Laurels of Norworth the

In the surveyor’s words

From the most serious findings on record at Laurels of Norworth the, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 25, 2024

  Based 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. […]

• Actual harm, isolatedF686Feb 9, 2026

  Based 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. […]

• Actual harm, isolatedF689Dec 10, 2025

  THE 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. […]

• Actual harm, isolatedF689Oct 18, 2023

  THE 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, isolatedF686Jul 15, 2022

  Based 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. […]