Inspection·November 26, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, review of facility policy and interview, the facility failed to ensure Resident #215 received adequate, timely and necessary care and services to prevent an acute change in condition related to hypokalemia (decreased potassium) level. Residents Affected - Few Actual Harm occurred beginning on 10/25/24 at 3:33 P.M. when Resident #215's laboratory results reflected a low potassium level of 3.0 mmol/L (normal range 3.5 -5.0) (indicative of hypokalemia) which went unreviewed and unaddressed by facility staff. On 10/28/24 Resident #215 began to experience shortness of breath and required supplemental oxygen. On 10/30/24 Resident #215's heart rate was noted to be between 41 and 46 beats per minute (low/bradycardic) and the resident informed staff his automated implanted cardioverter defibrillator (AICD) had alarmed. On 10/31/24 at 7:30 A.M. Resident #215 was noted to have a change in condition including a new irregular pulse with a listed heart rate of 46 (bradycardic), generalized weakness, and signs of delirium. Resident #215 was sent to a local emergency department where he was assessed to have chest pain with an abnormal heart rhythm of Ventricular Tachycardia (VT) and required multiple defibrillations to return to a normal heart rate and rhythm. The hospital records indicated Resident #215's VT was likely precipitated by his significant hypokalemia (low blood potassium) which was listed as 2.6 mmol/ml upon arrival to the emergency department. Resident #215 was subsequently admitted to the hospital and did not return to the facility. This affected one resident (#215) of three residents reviewed for quality of care/emergency care. The facility census was 215. Findings include: Review of the closed medical record for Resident #215 revealed an admission date of 10/22/24. Medical diagnoses included chronic systolic and diastolic heart failure, chronic obstructive pulmonary disease, type two diabetes, chronic respiratory failure, chronic kidney disease, paroxysmal atrial fibrillation, and encounter for adjustment and management of automatic implantable cardiac defibrillator. Resident #215 was transferred to a local hospital on [DATE] and did not return to the facility. Review of Resident #215's hospital discharge notes dated 10/22/24 revealed the resident had a scheduled visit with the cardiologist on 11/06/24. The hospital indicated he had recommended outpatient testing which included obtaining a Basic Metabolic Panel (BMP) and magnesium level in three to five days. Review of Resident #215's physician orders dated 10/24/24 revealed an order to draw a BMP on 10/25/24 and fax the results to the resident's cardiologist. A fax number for the provider was included in the order. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 365379 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 365379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Walden Park 5700 Karl Road Columbus, OH 43229 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)