Laurel Health & Rehabilitation Center

F 0600 Level of Harm - Minimal harm or potential for actual harm

investigations. Staff member A stated she was not able to locate any grievances or complaints reported to management for residents #s 7, 18, or 21 for the concerns outlined above. Staff members A and B both stated they were not aware of resident #18 being soaked with urine, resident #21's concerns with toileting, pads in her briefs, hitting her head on the wall, or a CNA yelling at her, and they were not aware of resident #7's fear of her roommate until the surveyor brought the concerns forward.

Residents Affected - Some

During an interview on 1/28/26 at 2:37 p.m., NF4 stated that grievances were the responsibility of the administrator, and she had no part in the grievances. NF4 stated that the only thing she did was to go out and interview residents if she was told to do so by the administrator. NF4 stated she did not know if grievances or complaints came in for residents #7, 18, or 21.

Review of the facility policy, Abuse Reporting and Response, updated October 202, reflected: [sic] -The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law.

1. 1. Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director.

. 3. Reports of alleged violations by others such as staff, residents, visitors, other healthcare providers, or others do not need to be explicitly characterized as abuse, neglect, mistreatment, or exploitation in order to require reporting, investigation, and further necessary steps. [sic]

Review of a facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 3/2025, showed: -Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse ., -Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Review of a facility policy titled, Abuse Policies and Procedures, dated 5/2025, showed: . Investigation: thorough investigation - Determine if the abuse, neglect, exploitation, and/or mistreatment has occurred and determine the extent and cause. Protection: Suspend and/or remove the alleged perpetrator from patient care area immediately. Protect residents from physical and psychosocial harm during and after an investigation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Laurel Health & Rehabilitation Center

820 3rd Ave Laurel, MT 59044

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to fully investigate an abuse allegation for 2 (#s 11 and 62) of 34 sampled residents. This deficient practice resulted in psychosocial distress for resident #11 who was feeling scared due to the physical and verbal abuse (with fear of a repeat event occurring with a fellow resident). Findings include: During an observation and interview on 1/27/26 at 9:46 a.m., resident #11 stated on the night of 12/28/25, resident #62 came into her room, held her arms down, tried to get into her bed with her, and yelled, You know who I am, repeatedly at resident #11. Resident #11 stated, (She) screamed for help for quite some time, and no one came. Resident #11 showed her arms were held above her head, crossed, and held down. She stated she tried to hit resident #62 but that did not work. She stated

she tried to hit him with her water cup next. She stated she would have hit him with her cane if she could have but it was across the room. She stated resident #62 had been in her room two other times. Both times, resident #62 had urinated in her toilet, and then left. Resident #11 stated she was scared and upset that

this happened and was fearful resident #62 would return to her room at night again and harm her. Resident #11 stated she was concerned he could potentially sexually assault her or make advances toward her. She stated she thought the facility had moved his room away from hers and was not award resident #62 was still

in the room next door.Review of a facility policy titled, Abuse Investigation, updated 10/22, showed: . 2. The Center identifies and interviews involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.During an interview on 1/27/2026 at 3:52 p.m., staff members A and B stated they did not have staff or resident interviews for the Facility Reported Incident that occurred on 12/28/25 with residents #s 11 and 62.During an interview on 1/28/2026 at 8:59 a.m., staff members A and B stated they now were able to find some staff statements from the Facility Reported Incident with resident #s 11 and 62 (shown below). Staff member A stated they did not consider the incident with resident #s 11 and 62 to be abuse and this was why their rooms were still located next to each other (until it was brought to the facility's attention by the survey team). Staff member A stated

the facility should have taken further action to investigate further which included staff and resident interviews, along with removing resident #11 from the potential abuse perpetrator during the investigation process.Review of a facility document, not titled and dated 12/28/25, showed: I [staff member V] CNA went to lunch at 2:20 a.m. I returned at 2:47 a.m. I went to my hall and found [resident #62] in . (another resident's room) . [Resident #11]'s light was on, and she was yelling for help. She was very upset and said that a man was trying to get into bed with her, she also said that she hit him and yelled for help and threw water at him I noticed water all over the room. [sic]

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet