director of Nursing confirmed the oversight.
The facility failed to use PPE and perform hand hygiene when exchanging water pitchers for residents suspected of having Norovirus. A CNA was observed entering multiple rooms without PPE, handling water pitchers, and not performing hand hygiene, despite the presence of contact isolation signs and PPE supplies. Interviews confirmed the need for contact isolation precautions due to suspected Norovirus.
The facility failed to provide the required 2-hour dependent adult abuse training within six months of hire for two CNAs. Staff D and Staff E completed the training beyond the mandated timeframe, which was confirmed by the Business Office Manager.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. Review of QAPI meeting attendance sign-in sheets from March 2025 through April 2026 showed that all required team members had not attended a quarterly QAA meeting since 5/27/25. During an interview on 4/15/26 at 12:40 PM, the DON acknowledged that not all required team members had attended the QAA meeting quarterly and stated that staff turnover and leadership changes had affected attendance. She also said the Infection Preventionist had sometimes been required to work on the floor as a charge nurse and therefore had not always been able to attend the meetings. The facility’s QAPI Plan, updated 3/1/26, stated the facility would meet monthly to discuss ongoing or new issues in the nursing home, and identified the required participants as the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director at minimum every 3 months, Activity Director, Social Worker, and Dietary Manager.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to provide professional standards of care when a CMA administered medications to a resident with diagnoses of hypertension, heart failure, anxiety, and depression, and a BIMS score of 15 indicating no cognitive impairment. During observation, the CMA administered Ipratropium-Albuterol inhalation solution via nebulizer and handed the resident a Budesonide-Formoterol inhalation aerosol inhaler at the same time. The resident removed the nebulizer mask and immediately inhaled two puffs from the inhaler before returning it to the CMA. The CMA did not instruct the resident to wait until the nebulizer treatment was complete, did not instruct the resident to wait one minute between puffs, and did not offer a mouth rinse after the inhaler was given. The manufacturer’s instructions for the inhaler state to rinse the mouth with water after use to prevent oral thrush, and the facility had no policy related to medication administration. The DON stated she had no prior knowledge of the action and confirmed the expectation was for staff to wait five minutes between administering medications and to offer an oral rinse after the inhaler.
Failure to Provide Scheduled Restorative ROM Program
Penalty
Summary
The facility failed to provide a restorative program for a resident with mobility concerns. Resident #6’s MDS documented diagnoses of quadriplegia, depression, bipolar disorder, and CVA, and the resident had a BIMS score of 15 indicating no cognitive impairment. The care plan, initiated on 9/12/2012, included a restorative rehab program with upper and lower extremity ROM exercises, shoulder pulleys, PROM, theraband exercises, and stretching to be completed 5-7 times per week. During interview, Resident #6 stated the facility was not providing restorative therapy five days a week and said she did not receive therapy when the restorative aide was off duty. Record review for the prior 30 days showed missed restorative therapy on March 20, March 25, March 27, March 30, and April 10. Staff A, the restorative aide, stated she works Monday through Friday except when she works every 3rd weekend as a CMA, and then she is off that Friday and Monday; she said floor aides were to complete restorative therapy using instructions in the EHR. Staff C and Staff D, CNAs, stated they were not aware they were supposed to provide restorative therapy for Resident #6 when the restorative aide was absent, and Staff D said she did not use the as-needed button in the EHR. The DON stated the restorative aide would tell staff when she would be gone so they knew to complete it, and that her expectation was for staff to complete the same routine as the restorative aide. The facility had no policy regarding restorative therapy.
Failure to Document Pneumococcal Vaccine Screening, Education, and Consent
Penalty
Summary
The facility failed to screen for eligibility, offer, provide education, and document consent or refusal for pneumococcal immunizations for 3 of 5 residents reviewed. Resident #6 had a BIMS score of 15 indicating intact cognition, and the record showed the last pneumococcal immunization was PCV13 on 10/5/2015. The clinical record did not document that the resident was educated about, offered, or consented to or refused PCV20 or PCV21. Resident #22 had a BIMS score of 13 indicating intact cognition, and the record showed the last pneumococcal immunization was PPSV23 on 10/15/2017. Resident #27 had a BIMS score of 15 indicating intact cognition, and the record showed the last pneumococcal immunization was PCV13 on 9/26/2017. For both residents, the clinical record did not document education, an offer of pneumococcal vaccination, or consent or refusal for PCV20 or PCV21. The Infection Preventionist stated the facility relied on physicians to track and notify staff when pneumococcal vaccines were due, and there was no internal process for managing these immunizations. The facility policy stated vaccines would be offered per physician order and current CDC or Iowa Department of Public Health recommendations.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically sexual abuse, by not preventing a male resident with a known history of inappropriate sexual behaviors from inappropriately touching two female residents on multiple occasions. The male resident, who had severe cognitive impairment and a history of making sexual comments and advances, was able to access and touch the breasts of two female residents, both of whom also had cognitive impairments. These incidents occurred despite the facility being aware of the male resident's behavioral history and having documented previous similar behaviors. The first female resident had severe cognitive impairment, aphasia, non-Alzheimer's dementia, and a traumatic brain injury. She required assistance with mobility and decision-making. On two separate occasions, the male resident was observed touching her chest, once under her shirt and once over her shirt, in common areas of the facility. In both cases, staff intervened after the inappropriate contact had already occurred. The second female resident, who had moderate cognitive impairment and a history of trauma, was also touched on the breast by the same male resident while being escorted to lunch. The male resident refused to stop when asked by staff and continued the inappropriate contact until physically separated. Despite the male resident's care plan including interventions such as 15-minute checks, increased monitoring, and environmental modifications (e.g., doorbells, closed doors), these measures were not effective in preventing repeated incidents of abuse. Staff interviews revealed inconsistent awareness and implementation of monitoring interventions, and there were lapses in supervision that allowed the male resident to access vulnerable residents. The facility's failure to ensure adequate supervision and effective implementation of interventions resulted in multiple instances of resident-to-resident sexual abuse.
Failure to Facilitate Resident Choice of Pharmacy for VA Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was able to exercise the right to choose a pharmacy, specifically regarding the use of Veterans Administration (VA) pharmacy benefits. The resident, who had no cognitive impairment and diagnoses including diabetes, Alzheimer's disease, anxiety disorder, and agitation, was documented as a veteran eligible for VA medications. Despite this, the facility did not facilitate the process for the resident to receive medications through the VA, resulting in the resident paying full price for multiple medications. Documentation showed that the resident's spouse inquired about VA coverage, and the Social Services Coordinator, Administrator, and Director of Nursing were made aware of the issue. However, the process to obtain VA medications was not completed, and the resident continued to receive medications outside of the VA system. Staff interviews and record reviews revealed that the necessary steps to transition the resident's medications to the VA pharmacy were not followed through, partly due to staff turnover and miscommunication. The Administrator assumed the process was handled after initial paperwork was completed, but later discovered it had not been finalized. The record lacked evidence that the resident was ever successfully enrolled to receive VA medications, and staff confirmed that the resident was not receiving medications through the VA at the time of the review.
Failure to Include Antidepressant in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was receiving psychotropic medication. The resident, identified as having moderate cognitive impairment and an unspecified nutritional deficiency, was prescribed Mirtazapine, an antidepressant, to address failure to thrive. Despite the Care Area Assessment (CAA) indicating that the use of psychotropic medication should be addressed in the care plan to avoid complications and minimize risks, the resident's care plan did not include any mention of the antidepressant use. The Director of Nursing (DON) acknowledged that the Mirtazapine should have been included in the care plan and confirmed that it was missed. The facility did not have a specific policy on care plans but followed the Code of Federal Regulations on comprehensive person-centered care planning. This oversight was identified during a review of the resident's records and through staff interviews, highlighting a deficiency in the facility's care planning process.
Failure to Update Care Plans for Residents with Changing Needs
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and revised after each assessment, as required by regulations. Resident #8, who had Alzheimer's disease and required substantial assistance with eating, was observed being fed by staff on multiple occasions, despite the care plan indicating that the resident ate and drank independently. The Director of Nursing (DON) confirmed that the resident's condition had declined and acknowledged that the care plan should have been updated to reflect the current status. The facility did not have a specific policy on care plans but followed federal regulations, which mandate that care plans be reviewed and revised by the interdisciplinary team after each assessment. Resident #14, diagnosed with non-Alzheimer's dementia, diabetes mellitus, and renal insufficiency, was documented as being independent with eating according to the Minimum Data Set (MDS) and care plan. However, staff documentation over a month-long period indicated that the resident required limited assistance with eating on 27 out of 30 days. This discrepancy between the care plan and the resident's actual needs was not addressed, indicating a failure to update the care plan to reflect the resident's current condition and care requirements.
Failure to Document Oxygen Therapy for Resident
Penalty
Summary
The facility failed to ensure proper documentation for a resident requiring oxygen therapy. Resident #11, who had moderate cognitive impairment and a diagnosis of pneumonia, was observed using oxygen at 2 liters per minute on multiple occasions. However, the Treatment Administration Record (TAR) for March 2025 only documented the use of oxygen on one day without specifying the liters used. The Director of Nursing confirmed that the facility lacked a policy for as-needed oxygen and relied on physician's orders, which should have been documented on the TAR if the resident received oxygen and at what setting.
Failure to Verify CNA Certification and Registration
Penalty
Summary
The facility failed to verify and ensure that a student CNA, Staff G, became certified and registered after completing the CNA course and taking the written exam. Staff G was hired as an environmental aide and later switched to a CNA role after reportedly passing the written exam on the third attempt. However, discrepancies were found between the test results provided by Staff G and those from the college, with the college indicating that Staff G failed all three attempts. Despite this, Staff G was allowed to work full-time as a CNA based on the incorrect test results she provided to the facility. The facility did not have a policy on nurse aide registry checks, which contributed to the oversight. The personnel file for Staff G lacked documentation of her registration on the Iowa Direct Care Worker Registry. The Business Office Manager and the DON were unaware of the discrepancy until they rechecked the registry and found that Staff G was not listed. The college confirmed that Staff G had failed the exam three times, and the document provided by Staff G appeared to have been altered. This failure to verify certification and registration led to Staff G working as a CNA without proper credentials, which was identified during the survey.
Failure to Provide Timely and Correct Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a notice of Medicare Non-coverage 48 hours in advance of services ending for one resident. Specifically, Resident #2, who had intact cognition and required significant assistance with mobility and transfers, was not given the Notice of Medicare Non-Coverage until two days after their skilled nursing facility (SNF) services ended. The social worker completed the notice paperwork late and apologized to the resident, who acknowledged and signed the forms on 10/04/23, despite the services ending on 10/02/23. Additionally, the facility used the incorrect Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) form for both Resident #2 and Resident #6, who also had intact cognition and required assistance with mobility and transfers. Resident #6 signed the incorrect ABN form on 8/29/23, even though their last covered day for SNF level of care was on 9/1/23. Staff interviews confirmed these deficiencies. The social worker acknowledged the errors and the late notice given to Resident #2. The facility administrator admitted that there was no specific policy for administering the Advance Beneficiary Notices (ABNs) and that the facility generally followed CMS regulations, aiming to issue written notifications within 48 hours of discharge from skilled services. The facility reported a census of 30 residents at the time of the survey.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to ensure that bed hold notices were signed by the resident or the resident's responsible person when residents were transferred out of the facility. This deficiency was identified for two residents. Resident #35, who had diagnoses including spinal stenosis, heart failure, and renal insufficiency, was transferred to the hospital for intravenous antibiotics but lacked a bed hold form for the hospital stay. The facility's policy required providing bed hold information upon admission and at the time of temporary absence, but this was not followed in Resident #35's case. Similarly, Resident #4, who had moderately impaired cognition and multiple diagnoses including anemia, hypertension, renal disease, and a stroke, was admitted to the hospital for a urinary tract infection and intravenous therapy. The clinical record for Resident #4 also lacked documentation of a bed hold notice upon discharge to the hospital. The Director of Nursing confirmed that the facility did not complete the required bed hold forms for these residents, indicating a failure to adhere to the facility's policy on bed hold notifications.
Failure to Use PPE and Perform Hand Hygiene During Norovirus Outbreak
Penalty
Summary
The facility failed to use personal protective equipment (PPE) and perform hand hygiene when exchanging water pitchers for residents suspected of having the Norovirus in rooms 208, 209, and 213. Staff A, a Certified Nurses Aide (CNA), was observed entering these rooms without PPE, placing new water pitchers on bedside tables, picking up used water pitchers, and securing them against herself using her forearm. Staff A then placed the used water pitchers on a wheeled cart and proceeded to the next room without performing hand hygiene. This process was repeated for multiple rooms, despite the presence of contact isolation signs and PPE supplies outside the rooms, indicating the requirement for gowns, gloves, and designated equipment for contact isolation. Interviews with the Administrator, a Licensed Practical Nurse (LPN), the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the residents in rooms 208, 209, and 213 required contact isolation precautions due to symptoms of suspected Norovirus, including nausea, vomiting, and diarrhea. The IP reported that test results for Norovirus were pending, and the DON confirmed that staff were expected to follow contact isolation precautions every time they entered the specified rooms. Despite these requirements, Staff A did not adhere to the necessary infection control protocols, leading to a deficiency in the facility's infection prevention and control program.
Failure to Provide Timely Dependent Adult Abuse Training
Penalty
Summary
The facility failed to provide the required 2-hour dependent adult abuse training within six months of hire for two employees, Staff D and Staff E. Staff D, a Certified Nursing Assistant (CNA), was hired on 3-23-23 and completed the training on 11-24-23, which is beyond the six-month requirement. Similarly, Staff E, also a CNA, was hired on 5-15-23 and completed the training on 11-24-23, also exceeding the six-month timeframe. The facility's policy mandates that each employee complete this training within six months of initial employment. This deficiency was verified and acknowledged by Staff F, the Business Office Manager, on 3-20-24.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Laurens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fonda Specialty Care | 17.8 mi | ★★★★★ | 4 | 0 |
| Emmetsburg Care Center | 19.7 mi | ★★★★★ | 10 | 0 |
| Ruthven Community Care Center | 20.1 mi | ★★★★★ | 2 | 0 |
| Palo Alto County Hospital | 20.6 mi | ★★★★★ | 0 | 0 |
| Lakeside Lutheran Home | 20.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.