The Laurels Of Galesburg
The Laurels of Galesburg in Galesburg, MI — inspection on March 31, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
bruise.contusion(bruise) of right upper arm.right dorsal forearm bruise, unknown mechanism of
report for Resident #102, with a reference date of 1/19/26, revealed the information was submitted to
the report was not submitted with the required 2-hour time frame.In an interview on 3/31/26 at 4:22pm, NHA A reported it was the expectation that staff would report a concern of resident abuse to him immediately.Review of a facility Abuse Prohibition Policy with a reference date of 9/9/22 revealed .It is the responsibility of all staff to provide a safe environment for the residents.
Definitions.f resident abuse.adverse event.mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies.
Staff members.shall immediately report incidents of abuse and suspected abuse, .
Definitions:.Neglect is the failure of employees to provide.services to a resident.to avoid physical harm, mental anguish or emotional distress.Misappropriation: means.deliberate misplacement.of a resident's belongings.Adverse event is an.undesirable.event that causes.serious injury.
235483 03/31/2026
The Laurels of Galesburg 1080 N 35th Street Galesburg, MI 49053
Review of an incident/accident report for Resident #100, dated 1/22/26 at 8:00 AM, revealed .Resident reported to nurse (LPN R) that during last rounds night shift nurse and (CNA) came into the room and changed her even though she verbalized that she was not wet and nurse (LPN M) held her wrists while CNA provided (incontinence) care .Resident Description: He grabbed my arms and twisted them, it hurt and I told him I was not very wet .Nurse assessed resident and observed a bruise on left arm.
Nurse noted redness on the left arm, no other bruising noted .nursing immediately reported to (Administrator A), report filed with Michigan .
Review of a Resident at Risk note for Resident #100, dated 1/22/26 at 9:30 AM, revealed .IDT (Interdisciplinary Team) met to discuss plan of care for resident who is long-term resident in the facility on hospice services, no plan to dc (discharge) home .Action Taken: Nursing assessed resident, bruise on left arm noted redness on right arm, pain managed with scheduled pain medications .Order for X-ray .Nursing to continue to monitor psychosocial status .
Review of the MI-FRI System (a system for long-term care facilities to report Facility Reported Incidents) revealed the incident involving Resident #100 on 1/22/26 was reported to the State Agency via online submission on 1/22/26 at 11:40 AM (more than two hours after the allegation of abuse was made).
Noted the documentation within the MI-FRI system indicated the incident was discovered (identified) at 10:00 AM despite being informed by LPN R of the concern between 6:30-7:00am that morning.
In an interview on 3/31/26 at 3:37 PM, Administrator A reported he was notified of Resident #100's allegation involving a potential staff-resident abuse situation on 1/22/26 in the morning (on day shift).
Administrator A reported Former Director of Nursing (DON) WW learned of the allegation from LPN R and came directly to his office to discuss the concern.
Administrator A reported he did not recall receiving a phone call from LPN R prior to that point involving the allegation made by Resident #100.
Administrator A reported Resident #100 told LPN R that LPN M had twisted her arm, and a bruise was noted on Resident #100's left arm.
Administrator A indicated he reported the allegation of abuse involving Resident #100 to the State Agency, however, there was an issue with the MI-FRI system that day and he had to notify IT for additional assistance.
Administrator A reported he was unsure when he first attempted to report the allegation of abuse to the State Agency on 1/22/26 and stated .I don't have a record of that .
Administrator A reported that an allegation of abuse should be reported to the State Agency within two hours.
235483 03/31/2026
The Laurels of Galesburg 1080 N 35th Street Galesburg, MI 49053
concerned LPN M gave residents diphenhydramine, an over-the-counter allergy medication known to
said, the other nurse gives it to me. LPN K reported then she found an opened bottle of
quite a bit of the medication was gone but none of the residents on the unit had an order for diphenhydramine HCI. LPN K reported LPN M recently stated to her We'll be ok tonight. I made sure everyone is going to sleep tonight. LPN K reported after her conversation with LPN M, she removed the open bottle of diphenhydramine from the medication storage room, but a new bottle was in its place the following night. LPN K reported she then told the supply clerk to take the medication out of the storage room and stop stocking it because she was concerned another nurse was giving it to residents without an order to do so.
When queried, LPN K reported she did not report the concern to NHA A because she did not have proof of her allegation that residents were being wrongfully medicated. In an interview on 3/31/26 at 2:21pm, Nurse Practitioner (NP) XX reported none of the residents on the memory care unit had an order to receive diphenhydramine. NP XX reported the use of that medication for those with dementia created a higher risk for falls and had a sedating effect on the patient.In an interview on 3/27/26 NHA A reported the facility was aware of an allegation of misuse of diphenhydramine and an investigation was underway.Review of a soft file provided by NHA A related to improper administration of diphenhydramine to residents, revealed the facility interviewed 9 of 27 licensed nurses employed by the facility. No record of LPN K being interviewed was provided.In an interview on 3/31/26 NHA A reported he spoke with LPN K, and she expressed general concerns about finding diphenhydramine in the medication storage room on the memory care unit.
When queried, NHA A denied that LPN K reported an allegation that LPN M was giving the medication to residents without a physician's order to make them sleep at night. NHA A confirmed this allegation would be investigated and reported.
Review of the state agency Facility Reported Incidents data base of 4/1/26 at 3:45pm, revealed the facility had not submitted an investigation related to the accusation of a nurse giving residents diphenhydramine without an order.Review of a facility Abuse Prohibition Policy with a reference date of 9/9/22 revealed .It is the responsibility of all staff to provide a safe environment for the residents.
Allegations of resident abuse.adverse event.mistreatment shall be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies.
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The Laurels of Galesburg 1080 N 35th Street Galesburg, MI 49053
hygiene .Incontinence care is provided timely according to each resident's needs .Resident's call
reach and answered in a timely manner .Responding to a Call Light .Identify the location and answer
them with .Go to the location of the call light, and turn off the light if you are able to meet the resident request .Do what the resident requests of you, if permitted. If you are unsure go ask the charge nurse .When finished, turn the call light off and replace the call light within resident's reach .
235483 03/31/2026
The Laurels of Galesburg 1080 N 35th Street Galesburg, MI 49053
strategies developed specifically for the resident .During the onsite survey, past noncompliance
to demonstrate monitoring of the corrective action and maintained compliance.
235483 03/31/2026
The Laurels of Galesburg 1080 N 35th Street Galesburg, MI 49053
(electronic medical record system) to document behaviors exhibited by the resident, including new,
notes regarding the behavior, interventions and changes to plan of care .
Review of the
complete documentation requirements as outlined by the company and recorded in the medical record using accepted principles of documentation .Aspects of resident care such as observations and assessments, administration of medications, and services or treatments performed must be documented in the resident medical record according to company policy .Be Complete.
All facts and pertinent information related to an event, course of treatment, resident condition, response to care, and deviation from standard treatment (including the reason for the deviation) must be documented .
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Galesburg, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Laurels of Galesburg or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.