Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
104% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
84% occupied
Based on a December 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 3
Date: Dec 10, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report and thoroughly investigate allegations of inappropriate sexual behavior and abuse involving residents.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to timely report and properly investigate sexual abuse and inappropriate sexual behavior incidents involving residents. The investigation confirmed multiple failures in reporting and investigation processes, as well as a serious injury due to improper transfer technique. The complaint number is OH2680058.
Findings
The facility failed to timely report allegations of sexual abuse involving multiple residents to the state agency and law enforcement. Additionally, the facility failed to thoroughly investigate incidents involving inappropriate sexual behavior and did not ensure safe transfer practices, resulting in a resident injury.
Deficiencies (3)
F 0609: The facility failed to timely report allegations of suspected abuse, neglect, or theft and report investigation results to proper authorities. This affected multiple residents with allegations of sexual abuse not reported to the State agency or law enforcement.
F 0610: The facility failed to thoroughly investigate incidents involving allegations of inappropriate sexual behavior affecting residents, including failure to file incident reports and notify the State agency.
F 0689: The facility failed to ensure safe transfers using a mechanical lift with two staff, resulting in a resident sustaining a right femur fracture and requiring surgery.
Report Facts
Residents affected: 4
Facility census: 106
Final written warning: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #505 | Registered Nurse | Named in allegation of sexual abuse by Resident #33. |
| CNA #286 | Certified Nursing Assistant | Operated mechanical lift alone causing resident injury; received final written warning. |
| Social Services Supervisor #520 | Involved in communication and investigation of sexual abuse allegations. | |
| Unit Manager #461 | Interviewed regarding reporting of sexual abuse allegations. | |
| LPN #446 | Licensed Practical Nurse | Notified about resident injury and bruise; interviewed about incident. |
Inspection Report
Routine
Census: 115
Deficiencies: 12
Date: Feb 19, 2025
Visit Reason
Routine inspection of Laurels of Norworth nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, environment, and staffing.
Findings
The facility had multiple deficiencies including inaccurate PASARR screenings, delayed vision and dental services, inadequate monitoring of resident weight loss, insufficient behavioral health care planning, improper medication management including unnecessary psychotropic and antibiotic use, unsafe food handling practices, unqualified social worker staffing, and environmental maintenance issues.
Deficiencies (12)
F 0644: The facility failed to ensure accurate Pre-admission Screening and Resident Review (PASARR) documents for residents, affecting two residents with inaccurate mental health diagnoses.
F 0646: The facility failed to timely coordinate level two PASARR evaluation with the state mental health agency for one resident with a significant change in condition.
F 0685: The facility failed to obtain vision services in a timely manner for one resident, resulting in delayed provision of eyeglasses.
F 0692: The facility failed to appropriately monitor significant weight loss and follow dietitian recommendations for two residents, delaying weekly weight checks and re-weighs.
F 0740: The facility failed to provide planning, treatment, and oversight for a resident's behavioral health related to catheter care, including lack of documentation of behaviors and interventions.
F 0757: The facility failed to provide parameters for as needed pain medications, resulting in inconsistent administration of acetaminophen and oxycodone for one resident.
F 0758: The facility failed to monitor behaviors and provide appropriate justification for psychotropic medication use for one resident with vascular dementia behaviors.
F 0790: The facility failed to timely obtain routine dental services for two residents, resulting in delayed denture replacement and dental follow-up.
F 0812: The facility failed to serve food in a safe and sanitary manner, with staff observed not changing gloves appropriately while handling food.
F 0850: The facility failed to ensure the social worker had required supervised social work experience for a facility with more than 120 beds.
F 0881: The facility failed to follow appropriate antibiotic stewardship protocols, including unnecessary multiple antibiotic use and lack of monitoring for two residents.
F 0921: The facility failed to maintain a clean and sanitary environment, with multiple maintenance issues observed in resident rooms and hallways.
Report Facts
Facility census: 115
Weight loss percentage: 5.26
Weight loss pounds: 13.2
Number of antibiotics administered simultaneously: 4
Number of residents affected by environmental issues: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Assistant #334 | Social Services Assistant | Confirmed inaccuracies in PASARR screenings and delays in level II evaluation coordination |
| Social Services Assistant #279 | Social Services Assistant | Responsible for coordinating ancillary services including vision and dental; confirmed delays in services |
| Registered Dietitian #353 | Registered Dietitian | Recommended increased nutritional supplements and weekly weights for Resident #87 |
| Restorative Certified Nursing Assistant #278 | Restorative Certified Nursing Assistant | Responsible for obtaining weekly weights; confirmed gaps in weight monitoring |
| Director of Nursing | Director of Nursing | Confirmed multiple deficiencies including weight monitoring, behavioral health documentation, medication parameters, and antibiotic stewardship |
| Registered Nurse #227 | Registered Nurse | Confirmed lack of pain medication parameters |
| Registered Nurse #236 | Registered Nurse | Confirmed lack of pain medication parameters and inconsistent administration |
| Psychiatric Nurse Practitioner #400 | Psychiatric Nurse Practitioner | Confirmed inappropriate justification for psychotropic medication and need for better behavior monitoring |
| Social Worker #291 | Social Worker | Lacked evidence of required supervised social work experience |
| Social Service Liaison #401 | Social Service Liaison | Confirmed no oversight or sign-off on social service work |
| Dietary Manager #271 | Dietary Manager | Observed improper glove use during food service |
| [NAME] #215 | Dietary Staff | Observed improper glove use during food service |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 3
Date: Nov 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Numbers OH00159365 and OH00159038, focusing on concerns related to diet preparation and infection prevention practices.
Complaint Details
The deficiencies represent non-compliance investigated under Complaint Numbers OH00159365 (dietary issues) and OH00159038 (infection control).
Findings
The facility failed to ensure pureed foods were prepared to maintain nutritive value and proper texture, and diet textures were not consistently served per physician orders. Additionally, staff failed to follow infection prevention guidelines by not wearing appropriate personal protective equipment during care.
Deficiencies (3)
F 0804: The facility failed to ensure pureed foods were prepared to maintain nutritive value and taste, resulting in pureed turkey burger lacking flavor and improper thickening methods.
F 0805: The facility failed to serve diet textures per physician orders, evidenced by serving shredded lettuce to a resident ordered to have pureed vegetables.
F 0880: The facility failed to follow infection prevention guidelines by not wearing gowns during Enhanced Barrier Precautions for a resident with a feeding tube.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Manager #60 | Interviewed regarding pureed turkey burger preparation | |
| Dietician #59 | Interviewed regarding pureed food consistency and diet orders | |
| Regional Dietician (RD) #58 | Interviewed regarding pureed food preparation and diet order adherence | |
| Director of Nursing (DON) | Confirmed incorrect diet texture served to Resident #77 | |
| Licensed Practical Nurse (LPN) #90 | Observed not wearing gown during PEG tube care for Resident #28 |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Date: Mar 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to resident rights violations, unsafe smoking practices, and medication storage issues.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00150945.
Findings
The facility failed to obtain resident consent before searching personal possessions, failed to ensure safe smoking practices resulting in immediate jeopardy due to a resident's oxygen igniting, and failed to maintain medications in a safe and secure manner. Multiple residents were found to be non-compliant with smoking policies, and corrective actions were implemented.
Deficiencies (3)
F 0557: The facility failed to obtain resident consent prior to searching a resident's personal possessions and removing items without resident knowledge, affecting one resident. The facility census was 108.
F 0689: The facility failed to ensure safe smoking practices and supervision, resulting in immediate jeopardy when a resident's oxygen ignited causing second-degree burns. The facility remained out of compliance at Severity Level 2 after corrective actions.
F 0761: The facility failed to maintain medications in a safe and secure manner when a medication cup was left at a resident's bedside without supervision. The facility census was 108.
Report Facts
Facility census: 108
Residents reviewed for smoking: 5
Residents who smoke independently: 19
Residents who require supervision with smoking: 4
Residents who smoke with unsafe storage: 2
Residents affected by personal possessions deficiency: 1
Residents affected by smoking deficiency: 5
Residents affected by medication storage deficiency: 1
Residents who smoke with supervision evaluations: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #150 | Licensed Practical Nurse | Wrote nursing progress note regarding Resident #135's burn incident |
| STNA #194 | State Tested Nurse Aide | Discovered burning smell and resident with burns; reported cigarette butts and lighter |
| LPN #162 | Licensed Practical Nurse | Left medication cup at Resident #26's bedside without supervision |
| Administrator | Conducted room searches, interviews, and confirmed incidents related to Resident #135 and Resident #26 | |
| DON | Director of Nursing | Participated in interviews, education, and corrective actions related to smoking and medication deficiencies |
| SW #184 | Social Worker | Conducted room searches and education on smoking policy |
| UM LPN #166 | Unit Manager Licensed Practical Nurse | Conducted smoking evaluations |
| UM LPN #165 | Unit Manager Licensed Practical Nurse | Conducted smoking evaluations |
| ADON #250 | Assistant Director of Nursing | Conducted smoking evaluations and staff education |
| STNA #251 | State Tested Nurse Aide | Educated on smoking policy after incident |
| STNA #207 | State Tested Nurse Aide | Educated on smoking policy after incident |
| STNA #225 | State Tested Nurse Aide | Educated on smoking policy after incident |
| RN #176 | Registered Nurse | Educated on smoking policy after incident |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
Annual inspection survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 1
Date: Oct 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an incident where a severely cognitively impaired resident eloped from the facility unsupervised and sustained injuries.
Complaint Details
This was an incidental finding discovered during the course of the complaint investigation. The facility unsubstantiated the allegation of injury of unknown origin but confirmed the resident eloped and sustained injuries.
Findings
The facility failed to provide adequate supervision to prevent Resident #113 from leaving the facility unsupervised, resulting in actual harm including head injury, facial lacerations, and other injuries. The facility conducted an investigation and implemented corrective actions including placing a wander guard and staff education.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent Resident #113 from eloping unsupervised, resulting in actual harm including a closed head injury, facial lacerations with stitches, hematoma, and other injuries.
Report Facts
Census: 112
Distance resident eloped: 0.4
Number of stitches: 7
Number of stitches: 3
Measurement of wounds: 2.5
Measurement of wounds: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #240 | Licensed Practical Nurse | Notified Director of Nursing about missing resident and involved in investigation |
| RN #289 | Registered Nurse | Noticed resident's breakfast tray was untouched and did not see resident during shift |
| RN #243 | Registered Nurse | Did not see resident and noted resident did not come down for breakfast |
| STNA #365 | State Tested Nursing Assistant | Did not see resident during shift and did not realize resident was missing until breakfast tray was uneaten |
| STNA #360 | State Tested Nursing Assistant | Did not recall seeing resident during shift |
| STNA #281 | State Tested Nursing Assistant | Did not see resident walking halls during shift |
| STNA #228 | State Tested Nursing Assistant | Helped search for missing resident and noted concern when breakfast was not eaten |
| Administrator | Placed call to police and updated staff on resident's location | |
| DON | Director of Nursing | Initiated investigation, provided staff education, and verified facility failed to identify length of time resident was missing |
| Physician #417 | Physician | Verified resident required supervision due to severe cognitive deficits |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 2
Date: Aug 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to facility maintenance issues including unsafe, unclean resident rooms and pest control problems involving mice and ants.
Complaint Details
This deficiency represents noncompliance under Master Complaint Number OH00145492 and Complaint Number OH00145368. Multiple residents reported mice sightings in their rooms, and exterminator reports showed ongoing pest issues with unaddressed recommendations.
Findings
The facility failed to maintain safe, clean, and sanitary resident rooms affecting 62 of 112 residents, with issues such as holes in walls, leaking air conditioners, dirty floors, and damaged molding. Additionally, the facility failed to adequately address pest control, with multiple residents reporting mice sightings and exterminator recommendations remaining unaddressed since 2018.
Deficiencies (2)
F 0921: The facility failed to maintain safe, clean, and sanitary resident rooms, with issues including holes in walls, leaking air conditioners, dirty floors, and damaged molding affecting 62 residents.
F 0925: The facility failed to implement an effective pest control program, resulting in mice and ants infestations and failure to act on exterminator recommendations dating back to 2018.
Report Facts
Residents affected: 62
Facility census: 112
Resident rooms: 70
Rooms with issues: 40
Residents affected by pest control issues: 12
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 1
Date: Jul 27, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to a significant medication error involving intravenous antibiotic administration.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144343.
Findings
The facility failed to ensure a resident received the prescribed intravenous antibiotic on the ordered date, resulting in a medication error affecting one resident out of five reviewed for intravenous medications.
Deficiencies (1)
F0760: The facility failed to ensure a resident received Daptomycin injection 800 mg by IV route every 24 hours on the ordered date of 06/10/23. The medication was administered starting 06/11/23 after a delay due to corporate permission requirements.
Report Facts
Facility census: 113
Residents reviewed for intravenous medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the medication error and delay in ordering medication |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication error rates exceeding five percent.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00142422.
Findings
The facility failed to ensure a medication error rate below five percent, with three medication errors out of 27 opportunities, resulting in an 11.11% error rate affecting three residents during medication pass observation.
Deficiencies (1)
F 0759: The facility failed to ensure medication error rates were below five percent. Three medication errors were identified involving incorrect dosages and missed administration for Residents #6, #39, and #93.
Report Facts
Medication errors: 3
Facility census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #212 | Licensed Practical Nurse | Prepared and administered incorrect dosage of Cholecalciferol to Resident #93. |
| LPN #213 | Licensed Practical Nurse | Failed to administer Fluticasone to Resident #39 and administered incorrect dosage of Cholecalciferol to Resident #6. |
| Assistant Director of Nursing #111 | Assistant Director of Nursing | Verified correct dosage of Cholecalciferol for Resident #6 and confirmed medication error. |
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 12
Date: Jul 15, 2022
Visit Reason
Annual survey inspection of Laurels of Norworth nursing home to assess compliance with regulatory requirements including resident care, medication administration, infection control, and safety.
Findings
The facility was found deficient in multiple areas including inadequate personal care for residents, failure to provide appropriate hospice documentation, pressure ulcer prevention and care, unsafe smoking material storage, delayed incontinence care, improper catheter care, respiratory care deficiencies, inconsistent pain medication administration, medication errors, unlocked medication cart, improper infection control practices, and malfunctioning call light system.
Deficiencies (12)
F 0677: The facility failed to provide adequate personal care including nail care and timely showers for dependent residents, affecting four residents. Observations showed long, jagged nails and inconsistent showering schedules.
F 0684: The facility failed to ensure contracted hospice documentation was available in the medical record for one resident receiving hospice services.
F 0686: The facility failed to prevent development of a Stage III pressure ulcer and failed to timely identify and properly treat the ulcer for one resident.
F 0689: The facility failed to ensure safe storage of smoking materials for five residents, allowing residents to keep cigarettes and lighters at bedside contrary to policy.
F 0690: The facility failed to provide timely incontinence care for one resident and failed to position an indwelling urinary catheter collection bag below the bladder for another resident.
F 0695: The facility failed to ensure a tracheostomy resident had the correct emergency respiratory supplies, lacking a smaller size inner cannula.
F 0757: The facility failed to provide consistent parameters for as needed pain medication administration, resulting in inconsistent dosing for one resident.
F 0759: The facility failed to administer medication according to physician orders for one resident and failed to properly prime insulin pens before administration.
F 0761: The facility failed to ensure medications were stored securely and administered with nurse supervision at bedside, and failed to lock a medication cart, potentially exposing medications to unauthorized access.
F 0805: The facility failed to provide a resident with a mechanical soft diet as ordered, instead providing a regular diet with uncut meat.
F 0880: The facility failed to implement proper infection prevention and control practices including improper PPE use, inadequate hand hygiene, failure to disinfect glucometer, and improper incontinence care.
F 0919: The facility failed to ensure a resident's call light system was functioning properly, causing delays in assistance.
Report Facts
Facility census: 114
Medication error rate: 9
Pressure ulcer size: 1.5
Pressure ulcer size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #743 | Licensed Practical Nurse | Verified long jagged nails, provided wound care, confirmed medication administration errors |
| LPN #500 | Licensed Practical Nurse | Observed medication administration errors and glucometer use without sanitizing |
| STNA #704 | State Tested Nursing Assistant | Observed providing incontinence care with improper infection control |
| STNA #712 | State Tested Nursing Assistant | Observed passing trays without proper PPE in isolation rooms |
| DON | Director of Nursing | Provided multiple confirmations of deficiencies and policy reviews |
| UM #210 | Unit Manager | Confirmed PPE requirements and medication storage issues |
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 9
Date: Dec 12, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, inaccurate medical records, lack of timely care conferences, inadequate activity provision, improper respiratory care, delayed dental services, improper food preparation and storage, and infection control lapses.
Deficiencies (9)
F 0550: The facility failed to maintain dignity for two residents by allowing one to wear a hospital bracelet containing personal information and another to remain in a hospital gown due to difficulty dressing. This affected 2 of 23 residents reviewed.
F 0578: The facility failed to ensure Resident #72's advance directive (code status) was accurately reflected in the medical record, affecting 1 of 23 residents reviewed.
F 0657: The facility failed to ensure timely quarterly care conferences for two residents, Resident #54 and Resident #100, affecting 2 of 23 residents reviewed.
F 0679: The facility failed to meet activity needs for Resident #4 by not providing appropriate materials or assistance during scheduled activities.
F 0695: The facility failed to administer oxygen per physician orders, failed to date oxygen tubing and humidification bottles, and failed to obtain a physician order for oxygen for Resident #103. This affected 3 of 19 residents on oxygen.
F 0791: The facility failed to provide timely physician-ordered dental services for Resident #4, who had an order for tooth extractions but no evidence of appointments or treatment.
F 0805: The facility failed to properly prepare pureed vegetables, which were semi-solid and not of pureed consistency, affecting 8 residents on a pureed diet.
F 0812: The facility failed to ensure food was stored correctly and not expired, including open uncovered flour, undated applesauce, and expired bread, affecting 111 of 113 residents receiving food.
F 0880: The facility failed to properly clean glucometers with approved disinfectants effective against C. difficile spores, failed to wear gowns during wound care for a resident on contact isolation with MRSA, and failed to post required contact isolation signage for a resident with C. difficile infection. This affected many residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 8
Residents affected: 111
Residents affected: 24
Facility census: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #52 | Licensed Practical Nurse | Removed hospital bracelet from Resident #60 |
| LPN #49 | Licensed Practical Nurse | Interviewed regarding Resident #54's hospital gown |
| Social Services #191 | Social Services Staff | Confirmed care conference delays for Residents #54 and #100 and dental arrangements for Resident #4 |
| PTA #144 | Physical Therapy Assistant | Observed wheeling Resident #4 to therapy and confirmed activity participation |
| Activities Assistant #160 | Activities Assistant | Observed Resident #4 during activities and provided craft supplies |
| LPN #60 | Licensed Practical Nurse | Confirmed oxygen administration issues for Resident #72 |
| RN #35 | Registered Nurse | Verified oxygen tubing undated for Resident #103 and performed wound care without gown for Resident #259 |
| RN #34 | Registered Nurse | Confirmed lack of oxygen order for Resident #103 |
| RN #222 | Registered Nurse | Observed cleaning glucometer with non-approved wipes |
| RN #31 | Registered Nurse | Observed cleaning glucometer with non-approved wipes |
| Director of Nursing | Director of Nursing | Confirmed oxygen order issues and glucometer cleaning policy non-compliance |
| Dietary Manager #172 | Dietary Manager | Verified food storage and expiration issues |
| STNA #97 | State-Tested Nursing Assistant | Confirmed lack of contact isolation signage for Resident #100 |
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