Health inspection·March 25, 2024

F 0557 hospital, he let the resident know he took the items out of his room and placed them in the DON's office. Level of Harm - Minimal harm or potential for actual harm Review of policy titled, Resident's Personal Property, dated 09/22/23, revealed residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. Strictly prohibited items included heating pads. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00150945. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. 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. This affected one (#135) of five residents reviewed for smoking. Additionally, the facility failed to ensure resident smoking materials were safely secured per facility policy for two (#12 and #30) of five residents reviewed for smoking which placed the residents at risk for the potential for more than minimal harm that was not Immediate Jeopardy. The facility identified 19 residents (#01, #07, #08, #11, #12, #17, #21, #26, #30, #34, #38, #39, #43, #47, #61, #76, #87, #93 and #105) who smoke independently and four residents (#50, #64, #69, and #72) who required supervision with smoking. The facility census was 108. On 03/13/24 at 10:18 A.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 12/26/23 at 5:30 A.M. when Resident #135, who utilized supplemental oxygen therapy via nasal cannula, lit his lighter in his room resulting in the oxygen igniting. Review of Resident #135's nursing progress note dated 12/26/23 at 7:57 A.M. written by Licensed Practical Nurse (LPN) #150 revealed there was a strange sound heard in the hallway with a burning smell noted. State Tested Nurse Aide (STNA) #194 discovered it was coming from Resident #135's room. Resident #135 was seen in the room panicking and anxiously gasping for air with a burned face. Resident #135 and his roommate (Resident #76) were safely taken out of the room to the nurse's station. The oxygen in the room was turned off. There was a cigarette butt, lighter, and a burned blanket that were found in the resident's room. The physician progress notes revealed the resident sustained second-degree burns that covered one-fourth of the right side of Resident #135's face and nostril. The facial burns were secondary to the resident using a lighter with supplemental oxygen on. Resident #135 refused to go to the hospital and the risk of serious infection was explained to the resident, but Resident #135 did not want to leave the facility. The Immediate Jeopardy was removed on 12/27/23 when the facility implemented the following corrective actions: • On 12/26/23 at 7:57 A.M., the DON spoke with Resident #135 and his roommate, Resident #76, regarding details of the incident and verified that no smoking materials were in the room at that time. Resident #135 stated he did not wish to continue to smoke and declined nicotine replacement. • On 12/26/23, the DON provided Resident #135 education regarding the facility smoking policy with Resident #135 expressing understanding of the education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 • Level of Harm - Immediate jeopardy to resident health or safety On 12/26/23 at 9:00 A.M., the Administrator and Social Worker (SW) #184 conducted room searches on all 25 residents who smoke with the permission of the residents and collected any smoking paraphernalia that was found. Re-education was provided to all 25 residents who smoke on the smoking policy and the proper storage of smoking materials by the Administrator and SW #184 on 12/26/23 with all 25 residents signing acknowledgement of the education on the smoking policy and procedure which included adherence to the facility smoking policy and procedure. Residents Affected - Few • On 12/26/23 from 9:00 A.M. through 4:00 P.M., the DON along with Unit Manager (UM) LPN #166, UM LPN#165, and Assistant Director of Nursing (ADON) #250 completed new smoking evaluations on all 25 residents who smoke to determine safety risk and need for supervision on 12/26/23. • On 12/26/23 all facility staff were re-educated on the smoking policy and the designated locations for smoking materials. Facility staff education continued prior to working their next scheduled shift by the DON and ADON #250 on the smoking policy and designated storage areas for smoking materials with all staff education completed on 12/27/23. • Ongoing weekly audits were conducted by SW #184 and the Administrator on 01/03/24, 01/09/24, 01/17/24, 01/24/24 and 01/31/24. Department managers have continued to complete random audits of resident rooms for smoking paraphernalia. Any issues identified will be immediately corrected. All audits to be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for review and recommendations. • Interviews with STNA #251, STNA #207, STNA #225 and Registered Nurse (RN) #176 on 03/13/24 at 2:48 P.M. revealed they were educated regarding the facility smoking policy after the incident took place with Resident #135, and verified they were knowledgeable about the content of the education. • Observation on 03/14/24 at 12:01 P.M. of the scheduled smoke break revealed staff and residents were outside in the designated smoking area and staff was providing supervision to all residents present in the smoking area. There were no oxygen tanks or unsafe smoking practices observed. Although the Immediate Jeopardy was removed on 12/27/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1) Review of Resident #135's medical record revealed an admission date of 02/08/22. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, depression, and chronic respiratory failure with hypoxia. Resident #135 was discharged on 02/29/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #135 was assessed as cognitively intact. Further review revealed the resident had no impairment to his upper or lower extremities and used a wheelchair. Resident #135 was assessed as independent for eating and bed mobility and required supervision or touching assistance for transfers. Review of the care plan dated 03/02/22 revealed Resident #135 wished to use smoking products and was assessed as being safe to smoke with supervision only. The resident reported he no longer wanted to smoke and will not be smoking and if he does, he must have supervision. Interventions were to assess the resident's ability to smoke safely, educate family and friends not to provide cigarettes directly to the resident, educate resident that oxygen use was prohibited in the smoking area, educate the resident on the smoking policy, and the staff will manage all smoking materials for unsafe and safe smokers. Review of the most recent smoking assessment dated [DATE] revealed Resident #135 was alert, consistent with decision ability, could grasp and hold a cigarette, and had quick response to fallen ashes. The resident could safely light and hold the cigarette, dispose of ashes, and extinguish the cigarette safely. Resident #135 removed his oxygen tubing before coming into the smoking area, and also followed the smoking guidelines per policy including smoking in the designated area and returning the smoking paraphernalia to the appropriate person/location. Resident #135 was assessed as a safe smoker and could smoke independently if he wished. Review of Resident #135's nursing progress note dated 12/26/23 at 7:57 A.M. written by LPN #150 revealed there was a strange sound heard in the hallway with a burning smell noted. STNA #194 discovered it was coming from Resident #135's room. Resident #135 was seen in the room panicking and anxiously gasping for air with a burned face. Resident #135 and his roommate (Resident #76) were safely taken out of the room to the nurse's station. The oxygen in the room was turned off. There was a cigarette butt, lighter, and a burned blanket that were found in the room. Resident #135 refused to be sent to the hospital and denied pain. A cold compress was applied to his face with Plurogel cream (a cream used to heal burns). The physician ordered Silvadene one (1) percent (%) cream (an antimicrobial cream used to treat and prevent wound sepsis from second- and third-degree burns) to be applied twice a day and Resident #135 refused for family to be notified. Review of a physician progress note dated 12/28/23 at 12:00 P.M. revealed there was a partial thickness burn to Resident #135's face. The resident had second-degree burns that covered one-fourth of the right side of Resident #135's face and nostril. The facial burns were secondary to the resident using a lighter with supplemental oxygen on. Resident #135 refused to go to the hospital and the risk of serious infection was explained to the resident, but Resident #135 did not want to leave the facility. Review of nursing progress notes dated 01/07/24 revealed Resident #135 had smoking materials found in his room and the items were removed. Resident #135 was educated on the smoking policy and on supervised smoking times, and the resident verbalized understanding. Review of nursing progress notes dated 01/09/24 revealed Resident #135 was found outside in the facility courtyard smoking without supervision and without staff knowledge. At that time, Resident #135 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 was placed on one-to-one supervision for continued non-compliance with the smoking policy. Level of Harm - Immediate jeopardy to resident health or safety Review of the resident risk management meeting dated 01/25/24 revealed Resident #135 exhibited non-compliance with smoking policy on numerous occasions and he was currently on one-to-one supervision to ensure his safety due to his need for continuous oxygen and desire to continue smoking. Smoking cessation was offered on numerous occasions and Resident #135 declined. The resident was currently receiving Remeron for depression, and Xanax and Hydroxyzine for anxiety. Resident #135 was issued a 30-day discharge notice due to putting the safety of himself and others at risk and plans to appeal this decision but does express a desire to discharge from the facility. Further review of the documentation from the resident risk management meeting revealed to continue Resident #135 on one-to-one supervision for safety, ensure the resident was compliant with the smoking policy, and offer psychiatric services as needed. Residents Affected - Few Review of a QAPI meeting document dated 01/29/24 revealed the smoking incidents related to Resident #135 were discussed as well as a review of safety of residents who smoke and the list of residents who smoke was reviewed. Interview with LPN #150 on 03/12/24 at 1:18 P.M. revealed on 12/26/23 at 5:30 A.M., STNA #194 discovered there was cigarette smoke and a burning smell coming from Resident #135's room. LPN #150 stated she and STNA #194 ran to the room and discovered Resident #135's face, nasal cannula, oxygen tubing, and part of the resident's blanket was burnt. LPN #150 verified there was a cigarette butt and a lighter lying on the bed. LPN #150 continued that Resident #150 was anxious because he did not have his supplemental oxygen on, so she took the resident out into the hall, placed his oxygen on, and asked him what he was doing. LPN #150 stated the resident indicated he lit his lighter to look for a pill he dropped in the bed and the oxygen ignited. LPN #150 stated there could not have been any pills in the bed because she watched the resident take all of his medications on 12/26/23 at 4:33 A.M. Concurrent interview with the Administrator and the DON on 03/12/24 at 2:30 P.M. confirmed Resident #135 ignited his oxygen tubing on 12/26/23 and burned his face, nostrils, and part of his blanket. Both the Administrator and the DON confirmed the resident was an independent smoker at the time and got the lighter and cigarettes from a visitor or family member, but did not know exactly who it was, and denied there was any documentation regarding this. The Administrator and the DON stated Resident #135's smoking materials were supposed to be handed back to the nurse at the nursing station to put them away for the next smoking time of the resident's choice. The Administrator and the DON stated they placed Resident #135 on supervised smoking, which meant someone would take the resident out to smoke beginning on 12/26/23 following the incident. Interview with Resident #76 on 03/13/24 at 7:48 A.M. revealed he was Resident #135's roommate when Resident #135 resided in the facility. Resident #76 stated, on 12/26/23 between 5:30 A.M. and 6:00 A.M., he was awakened by a poof sound and the smell of plastic, and he heard Resident #135 yell that he could not breathe because he had burnt the nasal cannula when it ignited with his cigarette lighter. Resident #76 denied he smelled cigarette smoke. Resident #76 stated the nursing staff came and took both him and Resident #135 out of the room. Resident #76 stated he did not see any fire but saw Resident #135's blanket was burnt, and the resident had burns on his face. Resident #76 stated he believed Resident #135 was trying to find his narcotic pain pill, oxycodone, in the bed and lit his lighter to look in the covers. Resident #76 stated Resident #135 smoked in the room multiple times and did not want to listen to anyone regarding smoking in the room. Resident #76 further stated Resident #135 did not feel like he needed to follow the rules and kept his smoking materials in the room with him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with the Administrator on 03/13/24 at 2:30 P.M. revealed on 12/26/23 Resident #135 did not want to smoke anymore because he was scared and a smoking cessation patch and an inhaler were offered, but the resident refused them. The Administrator stated Resident #135 was caught with smoking materials on 01/07/24 in his room and the resident was re-educated on the smoking policy, advised of the designated smoking times, and was informed he would be supervised. The Administrator stated on 01/09/24 Resident #135 was caught in the courtyard smoking unbeknownst to staff and was advised he would be on one-to-one supervision for smoking until he discharged from the facility. Resident #135 was issued a 30-day discharge notice on 01/22/24, and the Administrator stated the delay in the discharge notice was due to the resident's family not wanting Resident #135 to live with them, but one family member changed their mind and allowed Resident #135 to live with them. Interview with STNA #194 on 03/13/24 at 3:11 P.M. revealed on 12/26/23 at 5:30 A.M., she smelled cigarette smoke in the hallway and heard Resident #135 screaming. STNA #194 stated she went into Resident #135's room and the resident's cheeks, nostrils, forehead, and nasal cannula were burnt, and the nasal cannula was laying on the floor. STNA #194 confirmed she saw a cigarette butt and a lighter on Resident #135's bed along with a partially burnt blanket. STNA #194 stated Resident #135 denied smoking in his room. STNA #194 stated while collecting trash in the resident's room on another unspecified date she discovered cigarettes butts and reported them to the supervisor but could not specifically remember who she reported it to. 2) Medical record review for Resident #30 revealed an admission date of 03/01/23. Diagnoses included after care for knee and hip replacement and viral hepatitis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was assessed as cognitively intact. Resident #30 was independent for eating, bed mobility, transfers, and toileting. Review of the care plan dated 12/12/23 revealed Resident #30 wished to use smoking products and was assessed as being a safe smoker. The resident was educated on the smoking policy and was given a copy for his records. Interventions were to assess the resident's ability to smoke safely, educate family and friends not to provide cigarettes directly to the resident, educate the resident that oxygen use was prohibited in the smoking area, educate the resident on the smoking policy, and the staff will manage all smoking materials for unsafe and safe smokers. Review of the smoking evaluation dated 12/27/23 revealed Resident #30 was alert and consistent. The resident was able to grasp and hold a cigarette and had quick response to falling ashes. Resident #30 was safe to light smoking materials and held the materials safely. The resident disposed of the ashes in the ashtray and extinguished his cigarette safely. Resident #30 was deemed as a safe smoker. The evaluation was updated on 03/13/24 to show the resident was an unsafe smoker and had to be supervised because he would not turn in his smoking materials. Interview with the DON on 03/13/24 at 1:17 P.M. verified Resident #30 had smoking materials in his room that had to be removed. Interview with Resident #30 on 03/14/24 at 8:05 A.M. revealed he rolled his own cigarettes and kept his tobacco, rolling machine, and tubes in his room. Resident #30 stated the Administrator asked him to keep his smoking materials in the activity room and he could roll his cigarettes there when he needed to. Resident #30 stated he purchased the smoking supplies at the tobacco store. 3) Medical record review for Resident #12 revealed an admission date of 11/21/21. Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 included type two diabetes, depression, and asthma. Level of Harm - Immediate jeopardy to resident health or safety Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 was assessed as cognitively intact. The resident was independent for eating, toileting, bed mobility, and transfers. Residents Affected - Few Review of the care plan dated 12/13/23 revealed Resident #12 wished to use smoking products and was assessed as being a safe smoker. The resident was educated on the smoking policy and was given a copy for his records. Interventions were to assess the resident's ability to smoke safely, educate family and friends not to provide cigarettes directly to the resident, educate the resident that oxygen use was prohibited in the smoking area, educate the resident on the smoking policy, and the staff will manage all smoking materials for unsafe and safe smokers. Review of the smoking evaluation dated 12/27/23 revealed Resident #12 was alert and consistent. The resident was able to grasp and hold a cigarette and had quick response to falling ashes. The resident was safe to light smoking materials and held the materials safely. Resident #12 disposed of the ashes in the ashtray and extinguished his cigarette safely. Resident #12 was deemed as a safe smoker. On 03/13/24 the evaluation was updated to show the resident was an unsafe smoker and had to be supervised because he would not turn in his smoking materials. Interview with Resident #12 on 03/14/24 at 8:12 A.M. denied the staff found any smoking materials in his possession. Interview with the DON on 03/14/24 at 8:15 A.M. revealed the facility found a lighter in Resident #12's possession on 03/13/24, and stated the resident probably got the lighter at the gas station down the street, because the DON sees the resident there on a regular basis. Review of policy titled, Smoking Policy, dated 10/17/23, revealed residents may smoke under limited circumstances outlined in this policy but only in a designated outside smoking area, if this facility has in its sole discretion, designated such an outdoor smoking area. Staff members will maintain all smoking paraphernalia for all unsafe and safe smokers, for example cigarettes, cigars, pipes, lighters, lighter fluid, or any other matter or substance that contains a tobacco product. Staff members will distribute smoking materials to residents that are unsafe to smoke at the designated smoking times, and to residents that are deemed safe to smoke and may smoke independently, at their request. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: Review of the medical record for Resident #26 revealed an admission date of 10/27/23. Medical diagnoses included traumatic spinal cord dysfunction, paraplegia, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as cognitively intact. Resident #26 was independent for eating, independent for bed mobility, dependent for transfers, and required substantial/maximal assistance for toileting. Review of Resident #26's medical record revealed no assessment was completed for self-administration of medications. Observation on 03/11/24 at 10:43 A.M. revealed a medication cup with medications inside of it on Resident #26's bedside table in the resident's room. Interview with Resident #26 on 03/11/24 at 10:44 A.M. revealed Licensed Practical Nurse (LPN) #162 left the medications in the cup that morning. Interview with LPN #162 on 03/11/24 at 10:52 A.M. confirmed he left the medication cup with medications inside at the bedside for Resident #26. LPN #162 stated he was not supposed the leave them at the bedside, and confirmed he was supposed to watch Resident #26 take the medications. Review of the policy titled, Medication Administration, dated 10/17/23, revealed staff are to observe the resident swallow the oral medications. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 9 of 9