Laurels of Norworth the

Inspectors wroteBased on record review, observations, interviews, review of wound notes, review of hospital records and policy review, the facility failed to prevent the development of pressure ulcers and failed to ensure interventions were in place as ordered to prevent new or worsening pressure ulcers for Residents #20, #10, and #30. Actual harm occurred on 12/16/25 when it was discovered that Resident #20, who was at risk for skin breakdown with no pressure ulcers upon admission, developed an avoidable facility acquired unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) pressure ulcer injury to the right heel. [...]

Inspectors wroteBased on medical record reviews, interviews, and facility job descriptions, the facility failed to ensure Licensed Practical Nurses (LPN's) acted within their professional standards and their scope of training related to pressure ulcer wound assessments and staging of wounds. This affected two residents (#20 and #30) of three residents reviewed. The facility census was 116.1. Review of the medical record for Resident #20, revealed an admission date of 10/18/25. Diagnoses included but were not limited to Alzheimer's disease, depression, spinal stenosis and primary generalized osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 03 (00 to 15) indicated severe cognitive impairment. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on resident interview, medical record review, review of the self-reported incident (SRI) investigation and witness statements, review of hospital records, policy review, and review of the facility plan of correction documents, the facility failed to ensure a resident requiring transfers with a medical lift was transferred safely and with two staff assistance. Actual Harm occurred on 09/02/25 when Resident #60, who was dependent upon two staff for mechanical lift transfers, was being transferred via one staff assistance in a mechanical lift. The lift fell resulting in the resident sustaining a right femur fracture and subsequent surgery. This affected one (Resident #60) of three residents reviewed for injuries of unknown origin. The facility census was 106.

Inspectors wroteBased on interviews, medical record review, review of the State agency reporting system (CALS), review of emergency medical services (EMS) reports, review of police reports, review of facility emails, and policy review, the facility failed to timely report allegations of inappropriate sexual behavior made by four residents to the state agency and/or local law enforcement. This affected four residents (#33, #58, #77, #97) out of five residents reviewed for abuse. The facility census was 106.

Inspectors wroteBased on interviews, medical record review, review of facility emails, review of self-reported incident investigations (SRI) and review of facility policy, the facility failed to thoroughly investigate incidents involving allegations of inappropriate sexual behavior. This affected two residents (#58 and #77) out of five residents reviewed for abuse. The facility census was 106.

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to serve food in a safe and sanitary manner. This had the potential to affect 115 of 115 residents who receive food from the kitchen. The census was 115.

Inspectors wroteBased observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected four resident rooms (room numbers #60, #90, #215, and #226) and the northwest hallway. This had the potential to affect 54 residents residing in these resident rooms and who were near the northwest hallway.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) documents were accurate to the resident's conditions and diagnoses. This affected two (Residents #4 and #75) of three residents reviewed for PASARR assessments. The facility census was 115.

Inspectors wroteBased on record review, review of the facility policy, and staff interview the facility failed to ensure they timely followed up with state mental health agency for level two evaluation for Resident #22. This affected one (Resident #22) of four residents reviewed for pre-admission screening and resident review (PASARR) identification screenings. The facility census was 115.

Inspectors wroteBased on record review, staff interview, resident interview, and policy review, the facility failed to obtain vision services in a timely manner for Resident #60. This affected one (Resident #60) of two residents reviewed for vision. The facility census was 115.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to appropriately monitor the resident's significant weight loss and timely follow the registered dietitian's recommendations and facility policy. This affected two (Residents #87 and #94) of six residents reviewed for nutrition monitoring. The facility census was 115.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide planning, treatment, and oversight to resident behaviors regarding catheter care. This affected one (Resident #62) of one resident reviewed for behavior monitoring. The facility census was 115.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide parameters for as needed pain medication. This affected one (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 115.

Inspectors wroteBased on record review and staff interview, the facility failed to monitor behaviors and did not provide appropriate justification for a psychotropic medication for one (Resident #80) of five residents reviewed for unnecessary medications. The facility census was 115.

Inspectors wroteBased on record review, resident and staff interview, observation , review of policy, and review of the resident agreement, the facility failed to timely obtain routine dental services for residents. This affected two (Resident #60 and Resident #103) of two residents reviewed for dental services. The facility census was 115.

Inspectors wroteBased on medical record review, review of the facilities infection control log, staff interview, and facility policy review, the facility failed to to follow appropriate antibiotic stewardship protocols. This affected two (Residents #39 and #90) of five residents reviewed for unnecessary medications. The facility census was 115.

Inspectors wroteBased on personnel record review, staff interview, and policy review, the facility failed to ensure the social worker had the proper qualifications of one year of supervised social work experience in a health care setting for a facility with 126 beds. This had the potential to affect all 115 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure pureed foods were prepared in a manner to maintain nutritive value. This affected one (#46) of three residents reviewed for diet orders. The facility identified two residents with physician ordered pureed diets. The facility census was 112.

Inspectors wroteBased on observation, medical record review, review of a dietary meal ticket and staff interview, the facility failed to ensure diet textures were served per physician orders. This affected one (#77) of three residents reviewed for diet orders. The facility identified two residents with physician ordered pureed diets. The facility census was 112.

Inspectors wroteBased on observation, medical record review, review of Enhanced Barrier Precautions (EBP) signage, staff interview and review of facility policy, the facility failed to follow infection prevention guidelines for EBP when staff failed to wear appropriate personal protective equipment (PPE). This affected one (#28) of three residents reviewed for infection control. The facility census was 112.

Inspectors wroteBased on medical record review, review of a resident risk management meeting document, review of Quality Assurance Performance Improvement meeting documents, staff and resident interviews, and review of the facility's smoking policy, the facility failed to ensure Resident #135 exhibited safe smoking practices, stored his smoking materials appropriately, and did not smoke while near oxygen. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries when Resident #135 lit his lighter in his room while in bed and with his supplemental oxygen on and being delivered via nasal cannula. Resident #135's oxygen ignited, resulting in second-degree burns (burns involving the first two layers of skin) that covered one-fourth of the resident's face, both nostrils, and burnt a portion of Resident #135's bedding. [...]

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to obtain resident consent prior to searching a resident's personal possessions and removing personal items without resident knowledge. This affected one (#26) of three residents reviewed for personal property. The facility census was 108.

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to medications were maintained in a safe and secure manner. This affected one (#26) of one residents reviewed for medication storage. The facility census was 108.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, physician interview, review of the facility's Self-Reported Incident (SRI), review of the facility's elopement investigation, review of the police report, and facility policy review, the facility failed to provide adequate supervision of a severely cognitively impaired resident to prevent the resident from leaving the facility unsupervised. Actual Harm occurred to Resident #113 when she went unsupervised for approximately five hours, was found 0.4 miles from the facility by a Good Samaritan, which lead to being hospitalized and treated for a closed head injury, facial laceration with stitches, hematoma of face, left knee injury, and left hand injury. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy and procedure review, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #10. Actual harm occurred on 05/13/22 when Resident #10, who was severely cognitively impaired, was identified to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling), pressure ulcer to the right heel. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer. The facility failed to ensure the pressure ulcer was timely identified prior to being found as a Stage III with slough (Non-viable yellow, tan, gray, green or brown tissue; [...]

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure four residents ((#10, #31, #37 and #73), who were dependent on staff received care in the area of nail care and showers. This affected four of seven residents reviewed for activities of daily living (ADL). The facility census was 114. Findings Include: 1. Review of Resident #10's medical record revealed an initial admission date of 12/30/21 with diagnoses including atrial fibrillation, congestive heart failure, diabetes mellitus, adult failure to thrive, encephalopathy, chronic kidney disease, hypertension, anxiety disorder, dementia with behavioral disturbances and psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understands others, and has a severe cognitive deficit. [...]

Inspectors wroteBased on observations, record review, facility policy review, and interview the facility failed to ensure residents smoking materials were stored in a safe and secure manner. This affected five residents (#74, #67, #16, #57, and #14) of five residents reviewed for smoking. The facility census was 114.

Inspectors wroteBased on medical record review, observation, interview of facility staff, and facility policy, the facility failed to ensure medication was administered with a nurse at bed side and medications were stored in a safe and secure manner affecting two residents (#17, #74 ) out of four residents reviewed and failed to ensure that one medication cart was locked in patient care area. This had the potential to affect twelve residents ( #03, #06, #20, #21, #24, #35, #47,#50, #55, #59, #91, and #109) who were confused ,ambulatory, and wheelchair bound that propel independently. The facility census was 114. Findings Included: 1. Review of medical record revealed Resident #17 admission date of 10/06/21. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, anxiety, obstructive sleep apnea, and psychoactive substance abuse. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to follow proper infection control and isolation precaution procedures regarding personal protective equipment (PPE) usage, incontinence care, and hand washing and did not disinfect the glucometer. This affected nine (Resident #365, #366, #367, #368, #73, #77, #88, #31, and #10) of 25 residents reviewed during the annual survey. In addition, the facility failed to cleanse a glucometer after use on one resident (#61) , which had the potential to affect five residents whom the facility identified as residing on unit three and utilizing the glucometer. The census was 114. Findings Include: 1. Observations on 07/11/22 from 11:51 A.M. to 11:57 A.M. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure contracted hospice documentation was available as part of the resident's medical record. This affected one (Resident #33) of one resident reviewed for hospice services. The facility census was 114. Findings Include: Review of Resident #33's medical record revealed an initial admission date 06/19/17 with the diagnoses of COPD, bipolar disorder, dementia with behavioral disturbances, CHF, hypertensive heart disease, anorexia, protein-calorie malnutrition, senile degeneration of brain, anemia, H/O COVID-19, thyrotoxicosis with diffuse goiter. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had a severe cognitive deficit. Review of the mood and behavior revealed the resident rejected care. [...]

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to ensure one resident (#31) received incontinence care in a timely manner. This affected one of one resident reviewed for bowel and bladder incontinence. Additionally, the facility failed to ensure one resident's (#42) indwelling urinary catheter collection bag was positioned to promote optimal draining. This affected one of one resident reviewed for catheter care. The facility census was 114. Findings Include: 1. [...]

Inspectors wroteBased on medical record, observation, interview of staff, and policy, the facility failed to ensure that tracheostomy residents had the correct supplies. This affected one resident (#17) out of three tracheostomy residents reviewed. The facility census was 114. Findings Included: Review of medical record revealed Resident #17 revealed an admission date of 10/06/21. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, anxiety, obstructive sleep apnea, and psychoactive substance abuse. Review of quarterly Minimum Data Set (MDS) dated on 04/13/22 revealed resident was cognitively intact. Resident required for assistance supervision with one-person physical assist with bed mobility, toilet use, and personal hygiene. Resident required supervision setup help only for dressing, and transfers. Resident required setup help for all meals. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed provide appropriate parameters to ensure as needed pain medication was given in a consistent manner. This affected one (Resident #35) of five residents reviewed for unnecessary medications. The census was 114. Findings Include: Resident #35 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, chronic respiratory failure, unspecified protein calorie malnutrition, type II diabetes, hypertensive heart disease, esophagitis, tracheostomy status, hyperlipidemia, insomnia, depression, cognitive communication deficit, and schizoaffective disorder. Review of his Minimum Data Set (MDS) assessment, dated 05/06/22, revealed he had a significant cognitive impairment. [...]

Inspectors wroteBased on observation, record review, facility staff interview, policy review and manufacture administration directions, the facility failed to administer medication according to physicians order for one resident (#61) of five residents observed during medication pass, and failed to properly administer medication using an insulin pen for one resident (#61) of one resident observed receiving insulin. This resulted in a medication error rate of nine percent. The total facility census was 114. Findings Include: Observation of Resident #61 receiving medication on 07/13/22 at 8:31 A.M. revealed Licensed Practical Nurse (LPN) #500 administered the following medications to Resident #61: [...]

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed provide the appropriate diet to meet a residents needs. This affected one (Resident #73) of five residents reviewed for food. The census was 114.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review, the facility failed to ensure all call lights were functioning appropriately. This affected one (Resident #27) of one call lights attempted for functionality. The census was 114. Findings Include: Observations on 07/11/22 from 2:55 P.M. to 3:05 P.M. revealed surveyor pushing Resident #27 call light button five times; the call light did not activate the light above her entry door to her room, and it did not activate the light inside the room as well. The call light was plugged into the wall appropriately; the call light was simply not activating the signal to let others know she needed assistance. Director of Nursing and Plant and Maintenance Director #791 walked into Resident #27 room at approximately 3:05 P.M., both attempted to activate the call light, and it did not work for them either. [...]