Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurels Peak Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with osteoporosis, atrial fibrillation, and mobility needs care-planned to ambulate with a FWW and staff supervision was allowed by a per diem NA to walk in the hallway without the prescribed walker and without the NA maintaining control of the gait belt. The NA reported she had been told to let the resident do what she wanted and, after the resident declined use of the FWW and resisted hands-on assistance, the NA followed behind as the resident walked independently. While turning near the therapy area, the resident mis-stepped on an uneven area of the floor, fell forward, and sustained facial trauma and a brain bleed, later confirmed as a closed facial bone fracture. Interviews and documentation showed that the fall occurred because staff did not adhere to the resident’s care plan and did not consistently use or control the required assistive devices during ambulation.
A resident with moderate cognitive impairment and dementia, who was dependent on staff for daily care, repeatedly refused care and was verbally abusive towards staff over a seven-day period. Despite daily documentation of these behaviors in nursing progress notes, the MDS did not reflect any incidents of care rejection or abuse, and the facility could not provide a policy on MDS completion when asked.
A resident with cognitive deficits and a history of refusing care did not receive a revised, person-centered behavioral care plan or the required psychiatric follow-up after being started on sertraline for anxiety and agitation. The facility failed to document risk versus benefit assessments, conduct a root cause analysis, or identify triggers for the resident's behaviors, resulting in ongoing refusals of hygiene and incontinence care and the eventual discovery of maggots during wound care.
A resident with a history of cancer, atrial fibrillation, and diabetes continued to receive a blood thinner for 11 days after hospital discharge, despite instructions to hold the medication. Nursing staff did not clarify conflicting orders between the hospital's After Visit Summary and the facility's active medication list, resulting in ongoing administration of the anticoagulant and continued hematuria.
The facility failed to implement enhanced barrier precautions (EBP) for two residents during high-contact care activities. One resident with a brain neoplasm and an unstageable wound received peri care without the use of gowns, and another resident with diabetes and pressure ulcers was repositioned without a gown. The Director of Nursing confirmed that EBP should be used during such activities, as per facility policy.
The facility failed to consistently offer evening snacks to residents, affecting those with conditions like diabetes and COPD. Interviews revealed that residents were not offered snacks after dinner, and staff reported inconsistencies in snack availability. Snack bins were often inadequately stocked, and some residents were unaware of their existence. The dietary manager acknowledged budget constraints for snacks, and no facility policy on snacks was provided.
A resident with end-stage renal disease experienced inadequate monitoring and assessment post-dialysis, inconsistent enforcement of fluid restrictions, and lack of communication regarding dialysis refusals. The facility failed to perform necessary post-dialysis assessments, adhere to fluid restriction orders, and notify the provider of treatment refusals, compromising the resident's care.
The facility failed to label insulin pens with opened and expiration dates for three residents and did not provide clear resident identification on an insulin pen for one resident. Additionally, expired eye drop medication was administered to a resident. An LPN acknowledged the potential for medication errors, and the DON confirmed the labeling requirements. Facility policies were not adhered to, resulting in the administration of expired medication.
A resident with venous ulcers experienced inadequate infection control during wound care, as an LPN used scissors and a measuring tape that were placed on the floor without cleaning them. The resident, with a history of diabetes and peripheral vascular disease, required frequent dressing changes due to drainage. The facility's infection preventionist confirmed that items should not be placed on the floor, highlighting a breach in the facility's infection prevention policy.
The facility failed to maintain the kitchen ceiling tiles, tracks, lights, and vents in a clean and sanitary condition, potentially affecting all 51 residents. Observations revealed thick dark fuzzy material and black/brown debris on these components, with no clear responsibility for cleaning them. The dietary manager and director confirmed the need for cleaning or replacement, and no kitchen cleaning policy was provided.
The facility did not post daily nursing staffing information, affecting all residents and visitors. The document was outdated, and the DON confirmed the lapse, noting the previous receptionist responsible for posting had changed roles. No policy existed for posting nursing hours.
A resident with congestive heart failure was not properly monitored for fluid intake, weight gain, and edema as per physician orders. The facility failed to document significant weight changes and edema assessments, and staff did not consistently assist with compression socks. Interviews revealed a lack of communication and documentation, contributing to the deficiency.
Failure to Ensure Safe Ambulation and Adherence to Care Plan Leads to Resident Fall With Facial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff were competent in transferring and walking a resident who required transfer assistance, resulting in a fall with injury. The resident had diagnoses including respiratory failure, atrial fibrillation, osteoporosis, variants of Turner’s syndrome, and disorientation. On admission assessment, the resident had no documented cognitive or communication issues, used a front-wheeled walker (FWW), and required only supervision or partial assistance for transfers, ambulation, and toileting. The resident’s care plan directed staff to follow PT/OT for mobility, provide standby assistance for toileting and transfers with a FWW, and to have the resident ambulate to the bathroom with the FWW while staff remained present to provide encouragement. The care plan also noted mild loss of balance with the ability to recover independently and documented that the resident ambulated more safely with the FWW. On the day of the incident, the resident requested to walk as part of a walking program. According to the facility’s incident report and nursing progress notes, the resident was walking without the walker when she fell forward and struck her face, resulting in visible bruising, a hematoma to the right side of the head, and a nosebleed. The resident was transported to the ED, where she was diagnosed with a closed facial bone fracture and a brain bleed, and remained overnight before returning to the facility. The resident later reported that the nursing assistant had applied a gait belt but did not recall using the walker during the walk, and stated that the assistant was not holding the gait belt when they were walking. The resident described turning a corner and suddenly falling forward, characterizing the event as very traumatic. In a subsequent interview, the per diem nursing assistant reported that she had been told by other staff to let the resident do what she wanted and to stand by and watch. She stated that she found the resident in the bathroom without a walker or gait belt, assisted with toileting, and then allowed the resident to walk from the bathroom to the wheelchair without assistive devices. When the resident requested to walk in the hallway, the assistant offered the FWW with a wheelchair to follow, but the resident declined. The assistant stated she applied a gait belt, but when she attempted to hold it, the resident refused, insisting on walking independently. The assistant then followed behind as the resident walked from her room to the therapy entrance, where the resident mis-stepped at a dip in the floor and fell forward. The nurse manager, involved in the fall review, identified the root cause as the resident’s refusal to use the FWW combined with the assistant allowing the resident to ambulate without the prescribed assistive devices, contrary to the care plan and facility policies requiring use and proper handling of gait belts and assistive devices when indicated.
Failure to Accurately Document Resident Behaviors and Care Rejection in MDS
Penalty
Summary
The facility failed to accurately document a resident's verbal and physical abuse towards staff and repeated rejection of care in the Minimum Data Set (MDS) for one of three residents reviewed. During the seven-day evaluation period, nursing progress notes indicated that the resident, who had moderate cognitive impairment and dementia following a stroke, refused multiple aspects of care daily, including medication, hygiene, and housekeeping, and exhibited yelling at staff. However, the MDS for the same period did not reflect any behaviors or refusals of care. The social worker confirmed that such behaviors should be documented in the MDS, and the facility was unable to provide a policy on MDS completion when requested.
Failure to Revise Behavioral Care Plan and Provide Ordered Psychiatric Follow-Up
Penalty
Summary
A deficiency occurred when the facility failed to develop and revise a person-centered behavioral care plan, document risk versus benefit assessments for care refusals, conduct a root cause analysis, identify triggers for anxiety and agitation, and provide ordered psychiatric follow-up care for a resident with significant cognitive deficits. The resident had a history of refusing care, including bathing, changing soiled clothing and linens, and allowing housekeeping to clean her room. Despite repeated documentation of her refusals and the associated health hazards, the care plan interventions remained unchanged over multiple assessments, and no new strategies were developed to address her ongoing behavioral health needs. The resident was started on sertraline for irritability and anxiety following a psychiatric appointment, with instructions for staff to monitor her response and schedule a follow-up appointment in one month. However, the follow-up appointment was not scheduled as ordered, and this omission was not documented in the care plan. Staff delayed the appointment, hoping to find alternative placement for the resident, despite continued refusals of care and worsening hygiene. The facility was unable to provide documentation of risk versus benefit assessments related to the resident's refusals, and there was no evidence of a root cause analysis or identification of specific triggers for her behaviors. The resident's condition deteriorated, culminating in the discovery of maggots in her skin folds during wound care after ongoing refusals of hygiene and incontinence care. Interviews with staff and family confirmed that the facility had not implemented new interventions or scheduled the required psychiatric follow-up, and that the family had not requested a delay in psychiatric care. The care planning policy required individualized, person-centered interventions, but these were not developed or revised in response to the resident's persistent behavioral health issues.
Failure to Clarify Medication Orders After Hospital Discharge
Penalty
Summary
A deficiency occurred when nursing staff failed to clarify medication orders for a resident with a history of prostate cancer, atrial fibrillation, and diabetes, who was recently hospitalized for gross hematuria. Upon the resident's return from the emergency department, the After Visit Summary (AVS) instructed that the blood thinner rivaroxaban should be stopped, but the medication remained active in the facility's records. The nurse on duty relied on a nurse-to-nurse report stating there were no medication changes and did not seek clarification, resulting in the resident continuing to receive rivaroxaban for 11 days after the hospital had instructed it to be held. Documentation showed that the resident continued to experience blood in the urine during this period, and the facility's monitoring records reflected ongoing hematuria. Interviews with facility staff, including the RN, DON, and MD, confirmed that the order should have been clarified with the hospital, as the AVS instructions conflicted with the active medication list. The facility's policy required medications to be administered only upon written order from an authorized prescriber, but this was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents, R3 and R5, during high-contact care activities. R3, who had a diagnosis of malignant neoplasm of the brain and an unstageable wound, was observed receiving peri care for urine incontinence by nursing assistants (NAs) without the use of gowns, although gloves were worn. The NAs did not perform hand hygiene before changing gloves and their uniforms came into contact with the resident and the bed. Despite R3 being on EBP for a wound, the NAs did not adhere to the facility's policy requiring gowns for high-contact activities. Similarly, R5, who had diabetes, osteomyelitis, and pressure ulcers, was observed being repositioned by an NA without the use of a gown. The NA acknowledged the oversight after exiting the room. The Director of Nursing confirmed that it was expected for EBP to be used during high-contact activities, such as changing briefs and repositioning, as outlined in the facility's policy. The failure to adhere to these precautions was noted during the survey, indicating a lapse in infection prevention and control practices.
Inadequate Provision of Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently offer and provide a nutrient and/or calorie-substantive snack after the dinner meal and before bedtime to all residents, affecting 19 residents who voiced concerns. These residents included individuals with intact cognition and various diagnoses such as diabetes, chronic obstructive pulmonary disease (COPD), epilepsy, hypertension, and congestive heart failure. Interviews with residents revealed that they were not offered snacks after dinner, and some were unsure if they could receive snacks if requested. Observations and interviews with staff indicated that snack bins were available at nurses' stations, but they were often inadequately stocked, containing only a few items like pudding containers. Nursing assistants reported that they would provide snacks if residents asked, but many residents preferred items from vending machines, which required payment. The dietary manager and director acknowledged inconsistencies in offering snacks, particularly to diabetic residents, who should be offered snacks in the evening. During a resident council meeting, 16 residents confirmed they were not offered snacks after dinner. Some residents were unaware of the snack bins, and others noted that the bins usually contained only Jello cups. Diabetic residents specifically mentioned not receiving snacks after dinner, and one resident reported being told by the dietary manager that there was no budget for resident snacks. The facility did not provide a policy on snacks by the end of the survey.
Failure to Monitor Dialysis Care and Communication Lapses
Penalty
Summary
The facility failed to consistently monitor and assess a resident, identified as R99, for potential complications related to dialysis treatment. R99, who has diagnoses including end-stage renal disease, diabetes type 2, and peripheral vascular disease, was observed returning from dialysis in distress, having stopped treatment early due to shortness of breath and leg discomfort. Despite these symptoms, no staff entered R99's room to perform a post-dialysis assessment, which is a critical step in ensuring the resident's safety and well-being. The facility also failed to adhere to fluid restriction orders and monitor daily weights as prescribed. R99 reported inconsistent enforcement of fluid restrictions by staff, leading to confusion and potential health risks. Documentation revealed that fluid intake was not consistently recorded, and daily weights were not performed as ordered, with significant gaps in the records. This lack of adherence to prescribed care plans and orders indicates a systemic issue in the facility's management of R99's dialysis care. Furthermore, the facility did not notify the provider of R99's refusal to attend dialysis sessions or complete treatments, which is a critical communication lapse. Interviews with staff revealed a lack of awareness regarding R99's current care orders, including fluid restrictions and daily weights. The facility's Hemodialysis policy mandates that such refusals and complications be communicated to the resident's care team, yet this protocol was not followed, compromising R99's health management and continuity of care.
Medication Labeling and Expiration Oversight
Penalty
Summary
The facility failed to properly label insulin pens with opened and expiration dates for three residents, and did not provide clear resident identification on an insulin pen for one resident. During an observation of medication storage, it was noted that insulin pens for three residents were missing labels indicating when they were opened and their expiration dates, despite having labels available for this purpose. Additionally, an insulin pen for one resident was only marked with a room number, lacking clear and concise resident identification. This oversight was acknowledged by an LPN, who recognized the potential for medication errors and compromised resident safety. Furthermore, the facility did not dispose of expired eye drop medication for one resident. The expired medication was observed to have been administered after its expiration date, as confirmed by the medication administration record. The director of nursing confirmed that insulin pens should be labeled with resident information, opened date, and expiration date, and that eye drops should be dated upon opening. The facility's policy requires that medications be checked for expiration before administration and that expired medications be removed and destroyed. However, these procedures were not followed, leading to the administration of expired medication.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain a clean field and use clean supplies during wound care treatments for a resident with venous ulcers, leading to a deficiency in infection prevention and control. The resident, who had a history of diabetes type 2, peripheral vascular disease, end-stage renal disease, and cellulitis, required frequent dressing changes due to drainage from her lower extremities. During an observation, an LPN was seen using bandage scissors and a measuring tape that were repeatedly placed on the floor during the dressing change process. The LPN did not clean the scissors after they were placed on the floor or after the wound care was completed, which is against the facility's infection prevention and control policy. The resident had recently been hospitalized for an infection in her lower legs, and she reported that her dressings needed to be changed multiple times per day due to weeping. The LPN confirmed that the scissors and tape measure should not have been placed on the floor and acknowledged the failure to use a clean basin or barrier. The facility's infection preventionist also confirmed that items used during dressing changes should not be placed directly on the floor. The facility's policy emphasizes the importance of identifying potential infections and ensuring staff adhere to proper techniques to prevent infection.
Unsanitary Kitchen Ceiling Conditions
Penalty
Summary
The facility failed to maintain the kitchen ceiling tiles, tracks, lights, and vents in a clean and sanitary condition, which had the potential to affect all 51 residents. During an observation and interview with the dietary manager (DM)-A, it was noted that the kitchen ceiling components were covered with thick dark fuzzy material, and the vents were operational. DM-A was unsure who was responsible for cleaning these areas, suggesting it might be maintenance, but acknowledged that the kitchen staff clean according to a cleaning book that does not include the ceiling. The facility currently lacks a maintenance person, as the previous one left some time ago. Further observations revealed black/brown debris on the light above the meal tray preparation area, with similar debris on the ceiling tiles, tracks, and vents over food preparation areas. The dietary director (DD)-B confirmed the presence of debris and the need for cleaning or replacement of the ceiling components. A request for a policy on kitchen cleaning was made, but none was provided, indicating a lack of documented procedures for maintaining kitchen cleanliness.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the required nursing staffing information was posted daily, which had the potential to affect all 51 residents and visitors. On three consecutive days, the document titled 'Today's Total Nursing Staffing' was found to be outdated, with the last update dated over two months prior. The Director of Nursing (DON) confirmed that the nurse staff posting was not current and acknowledged that the facility was expected to post this information daily. The DON also revealed that the previous receptionist, who was responsible for posting the nursing staffing information, had changed roles, and the facility did not have a policy regarding the posting of nursing hours.
Failure to Monitor Fluid Restriction and Edema
Penalty
Summary
The facility failed to adhere to physician orders for a resident with congestive heart failure, specifically regarding fluid restriction and monitoring of weight gain and edema. The resident had a fluid restriction order of 2000 mL per day, divided between dietary and nursing, and was to be weighed daily with the physician notified of any significant weight gain. However, the resident's weight log showed instances of weight gain that were not reported to the physician, and there were missing entries for fluid consumption, indicating a lack of monitoring. Observations and interviews revealed that the resident experienced 3+ pitting edema, yet there was no documentation of edema assessments or monitoring in the resident's records. The resident reported that staff were often too busy to assist with compression socks, leading him to manage on his own. Nursing staff admitted to not documenting edema findings or consistently monitoring fluid intake, and there was no system in place to evaluate 24-hour fluid intake totals. The facility's policies required changes in a resident's condition to be reported to the physician, but this was not followed in the case of the resident's weight gain and edema. Interviews with staff, including the DON, indicated a lack of communication and documentation regarding the resident's fluid intake and edema, contributing to the deficiency in care.
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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 Mankato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaklawn Care & Rehabilitation Center | 1.6 mi | — | 2 | 0 |
| Pathstone Living | 1.7 mi | — | 25 | 0 |
| Hillcrest Care & Rehabilitation Center | 2 mi | — | 0 | 0 |
| Benedictine Living Community Of St. Peter | 14.4 mi | — | 8 | 0 |
| Whispering Creek | 14.9 mi | — | 0 | 0 |
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