Inspection·February 11, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Self Reported Incident (SRI) dated 01/13/25 and untimed revealed an allegation of physical abuse with description as: Resident #145 was hit on the right upper eyebrow by family member. Interviews from both residents and family member stating they got into an argument over a lighter. The family member was escorted out of the building and police were called. Resident #145 refused to make police report but facility continued on with report. The resident complained of nose pain on 01/13/25 and went to the hospital where it was shown the resident had a broken nose. Facility made staff aware not to allow the other resident's family member in the building. Both residents were provided with emotional support. The facility unsubstantiated the allegation due to the facility could not have predicted the event would happen. Review of the facility investigation dated 01/13/25 and untimed revealed interviews and written statements were completed by Resident #145, the Administrator, the Director of Nursing (DON), Registered Nurse (RN) #410, Smoking Aide (SA) #401, and the Alleged Perpetrator (AP) #500. There was no interview or written statement included from Resident #69 who was also on the smoking patio when the incident occurred. Review of the neurological checks completed on Resident #145 revealed the neurological checks were not completed at the proper time intervals. Review of the local hospital record dated 01/14/25 revealed Resident #145 was seen in the ED following being assaulted at his nursing home. The CT scan of the resident's maxillofacial showed an age-indeterminate nasal fracture with suspicion the fracture was an old fracture due to the resident not complaining of any nasal pain. There were no other acute findings noted. Resident #145's right eye was swollen shut with steri-strips already in place upon admission to the ED. The resident was discharged from the ED back to the nursing facility with Ibuprofen (non steroidal anti inflammatory) and Tylenol (analgesic) as needed for pain. Interviews on 02/11/25 at 10:20 A.M. and 1:04 P.M. with the Administrator revealed Resident #145, Resident #48, and Alleged Perpetrator (AP) #500 were outside on the smoking patio. Resident #145 and Resident #48 were both independent smokers. Resident #145 and AP #500 got into an altercation over a lighter or cigarettes and AP #500 hit Resident #145. AP #500 was escorted out of the building. The police were called and a report was filed on Resident #145's behalf. Resident #145 started complaining of pain and was sent to the hospital to be evaluated further. Resident #145 was found to have a fractured nose. AP #500 had not returned to the building since the incident. The Administrator stated the facility had attempted to reach AP #500 to discuss supervised visits at the facility but had not been able to reach the alleged perpetrator. Interview on 02/11/25 at 11:25 A.M. with Resident #145 revealed he was outside on the smoking patio when he asked a man for a cigarette. The man said no and a verbal altercation started, then the man knocked me out. The resident stated his right eye was swollen shut. The resident could not recall the man's name and did not know who the resident was that the man was with. Resident #145 stated he did go to the emergency room but did not recall any other injuries other than his eye being swollen shut. The resident stated he had not seen the man since the incident. Interview on 02/11/25 at 1:28 P.M. with Smoking Aide (SA) #401 revealed Resident #145, Resident #48, AP #500, and Resident #69 were present on the outside smoking patio when the incident occurred. SA #401 stated she was at her desk located inside the dining room area which looks out onto the smoking patio. States she saw them all doing fine, she looked away for a few seconds it seemed like and then Resident #145 and AP #500 were fighting. SA #401 confirmed AP #500 was the aggressor in the incident. Resident #145 fell out of his wheelchair and was laying on his right side with the right side of his face on the cement and AP #500 was still punching him. SA #401 yelled for assistance and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 2 of 5 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 02/11/2025 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few immediately responded to the smoking patio to try to break the fight up. Additional staff responded quickly and were able to break up the fight. AP #500 was escorted out of the building. SA #401 stated Resident #145 was bleeding really bad from his eyebrow and handed him a tissue to compress the cut on his eyebrow. The resident also complained of pain to his arm. Resident #145's hand was very swollen. The resident did not complain of pain anywhere else that she recalled. AP #500 had not returned to the facility again since the incident. Interview on 02/11/25 at 4:15 P.M. with the Administrator confirmed the neurological checks for Resident #145 were not completed at the correct time intervals for the resident. Review of facility policy titled Abuse Prohibition Policy, dated 10/14/22, revealed the policy stated, each resident shall be free from abuse. It is the responsibility of all staff to provide a safe environment for the residents. This deficiency represents non-compliance investigated under Complaint Number OH00161880. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 3 of 5 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 02/11/2025 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident and staff interviews, review of a facility self reported incident, review of the facility investigation, and facility policy review, the facility failed to complete a thorough investigation of an allegation of physical abuse of one resident (Resident #145). The deficient practice affected one resident (Resident #145) of three reviewed for abuse. The facility census was 204. Residents Affected - Few Findings Include: Review of the medical record for Resident #145 revealed an admission date of 02/01/21. Diagnoses included fracture of nasal bones (01/14/25), hemiplegia affecting unspecified side, personal history of traumatic brain injury, difficulty in walking, other seizures, and unspecified mental disorder due to a known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, revealed Resident #145 had intact cognition. The resident required minimal assistance which varied from independent to supervision from staff to complete Activities of Daily Living (ADLs). The resident exhibited physical and other behaviors toward others one to three days and verbal behaviors towards others four to six days of the review period. Review of the nurse progress notes dated from 01/13/25 to 01/21/25 revealed on 01/13/25 at 9:55 A.M., Resident #145 was struck twice on his right upper eye. The resident sustained an injury to the right upper eye. The site was cleaned with normal saline and covered with Kalex dressing. The Certified Nurse Practitioner (CNP) was notified and advised to monitor the resident for any changes in condition. An additional note on 01/13/25 at 9:55 A.M. revealed Resident #145 was outside in the smoking area and reported asking (another resident's) family member for a lighter. According to the resident, an argument occurred between them, however, the family member began cursing at him and struck him twice on his right upper eye which led to Resident #145 sustaining an injury to the right upper eye. On 01/13/25 at 2:18 P.M., Resident #145 was seen by the wound nurse for a laceration to the right eyelid. Steri-strips were applied. On 01/13/25 at 4:56 P.M., an addendum note was added stating the resident declined to go to the hospital. On 01/14/25 at an unknown time, a CNP note revealed Resident #145 was seen for follow up to an Emergency Department (ED) visit. The resident reported being assaulted while smoking outside of the facility. According to the resident and the police at bedside Resident #145 was assaulted by a visitor that was at the nursing home. The resident had a chronic fracture of left ulnar styloid but no acute findings. The Computed Tomography (CT) scan of maxillofacial showed an age-indeterminate left nasal bone fracture which was suspected to be old due to Resident #145 not having any pain along the bridge of nose. The resident complained of periorbital pain and bruising but no orbital fracture was noted. Review of the Self Reported Incident (SRI) dated 01/13/25 and untimed revealed an allegation of physical abuse with description as: Resident #145 was hit on the right upper eyebrow by family member. Interviews from both residents and family member stating they got into an argument over a lighter. The family member was escorted out of the building and police were called. Resident #145 refused to make police report but facility continued on with report. The resident complained of nose pain on 01/13/25 and went to the hospital where it was shown the resident had a broken nose. Facility made staff aware not to allow the other resident's family member in the building. Both residents were provided with emotional support. The facility unsubstantiated the allegation due to the facility could not have predicted the event would happen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 4 of 5 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 02/11/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of the facility investigation dated 01/13/25 and untimed revealed interviews and written statements were completed by Resident #145, the Administrator, the Director of Nursing (DON), Registered Nurse (RN) #410, Smoking Aide (SA) #401, and the Alleged Perpetrator (AP) #500. There was no interview or written statement included from Resident #69 who was also on the smoking patio when the incident occurred, but not involved in the incident . Residents Affected - Few Interviews on 02/11/25 at 10:20 A.M. and 1:04 P.M. with the Administrator revealed Resident #145, Resident #48, and Alleged Perpetrator (AP) #500 were outside on the smoking patio. Resident #145 and Resident #48 were both independent smokers. Resident #145 and AP #500 got into an altercation over a lighter or cigarettes and AP #500 hit Resident #145. AP #500 was escorted out of the building. The police were called and a report was filed on Resident #145's behalf. Resident #145 started complaining of pain and was sent to the hospital to be evaluated further. Resident #145 was found to have a fractured nose. AP #500 had not returned to the building since the incident. The Administrator stated the facility had attempted to reach AP #500 to discuss supervised visits at the facility but had not been able to reach the alleged perpetrator. Interview on 02/11/25 at 11:25 A.M. with Resident #145 revealed he was outside on the smoking patio when he asked a man for a cigarette. The man said no and a verbal altercation started, then the man knocked me out. The resident stated his right eye was swollen shut. The resident could not recall the man's name and did not know who the resident was that the man was with. Resident #145 stated he did go to the emergency room but did not recall any other injuries other than his eye being swollen shut. The resident stated he had not seen the man since the incident. Interview on 02/11/25 at 1:28 P.M. with Smoking Aide (SA) #401 revealed Resident #145, Resident #48, AP #500, and Resident #69 were present on the outside smoking patio when the incident occurred. SA #401 stated she was at her desk located inside the dining room area which looks out onto the smoking patio. States she saw them all doing fine, she looked away for a few seconds it seemed like and then Resident #145 and AP #500 were fighting. SA #401 confirmed AP #500 was the aggressor in the incident. Resident #145 fell out of his wheelchair and was laying on his right side with the right side of his face on the cement and AP #500 was still punching him. SA #401 yelled for assistance and immediately responded to the smoking patio to try to break the fight up. Additional staff responded quickly and was able to break up the fight. AP #500 was escorted out of the building. SA #401 stated Resident #145 was bleeding really bad from his eyebrow and handed him a tissue to compress the cut on his eyebrow. The resident also complained of pain to his arm. Resident #145's hand was very swollen. The resident did not complain of pain anywhere else that she recalled. AP #500 had not returned to the facility again since the incident. Interview on 02/11/25 at 4:15 P.M. with the Administrator confirmed he had not obtained a written statement or interviewed Resident #69 who was also outside at the time of the incident and witnessed the incident. Review of facility policy titled Abuse Prohibition Policy, dated 10/14/22, revealed the policy stated, each resident shall be free from abuse. The investigation may consist of: interviews with any witnesses to the incident. This deficiency presents non-compliance investigated under Complaint Number OH00161880. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 5 of 5