Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Laurels Peak Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with osteoporosis, atrial fibrillation, and mobility needs care-planned to ambulate with a FWW and staff supervision was allowed by a per diem NA to walk in the hallway without the prescribed walker and without the NA maintaining control of the gait belt. The NA reported she had been told to let the resident do what she wanted and, after the resident declined use of the FWW and resisted hands-on assistance, the NA followed behind as the resident walked independently. While turning near the therapy area, the resident mis-stepped on an uneven area of the floor, fell forward, and sustained facial trauma and a brain bleed, later confirmed as a closed facial bone fracture. Interviews and documentation showed that the fall occurred because staff did not adhere to the resident’s care plan and did not consistently use or control the required assistive devices during ambulation.
Failure to Assess and Authorize Bedside Medications: A facility allowed several residents to keep and use meds in their rooms without the required provider orders or SAM assessments. Residents were observed with OTC antacids, topical creams, nystatin powder, and inhalers at bedside or in the room, and interviews confirmed staff were unaware of the medications or that the residents were self-administering them without documentation.
A facility failed to follow infection control practices for multiple residents. A resident’s urinary drainage bag was observed resting on the floor, staff did not wear the required gown while emptying another resident’s catheter bag under EBP, an LPN did not perform hand hygiene between glove changes during wound care for a resident with a pressure ulcer, and a resident’s nebulizer machine and tubing were repeatedly left on the floor. Staff and the DON acknowledged several of these practices were not appropriate.
Detached heater covers were found in multiple resident rooms, with some covers on the floor, some buckled or pulled away from the wall, and others missing or loose with exposed metal edges. A resident with severe cognitive impairment said the cover in her room had been that way for a long time, while another resident with MS said the damaged panel had been present for a long time and maintenance had already looked at it. R5’s room had repeated issues with the heater cover coming off, and staff had used a pillow over the exposed area after the resident’s arm was scratched. The DON, MD, and RDO all acknowledged the problem was ongoing and that several rooms had the same condition.
Failure to process a resident's missing belongings grievance. A resident with intact cognition and diagnoses including DM2, anxiety, OCD, and mood disorder reported missing shirts and socks with sentimental value, but staff did not document the complaint in the grievance log or progress notes. Interviews showed staff handled missing items inconsistently and the facility policy required a grievance form and investigation for all missing valuables.
A resident with an indwelling urinary catheter and CPAP use had an incomplete care plan that did not address CPAP application, cleaning, or refusal, and did not include urinary leg bag or drainage bag care. The resident stated he filled the CPAP reservoir himself, had trouble adjusting the mask, and that his leg bag had not been emptied; staff later emptied 750 mL of urine. Interviews confirmed the care plan and Kardex lacked key instructions, and the DON and care coordinator acknowledged the missing care plan focus areas.
Failure to provide oral care setup as directed by the care plan and MDS. A resident with DM2, protein-calorie malnutrition, cellulitis, and sepsis had intact cognition and needed supervision or touching assistance for oral care, but staff did not consistently offer or set up oral care. The resident said he had his own teeth and had not been helped to brush them since admission, and observation showed toothbrush and toothpaste available but no basin in the room. An NA acknowledged oral care may have been missed, and an LPN and the DON stated the resident should have been assisted with setup for oral care.
Incomplete skin assessment and wound monitoring: A resident with DM, malnutrition, cellulitis, a pilonidal cyst, a stage II PU, and colon CA had multiple wounds that were not fully assessed or measured. Staff documented the coccyx and perianal areas but did not document measurements or wound bed assessments, and an RN said she did not measure the wounds because wound care staff did that. An LPN and the wound care specialist later stated they were unaware of the thigh wound until it was separately evaluated, when it was found to have measurable depth and undermining.
Delayed Scheduling of Vision Services: A resident with impaired vision, diabetes, and CAD requested ophthalmology and audiology appointments, but staff did not timely schedule the eye exam or address the vision issue in the care plan. The resident later reported worsening vision and difficulty reading the TV, and staff interviews confirmed the nurse manager had not attempted to arrange the appointment when first requested.
Improper cleaning and storage of respiratory equipment affected multiple residents receiving CPAP/BiPAP and nebulizer treatments. Equipment was observed left assembled after use with condensation in nebulizer canisters and water remaining in CPAP/BiPAP reservoirs, and one BiPAP mask was found on the floor. Staff and the DON confirmed nebulizers were expected to be rinsed and air-dried after each use and CPAP equipment cleaned, but interviews showed these practices were not consistently followed and some residents had no clear orders or care plan guidance for CPAP maintenance.
Incorrect Meal Service and Failure to Follow Resident Meal Selections: A resident with chronic pain syndrome, edema, liver transplant, and pain was on a low sodium, soft and bite sized diet with meal orders to be taken and alternatives offered. She reported receiving the wrong supper items, being served rice despite a note not to serve rice, and getting chicken nuggets instead of grilled chicken breast. Staff stated they were unaware of the incorrect meal service, and leadership said residents should receive their selected menu items or be offered another choice if unavailable.
A resident with moderate cognitive impairment and dementia, who was dependent on staff for daily care, repeatedly refused care and was verbally abusive towards staff over a seven-day period. Despite daily documentation of these behaviors in nursing progress notes, the MDS did not reflect any incidents of care rejection or abuse, and the facility could not provide a policy on MDS completion when asked.
A resident with cognitive deficits and a history of refusing care did not receive a revised, person-centered behavioral care plan or the required psychiatric follow-up after being started on sertraline for anxiety and agitation. The facility failed to document risk versus benefit assessments, conduct a root cause analysis, or identify triggers for the resident's behaviors, resulting in ongoing refusals of hygiene and incontinence care and the eventual discovery of maggots during wound care.
A resident with a history of cancer, atrial fibrillation, and diabetes continued to receive a blood thinner for 11 days after hospital discharge, despite instructions to hold the medication. Nursing staff did not clarify conflicting orders between the hospital's After Visit Summary and the facility's active medication list, resulting in ongoing administration of the anticoagulant and continued hematuria.
The facility failed to implement enhanced barrier precautions (EBP) for two residents during high-contact care activities. One resident with a brain neoplasm and an unstageable wound received peri care without the use of gowns, and another resident with diabetes and pressure ulcers was repositioned without a gown. The Director of Nursing confirmed that EBP should be used during such activities, as per facility policy.
The facility failed to consistently offer evening snacks to residents, affecting those with conditions like diabetes and COPD. Interviews revealed that residents were not offered snacks after dinner, and staff reported inconsistencies in snack availability. Snack bins were often inadequately stocked, and some residents were unaware of their existence. The dietary manager acknowledged budget constraints for snacks, and no facility policy on snacks was provided.
A resident with end-stage renal disease experienced inadequate monitoring and assessment post-dialysis, inconsistent enforcement of fluid restrictions, and lack of communication regarding dialysis refusals. The facility failed to perform necessary post-dialysis assessments, adhere to fluid restriction orders, and notify the provider of treatment refusals, compromising the resident's care.
The facility failed to label insulin pens with opened and expiration dates for three residents and did not provide clear resident identification on an insulin pen for one resident. Additionally, expired eye drop medication was administered to a resident. An LPN acknowledged the potential for medication errors, and the DON confirmed the labeling requirements. Facility policies were not adhered to, resulting in the administration of expired medication.
A resident with venous ulcers experienced inadequate infection control during wound care, as an LPN used scissors and a measuring tape that were placed on the floor without cleaning them. The resident, with a history of diabetes and peripheral vascular disease, required frequent dressing changes due to drainage. The facility's infection preventionist confirmed that items should not be placed on the floor, highlighting a breach in the facility's infection prevention policy.
The facility failed to maintain the kitchen ceiling tiles, tracks, lights, and vents in a clean and sanitary condition, potentially affecting all 51 residents. Observations revealed thick dark fuzzy material and black/brown debris on these components, with no clear responsibility for cleaning them. The dietary manager and director confirmed the need for cleaning or replacement, and no kitchen cleaning policy was provided.
The facility did not post daily nursing staffing information, affecting all residents and visitors. The document was outdated, and the DON confirmed the lapse, noting the previous receptionist responsible for posting had changed roles. No policy existed for posting nursing hours.
A resident with congestive heart failure was not properly monitored for fluid intake, weight gain, and edema as per physician orders. The facility failed to document significant weight changes and edema assessments, and staff did not consistently assist with compression socks. Interviews revealed a lack of communication and documentation, contributing to the deficiency.
Failure to Ensure Safe Ambulation and Adherence to Care Plan Leads to Resident Fall With Facial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff were competent in transferring and walking a resident who required transfer assistance, resulting in a fall with injury. The resident had diagnoses including respiratory failure, atrial fibrillation, osteoporosis, variants of Turner’s syndrome, and disorientation. On admission assessment, the resident had no documented cognitive or communication issues, used a front-wheeled walker (FWW), and required only supervision or partial assistance for transfers, ambulation, and toileting. The resident’s care plan directed staff to follow PT/OT for mobility, provide standby assistance for toileting and transfers with a FWW, and to have the resident ambulate to the bathroom with the FWW while staff remained present to provide encouragement. The care plan also noted mild loss of balance with the ability to recover independently and documented that the resident ambulated more safely with the FWW. On the day of the incident, the resident requested to walk as part of a walking program. According to the facility’s incident report and nursing progress notes, the resident was walking without the walker when she fell forward and struck her face, resulting in visible bruising, a hematoma to the right side of the head, and a nosebleed. The resident was transported to the ED, where she was diagnosed with a closed facial bone fracture and a brain bleed, and remained overnight before returning to the facility. The resident later reported that the nursing assistant had applied a gait belt but did not recall using the walker during the walk, and stated that the assistant was not holding the gait belt when they were walking. The resident described turning a corner and suddenly falling forward, characterizing the event as very traumatic. In a subsequent interview, the per diem nursing assistant reported that she had been told by other staff to let the resident do what she wanted and to stand by and watch. She stated that she found the resident in the bathroom without a walker or gait belt, assisted with toileting, and then allowed the resident to walk from the bathroom to the wheelchair without assistive devices. When the resident requested to walk in the hallway, the assistant offered the FWW with a wheelchair to follow, but the resident declined. The assistant stated she applied a gait belt, but when she attempted to hold it, the resident refused, insisting on walking independently. The assistant then followed behind as the resident walked from her room to the therapy entrance, where the resident mis-stepped at a dip in the floor and fell forward. The nurse manager, involved in the fall review, identified the root cause as the resident’s refusal to use the FWW combined with the assistant allowing the resident to ambulate without the prescribed assistive devices, contrary to the care plan and facility policies requiring use and proper handling of gait belts and assistive devices when indicated.
Failure to Assess and Authorize Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to assess and determine whether self-administration of medications was clinically appropriate and safe for 5 residents who were observed with medications at bedside or in their rooms. The report states that medications could only be kept at bedside or self-administered if there was a provider order and a completed assessment, but multiple residents had medications present without those requirements being met at the time of observation. One resident with GERD had a bottle of TUMS on an open shelf below the TV and stated he brought them from home and took them on his own. The LPN who served as care coordinator was not aware the TUMS were in the room and verified there was no order, no self-administration assessment, and no care plan for antacid self-administration. The DON later acknowledged the resident should not have had the TUMS without an order and assessment. Another resident had a bottle of calcium carbonate antacid on the bedside table and stated she took it for acid reflux without staff awareness. Staff confirmed there was no provider order to keep medications at bedside or for self-administration, and the DON confirmed there was no self-administration order or assessment. A third resident had multiple topical creams in the bathroom and had been using them since admission; no self-administration assessment, care plan, or provider order was present initially, although an order and assessment were later entered. A fourth resident had nystatin powder on the dresser next to the bed, stated staff were supposed to apply it but did not always do so, and the record did not include a plan of care, orders, or assessments for bedside medications. A fifth resident had two inhalers on the bedside table and stated he had been administering them himself since shortly after admission; the record initially lacked orders, a plan of care, or self-administration assessments for the inhalers, although a later order and assessment were entered. Staff interviews confirmed they were unaware several residents had medications in their rooms without the required orders and assessments.
Infection Control Failures With Catheter Care, EBP, Wound Care, and Nebulizer Equipment
Penalty
Summary
The facility failed to follow infection control practices when a resident with an indwelling urinary catheter had the drainage bag resting on the floor. R38 had diagnoses including neuromuscular dysfunction of the bladder, was dependent on staff for most ADLs, and had orders and a care plan directing staff to follow enhanced barrier precautions for the suprapubic catheter. During multiple observations, R38’s Foley catheter bag was hooked to the side pocket of the recliner with the bottom of the drainage bag resting on the floor. When this was observed with staff, the ADON stated the bag needed to be up off the floor but below bladder level and identified it as an infection control concern. The facility also failed to implement enhanced barrier precautions for another resident with an indwelling urinary catheter. R68 had diagnoses including benign prostatic hyperplasia, intact cognition, and used an electric wheelchair. His orders directed staff to follow EBP every shift for the Foley catheter, and signage outside the room indicated staff must wear gloves and gown for device care, including urinary catheter care. During observation, a NA entered the room to empty the leg bag without donning a gown, wore gloves only, and emptied the urine into a graduate. The NA stated she knew she should have worn a gown as well as gloves because the resident was on EBP, but she was in a hurry. The LPN confirmed staff were expected to wear a PPE gown when emptying the leg bag and stated staff had received training on EBP. The facility further failed to follow proper glove use and hand hygiene during wound care for a resident with a stage 3 pressure ulcer. R5 had moderately impaired cognition, required substantial assistance with transfers, and had wound care orders for the left first MTP area. During the dressing change, the LPN removed gloves, did not perform hand hygiene, retrieved clean gloves from a scrub pocket, used scissors from a scrub pocket, discarded gloves again, returned the scissors to the pocket without disinfecting them, and re-gloved without hand hygiene between glove changes. The LPN stated this was her normal practice and that hand hygiene between glove removal and re-gloving was not a standard part of her dressing change procedure. The DON stated staff were expected to remove gloves, complete hand hygiene, and get new gloves prior to applying the clean dressing. The facility also failed to ensure proper infection control practices for a resident receiving nebulizer treatments. R66 had diagnoses including bronchiolitis obliterans, acute respiratory failure, and COPD, and received continuous oxygen. During observations, the nebulizer machine and tubing were repeatedly seen on the floor next to the bed, with the resident stating that was where staff put it because the only outlet was behind the bed. On one observation, the nebulizer machine sat on the floor while the tubing ran from the machine to the nebulizer cup the resident was using. Staff later stated the nebulizer machine and tubing should not be on the floor because the floor is not clean, and the DON stated she would not expect either to be on the floor and that it is an infection issue.
Detached Heater Covers Left Multiple Resident Rooms in Disrepair
Penalty
Summary
The facility failed to maintain the physical environment in good repair because baseboard heating register covers were detached, loose, buckled, or missing in multiple resident rooms, including R29, R34, R5, R14, R25, R49, and R77. Survey observations and interviews showed exposed heating elements and/or sharp metal edges in these rooms, and the condition was described as an ongoing issue known to staff and management. The report states that the facility did not have a policy or procedure for requesting maintenance and that staff relied on TELS work orders or verbal reports to the maintenance director. R29, whose quarterly MDS indicated severely impaired cognition, bed-bound status, urinary incontinence, edema, and morbid obesity, was observed with the heat register cover on the floor beside the register. R29 stated it had been that way for a long time, that maintenance sometimes put it back on, and that staff sometimes stepped on the cover when coming around the side of her bed. On a later observation, the cover was again on the floor, and R29 stated it looked awful and she wished someone had fixed it. R34, who had multiple sclerosis and intact cognition, was observed with a baseboard heat register panel that had dark scratches, was pulled away from the heat coils, and was buckled. R34 stated it had been that way for a long time and that maintenance had looked at it the day before and said it would be fixed. The maintenance director later observed the condition and stated he was unaware of it, adding that he expected housekeeping staff to report items needing repair. The report also documents that R5 had repeated problems with a heater cover coming off, with exposed metal edges scratching the resident’s arm, and that staff had used a pillow over the heater as a temporary measure. Other residents, including R14, R25, and R49, were identified in the review as having rooms with detached, loose, or missing heater covers, and the regional director of operations observed multiple rooms with the same condition.
Failure to Process Missing Belongings Grievance
Penalty
Summary
The facility failed to follow its grievance process for a resident who reported missing clothing and other belongings. The resident had diagnoses of type 2 diabetes mellitus, obsessive-compulsive disorder, generalized anxiety, and mood disorder, and his MDS assessment identified intact cognition, understanding, and communication with no behaviors. During interview, the resident stated that a couple of shirts with sentimental value were missing after admission, that he had also been missing a couple pairs of labeled socks, and that he repeatedly told multiple staff members but did not receive follow-up or a response. He also stated that no one had offered to replace the missing shirts and that the items were not returned from laundry. Review of the grievance logs did not show a grievance form for the resident's missing clothing, and his progress notes did not include documentation about the missing items. Staff interviews showed inconsistent handling of missing belongings: one TMA stated forms were available at the nurses' station, a NA said she would look in the laundry room and then tell the nurse to complete a missing belongings report, and an LPN stated staff should report missing clothes but that the form was not being used consistently. The DON stated staff should look for missing belongings first and, if not found, complete a grievance form and send it to social services for follow-up. The facility's policy required a grievance form for all missing valuables and stated the employee receiving the report was responsible for initiating the form, with the administrator or designee to investigate and respond within 5 business days.
Incomplete Care Plan for CPAP and Urinary Catheter Care
Penalty
Summary
The facility failed to develop a complete, individualized care plan for a resident with an indwelling urinary catheter and CPAP use. The resident’s records showed diagnoses including pneumonia, obstructive sleep apnea, COPD, and hydronephrosis with ureteral stricture. The quarterly MDS indicated intact cognition, clear speech, independence or supervision with ADLs, non-ambulatory status, and use of an electric wheelchair. Physician orders included changing the foley/suprapubic catheter bag on shower day every Friday and following enhanced barrier precautions every shift for the foley catheter, but the resident’s care plan did not address urinary catheter drainage bag, leg bag, or CPAP machine care and maintenance. The resident’s care plan for sleep apnea contained language directed toward an infant and did not describe how staff were to assist the resident with applying the CPAP at night, how the CPAP should be cleaned and maintained, or what to do when the resident refused to wear it. The care plan also did not identify that the resident used a urinary leg bag or include instructions for emptying, cleaning, or maintaining the leg bag or overnight urinary drainage bag. The Kardex printed on 9/9/25 did not include cares for the urinary catheter or urinary leg bag other than foley catheter output, and the physician orders at the time of survey did not include leg bag or urinary drainage bag monitoring/care, or CPAP use or maintenance. During interviews and observations, the resident stated he had just returned from a four-day hospitalization for pneumonia, used the CPAP himself, and filled the reservoir with distilled water. The CPAP unit, mask cleaner, visible water and condensation in the reservoir, and an undated jug of distilled water were observed in the room. The resident stated the reservoir was never cleaned or rinsed out to his knowledge and that he had never seen his CPAP mask in the SoClean machine. He also stated he did not use the CPAP every night but felt better when he did and had trouble adjusting the mask himself. Later, the resident stated his urinary leg bag was full and had not been emptied, and staff then emptied 750 milliliters of urine from the bag. Nursing staff interviews confirmed that NAs did not have anything to do with the CPAP, while a TMA and the wing care coordinator acknowledged that the resident’s CPAP and leg bag care should have been addressed in the care plan and that the leg bag should be emptied regularly.
Failure to Provide Oral Care Setup as Directed
Penalty
Summary
The facility failed to assist with oral care as directed by the plan of care for one resident who had diagnoses including diabetes mellitus type II, protein-calorie malnutrition, cellulitis of the left lower leg, and sepsis. The resident’s MDS indicated intact cognition, clear speech, and the ability to understand and be understood, with supervision or touching assistance needed for oral care. The care plan identified a self-care deficit related to multiple health care issues and included assistance with bathing, dressing, and personal hygiene. The EMR task record included a personal hygiene tab but no specific oral care category, and the hygiene tab was documented on seven of 14 opportunities with limited to extensive staff assistance. During interview and observation, the resident stated he had his own teeth and had not been offered help brushing them since admission, though he could brush them himself if staff brought the supplies and a basin to spit into. A toothbrush and toothpaste were present unopened on the TV stand, and no basin was seen in the room or bathroom. On observation, the resident was assisted with a bed bath, transferred to a wheelchair, weighed, and returned to the room, but oral care was not set up or offered. The resident again stated no one had offered to set him up for oral care since he had been at the facility for about three weeks. An NA stated she generally sets residents up for oral care but may have been distracted, and later said she had not yet offered oral care that morning. An LPN stated oral care should be offered at least daily to residents who require assistance with set up, another LPN stated the resident should have a basin, toothbrush, and toothpaste available, and the DON stated staff would be expected to assist with set up for oral care if that is what the MDS states.
Incomplete skin assessment and wound monitoring
Penalty
Summary
The facility failed to complete a comprehensive skin assessment and to monitor impaired skin integrity for a resident with multiple wounds. The resident had diagnoses including diabetes mellitus type II, protein-calorie malnutrition, cellulitis of the left lower leg, a pilonidal cyst, a stage II pressure ulcer present on admission, and colon cancer. The resident’s care plan called for daily skin monitoring, weekly skin inspection, wound measurements, and assessment of wounds, with provider notification for changes. Hospital wound documentation from 8/19/25 identified a right posterior thigh wound of unclear etiology, perianal ulcers, and a coccyx cyst, and wound care orders were later written for the pilonidal cyst and perianal/posterior thigh areas. Facility skin assessments documented the coccyx wound and perianal area, but no wound measurements or wound bed assessments were recorded on those forms. During observation, nursing staff provided wound care to the coccyx, perianal area, and thigh area, and the resident stated the thigh area hurt when touched and had bled on occasion. When asked to measure the wounds, an RN stated she did not measure them because wound care staff did that. An LPN later stated she had not been aware of the thigh wound and did not see documentation of it on the skin or wound assessment forms. The wound care specialist and LPN later evaluated the thigh wound and found it measured 0.5 cm x 2.6 cm with a depth of 0.4 cm and undermining from 10 o’clock to 3 o’clock. The wound care specialist stated she had not been aware of the thigh wound until that evaluation and confirmed it was not part of the pilonidal cyst or pressure ulcer area. The DON stated she was not sure where the mix-up came from and did not provide wound assessments or measurements when asked. The facility policy required routine skin inspections, weekly skin inspections by licensed staff, and initiation of skin and wound evaluation when a significant alteration in skin integrity was noted.
Delayed Scheduling of Vision Services
Penalty
Summary
The facility failed to follow up on a resident’s request for vision care and failed to ensure timely scheduling of an eye appointment for R44. R44’s significant change in status MDS assessment indicated he was cognitively intact, had impaired vision, could see large print but not regular print in newspapers/books, did not use corrective lenses, and had diagnoses including diabetes and coronary artery disease. His care plan did not address the vision impairment, and at the care conference and in the hearing/vision form, staff documented that he requested ophthalmology and audiology appointments and that the nurse manager would work on scheduling them. R44 later reported that his vision had gotten worse and that he could not read the words on his TV, stating he had asked for an eye doctor appointment a few months earlier but had not been scheduled. Staff interviews confirmed the delay: the LPN did not recall the care conference details but believed the request had been relayed, the assigned nurse manager stated she had not made any attempt to schedule the appointment before the resident’s follow-up complaint, and the NP stated the facility should have made the eye appointment when requested in July. The DON also stated the appointment would have been expected to be scheduled when the resident raised concerns at the care conference.
Improper Cleaning and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of respiratory equipment, including nebulizers and CPAP/BiPAP devices, for 3 of 4 residents reviewed for respiratory equipment use. The report identified that respiratory devices were left assembled after use, with visible condensation in nebulizer canisters and water remaining in CPAP/BiPAP reservoirs. Equipment was observed on bedside tables and, in one instance, a BiPAP mask was found on the floor with the mask facing downward and touching the floor. R12 had diagnoses including respiratory failure and chronic lung disease, used BiPAP at bedtime, and self-administered nebulizer treatments after staff set up the equipment. The care plan and TAR directed staff to cleanse the BiPAP water chamber, mask, and tubing after use and to set up nebulizer treatments for self-administration. However, observations showed the BiPAP machine with water still in the chamber and the nebulizer fully assembled with condensation in the canister. Later observations showed the nebulizer remained connected and the BiPAP mask and tubing were on the floor. Staff interviews confirmed the nebulizer should have been rinsed and air-dried after use and that the BiPAP reservoir had not been cleaned or emptied that day. R44 had COPD, asthma, respiratory failure, and pneumonia, and received nebulized medications. After a treatment, the nebulizer remained assembled on the bedside table with the canister attached and condensation present. The resident stated some staff rinsed the canister after use and others did not. Nursing staff and the DON stated nebulizer canisters were expected to be rinsed after every use and left to air dry. R68 had diagnoses including pneumonia, OSA, COPD, and BPH, and used both CPAP and nebulizer treatments. The resident stated the CPAP reservoir water had remained in the machine since before hospitalization and had never been emptied, rinsed, or cleaned to his knowledge. Observations also showed the nebulizer chamber attached with condensation after treatments, and staff interviews confirmed there was nothing in the orders or care plan to guide cleaning and maintenance of the CPAP machine and mask.
Incorrect Meal Service and Failure to Follow Resident Meal Selections
Penalty
Summary
The facility failed to serve menu items as listed and planned for one resident who had diagnoses including chronic pain syndrome, edema, liver transplant, and pain. The resident’s care plan called for a low sodium diet, soft and bite sized textures, taking orders at meals, and offering alternatives. Her physician’s order also specified a low sodium diet, thin liquids, and upright positioning for meals. During interview and observation, the resident stated she did not receive the correct supper meal and reported that she frequently received food other than what she requested on her meal selection ticket. She showed a photo of a tray that contained only macaroni and cheese and cocoa, while her ticket showed selections including milk, hamburger on bun, ketchup, macaroni and cheese, ranch dressing, cocoa, and oranges. She stated she had to request missing items and was later brought a dry hamburger on a bun without condiments, which she added to the macaroni and cheese herself. The resident also reported that for a noon meal she requested mashed potatoes instead of rice but received cilantro rice, despite a typed note on her meal ticket indicating she should not be served rice. Later that day, her tray contained chicken nuggets instead of the grilled chicken breast she had selected, along with pasta salad, mandarin oranges, beets, cocoa, and chocolate ice cream. She stated the chicken nuggets were too hard for her and that is why she had requested grilled chicken breast. Staff interviews indicated the cook followed the meal tickets but was unaware the resident had been served incorrect items, and the culinary services director and regional director of operations stated they were unaware of the problem and expected residents to receive their selected menu items or be offered alternatives if items were unavailable. The facility policy stated that if a resident refuses or is unhappy with a meal, staff will create a care plan the resident is satisfied with and food services will offer a variety of foods at each scheduled meal.
Failure to Accurately Document Resident Behaviors and Care Rejection in MDS
Penalty
Summary
The facility failed to accurately document a resident's verbal and physical abuse towards staff and repeated rejection of care in the Minimum Data Set (MDS) for one of three residents reviewed. During the seven-day evaluation period, nursing progress notes indicated that the resident, who had moderate cognitive impairment and dementia following a stroke, refused multiple aspects of care daily, including medication, hygiene, and housekeeping, and exhibited yelling at staff. However, the MDS for the same period did not reflect any behaviors or refusals of care. The social worker confirmed that such behaviors should be documented in the MDS, and the facility was unable to provide a policy on MDS completion when requested.
Failure to Revise Behavioral Care Plan and Provide Ordered Psychiatric Follow-Up
Penalty
Summary
A deficiency occurred when the facility failed to develop and revise a person-centered behavioral care plan, document risk versus benefit assessments for care refusals, conduct a root cause analysis, identify triggers for anxiety and agitation, and provide ordered psychiatric follow-up care for a resident with significant cognitive deficits. The resident had a history of refusing care, including bathing, changing soiled clothing and linens, and allowing housekeeping to clean her room. Despite repeated documentation of her refusals and the associated health hazards, the care plan interventions remained unchanged over multiple assessments, and no new strategies were developed to address her ongoing behavioral health needs. The resident was started on sertraline for irritability and anxiety following a psychiatric appointment, with instructions for staff to monitor her response and schedule a follow-up appointment in one month. However, the follow-up appointment was not scheduled as ordered, and this omission was not documented in the care plan. Staff delayed the appointment, hoping to find alternative placement for the resident, despite continued refusals of care and worsening hygiene. The facility was unable to provide documentation of risk versus benefit assessments related to the resident's refusals, and there was no evidence of a root cause analysis or identification of specific triggers for her behaviors. The resident's condition deteriorated, culminating in the discovery of maggots in her skin folds during wound care after ongoing refusals of hygiene and incontinence care. Interviews with staff and family confirmed that the facility had not implemented new interventions or scheduled the required psychiatric follow-up, and that the family had not requested a delay in psychiatric care. The care planning policy required individualized, person-centered interventions, but these were not developed or revised in response to the resident's persistent behavioral health issues.
Failure to Clarify Medication Orders After Hospital Discharge
Penalty
Summary
A deficiency occurred when nursing staff failed to clarify medication orders for a resident with a history of prostate cancer, atrial fibrillation, and diabetes, who was recently hospitalized for gross hematuria. Upon the resident's return from the emergency department, the After Visit Summary (AVS) instructed that the blood thinner rivaroxaban should be stopped, but the medication remained active in the facility's records. The nurse on duty relied on a nurse-to-nurse report stating there were no medication changes and did not seek clarification, resulting in the resident continuing to receive rivaroxaban for 11 days after the hospital had instructed it to be held. Documentation showed that the resident continued to experience blood in the urine during this period, and the facility's monitoring records reflected ongoing hematuria. Interviews with facility staff, including the RN, DON, and MD, confirmed that the order should have been clarified with the hospital, as the AVS instructions conflicted with the active medication list. The facility's policy required medications to be administered only upon written order from an authorized prescriber, but this was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents, R3 and R5, during high-contact care activities. R3, who had a diagnosis of malignant neoplasm of the brain and an unstageable wound, was observed receiving peri care for urine incontinence by nursing assistants (NAs) without the use of gowns, although gloves were worn. The NAs did not perform hand hygiene before changing gloves and their uniforms came into contact with the resident and the bed. Despite R3 being on EBP for a wound, the NAs did not adhere to the facility's policy requiring gowns for high-contact activities. Similarly, R5, who had diabetes, osteomyelitis, and pressure ulcers, was observed being repositioned by an NA without the use of a gown. The NA acknowledged the oversight after exiting the room. The Director of Nursing confirmed that it was expected for EBP to be used during high-contact activities, such as changing briefs and repositioning, as outlined in the facility's policy. The failure to adhere to these precautions was noted during the survey, indicating a lapse in infection prevention and control practices.
Inadequate Provision of Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently offer and provide a nutrient and/or calorie-substantive snack after the dinner meal and before bedtime to all residents, affecting 19 residents who voiced concerns. These residents included individuals with intact cognition and various diagnoses such as diabetes, chronic obstructive pulmonary disease (COPD), epilepsy, hypertension, and congestive heart failure. Interviews with residents revealed that they were not offered snacks after dinner, and some were unsure if they could receive snacks if requested. Observations and interviews with staff indicated that snack bins were available at nurses' stations, but they were often inadequately stocked, containing only a few items like pudding containers. Nursing assistants reported that they would provide snacks if residents asked, but many residents preferred items from vending machines, which required payment. The dietary manager and director acknowledged inconsistencies in offering snacks, particularly to diabetic residents, who should be offered snacks in the evening. During a resident council meeting, 16 residents confirmed they were not offered snacks after dinner. Some residents were unaware of the snack bins, and others noted that the bins usually contained only Jello cups. Diabetic residents specifically mentioned not receiving snacks after dinner, and one resident reported being told by the dietary manager that there was no budget for resident snacks. The facility did not provide a policy on snacks by the end of the survey.
Failure to Monitor Dialysis Care and Communication Lapses
Penalty
Summary
The facility failed to consistently monitor and assess a resident, identified as R99, for potential complications related to dialysis treatment. R99, who has diagnoses including end-stage renal disease, diabetes type 2, and peripheral vascular disease, was observed returning from dialysis in distress, having stopped treatment early due to shortness of breath and leg discomfort. Despite these symptoms, no staff entered R99's room to perform a post-dialysis assessment, which is a critical step in ensuring the resident's safety and well-being. The facility also failed to adhere to fluid restriction orders and monitor daily weights as prescribed. R99 reported inconsistent enforcement of fluid restrictions by staff, leading to confusion and potential health risks. Documentation revealed that fluid intake was not consistently recorded, and daily weights were not performed as ordered, with significant gaps in the records. This lack of adherence to prescribed care plans and orders indicates a systemic issue in the facility's management of R99's dialysis care. Furthermore, the facility did not notify the provider of R99's refusal to attend dialysis sessions or complete treatments, which is a critical communication lapse. Interviews with staff revealed a lack of awareness regarding R99's current care orders, including fluid restrictions and daily weights. The facility's Hemodialysis policy mandates that such refusals and complications be communicated to the resident's care team, yet this protocol was not followed, compromising R99's health management and continuity of care.
Medication Labeling and Expiration Oversight
Penalty
Summary
The facility failed to properly label insulin pens with opened and expiration dates for three residents, and did not provide clear resident identification on an insulin pen for one resident. During an observation of medication storage, it was noted that insulin pens for three residents were missing labels indicating when they were opened and their expiration dates, despite having labels available for this purpose. Additionally, an insulin pen for one resident was only marked with a room number, lacking clear and concise resident identification. This oversight was acknowledged by an LPN, who recognized the potential for medication errors and compromised resident safety. Furthermore, the facility did not dispose of expired eye drop medication for one resident. The expired medication was observed to have been administered after its expiration date, as confirmed by the medication administration record. The director of nursing confirmed that insulin pens should be labeled with resident information, opened date, and expiration date, and that eye drops should be dated upon opening. The facility's policy requires that medications be checked for expiration before administration and that expired medications be removed and destroyed. However, these procedures were not followed, leading to the administration of expired medication.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain a clean field and use clean supplies during wound care treatments for a resident with venous ulcers, leading to a deficiency in infection prevention and control. The resident, who had a history of diabetes type 2, peripheral vascular disease, end-stage renal disease, and cellulitis, required frequent dressing changes due to drainage from her lower extremities. During an observation, an LPN was seen using bandage scissors and a measuring tape that were repeatedly placed on the floor during the dressing change process. The LPN did not clean the scissors after they were placed on the floor or after the wound care was completed, which is against the facility's infection prevention and control policy. The resident had recently been hospitalized for an infection in her lower legs, and she reported that her dressings needed to be changed multiple times per day due to weeping. The LPN confirmed that the scissors and tape measure should not have been placed on the floor and acknowledged the failure to use a clean basin or barrier. The facility's infection preventionist also confirmed that items used during dressing changes should not be placed directly on the floor. The facility's policy emphasizes the importance of identifying potential infections and ensuring staff adhere to proper techniques to prevent infection.
Unsanitary Kitchen Ceiling Conditions
Penalty
Summary
The facility failed to maintain the kitchen ceiling tiles, tracks, lights, and vents in a clean and sanitary condition, which had the potential to affect all 51 residents. During an observation and interview with the dietary manager (DM)-A, it was noted that the kitchen ceiling components were covered with thick dark fuzzy material, and the vents were operational. DM-A was unsure who was responsible for cleaning these areas, suggesting it might be maintenance, but acknowledged that the kitchen staff clean according to a cleaning book that does not include the ceiling. The facility currently lacks a maintenance person, as the previous one left some time ago. Further observations revealed black/brown debris on the light above the meal tray preparation area, with similar debris on the ceiling tiles, tracks, and vents over food preparation areas. The dietary director (DD)-B confirmed the presence of debris and the need for cleaning or replacement of the ceiling components. A request for a policy on kitchen cleaning was made, but none was provided, indicating a lack of documented procedures for maintaining kitchen cleanliness.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the required nursing staffing information was posted daily, which had the potential to affect all 51 residents and visitors. On three consecutive days, the document titled 'Today's Total Nursing Staffing' was found to be outdated, with the last update dated over two months prior. The Director of Nursing (DON) confirmed that the nurse staff posting was not current and acknowledged that the facility was expected to post this information daily. The DON also revealed that the previous receptionist, who was responsible for posting the nursing staffing information, had changed roles, and the facility did not have a policy regarding the posting of nursing hours.
Failure to Monitor Fluid Restriction and Edema
Penalty
Summary
The facility failed to adhere to physician orders for a resident with congestive heart failure, specifically regarding fluid restriction and monitoring of weight gain and edema. The resident had a fluid restriction order of 2000 mL per day, divided between dietary and nursing, and was to be weighed daily with the physician notified of any significant weight gain. However, the resident's weight log showed instances of weight gain that were not reported to the physician, and there were missing entries for fluid consumption, indicating a lack of monitoring. Observations and interviews revealed that the resident experienced 3+ pitting edema, yet there was no documentation of edema assessments or monitoring in the resident's records. The resident reported that staff were often too busy to assist with compression socks, leading him to manage on his own. Nursing staff admitted to not documenting edema findings or consistently monitoring fluid intake, and there was no system in place to evaluate 24-hour fluid intake totals. The facility's policies required changes in a resident's condition to be reported to the physician, but this was not followed in the case of the resident's weight gain and edema. Interviews with staff, including the DON, indicated a lack of communication and documentation regarding the resident's fluid intake and edema, contributing to the deficiency in care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 74 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mankato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaklawn Care & Rehabilitation Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Pathstone Living | 1.7 mi | ★★★★★ | 25 | 0 |
| Hillcrest Care & Rehabilitation Center | 2 mi | ★★★★★ | 5 | 0 |
| Benedictine Living Community Of St. Peter | 14.4 mi | ★★★★★ | 8 | 0 |
| Whispering Creek | 14.9 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Laurels Peak Care & Rehabilitation Center.
100% money-back within 48 hours.
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.