Cycle 1
Health 2025-09-10 · Fire 2025-09-10
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Galesburg, MI
The Laurels of Galesburg
2-star overall rating with 2-star inspections with $134,023 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1080 N 35th Street, Galesburg, MI
(269) 665-7043
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1989-02-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
84 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,595
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.68% · Performance 24.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.56% · Performance 8.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.71
Baseline 56.34% · Performance 56.70% · Measure score 1.71 · Achievement 1.71 · Improvement 0
Adjusted total nurse staffing
2.91
Baseline 2.98 hours · Performance 3.91 hours · Measure score 2.91 · Achievement 2.91 · Improvement 2.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 4.35% · Lower 95% interval 6.44% |
| Discharge to community | 46.61% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 35.14% · Lower 95% interval 32.3% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 28 · Denominator 30 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 1 · Denominator 30 |
| Discharge self-care score | 52.38% |
53.69%
1.3 pts worse
|
Numerator 11 · Denominator 21 |
| Discharge mobility score | 52.38% |
50.94%
1.4 pts better
|
Numerator 11 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.69% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 16% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 1.67% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 120 |
| Staff flu vaccination coverage | 22% |
42%
20 pts worse
|
Numerator 33 · Denominator 150 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 7 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
1.7
1.9 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.2% |
95.0%
14.8 pts worse
|
93.4%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 83.1% · Q3 78.7% · Q4 70.5% · 4Q avg 80.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
95.0%
0.9 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.1%
3.7 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 8.5% · Q3 8.0% · Q4 5.1% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.5%
1.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.8% · Q3 3.1% · Q4 1.5% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.7% |
19.6%
7.1 pts worse
|
19.6%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 28.3% · Q3 24.6% · Q4 20.9% · 4Q avg 26.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.2% |
16.5%
16.7 pts worse
|
16.7%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 34.9% · Q3 36.4% · Q4 29.6% · 4Q avg 33.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 4.4% |
0.1%
4.3 pts worse
|
0.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 7.0% · Q3 0.0% · Q4 2.6% · 4Q avg 4.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.3% |
13.9%
12.4 pts worse
|
16.3%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 32.6% · Q3 16.4% · Q4 24.2% · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.6% |
11.7%
7.9 pts worse
|
14.9%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 25.9% · Q3 13.8% · Q4 18.0% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.4% · Q3 1.4% · Q4 2.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
20.4%
5.7 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 29.1% · Q3 15.0% · Q4 28.2% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.6%
0.4 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.9% · Q3 5.3% · Q4 2.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
82.8%
0.1 pts worse
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 81.2% · Q3 83.6% · Q4 83.1% · 4Q avg 82.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.5%
4.8 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 8.3% · Expected 13.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.3%
0.8 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 3.3% · Q4 3.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.6% |
79.5%
8.1 pts better
|
79.7%
7.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 43.1% |
24.2%
18.9 pts worse
|
23.9%
19.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 43.1% · Observed 41.7% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
25 health deficiencies
Top issue: Resident Rights (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-07-26 · Fire 2023-07-26
23 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-13
F · Potential for more than minimal harm
2025-09-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-09-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-13
F · Potential for more than minimal harm
2024-09-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-11
F · Potential for more than minimal harm
2023-07-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-07-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-18
Inspection history
Recent health citations
G · Actual harm
2025-09-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-28
F · Potential for more than minimal harm
2025-09-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-13
F · Potential for more than minimal harm
2025-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-10-13
E · Potential for more than minimal harm
2025-09-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-10-13
D · Potential for more than minimal harm
2025-09-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-13
D · Potential for more than minimal harm
2025-09-10
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-10-13
D · Potential for more than minimal harm
2025-09-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-13
D · Potential for more than minimal harm
2025-09-10
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-10-13
D · Potential for more than minimal harm
2025-09-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-13
G · Actual harm
2025-01-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-10
D · Potential for more than minimal harm
2024-12-19
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-09-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-16
G · Actual harm
2024-03-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-10
G · Actual harm
2024-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-10
G · Actual harm
2024-01-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-12
G · Actual harm
2023-07-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-26
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-26
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-05-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-20
Penalties and ownership
What sits behind the stars
$0
2024-12-19
Payment Denial
Payment Denial · denial start 2025-02-20 · 18 days
18 day denial
$77,701
2024-03-21
Fine
Fine · fine $77,701
Fine
$40,729
2024-01-19
Fine
Fine · fine $40,729
Fine
$15,593
2023-07-26
Fine
Fine · fine $15,593
Fine
Ownership
Laurel Health Care Holdings, Inc.
5% Or Greater Direct Ownership Interest · Organization
Ciena Healthcare Management Inc
Operational/Managerial Control · Organization
Di Rezze, Justin
Operational/Managerial Control · Individual
Khan, Anis
Operational/Managerial Control · Individual
Khan, Anis
Corporate Officer · Individual
Laurel Acquisition Holding Corporation
5% Or Greater Indirect Ownership Interest · Organization
Mohammad A Qazi Living Trust Dated 09/26/97
5% Or Greater Indirect Ownership Interest · Organization
Qazi, Mohammad
5% Or Greater Indirect Ownership Interest · Individual
Qazi, Mohammad
Operational/Managerial Control · Individual
Qazi, Mohammad
Corporate Director · Individual
Qazi, Mohammad
Corporate Officer · Individual
Stobb, David
Corporate Officer · Individual
Underly, Chad
Operational/Managerial Control · Individual
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1-star overall rating with 1-star inspections with $69,430 in total fines with 31 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
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2-star overall rating with 2-star inspections with $31,186 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Evergreen Manor Senior Care Center
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4-star overall rating with 4-star inspections with 3 recent health deficiencies
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