Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hill Nursing Center during CMS and state inspections, most recent first.
A resident with a Stage 4 sacral pressure ulcer and intact cognition returned from a wound clinic with an order from an NP for wheelchair seat mapping to obtain a new cushion after a prior Roho cushion had been removed. Facility staff documented the order and faxed it to a vendor, but the fax was sent to an incorrect number, and the seat mapping was neither timely ordered nor completed. Follow-up notes showed that when staff later contacted the vendor, the vendor reported not receiving the fax and requested the order again, leading to prolonged delays in scheduling the seat mapping and failure to carry out the physician’s wound care-related order.
The facility failed to follow proper dish sanitation practices, risking foodborne illnesses. The dish machine required a chlorine rinse concentration of 50 ppm, but Staff 26 did not know how to test chemical levels and inaccurately recorded them based on trends. Staff 27 confirmed the log's inaccuracy, and leadership acknowledged the need for consistent testing.
The facility failed to timely report allegations of abuse and altercations involving three residents with cognitive impairments. Incidents involving inappropriate touching and verbal altercations were reported to the State Survey Agency 16 days late, contrary to facility policy. Staff awareness did not translate into prompt reporting, leading to delayed Facility Reported Incident submissions.
A resident with chronic pain was found with two fentanyl patches, indicating a failure to remove the old patch before applying a new one. This error was discovered during a medication error investigation, revealing a lapse in the administration process for pain management.
A resident with dementia and depression was verbally abused by another resident with delusional disorders. Despite staff awareness, the incident was not reported or documented as abuse, and the behavior was dismissed as normal. The facility failed to adhere to its policy to prevent and investigate abuse, placing residents at risk.
A resident developed a new pressure ulcer that was identified by a CNA but not assessed by a nurse until the following day, leading to delayed treatment. Communication lapses among staff contributed to the oversight, as the assigned LPN was not informed, and the wound nurse assessed the ulcer only after being notified the next day.
A resident with atrial fibrillation and high blood pressure received hydralazine despite having systolic blood pressures below the prescribed threshold. The MAR required holding the medication if the systolic pressure was less than 120, but it was administered multiple times with readings below this level. Staff, including an RN and an LPN, acknowledged the error, and the DNS confirmed the failure to follow physician orders.
A resident with a stroke diagnosis and identified dental issues, including likely cavities and broken molars, did not receive necessary dental services. Despite the MDS indicating these issues, the care conference failed to address the need for a dental assessment. Staff interviews revealed that the resident's representative was not contacted to offer dental services, and a dental referral was not made as required.
The facility failed to prevent cross-contamination by storing clean items, including pillows and cushions, on the dirty side of the laundry room. Staff responsible for laundry and housekeeping reported the issue to the maintenance director, but the items remained for about a month. The Assistant Maintenance Director admitted to placing the items there, unaware of the infection control issue. The Administrator and DNS were informed and acknowledged the concern.
The facility failed to thoroughly investigate allegations of abuse and injuries for three residents. A resident with severe cognitive impairment was found with a bruise, but witness statements were not collected from all involved staff. In another case, an alleged inappropriate touching incident was not properly documented, lacking critical details and witness information. The administration acknowledged the failure to conduct comprehensive investigations, placing residents at risk.
The facility failed to follow physician orders and medication protocols for four residents, leading to unmet care needs. A resident with a stroke did not receive bowel care medication as ordered, while another with a history of falls did not have required neuro checks documented after an unwitnessed fall. A hospice patient was given nitroglycerin without notifying hospice, and a resident with chronic pancreatitis did not receive necessary medication due to the facility's failure to obtain it.
Failure to Follow Physician Orders for Wheelchair Seat Mapping for Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for wound care interventions for one cognitively intact resident with a Stage 4 sacral pressure ulcer and a history of stroke. The resident was evaluated in a wound ostomy clinic, where the nurse practitioner documented that the resident’s wound healing had stalled and ordered a wheelchair seat mapping to obtain an appropriate new wheelchair cushion after a previously ordered Roho cushion had been removed from use. The order specified that the facility should schedule the seat mapping appointment, and a progress note documented that the resident returned from wound care with this new order related to the sacral pressure injury. The order was faxed to a vendor the same day. Despite this, subsequent documentation showed that the seat mapping was not timely ordered or completed. Two days after the order, the nurse practitioner confirmed that the seat mapping had still not been ordered or completed. Weeks later, a nurse’s progress note indicated that when staff called the vendor for an update, the vendor reported they needed the order faxed, and a later note documented that the vendor had not received any faxes from the facility. It was confirmed that the facility had faxed the order to an incorrect fax number. Additional information from the DNS indicated that the referral had to be re-faxed months later and that there were ongoing unsuccessful attempts at communication with the vendor, resulting in a significant delay between the original order and the scheduling of the seat mapping appointment. This sequence of events reflects the facility’s failure to ensure timely and accurate coordination and follow-through on the physician’s order for wheelchair seat mapping for the resident’s pressure ulcer management.
Failure to Follow Dish Sanitation Practices
Penalty
Summary
The facility failed to properly follow dish sanitation practices in the kitchen, which placed residents at risk for foodborne illnesses. The dish machine required a chlorine rinse concentration of 50 parts per million to sanitize dishes. However, Staff 26, who was responsible for operating the dish machine, did not know how to test the chemical levels. Despite this, Staff 26 recorded the chemical concentration as adequate on the Dish Machine log for multiple shifts by using the documented trends of other staff, rather than actual testing. Staff 27, the Dietary Manager, acknowledged that the Dish Machine log was inaccurate and that the facility did not verify proper chemical levels during each shift. This was further confirmed by Staff 1, the Administrator, Staff 2, the DNS, and Staff 12, the Regional Director of Clinical Operations, who acknowledged the need for consistent testing of chemical levels using test strips to ensure proper dish sanitation.
Delayed Reporting of Abuse and Altercations
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency in a timely manner for three residents. Resident 7, who had dementia and mild cognitive impairment, was involved in an incident where it was reported that they inappropriately touched another resident. The facility became aware of this allegation on November 24, 2024, but did not report it until December 9, 2024, which was 16 days later. Similarly, Resident 19, who had severe cognitive impairment due to a stroke, was reportedly touched inappropriately by another resident on the same date, and this incident was also reported 16 days late. Staff members involved in these incidents failed to report them promptly, and the facility administrator acknowledged the delay in reporting. Additionally, an altercation occurred between Resident 12, who had dementia and depression, and Resident 20, who had delusional disorders and mild cognitive impairment. Resident 12 reported feeling uncomfortable and intimidated after Resident 20 yelled and cussed at them during dinner. Despite staff being aware of the incident, it was not reported to the administration or the State Survey Agency in a timely manner. The facility's policy required documentation and investigation of such incidents to protect residents, but this was not adhered to, resulting in a delayed Facility Reported Incident submission.
Medication Error in Fentanyl Patch Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically related to the administration of fentanyl patches. A resident, who was admitted with diagnoses including prostate cancer, UTI, and chronic pain, was prescribed a fentanyl transdermal patch to be applied every three days. However, on one occasion, two patches were found on the resident, indicating that the old patch was not removed before the new one was applied. This oversight was discovered when a nurse found two patches on the resident's shoulders, neither of which had dates or signatures. The resident's care plan required staff to monitor pain and medication administration, but the failure to remove the old patch before applying a new one suggests a lapse in following this plan. Interviews with staff confirmed the standard practice of removing the old patch before applying a new one, which was not adhered to in this instance. The incident was identified during a medication error investigation, highlighting a significant lapse in the administration process for pain management in the resident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, as evidenced by an incident involving two residents. Resident 12, who was admitted with dementia and depression, reported feeling uncomfortable and intimidated after Resident 20 yelled and cussed at them during a meal. Resident 20, who had a history of delusional disorders and mild cognitive impairment, exhibited verbal behaviors directed towards others. Despite staff being aware of the incident, it was not reported or documented as an abuse incident, and the behavior was dismissed as normal by some staff members. Multiple staff members, including CNAs and the Dietary Manager, were aware of the verbal altercation but did not take appropriate action to report it as abuse. Staff 21, a CNA, witnessed the incident and reassured Resident 12 that Resident 20's behavior was normal, failing to recognize it as verbal abuse. The facility's administrator acknowledged the deficiency, noting that the perception of Resident 20's behavior as normal needed correction. The lack of proper reporting and intervention placed residents at risk for abuse, as the facility did not adhere to its policy to prevent, identify, and investigate potential abuse instances.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to assess a newly identified pressure ulcer for a resident, which led to a delay in treatment and potential pain. The resident was admitted in March 2025 without any pressure ulcers. On March 18, 2025, during the evening shift, a CNA identified a new open area on the resident's left leg. However, the clinical record did not show that a nurse assessed this new open area on the same day. The following day, a CNA reported a new wound on the resident's heel that required assessment due to leakage. The wound was later assessed as a Stage II pressure ulcer with significant drainage. Staff interviews revealed communication lapses among the staff. The LPN assigned to the resident on March 18 was not informed by the CNA about the new pressure ulcer. Another LPN, who was informed by the CNA, instructed the CNA to notify the assigned LPN after her lunch break, but no follow-up occurred. The wound nurse was unsure of the exact time she was notified on March 19 but assessed and treated the wound once informed. The Director of Nursing Services and a Regional RN confirmed that the pressure ulcer was identified on March 18 but was not assessed or treated until the next day.
Inappropriate Dosing of Blood Pressure Medication
Penalty
Summary
The facility failed to provide appropriate dosing of medications for a resident with atrial fibrillation and high blood pressure. The resident was admitted in March 2025, and the care plan required medications to be administered according to physician orders. The March 2025 Medication Administration Record (MAR) specified that hydralazine should be administered three times daily and held if the systolic blood pressure was less than 120. However, the resident received hydralazine on multiple occasions with systolic blood pressures below 120, including readings of 119, 104, 108, and 115. Staff members, including an RN and an LPN, acknowledged administering the medication outside the prescribed parameters. The Director of Nursing Services confirmed that physician orders were not followed.
Failure to Provide Dental Services for Resident with Identified Dental Issues
Penalty
Summary
The facility failed to provide necessary dental services to a resident who was admitted with a diagnosis of stroke and identified dental issues, including likely cavities and broken molars. The resident's admission Minimum Data Set (MDS) indicated these dental issues, but the subsequent care conference did not address whether the resident or their representative wanted a dental assessment. Observations showed the resident eating without signs of pain, but staff interviews revealed a lack of follow-up on the dental issues. Staff 17 from Social Services admitted not reaching out to the resident's representative to offer dental services, and Staff 15, an LPN Resident Care Manager, acknowledged the dental issues but did not discuss them with the resident's representative. The Director of Nursing Services (DNS) and Regional RN confirmed that the MDS should have triggered a dental referral, which was not made.
Infection Control Deficiency in Laundry Room
Penalty
Summary
The facility failed to ensure that clean items were not stored in contaminated areas, specifically in the laundry room, which posed a risk of cross-contamination to residents. During an observation on March 26, 2025, it was noted that approximately 15 pillows, four uncovered styrofoam cushions, and a triangular wedge were stored on the dirty side of the laundry room. Staff 35, responsible for laundry and housekeeping, stated that these items had been stored there for about a month and had reported her concerns to the maintenance director, but the items were not removed. Staff 36, the Assistant Maintenance Director, confirmed placing the items in the laundry room on the soiled linen side and admitted to being unaware of the infection control issue. On March 28, 2025, the Administrator and Director of Nursing Services were informed of these findings and acknowledged the infection control concern due to potential cross-contamination.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin for three residents. Resident 4, who was admitted with severe cognitive impairment, was observed with a bruise under the left eye. Despite multiple staff members being involved in the resident's care, witness statements were not collected from all CNAs involved. Staff members acknowledged the lack of follow-up and incomplete documentation regarding the incident. The facility's administration confirmed the investigation was neither thorough nor complete. In another incident, the facility failed to conduct a thorough investigation of an alleged inappropriate touching incident involving Residents 7 and 19. The incident report was incomplete, lacking critical details such as the time, location, and witness information. Staff members involved did not follow the facility's abuse protocol, and the administration acknowledged the failure to conduct a comprehensive investigation. These deficiencies placed residents at risk for abuse and demonstrated a lack of adherence to proper investigative procedures.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to physician orders and provide necessary medications for four residents, leading to unmet care needs. Resident 6, who was admitted with a stroke diagnosis, did not receive bowel care medication as per the physician's order after five days without a bowel movement. Despite the protocol requiring administration of specific laxatives and notification of the provider, these steps were not followed, as acknowledged by the Director of Nursing Services. Resident 19, with a history of stroke and falls, experienced an unwitnessed fall on March 11, 2025. The facility's protocol required neuro checks and vital sign monitoring for 72 hours post-fall, but there was no documentation of these checks being completed. Staff members were aware of the protocol, but the Registered Nurse responsible for the fall investigation admitted to not ensuring the completion of the required checks. Resident 25, receiving hospice care for heart failure, was administered nitroglycerin for chest pain without notifying hospice as required by the physician's order. The hospice director confirmed they were not informed of the medication administration. Additionally, Resident 84, diagnosed with chronic pancreatitis, did not receive Zenpep medication due to the facility's failure to obtain it or find an alternative, despite the resident experiencing symptoms like nausea and diarrhea after the medication was discontinued.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grants Pass
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Care Of Rogue Valley | 0.7 mi | ★★★★★ | 2 | 0 |
| Highland House Nursing & Rehabilitation Center | 1.4 mi | ★★★★★ | 17 | 0 |
| Royale Gardens Health & Rehabilitation Center | 1.4 mi | ★★★★★ | 13 | 0 |
| Avamere Health Services Of Rogue Valley | 24.2 mi | ★★★★★ | 0 | 0 |
| Avamere At Three Fountains | 24.6 mi | ★★★★★ | 5 | 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.