Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurelwood Community Living Center during CMS and state inspections, most recent first.
A controlled substance prescribed for a cognitively intact resident with a left femur fracture was delivered and signed for by an LPN but was not entered on the narcotic accountability record or narcotic box package count and was later found to be missing. One LPN reported receiving the blister pack of thirty Hydrocodone/Acetaminophen 10-325 mg tablets from another LPN, placing it on the nurses’ station, and leaving the area, while both LPNs stated they were in the medication room as the medication remained unattended. The DON and Administrator confirmed that staff failed to secure the controlled medication as required by facility policy and that the missing tablets could not be located.
Surveyors found that staff failed to properly secure and store medications for two residents. For one resident, an LPN received a delivery of Hydrocodone-Acetaminophen, passed it to another LPN, and the controlled medication was left unattended at the nurses’ station instead of being immediately locked and entered into the narcotic count, after which it could not be located. For another resident, two bottles of Lorazepam oral concentrate, documented on the narcotic record and labeled to be protected from light and refrigerated, were observed stored in a locked medication cart rather than in the designated medication refrigerator, even though staff acknowledged knowing the manufacturer’s refrigeration requirement.
A resident with moderate cognitive impairment and a history of encephalopathy repeatedly removed his seatbelt during van transport from a medical appointment. Despite the CNA driver's attempts to refasten the belt and encourage compliance, the resident ultimately fell from his wheelchair inside the van. The CNA assessed the resident and continued transport without requesting additional assistance, and the incident was reported to nursing staff upon arrival. The resident sustained an abrasion and was sent to the hospital as a precaution.
A resident with a history of constipation and diarrhea experienced six consecutive days without a bowel movement, but the physician was not notified and no constipation medications were administered. Despite facility policy requiring notification for significant changes, staff did not document interventions or provider contact, and the resident continued to receive antidiarrheal medication. The resident was ultimately hospitalized and diagnosed with fecal impaction.
A resident with a history of constipation experienced multiple days without a documented bowel movement, while continuing to receive antidiarrheal medication and not receiving prescribed PRN laxatives. Staff did not document interventions or notify the physician as required by the care plan, resulting in the resident being hospitalized for fecal impaction.
A resident with a history of constipation and diarrhea experienced multiple undocumented days without a bowel movement, resulting in hospitalization for fecal impaction. Despite standing orders and alerts for constipation management, there was no documentation of nursing interventions, use of PRN laxatives, or physician notification. The resident continued to receive antidiarrheal medication, and staff interviews confirmed a lack of awareness and response to the ongoing issue.
The facility did not maintain a sanitary kitchen environment, as evidenced by the presence of rat droppings in food storage, live roaches observed on a resident's meal tray and kitchen equipment, and ongoing pest activity documented in pest control logs. Staff interviews revealed gaps in pest control oversight and lapses in maintaining kitchen sanitation standards.
A CNA failed to cleanse a resident's perineal area during a brief change, applying a clean brief without following the facility's perineal care policy. The resident was dependent on staff for ADLs, had severe cognitive impairment, and was frequently incontinent. The omission was acknowledged by the CNA, and the DON confirmed that proper incontinence care is expected to prevent infection and skin issues.
A wound care treatment cart containing medications and supplies was left unlocked and unattended in a hallway for about 20 minutes while a nurse performed wound care in a resident's room with the door closed. Facility policy requires carts to be locked when out of sight, and both the nurse and DON confirmed the cart should have been secured to prevent unauthorized access.
Unsecured Controlled Medication Left Unattended and Lost
Penalty
Summary
The facility failed to prevent misappropriation of resident property when a controlled substance prescribed for a resident was left unattended and subsequently went missing. Facility policies on abuse and neglect defined misappropriation of resident property to include missing prescription medications or diversion of resident medications, including controlled substances, and the Medication-Controlled Substances policy required that only authorized licensed nursing and pharmacy personnel have access to controlled medications, that all controlled substances be stored in a locked cabinet or compartment, and that accurate accountability of all controlled drugs be maintained. Despite these policies, a pharmacy courier delivered thirty Hydrocodone/Acetaminophen 10-325 mg tablets for a resident with a left femur fracture, and the medication was signed for by an LPN but was not signed onto the narcotic accountability record, was not documented on the narcotic box package count, and could not be located. The resident, who was cognitively intact with a BIMS score of 15 and had a physician’s order for Hydrocodone/Acetaminophen, was later informed that the tablets delivered had been lost. Interviews revealed that one LPN received the blister pack of thirty Hydrocodone/Acetaminophen tablets from another LPN and placed it on the nurses’ station before leaving the area, leaving the controlled medication unattended. Both LPNs reported being in the medication room while the medication remained unattended at the nurses’ station. The DON reported being notified that the medication was missing and that an investigation confirmed the medication could not be located and had been left unattended, and the Administrator confirmed staff failed to ensure controlled medications were secured and accessible only to authorized personnel and that the facility was unable to determine the location of the missing medication.
Failure to Secure Controlled Drugs and Follow Refrigerated Storage Requirements
Penalty
Summary
The deficiency involves the facility’s failure to store and secure medications, including controlled substances, in accordance with professional standards and manufacturer instructions. For Resident #1, who was admitted with a left femur fracture and was cognitively intact with a BIMS score of 15, the physician ordered Hydrocodone-Acetaminophen 10-325 mg tablets. A facility investigation documented that a pharmacy courier delivered 30 tablets of this controlled medication, which were received and signed for by an LPN but were never documented in the narcotic count system and were later unable to be located. One LPN reported that after receiving the Hydrocodone-Acetaminophen from another LPN, she left the medication unattended at the nurses’ station while she completed other tasks instead of immediately securing it in the locked medication cart. The LPN who initially received the medication from the courier confirmed that the controlled medication had not been immediately secured in the locked cart following delivery. For Resident #3, who was admitted with heart disease and had a BIMS score of 10 indicating moderately impaired cognition, the physician ordered Lorazepam (Ativan) oral concentrate. The narcotic record showed that two containers of Lorazepam were signed into the narcotic record on the date of admission. Manufacturer prescribing information for the Lorazepam oral concentrate specified that it must be protected from light and stored refrigerated at 36–46°F. During a controlled drug count, surveyors observed that two bottles of Lorazepam oral concentrate for this resident were stored in the locked medication cart rather than in a refrigerator, despite the label instructions requiring refrigeration. One LPN confirmed the manufacturer’s storage instructions on the label but was unsure why the medication had not been refrigerated, and another LPN acknowledged awareness that the medication required refrigeration but confirmed it had been stored in the medication cart instead of the designated medication refrigerator.
Failure to Prevent Accident During Resident Transport
Penalty
Summary
The facility failed to ensure adequate supervision and prevent an avoidable accident when a resident with moderately impaired cognition, as indicated by a Brief Interview for Mental Status Summary score of 8 and a diagnosis of encephalopathy, was transported in the facility van. During the return trip from a doctor's appointment, the resident repeatedly unfastened his seatbelt and expressed a desire to go home with his sister. The certified nurse aide (CNA) driving the van stopped to refasten the seatbelt and encouraged the resident to remain secured, but the resident continued to remove the belt. On the second occasion, the resident fell from his wheelchair to the floor of the van. The CNA assessed the resident after the fall and returned him to his chair, then continued driving to the facility, where the incident was reported to nursing staff. Upon arrival, the resident was found to have an abrasion over his left eye and was sent to the hospital as a precaution. Interviews with facility leadership acknowledged that the resident's behavior of repeatedly unfastening his seatbelt contributed to the incident, and that the safest action would have been to stop transport and request assistance after the initial unfastening. However, the CNA continued transport after the fall, and the incident was only reported upon arrival at the facility.
Failure to Notify Physician of Prolonged Constipation Leading to Hospitalization
Penalty
Summary
The facility failed to notify the physician of a resident who had no documented bowel movement for six consecutive days, resulting in the resident being hospitalized for evaluation and diagnosed with fecal impaction. Despite the facility's policy requiring nursing staff to notify the physician of significant changes in a resident's condition, there was no documentation of nursing interventions, administration of constipation medications, or provider notification regarding the resident's ongoing constipation prior to hospitalization. Interviews with staff confirmed that while CNAs are expected to alert nurses after three days without a bowel movement and the EHR system provides alerts, the physician was not notified unless medications were ineffective. However, in this case, no medications for constipation were administered, and the physician was not informed of the resident's condition. The resident had a history of constipation and diarrhea, with a diagnosis of constipation and was receiving antidiarrheal medication (Lomotil) despite multiple days without a bowel movement. The medical record and MAR showed no documentation of interventions or physician notification during the periods of constipation, and the resident continued to receive Lomotil without any PRN laxatives being administered. The facility also lacked a specific policy regarding constipation or bowel movements, and the DON confirmed unawareness of the resident's lack of bowel movements prior to hospitalization.
Failure to Implement Comprehensive Care Plan for Constipation Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a known history of constipation, resulting in the resident being hospitalized for fecal impaction. The resident had a care plan in place identifying her risk for constipation related to polypharmacy, with goals and interventions such as following bowel management orders, administering Glycolax as needed, and monitoring for signs and symptoms of complications. Despite this, documentation revealed multiple instances where the resident went several consecutive days without a documented bowel movement, including a period of six days, without evidence of appropriate interventions or provider notification. The resident continued to receive Lomotil, an antidiarrheal medication, three times daily during these periods of no bowel movement, and the PRN laxative MiralAX was not administered. There was no documentation of nursing interventions, administration of constipation medications, or notification to the physician regarding the resident's lack of bowel movements prior to her hospitalization. Interviews with facility staff, including the DON and the physician, confirmed that the physician was not informed of the resident's condition and that standing orders for constipation management were not followed. The facility's policy required ongoing assessment and timely revision of care plans, as well as prompt intervention and communication when residents experienced changes in condition. However, staff failed to follow these protocols, resulting in a lack of action when the resident did not have bowel movements for several days. This failure to implement and update the care plan as required led to the resident's hospitalization for fecal impaction.
Failure to Identify and Respond to Constipation Leading to Hospitalization
Penalty
Summary
The facility failed to identify and respond to a clinically relevant pattern of constipation for a resident, resulting in hospitalization for fecal impaction. The resident, who had a history of constipation and alternating diarrhea, experienced multiple days without a documented bowel movement in January. Despite standing orders for constipation management and alerts in the facility's system for three consecutive days without a bowel movement, there was no documentation of nursing interventions, administration of constipation medications, or physician notification during these periods. The resident continued to receive Lomotil, an antidiarrheal medication, even as the lack of bowel movements persisted, and a PRN order for MiralAX was not utilized. Interviews with staff revealed that CNAs were expected to notify nurses of bowel movement issues, and nurses were to follow standing orders and notify the physician if interventions were ineffective. However, the DON was unaware of the resident's ongoing constipation, and the physician was not informed of the absence of bowel movements for six consecutive days prior to hospitalization. The facility did not have a specific policy for constipation or bowel movements, and documentation failed to reflect any assessment or intervention for the resident's constipation prior to the acute hospital admission for fecal impaction.
Failure to Maintain Sanitary and Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary and pest-free environment in the kitchen, as evidenced by multiple observations of pest activity and inadequate pest control measures. During a kitchen tour, a cardboard box containing cereal was found with rat droppings and shredded cardboard, and a glue trap with peanut butter was observed on the pantry floor. The Dietary Manager confirmed the presence of rat droppings and expressed concern about a gap beneath the kitchen's back door, which could allow rodent entry. The Maintenance Supervisor acknowledged the possibility of rodents entering through this gap, especially since the solid back door was sometimes left open for air circulation when the air conditioning was not functioning. Additionally, pest control logs indicated ongoing issues with mice and roaches, with activity noted during monthly visits in the preceding months. Further observations included a live roach crawling across a resident's meal tray during meal assembly, which was confirmed and removed by dietary and maintenance staff. Another live roach was seen on top of the low-temperature dishwasher. The Registered Dietitian, who conducts monthly kitchen tours, reported not having observed pest activity during her inspections but expected staff to maintain effective pest control and sanitation. The Administrator was unaware of the pest issues and attributed lapses in oversight to high staff turnover. Facility policies required the kitchen to be kept clean and protected from pests, but these standards were not met, as evidenced by the ongoing pest activity and lack of effective control measures.
Failure to Provide Proper Incontinence Care During Brief Change
Penalty
Summary
A deficiency was identified when a Certified Nurse Aide (CNA) failed to provide appropriate incontinence care to a resident who was dependent on staff for activities of daily living and was incontinent of bowel and bladder. During an observed brief change, the CNA removed a soiled brief and applied a clean one without cleansing or rinsing the resident's perineal area or buttocks, contrary to the facility's perineal care policy. The CNA later acknowledged that she did not provide perineal care during the change and attributed the omission to being nervous during the observation, despite knowing the correct procedure. The resident involved had a diagnosis of Metabolic Encephalopathy, was severely cognitively impaired, and required staff assistance for toileting hygiene. Facility policy required thorough cleaning of the perineal area with soap and water, rinsing, and drying during incontinence care, which was not followed in this instance. The Director of Nursing confirmed that staff are expected to always provide proper incontinence care to prevent infections or skin breakdown.
Unattended and Unlocked Wound Care Cart with Medications
Penalty
Summary
A wound care treatment cart was observed left unlocked and unattended in a hallway for approximately 20 minutes while a registered nurse entered a resident's room to perform wound care with the door closed. The facility's policy requires that medication carts remain closed and locked when out of sight of the administering nurse or aide, and that no medications are kept on top of the cart. During the observation, the cart contained items such as bactericidal isopropyl alcohol-based sanitizer wipes, Santyl ointment, normal saline, betadine, and nail clippers. The registered nurse confirmed that the cart was left unlocked and unattended, acknowledging that it should have been secured to prevent resident access. The Director of Nursing also confirmed that staff are expected to keep carts locked and not leave them unattended, citing risks such as possible resident poisoning from substances like betadine or Santyl, and unauthorized access by untrained staff. The incident was found to be out of compliance with both facility policy and regulatory requirements for the secure storage of drugs and biologicals.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Comfort Care Nursing Center | 0.1 mi | ★★★★★ | 8 | 0 |
| Care Center Of Laurel | 0.2 mi | ★★★★★ | 0 | 0 |
| Jones Co Rest Home | 6.1 mi | ★★★★★ | 1 | 1 |
| Jasper County Nh | 19 mi | ★★★★★ | 9 | 0 |
| Landmark Of Collins | 23.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.