Latimer Nursing Home

In the surveyor’s words

From the most serious findings on record at Latimer Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880May 3, 2024

  Based on observation, record review, and interview, the facility failed develop, implement a policy and procedure for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The administrator identified 23 residents who resided in the facility. Findings: There was no policy and procedure for Legionella and other opportunistic waterborne pathogens in the building water system. On 05/03/24 at 10:16 a.m., the maintenance man stated the facility did not have a policy and procedure for Legionella at this time, but they were working on writing a policy and procedure for Legionella and other waterborne pathogens for the facility.

• No harm, potential for more than minimal, widespreadF578Mar 23, 2023

  Based on record review and interview, the facility failed to ensure residents were informed and provided written information concerning the right to accept or refuse to formulate an advance directive. The Resident Census and Conditions of Residents, dated 03/21/23, documented a census of 27 residents. Findings: A review of the facility's policies failed to show implementation of a policy for advance directives. A review of records failed to show written advanced directive information had been provided to residents. On 03/22/23 at 4:00 p.m., the DON reported they were unaware of the requirement to inform and provide written information to residents regarding the right to accept or refuse to formulate an advance directive.

• No harm, potential for more than minimal, patternF584May 13, 2025

  Based on observation and interview, the facility failed to provide an environment free of urine odors for 1 of 2 halls. The Point of Care Rooms/Beds roster showed there were 14 residents residing on the South hall. Findings: On 05/05/25 at 12:30 p.m., there was a strong urine odor present on the South hall. On 05/06/25 at 7:50 a.m., there was a strong urine odor present on the South hall. On 05/07/25 at 7:55 a.m., there was a strong urine odor present on the south hall. On 05/07/25 at 4:07 p.m., LPN #3 stated in the morning the South hall smelled of urine. LPN #3 stated the odor got stronger when they opened the hopper room door. LPN #3 stated the strong urine smelled like the residents on the hall needed to drink more water. […]

• No harm, potential for more than minimal, patternF755May 13, 2025

  Based on record review and interview, the facility failed to ensure a resident received their pain medication as ordered by the physician for 1 (#20) of 1 sampled resident reviewed for narcotic pain medication use. The MDS coordinator identified 15 residents received narcotic pain medications. Findings: Resident #20's quarterly assessment, dated 03/24/25, showed Resident #20 was cognitively intact with a BIMS score of 15 and had diagnoses which included multiple sclerosis and chronic pain. Physicians orders, dated 03/26/25, showed Resident #20 was to receive: a. hydrocodone/acetaminophen (narcotic pain reliever) 10/325 mg, Give one tablet every six hours; b. cyclobenzaprine (muscle relaxant) 10 mg. Give one tablet in the morning, afternoon, and at bedtime; c. […]

• No harm, potential for more than minimal, patternF880May 13, 2025

  Based on observation, record review, and interview, the facility failed to utilize EBP for 1 (#21) of 1 resident who was observed to receive catheter care. The Matrix for Providers identified three residents with urinary catheters. Findings: On 05/05/25 at 1:13 p.m., Resident #21 was observed in bed with a catheter bag hooked to the side of the bed. There was no sign to utilize enhanced barrier precautions nor was there enhanced barrier precaution equipment visible near the entrance to the resident's room or in the resident's room. On 05/08/25 at 2:50 p.m., CNA #4 was observed to drain the resident's urinary catheter. There was a towel, washcloth, and gloves lying on the floor near the foot of the resident's bed. […]