Inspection Reports for Laurelwood Health Care
200 Birch Street, Jackson, TN, 38301
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
53 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 7
Date: Jan 24, 2025
Visit Reason
The inspection was conducted as a regulatory annual survey of Laurelwood Health Care Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide complete advance directive information to residents, inadequate pressure ulcer care, failure to properly investigate and document falls, improper catheter care, failure to monitor weekly weights as ordered, unsanitary food service conditions, and failure to follow infection control practices during medication administration.
Deficiencies (7)
Failed to provide information to residents regarding their right to refuse treatment or formulate an advance directive for 6 of 24 residents reviewed.
Failed to have physician orders and provide pressure ulcer treatments for 1 of 4 residents reviewed.
Failed to take appropriate actions and document investigation after a fall for 1 of 3 residents reviewed.
Failed to provide appropriate catheter care and maintain dignity for 1 resident with an indwelling urinary catheter.
Failed to follow facility policy for monitoring weekly weights for 1 resident reviewed for nutritional status.
Failed to ensure food was served under sanitary conditions including use of carbon covered cookware, malfunctioning dishwasher, expired foods, and unsanitary plates and silverware.
Failed to ensure infection control practices were followed during medication administration, including failure to wear PPE and perform hand hygiene for a resident on enhanced barrier precautions.
Report Facts
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 53
Residents receiving lunch: 51
Residents receiving breakfast: 49
Weight loss percentage: 7.65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in pressure ulcer treatment deficiency for Resident #258 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including pressure ulcer care, fall investigation, catheter care, weight monitoring, and infection control |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food sanitation deficiencies and dishwasher malfunction |
| VP of Nutrition | Vice President of Nutrition | Interviewed regarding nutritional monitoring and weight loss of Resident #1 |
| LPN A | Licensed Practical Nurse | Named in infection control deficiency for failure to follow enhanced barrier precautions during medication administration |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Date: Mar 26, 2024
Visit Reason
The inspection was conducted based on complaints and allegations related to housekeeping, abuse reporting, investigation of injuries, care planning, fall prevention, and nutritional care.
Complaint Details
The complaint investigation revealed failures in housekeeping, abuse reporting, injury investigation, care planning, fall prevention, supervision, and nutritional care. Resident #42 was a focus due to injuries of unknown source and fall-related issues. Resident #11 was reviewed for enteral feeding concerns.
Findings
The facility failed to maintain a sanitary environment in multiple resident rooms and communal areas, failed to timely report and investigate injuries of unknown source, failed to conduct thorough investigations of falls and bruises, failed to hold care plan meetings and update care plans, failed to prevent falls and adequately supervise a cognitively impaired resident, and failed to provide adequate nutritional care and timely implement dietitian recommendations.
Deficiencies (6)
Failed to provide effective housekeeping to maintain a sanitary environment in 8 of 35 resident rooms, 1 of 4 communal bathrooms, and 1 of 3 scales observed.
Failed to timely report injuries of unknown source to proper authorities for 1 of 13 residents reviewed for abuse (Resident #42).
Failed to thoroughly investigate an unwitnessed fall with injury and bruises of unknown source for Resident #42.
Failed to develop and implement a comprehensive care plan and conduct care plan meetings for Resident #356 and failed to update care plan for Resident #42.
Failed to ensure a safe environment and adequate supervision to prevent accidents for Resident #42, resulting in immediate jeopardy due to failure to monitor and assess post-fall pain and delayed fracture diagnosis.
Failed to provide adequate nutritional care and timely implement dietitian recommendations for enteral feeding for Resident #11.
Report Facts
Residents affected: 8
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Weight loss percentage: 7.9
Feeding rate: 45
Feeding rate: 50
Weight: 104
Weight: 105.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Named in failure to identify bruises on Resident #42 prior to surveyor observation |
| DON | Director of Nursing | Confirmed failures in identifying bruises, timely investigations, and care plan updates for Resident #42 |
| Administrator | Facility Administrator | Confirmed delayed reporting and investigation of Resident #42's injuries |
| Housekeeper O | Housekeeper | Interviewed regarding cleaning duties and lack of cleaning schedule for over bed tables |
| Housekeeping Supervisor | Housekeeping Supervisor | Confirmed no schedule to clean over bed tables |
| RD | Registered Dietitian | Made recommendations for enteral feeding rate increase for Resident #11 |
| ADON | Assistant Director of Nursing | Responsible for implementing RD recommendations and monitoring weights |
| CNA C | Certified Nursing Assistant | Involved in weighing Resident #11 and interviewed about weight monitoring |
| CNA K | Certified Nursing Assistant | Involved in weighing Resident #11 and interviewed about weight monitoring |
Inspection Report
Routine
Census: 35
Deficiencies: 9
Date: Mar 26, 2024
Visit Reason
Routine inspection based on policy review, observation, and interviews to assess compliance with housekeeping, abuse reporting, care planning, podiatry services, fall prevention, nutrition, food safety, and infection control standards.
Findings
The facility failed to maintain a sanitary environment in resident rooms, communal bathrooms, and equipment; failed to timely report and investigate injuries of unknown source; failed to conduct care plan meetings and update care plans; failed to provide timely podiatry care; failed to prevent falls and properly monitor a resident post-fall resulting in immediate jeopardy; failed to provide adequate nutrition via enteral feeding; failed to maintain sanitary food service conditions; and failed to ensure proper infection control practices during medication administration.
Deficiencies (9)
Failed to provide effective housekeeping to maintain a sanitary environment in 8 of 35 resident rooms, 1 of 4 communal bathrooms, and 1 of 3 scales observed.
Failed to timely report injuries of unknown source to appropriate authorities for 1 of 13 residents reviewed for abuse (Resident #42).
Failed to thoroughly investigate an unwitnessed fall with injury and bruises of unknown source for 1 of 13 residents reviewed for abuse/neglect (Resident #42).
Failed to conduct care plan meetings for 1 of 14 residents and failed to update care plan for 1 of 14 residents reviewed for care planning.
Failed to provide podiatry care and services for 1 of 1 resident reviewed for podiatry services (Resident #46).
Failed to ensure a safe environment and adequate supervision to prevent accidents, failed to monitor and assess a resident post-fall resulting in immediate jeopardy (Resident #42).
Failed to provide and maintain adequate nutritional status via enteral feeding for 1 of 3 residents reviewed for enteral feeding (Resident #11).
Failed to ensure food was stored, prepared, and served under sanitary conditions including dirty equipment, dirty kitchen floors, and non-functional paper towel dispenser.
Failed to ensure proper infection control practices were followed when 2 of 3 nurses failed to clean reusable equipment before use on residents during medication administration.
Report Facts
Residents affected: 8
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Census: 52
Residents receiving meal trays: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN M | Licensed Practical Nurse | Failed to clean temporal thermometer after use during medication administration |
| LPN N | Licensed Practical Nurse | Failed to clean stethoscope after use during medication administration |
| Director of Nursing | Director of Nursing | Confirmed infection control practices for cleaning equipment after use |
| Housekeeper O | Interviewed about cleaning resident rooms | |
| Housekeeping Supervisor | Confirmed no schedule to clean over bed tables | |
| LPN L | Licensed Practical Nurse | Assessed Resident #42's bruises after surveyor observation |
| CNA J | Certified Nursing Assistant | Interviewed about bruises on Resident #42 |
| CNA A | Certified Nursing Assistant | Interviewed about bruises on Resident #42 |
| Treatment Nurse | Noticed bruise on Resident #42's lip on 3/20/2024 | |
| Administrator | Facility Administrator | Confirmed delayed reporting and investigation of bruises on Resident #42 |
| Physical Therapy Director | Reported Resident #42's pain to nursing post-fall | |
| Certified Nursing Assistant B | Certified Nursing Assistant | Witnessed Resident #42's fall on 10/14/2023 |
| Registered Dietitian | Registered Dietitian | Recommended increase in enteral feeding for Resident #11 |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for implementing RD recommendations |
| Dietary Manager | Dietary Manager | Interviewed about kitchen sanitation and food safety issues |
| Certified Nursing Assistant C | Certified Nursing Assistant | Responsible for weighing residents including Resident #11 |
| Certified Nursing Assistant K | Certified Nursing Assistant | Responsible for weighing residents including Resident #11 |
| Intern Physician | Intern Physician | Ordered X-ray for Resident #42 but order not entered in EMR |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
Annual survey inspection of Laurelwood Health Care Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 14, 2022
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, pressure ulcer care, fall prevention, medication storage, and environmental safety in the nursing home.
Findings
The facility failed to provide timely Advanced Beneficiary Notices to residents when therapy services were discontinued, failed to properly document and administer pressure ulcer treatments and antibiotics, did not adequately prevent falls or follow care plans, improperly stored medications including expired and mixed internal/external medications, left medications unattended, and failed to maintain a clean and sanitary environment in the women's bathroom/shower room.
Deficiencies (5)
Failed to provide 3-day notice and Advanced Beneficiary Notice (ABN) to residents when therapy services were discontinued.
Failed to provide appropriate pressure ulcer care including documentation of antibiotic administration, wound treatments, and hand hygiene during wound care.
Failed to follow fall prevention policy and care plan for a resident at risk for falls, including lack of fall mats and concave mattress.
Failed to ensure medications were properly and securely stored; internal, external medications and chemicals were stored together; expired medications present; medications left unattended in resident rooms.
Failed to maintain a safe and sanitary environment in the 100 Hall Women's Bathroom/Shower Room with debris, used adult brief, dirty shower chair, stool on floor, and strong malodorous odor.
Report Facts
Residents affected: 3
Medication administration dates missed: 10
Fall incidents: 3
Expired medication packs: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Confirmed mailing and timing issues with Advanced Beneficiary Notices for Residents #7, #31, and #99 | |
| Assistant Director of Nursing | ADON | Observed failing to perform hand hygiene properly during wound care for Resident #40 |
| Director of Nursing | DON | Confirmed failures in hand hygiene, medication administration, fall prevention, and environmental cleanliness |
| Licensed Practical Nurse #4 | LPN | Confirmed failure to report or complete incident report for Resident #13's fall on 1/10/2022 |
| Licensed Practical Nurse #2 | LPN | Confirmed no fall mat in place for Resident #13 until 1/13/2022 |
| Licensed Practical Nurse #1 | LPN | Confirmed improper storage of medications and chemicals together |
| Registered Nurse #1 | RN | Observed leaving medications unattended in Resident #147's room |
| Director of Environmental Services | Confirmed unsanitary conditions in 100 Hall Women's Bathroom/Shower Room |
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