Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Laurel Health & Rehabilitation Center during CMS and state inspections, most recent first.
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.
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.
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.
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.
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 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.
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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 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 | — | 0 | 0 |
| Aspen Meadows Health And Rehabilitation Center | 11.5 mi | — | 23 | 0 |
| Yellowstone River Nursing And Rehabilitation | 11.6 mi | — | 6 | 0 |
| Skyline Heights Nursing And Rehabilitation | 12 mi | — | 22 | 1 |
| Billings Rehabilitation And Nursing Llc | 14.7 mi | — | 22 | 0 |
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