Cycle 1
Health 2025-01-24 · Fire 2025-01-24
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Jackson, TN
Laurelwood Health Care Center
2-star overall rating with 2-star inspections with $126,516 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
200 Birch St, Jackson, TN
(731) 422-5641
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ahava Healthcare
Operator or chain grouping
Approved since
1997-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,549
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.04
Baseline 70.00% · Performance 54.00% · Measure score 3.04 · Achievement 2.37 · Improvement 3.04
Adjusted total nurse staffing
2.22
Baseline 3.93 hours · Performance 3.71 hours · Measure score 2.22 · Achievement 2.22 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 6.52% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 4.55% |
0.77%
3.8 pts worse
|
Numerator 1 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 1 · Denominator 22 · Adjusted rate 3.35% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 63 |
| Staff flu vaccination coverage | 56% |
42%
14 pts better
|
Numerator 28 · Denominator 50 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.6
1.4 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
89.9%
7.5 pts worse
|
93.4%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.0% · Q2 80.4% · Q3 82.0% · Q4 81.2% · 4Q avg 82.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.5%
1.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.6%
1.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.9% · Q3 6.0% · Q4 6.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
11.8%
8.6 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 2.3% · Q4 2.1% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.2%
2.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.3% · Q3 2.1% · Q4 6.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 68.5% |
32.2%
36.3 pts worse
|
19.6%
48.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.0% · Q2 65.9% · Q3 72.9% · Q4 66.0% · 4Q avg 68.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 48.7% |
18.1%
30.6 pts worse
|
16.7%
32 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 50.0% · Q4 54.5% · 4Q avg 48.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.9% |
19.9%
11 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
15.3%
2 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 23.8% · Q3 9.3% · Q4 19.0% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.9%
0.9 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
20.2%
2 pts better
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 9.6% · Q3 10.8% · Q4 26.4% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.4%
0.3 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.5% · Q3 0.0% · Q4 7.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.6% |
79.6%
32 pts worse
|
81.7%
34.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 47.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 17.4% |
1.6%
15.8 pts worse
|
1.6%
15.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 17.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-26 · Fire 2024-03-26
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-01-14 · Fire 2022-01-14
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-03-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-15
D · Potential for more than minimal harm
2022-01-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-02-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-24
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-13
J · Immediate jeopardy
2024-03-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-26
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-19
D · Potential for more than minimal harm
2022-01-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-02-13
D · Potential for more than minimal harm
2022-01-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-02-13
D · Potential for more than minimal harm
2022-01-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-02-13
D · Potential for more than minimal harm
2022-01-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-02-13
D · Potential for more than minimal harm
2022-01-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-02-13
Penalties and ownership
What sits behind the stars
$126,516
2024-03-26
Fine
Fine · fine $126,516
Fine
$0
2024-03-26
Payment Denial
Payment Denial · denial start 2024-03-29 · 21 days
21 day denial
Ownership
Mfi Healthcare Tn LLC
5% Or Greater Direct Ownership Interest · Organization
Philipson Family Limited Liability Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Niederman, Anshel
5% Or Greater Indirect Ownership Interest · Individual
Labin, Shiya
5% Or Greater Indirect Ownership Interest · Individual
Neuman, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
King, James
Operational/Managerial Control · Individual
Moore, Lori
Operational/Managerial Control · Individual
Niederman, Anshel
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Mission Convalescent Home
Jackson, TN
3-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Cypress Grove Post Acute
Jackson, TN
3-star overall rating with 3-star inspections with $17,355 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
West Tennessee Post Acute
Jackson, TN
3-star overall rating with 3-star inspections with 7 recent health deficiencies
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