Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurel Health & Rehabilitation Center during CMS and state inspections, most recent first.
QAPI system was not used to identify or address performance improvement issues related to grievances, abuse and neglect allegations, bowel and bladder care for dependent residents, and infection control. Staff reported monthly manager meetings were discussion-based, with no data trends, no minutes for the last QAPI meeting, no root-cause analyses, and no performance improvement plans over the past 12 months. Records showed the QAA agenda, abuse/neglect policy, and QAPI plan called for data-driven review and coordination with QAPI.
The facility failed to have an annual QAPI improvement project focused on high-risk or problem-prone areas identified through data collection and analysis. During interview and record review, staff could not provide QAPI meeting minutes, only an agenda and attendance sheet, and stated the QAPI group had not discussed abuse and neglect, grievances, infection control, dental needs, bathing, activities for disabled residents, care planning, or antibiotic stewardship. Staff also stated there were no performance improvement plans for the past 12 months.
Infection control practices were not followed during resident care, linen handling, and storage. A resident on antibiotics for a UTI reported being left wet and said a CNA wiped from back to front; during observed peri-care, staff did not use the required PPE for EBP and did not clean the front peri-area. For another resident, staff changed gloves but did not perform hand hygiene between dirty and clean toileting tasks. Dirty linen was carried unbagged in the hall, clean pillows were stored in the dirty linen room, and multiple clean supplies and room surfaces were found improperly stored or damaged.
Failure to maintain an antibiotic stewardship program was identified when staff reported the IP was unavailable during the survey week and that the facility had no ASP in place. The IP tracked infections but did not review lab results or antibiotic sensitivity data, and no antibiogram or infection audits could be located. A resident was being treated for a facility-acquired E. coli UTI, and the infection line listing showed UTIs made up 40% of the month’s infections.
Multiple residents experienced abuse, neglect, and unaddressed complaints, including a resident who reported that another resident entered her room at night, held her down, attempted to get into bed with her, and yelled at her while she screamed for help without timely staff response, leaving her fearful of further harm. Another resident, dependent on staff for toileting and transfers and with depression and communication deficits, repeatedly expressed fear of her roommate’s loud, hostile behavior and felt staff did not listen to her concerns. Additional residents reported being left wet in bed, having pads added to briefs so CNAs would not have to change them as often, being turned by a single staff member despite a two-person assist requirement, having their heads hit against the wall during care, and being found in the morning soaked in urine from shoulders to shoes in the same clothes as the previous day. Several staff described routinely finding soaked beds, poor peri and oral care, and complaints about missed or improper care, while leadership reported being unaware of these issues and unable to locate related grievances, despite policies requiring immediate reporting and investigation of suspected abuse and neglect.
Resident council concerns were not shown to be acknowledged, investigated, or resolved. During a council meeting, staff did not review prior minutes or follow up on ongoing complaints about missing laundry, cold meals, and delayed call light response. Staff reported only verbal follow-up with departments and no grievance forms were filed for council concerns, while records showed multiple grievances without documented investigation, resolution, or written response.
Grievance complaints were not investigated or resolved. A resident reported multiple complaints about staff behavior, incontinence care, dietary issues, and another resident's toileting needs, but said she received a response to only one grievance and that complaints to nurses and CNAs were not addressed. Record review showed missing grievance forms, no documented investigation or resolution for many complaints, and the facility's grievance process was not followed as required by policy.
Failure to Report Allegations of Abuse and Neglect: The facility did not report allegations of abuse and neglect involving three residents to the State Survey Agency. One resident was fearful of going to her room and said staff left her there, another reported a CNA hit her head on the wall, yelled at her, and left her wet overnight, and a third was found urine-soaked in bed and still in the same clothes from the prior day. Staff described recurring concerns with wet beds, poor peri care, missed oral care, and delayed response to call lights, but these allegations were not escalated as required.
Failure to provide ordered ADL care and scheduled hygiene services: A resident with DM did not receive regular toenail care, while staff said the task should have been done weekly or biweekly but no order was in place. Two residents reported not getting the promised weekly baths, and another resident admitted for end-of-life care was reported to have gone without oral care or a shower on arrival, despite a care plan for twice-weekly bathing and assisted oral hygiene.
Two residents were involved in an alleged abuse incident in which one resident reported that a male resident entered her room at night, held her arms down, tried to get into bed with her, and ignored her prolonged calls for help, after having previously entered her room on other occasions. The resident described being very upset and fearful of further harm. Although facility policy required interviewing the alleged victim, alleged perpetrator, and witnesses, leadership acknowledged they did not initially complete staff or resident interviews and did not treat the event as abuse, even though a CNA later documented finding the male resident in another room, the call light on, the resident yelling for help, and water thrown around the room.
Failure to report and investigate missing resident clothing: A resident reported that several shirts were taken from her closet and others were never returned from laundry, but staff only searched briefly and did not complete the required grievance form. An LPN/staff member stated the missing items should have been reported to management, yet no grievance documentation was found in the facility records.
A resident left the facility with a friend and did not return as expected, then contacted the facility and family reported car trouble. When the resident’s friend later tried to bring her back, an NF told the friend the resident could not return and would need ER evaluation, stating she had been discharged after being gone for three midnights. Staff later stated the resident had not been gone for three midnights, should have been allowed to return, and there was no planned discharge or discharge documents available.
Failure to Provide Written Transfer Notice: The facility did not provide the resident's representative with a written notice explaining the reason for a hospital transfer for a resident sent out for stroke-like symptoms. The rep stated no transfer letter was received, and record review found no documentation of the notice in the resident's EMR.
A resident with PTSD from the Vietnam and Kuwait War reported memories and flashbacks, with loud noises and people walking behind him identified as triggers. He stated staff had not asked about his triggers. Review of the care plan showed behavioral monitoring and guidance not to pressure the resident if he did not want to talk about stress, but it did not address his triggers or interventions.
Failure to Provide Accessible Activities for a Resident With Hearing and Vision Impairments: A resident with highly impaired hearing and impaired vision stated she could not hear or see group activities well enough to participate, so she stopped attending and spent time alone in her room watching TV. Staff reported they visited only about every 2 weeks, had not explored assistive devices or alternative activities such as books on tape, and had not considered additional 1:1 activities due to staffing limits.
Failure to Assist Resident With Hearing Aid Services: A resident who was very hard of hearing reported broken hearing aids and said the facility would not help him get to the VA for repairs. He stated he could not converse with staff or his physician and that there was no social worker available to help with the process. Staff reported social services duties had shifted after an employee quit, and the facility policy included referral and appointment information for hearing and vision services.
Incontinence Care and Peri-Care Deficiencies: Staff failed to provide appropriate toileting hygiene, brief changes, and peri-care for multiple residents with bladder and bowel incontinence. One resident reported being left wet overnight, having a pad placed in her brief instead of being changed, and being on antibiotics for an E. coli UTI; another was found soaked with urine and still in the same clothes from the prior day; a third had poor peri-care with red, inflamed pannus folds. Staff also performed incomplete peri-care and did not use the required PPE for Enhanced-Barrier Precautions.
Failure to provide needed feeding and hydration assistance: A resident with Down syndrome who was dependent for eating and oral care was observed with food retained in the mouth, inadequate intake, and drinks left largely untouched while meals were delivered without staff present to assist. Staff stated the resident was not getting enough food or fluids, had difficulty chewing, and was completely dependent on staff for hydration and nutrition needs, but the care plan did not reflect that level of assistance.
A resident receiving continuous tube feedings had a bag that remained dated from the prior day during repeated observations, with no staff initials on it and spilled formula on the bag and floor. The resident said she was unsure whether new tubing was used daily and had seen staff refill the same bag before. Staff stated tube feed bags and tubing were supposed to be changed every 24 hours and that the bag should be initialed, dated, and timed.
Failure to provide trauma-informed care for a resident with PTSD. A resident with PTSD reported memories and flashbacks from war experiences and said loud noises and people walking behind him were triggers, but staff had not asked about his triggers. His care plan and trauma-informed care assessment only referenced PTSD and the Vietnam War, with no specific triggers or interventions identified.
Medication administration error rate exceeded 5% during observed med passes. An RN/LPN preparing meds for one resident found a B-complex order on the MAR did not match the bottle label for Nephro Vitamins and stated the order was unclear, so the med should not be given. In another med pass, staff gave enteral water flushes and free water for a resident’s G-tube meds in amounts that did not match the MD order, with the nurse noting the syringe markings were hard to see and not recognizing other issues with the amount given.
Failure to Offer Dental Services in a Timely Manner: Two residents with broken and missing teeth were not offered dental services in a timely manner. One resident said no one had asked about dental care and he had difficulty chewing hard foods; another said he had told nursing staff several times that he needed a dentist, had trouble eating certain foods, and had no dental appt scheduled. Care conference records did not document dental referrals or that dental needs were discussed.
Failure to provide a resident’s preferred Jello. A resident with a throat tumor and dysphagia stated Jello was the only food she could eat besides tube feed, but the facility often ran out and never had her preferred strawberry flavor, offering orange instead. Staff said the facility made Jello from scratch, were unaware of residents requesting it for diet or swallowing needs, and the nutrition room had no Jello at the time of observation.
A resident was admitted with a documented amount of cash, but after the resident's death, a significant portion of the cash was reported missing by the family. There was no documentation of the cash's disposition, and the facility's QAPI committee was not notified or involved in reviewing the event or implementing a performance improvement plan to address deficiencies in personal property management.
A cognitively impaired resident was admitted with a large sum of cash, which was documented on the personal belongings inventory. The facility did not address the safekeeping of the cash or educate the resident or representative about the risks. After the resident's death, most of the cash was missing, and records lacked proper reconciliation or documentation of efforts to protect the property.
A resident sustained a humerus fracture after an unwitnessed fall in the bathroom. Although the incident was reported to the State Survey Agency, the facility failed to submit the required investigative findings within the mandated timeframe, with the report being filed one day late due to a lapse in staff responsibilities during a period of administrative transition.
The facility failed to submit mandatory staffing data to CMS for the fourth quarter of fiscal year 2024, resulting in a One Star Staffing Rating. Staff member I mistakenly submitted the data through a state-specific website instead of the federal CMS site. An error in the data submission for July, August, and September 2024 was not corrected in time, and the facility could not provide proof of successful submission before the survey ended.
A facility failed to ensure accurate administration and documentation of controlled substances for residents, involving errors by three nursing staff members. These errors included incorrect dosing and failure to document medications in the controlled substance log book and MAR. The residents involved had conditions requiring controlled substances for pain and anxiety management, but no harm was reported. The nursing staff were terminated following the investigation.
A facility failed to ensure proper infection control practices for a resident on enhanced barrier precautions. A staff member did not change gloves or perform hand hygiene when leaving and returning to the resident's room during enteral feeding. Additionally, no gown was worn, and there was no signage indicating the need for enhanced precautions. Staff were unaware of the PPE requirements, contrary to facility policy.
The facility failed to provide written notification of hospital transfers for three residents. Staff verbally informed residents or their representatives but did not provide the required written documentation. This deficiency was identified through staff interviews and review of residents' records, which showed multiple hospital transfers without written notices.
The facility failed to provide timely bed hold notices to residents or their representatives during hospital transfers. A staff member responsible for bed hold agreements admitted no written documentation was provided. One resident's representative reported never receiving a written notice, while another resident and their representative also did not receive any documentation. A third resident did not recall receiving bed hold information. There was confusion among staff about who was responsible for providing these notices.
QAPI system not used to track and address key quality issues
Penalty
Summary
The facility failed to maintain and use a QAPI system to identify and address performance improvement issues related to grievances, abuse and neglect allegations, bowel and bladder care for dependent residents, and infection control. During interview and record review, staff member A stated the facility met monthly with department managers, but the managers did not bring data to the meetings and the discussions were described as conversation-type meetings focused on ideas to resolve issues rather than trend review. Staff member A stated the QAPI group reviewed customer satisfaction surveys and Quality Measures, but did not have minutes or documentation for the last QAPI meeting and did not have root-cause analyses to review for areas of concern. Staff member A stated the QAPI group had not discussed concerns related to abuse and neglect, grievances, infection control, or antibiotic stewardship, and that the Infection Preventionist discussed concerns without presenting data to evaluate trends. Staff member A also stated the facility did not have any performance improvement plans for the past twelve months. Record review showed an Appendix 4A QAA Committee Agenda and Attendance Sheet dated February 2018 listing seven primary areas of data presentation with 49 specific items, and a facility policy on Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation that included neglect and coordination with QAPI. The facility’s QAPI Plan, updated October 2018, stated that improvement changes and decisions are based on data and measurements rather than opinions and ideas.
QAPI Program Lacked Documented Performance Improvement Activity
Penalty
Summary
The facility failed to have an annual improvement project focused on high risk or problem-prone areas identified through data collection and analysis. During an interview and record review on 1/28/26 at 2:45 p.m., staff member A did not have minutes or other documentation to present for the last QAPI meeting and only had an agenda and attendance sign-in sheet. Staff member A stated that the QAPI group had not discussed concerns related to abuse and neglect, grievances, infection control, dental needs, bathing, activities for disabled residents, care planning, or antibiotic stewardship, and stated the facility did not have any performance improvement plans for the past 12 months. Review of the facility QAPI Plan dated October 2018 stated that the QAA Committee oversees the Center QAPI program and is responsible for identifying areas requiring performance improvement, collecting data, developing and implementing corrective action, and creating monitors to determine and validate whether changes are effective and sustained.
Infection Control Failures During Care, Linen Handling, and Storage
Penalty
Summary
The facility failed to ensure infection control practices were followed during incontinence care for a resident who reported being left wet at night with a pad added to her brief so staff would not have to change her as often. The resident stated she was currently on antibiotics for a urinary tract infection and reported that one CNA wiped from back to front, after which she developed an E. coli urinary tract infection. During an observation, a staff member assisted the resident off the toilet and with peri-care without wearing the appropriate PPE required for Enhanced-Barrier Precautions, then used multiple wipes from behind the resident while she stood up and did not clean the resident’s vaginal or front area. The staff member later stated he could not really reach through from the back because the resident was big, but tried a little. The resident’s care plan reflected she required maximal assist with toileting hygiene, care in pairs, and Enhanced Barrier Precautions for lower extremity wounds when high-contact care was provided. The facility also failed to ensure hand hygiene was performed between dirty and clean tasks during toileting care for another resident. Two staff members brought the resident to her room to toilet her, completed hand hygiene, and put on gloves. One staff member assisted with removing the soiled brief and cleaning the resident from front to back, then stopped and changed gloves without performing hand hygiene. That staff member then assisted the resident with putting on a clean brief and redressing without completing hand hygiene between the dirty and clean tasks, and later stated she forgot to complete hand hygiene before putting on new gloves. Additional infection control concerns were observed in linen handling, storage, and environmental cleanliness. A staff member was observed carrying dirty linen down the hall against her body, unbagged and touching her scrub top. In the laundry area, clean bagged pillows were stored in the dirty linen room on a shelf next to dirty linen bins, and staff stated clean items should not be stored there. In storage areas, boxes of nasal cannulas, trach tubes, lidocaine patches, catheter bags, and ABD pads were found on the floor or too close to the floor, clean towel blankets were uncovered on a shelf near the bathtub, and the nutrition room had a waterlogged counter and damaged linoleum with exposed unfinished flooring and a hole in front of the refrigerator.
Failure to Maintain an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and maintain an antibiotic stewardship program to promote the appropriate use of antibiotics. During interview and record review, staff member P stated the Infection Preventionist was not available during the week of the survey and reported that the facility did not have an antibiotic stewardship program in place. Staff member P also stated the Infection Preventionist tracked infections but did not address specific laboratory results or the sensitivity of the infectious agent to the antibiotic ordered by the physician, and was unable to locate an antibiogram or audits for the infections. Resident #21 was reported to be receiving treatment for a facility-acquired E. coli urinary tract infection. The facility's Line Listing for Infections by Resident, dated 10/1/25, showed that 40 percent of the infections for October were urinary tract infections. The Infection Preventionist job description, updated March 2025, stated that the role directs antibiotic stewardship activities by tracking antibiotic doses, adherence to evidence-based criteria, and reviewing antibiotic resistance patterns. The facility's Antimicrobial Stewardship Program policy, updated March 2018, stated that the Infection Preventionist monitors and supports ASP activities through rounds, audits, review of provider orders, documentation, and available antibiogram, pharmacy reports, and clinical reports, and reviews antibiotic resistance patterns using monthly line listings, center maps, infection control reports, and center antibiograms.
Failure to Protect Residents From Abuse, Neglect, and Inadequate Response to Complaints
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect, and to respond appropriately to allegations and signs of mistreatment. One resident reported that another resident entered her room at night, held her arms down, attempted to get into bed with her, and repeatedly yelled at her while she screamed for help and no staff responded for some time. She stated this resident had previously entered her room on two other occasions and used her toilet. She remained fearful that he might return and potentially harm or sexually assault her, and she believed his room had been moved away from hers, although their rooms remained side by side. Facility documentation from that night showed a CNA returned from break to find the alleged perpetrator in another resident’s room and the victim yelling for help with water all over the room, but facility leadership later could not locate resident interviews about the incident and were unaware of the victim’s ongoing fear and feelings of being unsafe. Another resident expressed fear and distress related to her roommate’s behavior and the environment in their shared room. She cried and begged staff not to take her back to her room, stating she was scared to go in because her roommate wanted everything her way, kept the TV very loud so she could not rest, became angry when she entered the room, and insisted her own needs be the priority. The resident stated she had reported these concerns to CNAs and nurses, but felt no one listened. During an observation when staff brought her to the room for toileting, the roommate yelled, “Now what?!” and became agitated with staff and the resident before growling and returning to bed. The resident’s care plan showed she was dependent for toileting, required a Hoyer lift for transfers, and had hearing impairment, expressive aphasia, and depression, indicating she relied heavily on staff to advocate for and address her concerns. A third resident reported being left wet at night with an additional pad placed in her brief so staff would not have to change her as often. She stated she was on antibiotics for a UTI and believed CNAs were not changing her during the night. She also reported that staff frequently attempted to turn her alone despite her care plan requiring two-person assistance and use of a sit-to-stand, causing pain and resulting in her head being hit against the wall repeatedly during brief changes. She described a night CNA answering her call light, saying she would return, but failing to come back, leaving her to wet herself and her bed, and then later yelling at her for wetting herself and adding a pad to her brief while stating she did not want to change her every two hours. Her care plan and MDS confirmed she required maximal assistance with toileting hygiene, care in pairs, and that she was on antibiotics for a UTI. Another resident was found by a staff member in the morning lying diagonally in bed with his feet dangling off the edge, soaked with urine from his shoes to his shoulders, with urine pooling in the bed and the bed saturated. He was still in the same clothing from the previous day. The staff member reported that earlier staff had tried to get him up but, after he refused, they left him in bed in that condition. The resident had severe cognitive impairment per his BIMS score, required maximal assistance for toileting, dressing, and walking, and was incontinent of bladder and bowel, indicating he was dependent on staff for continence care and repositioning. The staff member stated the resident did not resist care when she later attempted to get him up and clean. Multiple staff interviews described a pattern of neglected care, particularly on the night shift. One nurse reported frequent complaints about resident care being neglected, including improper transfers, residents’ heads being hit on the wall when only one staff member was used instead of two, soaked beds, use of pads in briefs to avoid changing them, unmet food preferences, and medications not given on time. She stated she re-educated CNA staff, many of whom were agency staff, but did not report these concerns to management. Other staff reported commonly finding residents in soaked beds, poor peri care, lack of oral care, and residents complaining about not receiving peri cream or timely brief changes. One staff member specifically noted that one resident was soaked and had inadequate peri care, resulting in red and inflamed skin folds around her pannus. Despite these repeated concerns, facility leadership reported they were unaware of the specific neglect issues for several residents and could not locate grievances or complaints related to them, even though staff stated they had reported issues to nurses or written grievances. Facility policies required immediate reporting, investigation, and protection related to suspected abuse and neglect, but the described events show failures to follow these policies and to protect residents from abuse, neglect, and psychosocial harm.
Resident Council Concerns Were Not Documented as Resolved
Penalty
Summary
The facility failed to provide evidence that it acknowledged and resolved, or attempted to resolve, concerns brought forward by the resident council. During observation of the resident council meeting, staff member C asked the residents how things were going, but did not read the prior meeting minutes or follow up on the previous month’s concerns. Residents in attendance reported ongoing, unresolved issues with missing laundry, meals being served cold, and call lights not being answered in a timely manner. Staff member C stated she had recently been assigned as the resident council’s staff liaison and that she transcribed the meeting minutes and would follow up with departments when residents voiced concerns. She stated the follow-up was verbal only, was not provided in writing, and she did not file a grievance form. She also stated she would follow up with residents at the next monthly meeting to see whether concerns had been resolved. Staff member A stated facility grievance forms were unavailable for a period of time and that 21 grievances from an earlier period had not been investigated. Staff member A also stated she did not know why those grievances had not been investigated or why residents had not received written responses. Review of resident council meeting minutes from January 2025 through January 2026 showed repeated concerns about late medications, long call light times, delayed bathroom assistance, poor food palatability, cold food, missing or incorrect laundry, garbage bins not being emptied, poor room cleaning, limited administration contact, and other care concerns. Review of grievance forms showed no forms from a later period and 21 of 39 grievances lacked documentation of investigation, resolution, or notification of resolution. The posted grievance procedure stated the administrator oversees the grievance process, department managers respond within five business days, and the person with the grievance has the right to a written decision.
Grievance complaints were not investigated or resolved
Penalty
Summary
The facility failed to ensure grievances voiced or submitted by residents were followed up on and resolved for 1 of 34 sampled residents, resident #21. During interview, resident #21 stated she had filed several complaints over the past couple of months regarding staff behavior, positioning during incontinence care, dietary concerns, and an incident in which resident #7 was brought to the dining room without being toileted first and had urinated in her chair several times a week. Resident #21 stated she had only received a response to one grievance and reported that she regularly complained to staff nurses and CNAs about pain caused by the night shift CNA's incontinence care. She also stated she did not attend resident council because nothing gets done when residents complain. Staff interviews and record review showed the grievance process was not followed. Staff member A stated the grievance forms were missing from 10/7/25 through 1/25/26 and that NF4, who was responsible for grievances, no longer worked at the facility. Staff member A stated she did not know why the 21 grievances completed by residents between 6/12/25 and 10/7/25 had not been investigated, resolved with the resident involved, and signed off by her. NF4 stated she received an average of three grievances a week and turned them into staff member A, but she did not know where the grievances were. Review of the facility grievance forms dated 6/12/25 through 1/26/26 showed no grievance forms from 10/8/25 through 1/26/26, and 21 of 39 grievance forms contained resident complaints but no investigation, resolution, or person notified of the resolution. The posted grievance policy identified the Administrator as the grievance official and stated grievances were to be routed to the appropriate department manager, responded to within five business days, and maintained for a minimum of three years.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Survey Agency for three sampled residents. Resident #7 was observed crying while being taken to her room and stated she was scared to go in there, did not want to be taken to her room, and felt depressed because her roommate wanted everything her way and staff left her there. She also stated she had reported her concerns to CNAs and nurses, but nothing was done. The report states that because of the lack of response, she continued to have ongoing fear and psychosocial harm. Resident #21 reported that a CNA hit her head on the wall during two-person assist care, yelled at her, and placed a pad in her brief. She also stated she was often left wet with only a pad added to her brief at night so staff would not have to change her as often, and that on one night a CNA answered her call light, said she would return, and did not come back until after the resident had wet herself and her bed. The resident was on an antibiotic for a urinary tract infection. Staff member M stated resident #21 frequently reported neglect concerns, including not being changed, not being turned or changed with two people, pain during care, head being hit on the wall, pads being placed in her brief, dietary complaints, and delayed response to call lights, but these concerns were not reported to the Administrator as abuse or neglect. Resident #18 was found by staff member M diagonally in bed, with his feet dangling off the bed, urine-soaked from his shoes to his shoulders, his bed urine-soaked, and urine pooling in the bed. He was still dressed in the same clothing from the day before, and staff stated he had been left in that condition after refusing to get up earlier that morning. Staff member M stated it appeared he had been left unattended all night without care, and the neglect concern was reported only to another staff member, not to the Administrator. Additional staff stated they commonly found residents in urine-soaked beds, poor peri care, and missed oral care, and staff member A stated the concerns described for residents #7, #18, and #21 would qualify as allegations that should be reported to the State Survey Agency.
Failure to Provide Ordered ADL Care and Scheduled Hygiene Services
Penalty
Summary
The facility failed to ensure proper ADL care was completed for a resident who was not receiving toenail care, while the resident’s roommate reported receiving toenail clipping twice a week during showers. During observation and interview, the resident stated her toenails had only been clipped once since admission and her feet were notably odorous after her socks and shoes were removed. Staff stated the resident, who had diabetes, should have had toenails clipped biweekly or at least weekly by a nurse, but there was no order in place for the task, and staff identified that the responsibility to obtain or enter the order had not been completed. The resident had been admitted to the facility about three months earlier. The facility also failed to provide showers or baths as expected for three residents. Two residents in the Lilac hallway stated they were not receiving the weekly baths that had been promised, and one resident and a family member stated the only showers the resident received were from hospice once a week. Facility shower schedules showed showers were to be given to the Lilac hallway on Wednesdays and Saturdays, but the residents’ records documented only bed baths or hospice shower entries. For another resident admitted for end-of-life care, a family member reported the resident had not had his teeth brushed or taken a shower since arrival, and the toothbrush remained sealed in its original package. The resident’s care plan called for bathing/showering twice per week and oral hygiene with substantial/maximal assistance, and the shower log showed showers were documented on a weekly basis.
Failure to Fully Investigate Resident-on-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate an allegation of abuse between two residents and to follow its own abuse investigation policy. One resident reported that on the night of 12/28/25, another resident entered her room, held her arms above her head and down, attempted to get into bed with her, and repeatedly yelled, “You know who I am.” She stated she screamed for help for quite some time and no one came. She described trying to defend herself by hitting the other resident, throwing water at him, and wishing she could have used her cane, which was across the room. She also reported that the same resident had previously entered her room on two other occasions and used her toilet before leaving. The resident stated she was scared, upset, and fearful that the other resident would return at night and potentially harm or sexually assault her, and she was not aware that his room remained next door to hers. The facility’s written policy on abuse investigations, updated 10/22, required identification and interviews of involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegations. However, during interviews, facility leadership acknowledged they did not initially have staff or resident interviews for the facility-reported incident involving the two residents. They later located some staff statements, including one from a CNA who documented returning from lunch to find the alleged perpetrator in another resident’s room, the alleged victim’s call light on, and the alleged victim yelling for help, very upset, and reporting that a man had tried to get into bed with her, that she had hit him, yelled for help, and thrown water at him, with water observed all over the room. Staff further stated they did not consider the incident to be abuse at the time, which contributed to the residents’ rooms remaining next to each other and to the lack of a complete investigation consistent with facility policy.
Failure to Report and Investigate Missing Resident Clothing
Penalty
Summary
The facility failed to exercise reasonable care to protect a resident’s personal property from loss or theft for 1 of 34 sampled residents, resident #6. During an interview, resident #6 stated that about six months earlier, two shirts were taken from her clothes closet and five additional shirts were never returned from the facility’s laundry service. She reported the missing items to facility staff, and housekeeping searched for the items for a short period but did not locate them. Resident #6 stated no facility staff followed up with her after the report of the missing clothing. During an interview, staff member A stated that if a resident’s personal belongings were lost or stolen, she would expect the facility to replace the items. She also stated that resident #6’s lost or stolen items should have been reported by staff using a grievance form and submitted to management, but she did not know why the required forms were not completed. Review of the facility grievance forms dated 6/5/25 through 1/25/26 did not show a grievance form for resident #6’s lost or stolen property. The facility’s NOTICE OF THEFT AND LOSS CONTROL POLICY stated that staff who receive a report of a missing item must complete a Grievance Form and forward it to Social Services for investigation and documentation.
Improper discharge and refusal to readmit a resident
Penalty
Summary
The facility failed to permit a resident to remain in the facility and did not provide written notice or a safe discharge plan before refusing the resident’s return. Resident #72 was admitted to the facility and later left the facility at 12:30 p.m. on 12/5/25 with a friend. The resident did not return by midnight, called the facility at 1:40 a.m. and left a voicemail stating her car broke down on the way back from visiting her mother, and the resident’s sister later called to report the resident had car trouble and would likely return the next day. On 12/7/25, the resident’s female friend called the facility to arrange the resident’s return, but NF4 told her the resident could not return and would need to go to the emergency room for evaluation. NF4 stated the resident had been gone for three midnights and had been discharged from the facility, and that the resident would need emergency room screening to determine whether the facility and provider would be willing to readmit her due to noncompliance and elopement. Staff member A later stated she was not aware NF4 had told the resident and family she could not return, stated the resident had not been gone for three midnights and should have been allowed to return, and stated there was no documentation that the hospital care manager received a response to the request for information. Staff member A also stated the discharge was not planned and no discharge documents were available.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of the reason for transfer when resident #35 was transferred to the hospital for stroke-like symptoms. During an interview, NF2 stated she did not receive a written notice of transfer from the facility. Staff member A stated the social services department would have been responsible for sending the written notice for the hospitalization, and that it appeared the letter was not sent because it was not documented in the resident's electronic medical record. Review of resident #35's electronic medical record did not include a transfer notice for the facility-initiated transfer, and when a copy of the transfer notification was requested, no additional documentation was received by the end of the survey.
PTSD Triggers Not Included in Care Plan
Penalty
Summary
The facility failed to ensure that resident #61’s PTSD triggers were included on the care plan. During an interview, the resident stated he had PTSD from the Vietnam and Kuwait War and reported memories and flashbacks from both wars. He said loud noises and people walking behind him could trigger him, including when seated at a restaurant with people moving behind him, and he stated staff had not asked him about his triggers. Review of the care plan, initiated 7/2/25 and revised 1/27/26, showed behavioral monitoring for PTSD and a note that if the resident did not want to talk about stress, staff should not pressure him and should notify nursing or social services for follow-up, but the care plan did not address any triggers or interventions.
Failure to Provide Accessible Activities for a Resident With Hearing and Vision Impairments
Penalty
Summary
The facility failed to ensure that a resident with significant hearing and vision limitations was provided group and individual activities that met her needs and preferences. The resident was observed sitting in her room in a wheelchair, positioned close to a television with the volume turned up very high, while the curtains were closed and the room was dark. During interview, she stated she had tried to participate in activities but could not hear or see them well enough to actively participate, so she stopped attending. She also stated there were no activities for someone who is blind and deaf, and that she did not receive regular visits from activities staff. The resident stated she liked to socialize with others and loved to read before her vision declined, but she now used a pocket talker during the conversation and said it was not effective for group activities. Staff stated they visited her about once every two weeks and had attempted to engage her in group activities, but she did not participate because she could not hear or see during the activities. Staff also stated they had not looked into books on tape, assistive devices, or alternative activities for residents who were hard of hearing and legally blind, and had not considered additional one-to-one activity due to staffing limitations. The resident's MDS reflected highly impaired hearing with absence of useful hearing, impaired vision, and that she was feeling down, depressed, or hopeless.
Failure to Assist Resident With Hearing Aid Services
Penalty
Summary
The facility failed to offer and ensure hearing aids were properly working for resident #63. During observation and interview, the resident was very hard of hearing and stated he wanted his hearing aids fixed. He reported that whenever he requested anything, the facility took a long time to get it fixed. On follow-up interview, the resident stated his hearing aids were broken and the facility would not help him get to the VA to have them repaired. He also stated he was unable to converse with anyone, including healthcare workers and his physician, and that there was no social worker at the facility to help with the process of getting to the VA. The resident had been admitted to the facility on 8/29/25. Staff later stated the social services employee had quit and the social services duties were being handled by two staff members, and one staff member said residents were being asked about hearing, eye, and dental appointments during care conferences. The facility policy stated social services/designee provides referral and appointment information, and a note on the policy referenced care conference evaluation areas for requested referrals including hearing and vision.
Incontinence Care and Peri-Care Deficiencies
Penalty
Summary
The facility failed to ensure incontinent residents received treatment and services to prevent urinary tract infections, avoid skin breakdown, and maintain continence to the degree possible for 3 of 34 sampled residents. Resident #21 stated she was often left wet at night, that staff added a pad to her brief so they would not have to change her as often, and that she was currently on antibiotics for an E. coli UTI because CNAs were not changing her during the night or cleaning her properly. She also stated a night CNA answered her call light and said she would come back but never did, and that she wet herself and her bed. Resident #21 reported that a CNA yelled at her and said, "I don't want to have to change you every two hours," and that she reported this to staff the next morning. During observation, staff member K assisted resident #21 off the toilet and began peri-care without appropriate PPE for Enhanced-Barrier Precautions. Staff member K cleaned only the resident's anus from behind while she stood up, did not clean the vaginal or front peri-area, and then pulled up her brief and pants. When asked about the Enhanced-Barrier Precautions sign, staff member K shrugged and stated he could not really reach through from the back because the resident was big, but he tried a little. Resident #21's care plan reflected she required maximal assist with toileting hygiene, use of a sit-to-stand for transfers, care in pairs, and that she was on an antibiotic for a UTI. Resident #18 was found by staff member M diagonally in bed with his feet dangling off the bed, soaked with urine from his shoes to his shoulders, with urine pooling in the bed, and still dressed in the same clothing from the day before. Resident #18 had a BIMS score of 3 and required maximal assistance for toileting, dressing, and walking, with incontinence of bladder and bowel. Staff members also reported frequently finding residents in soaked beds and poor peri-care, including resident #7 being soaked and having red, inflamed folds around the pannus due to improper peri-care. The facility did not have a policy specific to assisting residents with incontinence care.
Failure to Provide Needed Feeding and Hydration Assistance
Penalty
Summary
The facility failed to offer fluids and nutrition to a dependent resident who was documented as dependent for oral hygiene and eating, had Down syndrome, and had residual food in the mouth after meals. During an observation and interview, a staff member stated the resident was not getting enough fluids or food throughout the day, had not voided the prior day, and staff could not answer questions about the resident’s voiding frequency. The staff member also found food between the resident’s bicuspids and stated the resident did not have the right type of diet for her current ability, noting the food should have been cut up smaller because she was having a hard time chewing. Subsequent observations showed the resident with full cups of apple juice and cranberry juice, then later with the same fluid levels while breakfast was delivered to the bedside without staff present to feed her. Later observations showed minimal intake of the juices and a full cup of water that remained largely unchanged for several hours. A staff member later brought applesauce, Jello, and ice cream and was able to get the resident to eat, and stated the resident was completely dependent on staff for hydration and nutrition needs, that staff needed to communicate well with CNAs, and that the resident probably needed a supplement. The resident’s physician order listed a regular diet with soft and bite-sized texture and thin liquids, but there was no physician order to feed the resident, and the care plan did not show that she was completely dependent on staff and required feeding and hydration assistance during meals.
Tube feed bag not changed every 24 hours
Penalty
Summary
The facility failed to ensure tube feed bags were changed every 24 hours for resident #11, who was receiving continuous tube feedings. During an observation on 1/27/26 at 9:46 a.m., the resident’s continuous tube feed bag was dated 1/26/26 and had no staff initials on it. During another observation on 1/28/26 at 8:12 a.m. and interview at 10:17 a.m., the tube feed bag was still dated 1/26/26, with spilled tube feed formula on the outside of the bag and a significant amount spilled on the floor. The resident stated she did not know if new tubing was used every day, but said she had seen staff refill the same bag before. Staff member L stated on 1/28/26 at 8:15 a.m. that tube feed bags were changed every 24 hours, and staff member U stated on 1/29/26 at 7:40 a.m. that tube feed bags and tubing needed to be changed every 24 hours and that staff initialed, dated, and timed the bag.
Failure to Provide Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
The facility failed to ensure a resident with PTSD received trauma-informed care that accounted for his experiences and preferences to help identify and mitigate triggers that could cause re-traumatization. Resident #61 had diagnoses including PTSD and stated he experienced memories and flashbacks from the Vietnam and Kuwait Wars, with triggers such as loud noises and people walking behind him. He also stated that no staff members had asked him about his triggers, although he felt that knowing them was important for staff to know. The resident’s care plan, initiated 7/2/25 and revised 1/27/26, noted PTSD from the Vietnam War and included only that if the resident did not want to talk about the stress he was feeling, staff should not pressure him; no other triggers or interventions were identified. The Trauma Informed Care Assessment also identified PTSD but provided only general references to the Vietnam War without specifics about what caused anxiety, worry, or flashbacks, and it did not include interventions. The facility policy on trauma-informed care stated that assessment results should support care and that the care plan should be updated with goals and interventions.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
Medication administration error rate exceeded 5% during 2 of 26 observed medication administrations, with an observed error rate of 7.41%. During an observation on 1/27/26, staff member S prepared morning medications for resident #74 and compared the MAR to the medication bottle labeled Nephro Vitamins. The contents listed on the bottle did not match the MAR, which showed Nephro-Vite Oral Tablet 0.8 MG (B-Complex w/C & Folic Acid). Staff member S hesitated, stated the medication on the bottle and the MAR were different, and after clarification with the DON stated the order was not clear and the medication should not be given. During an observation on 1/28/26, staff member L prepared aspirin, Tylenol, losartan, omeprazole, Miralax, and Nutren 1.5 enteral tube feed for resident #25 and administered water through the G-tube in amounts that did not follow the physician's orders. Staff member L gave multiple flushes and free water amounts, including 122 cc of water between medications and 100 cc of free water, while the order required water flushes totaling 245 cc and 5-10 cc H2O between each medication. The total amount given during the medication administration was 222 cc of water, compared with the 355 cc ordered. Staff member L stated it was hard to see the syringe markings and said the resident could have extra water because he was allowed to drink orally, and did not identify other issues with giving too much or too little water in the G-tube.
Failure to Offer Dental Services in a Timely Manner
Penalty
Summary
The facility failed to ensure dental services were offered in a timely manner for 2 residents. Resident #4 stated during observation and interview that he would like to see a dentist if that option was available and said no one had asked him about dental care since he had been at the facility. He had broken and missing teeth and blackened areas on his front teeth, and he reported avoiding hard foods because they hurt when he tried to chew them. A facility document noted that on 1/29/26 he did not want a dental appointment at that time, and his care conference record dated 1/4/26 listed referrals or recommendations for several services but did not mention whether dental needs were asked about at the care conference. During interview, NF8 stated the resident would benefit greatly from going to the dentist, that finances were a concern, and that staff did not ask him about going to the dentist at the last care conference. Resident #57 was observed lying on his bed and stated he had broken and missing teeth in the bottom of his mouth. He moved his tongue along the inside of his cheek during the interview and said it was difficult to eat certain foods. He stated it had been some time since he had been to the dentist and that he had told nursing staff several times, but nothing was done. Staff member Q stated resident concerns should be reported to the nurse on shift and then to management, and staff member B stated the resident had no dental appointments scheduled, though one would be scheduled that day. The resident’s care conference record listed no referrals or recommendations for dental services, his dental visit record showed his last dental appointment was 1/13/25, and his care plan included coordinating dental care and monitoring for oral/dental problems.
Failure to Provide Resident’s Preferred Jello
Penalty
Summary
The facility failed to provide a resident’s preferred Jello to one resident out of 34 sampled residents. During an interview, the resident stated the facility would often run out of Jello and that strawberry Jello was her favorite, but it was never available to her; she reported that when Jello was available, it was always orange. The resident also stated she had a tumor in her throat that would not allow her to swallow other foods and that Jello was the most important thing she could eat besides her continuous tube feed. Staff stated the facility had several Jello flavors, including cherry, lime, orange, and strawberry, but that it was made from scratch because it was less expensive than individual cups. Staff also stated they were unaware of any residents requesting Jello specifically because of diet or swallowing difficulty. During observation, the nutrition room refrigerator had no Jello present, and staff stated Jello was only in the nutrition room about 50% of the time. Review of the resident’s physician order showed a regular diet with soft and bite-sized texture, thin liquids, and ice chips/small bites as desired for comfort related to dysphagia.
Failure to Track and Safeguard Resident Personal Belongings Through QAPI
Penalty
Summary
The facility failed to identify and correct a deficiency related to the management and tracking of residents' personal belongings, specifically cash, through its QAPI process. A resident was admitted with $891.00 in cash documented at admission, but there was no further documentation regarding the disposition of the cash until the resident's spouse reported approximately $800 missing after the resident's death. The facility-reported event was submitted to the State Survey Agency, but there was no evidence that the QAPI committee was notified or that the event was reviewed as part of the facility's quality assurance process. Interviews with staff revealed that the previous administrator, who would have been responsible for reporting and tracking the event, was no longer employed, and the new administrator was unavailable. Staff confirmed that there was no documentation showing QAPI awareness or any performance improvement plan in progress to address the system failure in managing residents' personal property. The lack of QAPI involvement and absence of corrective action placed all residents at increased risk for loss or theft of personal belongings.
Failure to Safeguard Cognitively Impaired Resident's Property
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a cognitively impaired resident's property, resulting in the loss of a significant sum of money. Upon admission, the resident was documented as having $891.00 in cash, which was included on the personal belongings inventory. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 9, was not asked to address the safekeeping of the cash, nor was there documentation that the facility educated the resident or their representative about the risks of keeping such a large amount of money in their possession. After the resident's death, only $58.00 was returned to the resident's spouse, with $833.00 unaccounted for. The facility's records, including the personal belongings inventory and the record of death, lacked proper reconciliation and signatures to confirm the status of the resident's property at discharge. Staff interviews confirmed that a resident with this level of cognitive impairment would not be expected to make sound decisions regarding their belongings. There was no evidence in the nursing, social service, or activity progress notes that the facility took steps to safeguard the cash or to document any interventions related to the resident's property. The facility did not reconcile the admission inventory list upon the resident's death, nor did it document any attempts to keep the belongings safe. Additionally, the facility failed to address this system failure through its QAPI process.
Late Submission of Investigative Findings for Reportable Incident
Penalty
Summary
Facility staff failed to report the investigative findings of a reportable incident involving a resident who experienced an unwitnessed fall in the bathroom, resulting in a humerus fracture. The incident was initially reported to the State Survey Agency, but the required investigative findings were not submitted within the mandated five working days. The findings were ultimately reported one day after the submission deadline. Staff interviews revealed that the responsibility for submitting reportable incidents had shifted between staff members due to administrative changes, and the staff member responsible at the time was aware of the delay but could not recall the reason for it. Documentation confirmed that the delay in reporting was recognized internally, and the staff member responsible had reported the issue to the QAPI committee. The deficiency was identified through review of facility records, interviews with staff, and examination of the timeline of incident reporting. The report specifically notes that the late submission of investigative findings was limited to this incident, with no additional late reports identified during a retrospective audit.
Failure to Submit Mandatory Staffing Data to CMS
Penalty
Summary
The facility failed to submit the mandatory staffing information for the fourth quarter of the federal fiscal year 2024, as required by the Centers for Medicare and Medicaid Services (CMS). The CMS report titled 'PBJ Staffing Data Report' indicated that the facility triggered a failure to submit data for the quarter, resulting in a One Star Staffing Rating. During the entrance conference, the facility was informed of this deficiency. Staff member B attempted to provide copies of the staffing reports, which were submitted by staff member I. However, it was discovered that staff member I had submitted the staffing data through a Montana state-specific website, not the federal website established by CMS for reporting mandatory staffing data. Further investigation revealed that the facility had submitted staffing data monthly to the Montana Department of Public Health and Human Services (DPHHS), which was used for state activities and had no known affiliation with CMS. Staff members A and B contacted a corporate representative to clarify the responsibility for submitting the required CMS staffing data. It was explained that there had been an error with the data submission for July, August, and September 2024, and the error was not corrected in time to meet the deadline. The facility was unable to provide proof of successful submission of the staffing data to CMS for the specified quarter before the end of the survey.
Controlled Substance Documentation and Administration Errors
Penalty
Summary
The facility failed to ensure the accurate administration, accounting, and documentation of controlled substance medications for four residents. The investigation revealed that three licensed nursing staff members, identified as NF4, NF5, and NF6, were responsible for multiple medication errors. These errors included administering incorrect doses of morphine, hydromorphone, and oxycodone, as well as failing to document the administration of lorazepam and other controlled substances in the controlled substance log book and the Medication Administration Record (MAR). The residents involved had various medical conditions requiring controlled substances for pain management and anxiety. Resident #38 had Huntington's chorea with anxiety, Resident #24 had dementia with chronic pain, Resident #109 had undergone right foot surgery with osteomyelitis, and Resident #27 had chronic pain and neuropathy. The failure to correctly administer and document medications increased the risk of deterioration in their medical conditions, although no physical or psychosocial harm was observed or reported. The investigation also highlighted discrepancies in the documentation practices of the nursing staff. NF5 and NF4 had numerous instances where medications were documented in one record but not the other, and NF6 was found to have pre-filled documentation for peers. Despite being educated on medication administration and documentation, the nursing staff did not adhere to the facility's policies and professional standards, leading to their termination and notification to the Montana State Board of Nursing.
Inadequate Infection Control Practices for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the care of a resident on enhanced barrier precautions. During an observation, a staff member was seen training a new nurse on medication administration via enteral feeding for a resident. The staff member wore gloves into the resident's room but did not change them or perform hand hygiene when leaving the room to gather supplies, nor upon returning. Additionally, the staff member did not wear a gown while starting the tube feeding, which is required under enhanced barrier precautions for residents with indwelling medical devices such as feeding tubes. Further observations revealed that there was no signage indicating enhanced barrier precautions outside the resident's room. A staff member admitted to not being aware of the additional PPE required for such precautions, and another staff member suggested the signage might have been removed by a roommate. The facility's policy on enhanced barrier precautions clearly states the need for gown and gloves during high-contact activities and emphasizes hand hygiene before and after patient contact, which was not adhered to in this instance.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for facility-initiated transfers to the hospital for three residents. Staff interviews revealed that the nursing staff verbally informed residents or their representatives about the transfer, but did not provide written documentation as required. Staff member D was unaware of the requirement to provide written notification, and staff member E confirmed that no paperwork was completed or provided to the residents or their representatives. Resident #7 was transferred to the hospital for an acute change in medical condition, but the facility document only indicated verbal notification without specifying who was informed. Resident #37 reported being hospitalized multiple times in the past year without receiving any paperwork regarding the reasons for the transfers. The electronic health record (EHR) for resident #37 showed several hospital transfers, but lacked documentation of written notices. Similarly, resident #111 was hospitalized in late November 2024 and did not recall receiving any paperwork. Staff member B stated that the floor nurse was responsible for providing written notice, but this was not done. The deficiency highlights a lack of compliance with the requirement to provide written notification of transfers to residents and their representatives.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide the required bed hold notice to residents or their representatives in a timely manner during transfers to the hospital. This deficiency was identified for three residents out of a sample of eighteen. Staff member D, who was responsible for completing bed hold agreements, admitted that no written documentation was provided to the residents or their representatives. Staff member E indicated that the social services department was responsible for completing the bed hold agreement, suggesting a lack of clarity in the process. Resident #7 was transferred to the hospital for an acute change in medical condition, but their representative, NF2, reported never receiving any written bed hold notice. Similarly, resident #37, who had been hospitalized multiple times, and their representative, NF1, also did not receive any documentation regarding bed hold information. Resident #111, hospitalized in late November, did not recall receiving any bed hold information either. Staff member B stated that nursing was supposed to give the resident bed hold notice paperwork, but was unaware that staff member D was not providing copies of the bed hold notice information.
What surveyors are citing around you — mapped
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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 156 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Laurel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St John's Lutheran Home | 11.1 mi | ★★★★★ | 7 | 0 |
| Aspen Meadows Health And Rehabilitation Center | 11.5 mi | ★★★★★ | 23 | 0 |
| Yellowstone River Nursing And Rehabilitation | 11.6 mi | ★★★★★ | 12 | 0 |
| Skyline Heights Nursing And Rehabilitation | 12 mi | ★★★★★ | 22 | 1 |
| Billings Rehabilitation And Nursing Llc | 14.7 mi | ★★★★★ | 27 | 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 August 2026) and official state health department websites.