Federal inspectors found Layhill Nursing and Rehabilitation Center systematically failed to report abuse allegations within required timeframes, sometimes delaying notifications to state regulators for months while accused employees continued caring for residents.
The facility violated reporting requirements in five of 27 abuse cases reviewed during a June 2024 complaint inspection. Staff were supposed to notify the state within two hours of any allegation. Instead, some incidents went unreported for nearly two months.
In one case from September 2023, a family member emailed facility leaders about an incident involving their relative, writing "It's been several days since my initial call to you about this incident." The facility didn't report the allegation to state regulators until the same day they received the email — five days after the alleged abuse occurred.
The Director of Nursing acknowledged the email showed the facility knew about the allegation before they reported it, but couldn't provide additional information about the family's initial complaint.
A December 2022 incident involving the photographing allegation wasn't reported to state regulators until 7 hours and 33 minutes after it occurred. The accused nursing assistant's timesheet showed she worked from 6:54 AM to 3:00 PM that day and wasn't removed from duty when the report was made.
Another delay stretched nearly two months. In February 2024, a Unit Manager interviewed a resident about an alleged incident and reported it to clinical management staff the next day. But the facility didn't notify state regulators until April — almost two months later.
The Unit Manager told inspectors: "Once I report it to the administration, I take my hands off, they do the reporting and investigation."
Some allegations weren't reported at all. In March 2024, a family member texted the former Administrator at 10:25 AM saying a nurse was "rough" with their relative and to "stop abusing" the resident. The Administrator responded he was "looking into it now" but never filed a state report.
When inspectors asked why, both the Director of Nursing and former Administrator said they found it wasn't abuse during their investigation. The Director of Nursing confirmed they failed to report the allegation as required.
Beyond delayed reporting, the facility's investigations were incomplete and inadequate. In the September 2023 case, the family described "a woman with yellow hair" as the perpetrator, but investigators never tried to identify her.
A night supervisor mentioned a Certified Medication Aide interacted with the resident, but investigators didn't interview any CMAs. When the Director of Nursing was asked to identify the CMA working that night, she said the facility had no CMAs on night shift. The investigation never determined who the supervisor was referencing.
Staff statements from abuse investigations revealed unsigned documents without dates or times. In one case involving the photographing allegation, the accused employee's typed statement wasn't signed and contained no indication when it was written or when the events occurred.
Some investigations took too long to complete. A May 2024 incident was supposed to be finalized within five business days but wasn't submitted until eight days later.
The facility also failed to provide required education to staff after abuse allegations. In the September 2023 case, 29 employees attended abuse prevention training, but investigators found no evidence the three staff members who worked with the resident during the alleged incident received any education.
One investigation revealed a Geriatric Nursing Assistant who answered "yes" when asked if she recently witnessed a resident being abused, neglected or treated rudely. No explanation was documented, and there was no indication the Administrator investigated further.
Missing investigation files compounded the problems. For a 2021 incident where a resident alleged abuse by "a gang of hooligans," the facility provided only progress notes and psychiatric records. The Director of Nursing said they didn't have the investigation file.
Another case from August 2023 was missing interviews with nursing staff who were scheduled on the day of the alleged abuse. The Director of Nursing couldn't confirm whether staff interviews were ever conducted.
The facility's handling of immediate safety measures was equally problematic. After a December 2023 incident, staff were educated to have two people present when providing care to one resident. A nurse practitioner ordered "two person assist with ADLs, transfers, and any procedures every shift" on December 29, 2023.
But this safety measure wasn't added to the resident's care plan until May 15, 2024 — nearly five months later. Staff statements from subsequent abuse investigations showed employees continued providing care alone during this gap.
In a June 2024 incident, a nursing assistant assisted the resident in the bathroom without another staff member present. When asked about this violation, the Director of Nursing said if another female staff wasn't available, "staff are to provide care to the resident alone to maintain dignity."
The facility's problems extended beyond abuse reporting to basic care failures. Inspectors found staff didn't follow physician orders for wound care, missed required medication doses, and failed to complete required resident assessments.
One resident admitted after circulatory surgery had three surgical incisions requiring daily wound care, but only one wound had physician orders for treatment. Another resident's scalp wound from brain surgery went unassessed and untreated for days after admission.
A resident with congestive heart failure had multiple conflicting orders for daily weights that staff failed to clarify with doctors. Weights were missed on 33 separate dates over three months.
The facility also failed to maintain complete medical records. Discharge summaries were missing for four residents, and one physician note wasn't entered into a medical record until two months after it was written.
Staff competency checks were incomplete. One nursing assistant accused of abuse had never completed the required competency evaluation during five years of employment.
The inspection found systemic failures in the facility's Quality Assurance program. During a hot water system malfunction from November 2023 to January 2024, temperature readings showed dangerous 140-degree water in shower rooms — well above the facility's 100-120 degree safety range.
The maintenance director claimed these readings were "recorded in error," but the facility never reported the malfunction to state regulators and the Quality Assurance committee failed to review temperature logs as required by their own plan.
Layhill Nursing and Rehabilitation Center serves residents requiring skilled nursing care and rehabilitation services. The June inspection was conducted in response to complaints about the facility's operations.
The facility has 30 days to submit a plan of correction addressing each violation. State regulators will conduct follow-up inspections to verify compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Layhill Nursing and Rehabilitation Center from 2024-06-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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