Inspection·October 9, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a score of 18 indicating the resident was at a low risk for skin breakdown.Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required partial/moderate assistance to sit on the side of the bed. The resident was at risk for skin breakdown and had no skin issues. The facility implemented the interventions pressure reducing device to bed, application of non-surgical dressings and application of dressings to feet. Review of the closed medical record revealed no weekly comprehensive assessment for the MASD until 08/14/25 when the resident was found to have Moisture Associated Skin Damage (MASD) to the sacrum measuring 9.2 centimeters (cm) by 12.0 cm by 0.1 cm and described as being pink and/or red in color with no exudate. The facility implemented to cleanse the areas with soap and water and apply Triad paste. Review of the resident's skin and wound evaluation dated 08/20/25 revealed the MASD to the sacrum measured 6.5 cm by 6.8 cm and described as being pink and/or red in color with light sanguineous/bloody exudate. The facility determined the wound was stable and continued the current treatment.On 09/25/25 at 10:53 A.M., an interview with Licensed Practical Nurse (LPN) #407 who functions as one of the two wound nurses for the facility revealed the resident was admitted to the facility with MASD and also a rash. The LPN revealed she charted on the wound weekly, however failed to document a weekly comprehensive assessment of the wound until 08/14/25. LPN #407 verified the MASD should have been comprehensively assessed weekly.On 09/29/25 at 9:05 A.M., an interview with the Director of Nursing (DON) verified the MASD should have been comprehensively assessed weekly. 2. Review of the medical record for Resident #117 revealed an initial admission date of 06/02/25 with the diagnoses including but not limited to end stage renal disease (ESRD), severe protein calorie malnutrition, chronic obstructive pulmonary disease, diabetes mellitus, alcoholic cirrhosis of liver without ascites, right above the knee amputation (RAKA) anemia, peripheral vascular disease, left below the knew amputation (LBKA), cachexia, dependence on renal dialysis, 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 (see definition of undermining and tunneling) pressure ulcer of sacral region, congestive heart failure (CHF), major depressive disorder, hypertension, hyperlipidemia, anxiety disorder, insomnia and chronic pain syndrome. Review of the plan of care dated 06/03/25 and last revised on 09/25/25 revealed the resident had actual impaired skin related to stage III pressure injury to coccyx and unstageable to left stump. Interventions included conduct skin assessment weekly and measure area(s) and document, cushion to wheelchair, enhanced barrier precautions (EBP), observe for signs of discomfort with dressing changes and administer pain medication as ordered, observe for signs of infection related to areas, refer to dietitian as needed, specialty bed as ordered and treatment as ordered. Review of the resident's Braden Scale dated 06/24/25 revealed a score of 16 indicating the resident was at low risk for skin breakdown. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors including rejection of care. The assessment indicated the resident required partial to moderate assistance with bed mobility, was dependent on transfers and non-ambulatory. The assessment indicated the resident was frequently incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had one unhealed stage III pressure ulcer that was present on admission. The facility implemented the interventions pressure reducing device to bed, pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications other than to feet. Review of the wound care progress note dated 09/17/25 at 8:00 A.M. revealed the resident had a new pressure ulcer stage III with 100% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 2 of 6 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 10/09/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eschar with seropurulent drainage to his left below the knee amputation. The resident was started on an antibiotic for cellulitis and the wound treatment of cleanse with normal saline (NS), pat dry, apply betadine soaked gauze to wound bed and cover with bordered foam dressing daily and as needed was implemented. The wound measured 1.5 centimeters (cm) by 1.6 cm and was covered with eschar. The wound had a moderate amount of seropurulent exudate. Review of the progress note dated 09/17/25 at 1:15 P.M. revealed during wound care the resident was noted with a wound to his left below the knee amputation. The wound was 100% eschar measuring 1.5 cm by 1.6 cm. The immediate intervention was to float the stump off the bed with a pillow. Review of the resident's weekly skin and wound evaluation dated 09/17/25 revealed the resident was found to have an unstageable pressure ulcer to his left below the knee amputation site. The wound measured 1.5 centimeters (cm) by 1.6 cm and was covered with eschar. The wound had a moderate amount of seropurulent exudate. The facility implemented the treatment to cleanse with normal saline, apply betadine moistened gauze and cover with a foam dressing. Review of the wound care progress note dated 09/24/25 revealed the resident's unstageable pressure ulcer to the left BKA was now 100% slough with no peri-wound erythema. The resident was to complete the antibiotic therapy for cellulitis on this date. The progress note documented the recommendations to Review of the resident's weekly skin and wound evaluation dated 09/24/25 revealed the resident's unstageable pressure ulcer to the left below the knee amputation site measured 1.8 cm by 1.5 cm by 0.2 cm. Further review of the assessment revealed the wound had no description of the wound. Continue supportive care and should be repositioned frequently. The resident should be supported with pillows or wedges to prevent pressure on wound. The wound measured 1.8 cm by 1.5 cm by 0.2 cm with a moderate amount of serosanguineous exudate. The facility continued the current treatment. Review of the resident's monthly physician orders for September 2025 identified orders dated 06/02/25 wound care practitioner to evaluate and treat as indicated, 09/17/25 cleanse wound to left stump with normal saline, pat dry, apply betadine moistened gauze, cover with foam dressing every shift for wound care and as needed if falls off or becomes soiled, 09/25/25 gel cushion for wound care every shift and alternating air mattress to bed every shift for wound care. On 09/25/25 at 12:16 P.M., observation of Resident #117 revealed the resident was positioned on his left side with the wound to his left stump positioned on the air mattress with no off-loading. Further observation revealed the proactive alternating air mattress was set for the weight of 660 pounds to 750 pounds when the resident's weight obtained on 09/25/25 was 119.2 pounds. On 09/25/25 at 12:22 P.M., an interview with Licensed Practical Nurse (LPN) #481 verified the wound to the resident's left stump had no offloading and the mattress was not set for the resident's currently weight providing no offloading. On 09/29/25 at 9:05 A.M., an interview with the Director of Nursing (DON) revealed the LPN #481 terminated her employment with the facility on 09/26/25 and had purposely been documenting the wounds wrong or not documenting on wounds at all. The DON revealed the Wound Nurse Practitioner reviewed the resident's wound and reclassified the wound as vascular due to the resident's extensive vascular history and bilateral lower limb amputation. Review of the facility policy titled, Skin Management, last revised on 08/14/24 revealed residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. The licensed nurse will initiate documentation in the electronic medical record, which includes a description of the skin impairment as follows, in the electronic health record the licensed nurse will document weekly until the area is resolved. This deficiency represents non-compliance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 3 of 6 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 10/09/2025 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 0686 investigated under Complaint Number 2604004 and a recite to the annual survey conducted on 08/13/25. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 4 of 6 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 10/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm 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 closed record review, fall investigation review, interviews and facility policy review, the facility failed to provide the care and supervision to prevent an unavoidable fall. This affected one resident (#214) of three residents reviewed for falls. The facility census was 209.Findings Include:Review of the closed record for Resident #214 revealed an initial admission date of 07/17/25 with the latest readmission of 08/10/25 with the diagnoses including but not limited to chronic kidney disease, moderate protein calorie malnutrition, bacteremia, chronic bronchitis, acute respiratory failure with hypoxia, metabolic encephalopathy, fatty liver, hypertension, anemia, secondary hyperparathyroidism of renal origin, chronic peripheral venous insufficiency, dysphagia, muscle wasting and atrophy, difficulty in walking, benign neoplasm of colon, dependence on renal dialysis, abdominal aortic aneurysm, gout, benign neoplasm of left kidney, polyneuropathy, chronic pain syndrome, depression, guttate psoriasis, constipation, osteoporosis, hyperlipidemia, anxiety disorder and non-compliance with medication regimen.Review of the resident's nursing comprehensive evaluation dated 07/17/25 revealed the resident required one assist with transfers and ambulation and the resident had a history of falls and a fear of falling. Review of the plan of care dated 07/18/25 revealed the resident was at risk for injury and falls related to medication effects, opioid use, impaired vision, hearing loss, depression, anxiety, impaired mobility, incontinence of bowel and bladder, unsteady gait and pain. Interventions included administer medications as ordered, anticipate and meet needs as needed, do not leave resident unattended in the bathroom, encourage the resident to wear appropriate footwear as needed, follow facility fall policy, Hoyer lift for transfers, keep the resident's environment as safe as possible, orient to surrounds as needed, provide resident with activities that minimize the potential for falls while providing diversion and distraction, therapy to evaluate and treat as ordered and as needed, put the call light withing reach and encourage him to use it for assistance as needed and staff educated not to leave the resident unattended at the side of his bed and utilize the Hoyer lift for transfers.Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required partial/moderate assistance to sit on the side of the bed. The assessment indicated the resident had a history of calls prior to admission to the facility. Review of the progress note dated 08/16/25 at 6:00 A.M. revealed the nurse was called to the resident's room due to a fall. The resident was noted on the floor between the bed and his dialysis chair. Two superficial skin tears were observed to his left arm. The resident reported, I slid off the bed as I was waiting on my washcloth. The facility implemented the intervention to not leave the resident sitting on the side of the bed alone. Review of the fall investigation dated 08/16/25 at 6:00 A.M. revealed the nurse was called to the resident's room due to a fall. The resident was noted on the floor between the bed and his dialysis chair, and two superficial skin tears were observed to his left arm. The resident reported, I slid off the bed as I was waiting on my washcloth. Review of the post fall evaluation dated 08/16/25 revealed the resident was sitting on the side of the bed unattended and slipped. The resident was found in between his bed and dialysis chair. The post fall evaluation determined the root cause was the resident was unattended sitting on the side of the bed getting ready for dialysis when he slipped between the bed and dialysis chair. Staff were educated to not leave the resident unattended sitting on the side of the bed. The interdisciplinary team (IDT) also placed the new intervention to make the resident a Hoyer lift with transfers. On 09/25/25 at 12:48 P.M., an interview with the Director of Nursing (DON) verified the resident was left sitting on the side of the his bed alone while the Certified Nursing Assistant (CNA) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 5 of 6 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 10/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm left the room leaving the resident unsupervised. The DON verified the resident fell from his bed when the CNA left the room leaving the resident unattended.Review of the facility policy titled, Fall Management, last revised on 07/08/25 revealed the facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls.This deficiency represents non-compliance investigated under Complaint Number 2604004 and a recite to the annual survey conducted on 08/13/25. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365379 If continuation sheet Page 6 of 6