Inspection visit
Inspection
28 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 28 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident
#38 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction, retention of urine,
paraplegia, dysphagia oropharyngeal phase, major depressive disorder, paranoid schizophrenia, anxiety
disorder, neuromuscular dysfunction of bladder, diabetes type II, heart failure, hypertension and chronic
obstructive pulmonary disease.
Review of the MDS dated [DATE] revealed the resident had moderate cognitive impairment. Her functional
status was listed as extensive two-person assist to totally dependent on staff for all activities of daily living.
Further review of the medical record revealed Resident #38 was sent out to the local hospital on two
occasions (07/11/18 and 11/06/18). There was no evidence of notice of transfer was given to the resident or
to their representative.
Interview with CRCC #300 on 01/15/19 at 6:30 P.M. confirmed the facility did not give Resident #38 or their
representative a notice of transfer giving the reason for the transfer.
Review of the facility Bed Hold and Return to Facility policy dated December 2016 revealed the facility will
provide written information of the bed hold policy to the resident or resident's representative upon leaving
for hospitalization. The bed hold policy did not provide any information regarding the Ombudsman being
notified of transfers and discharges from the facility.
2. Medical record review for Resident #19 revealed admission date of 09/22/17. Medical diagnoses included
atrial fibrillation, heart failure, and deaf nonspeaking.
Review of the annual MDS dated [DATE] revealed Resident #19 was cognitively intact. Functional status
was independent for bed mobility, transfers, eating and toilet use. She was always continent for bowel and
bladder.
Review of progress notes dated 10/01/18 revealed Resident #19 went to a physician's appointment and
was sent to the hospital for admission related to edema from her congestive heart failure. The resident
returned to the facility on [DATE].
Further review of the record revealed no notice of transfer or no notice to the Ombudsmen.
Interview with CRCC #300 on 01/16/19 at 3:45 P.M. revealed the facility failed to notify Ombudsmen in a
timely manner. Notice to the Ombudsman was made on 01/16/19.
(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 39
Event ID:
365457
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
3. Review of the medical record for Resident #21 revealed an admission date of 10/24/18 and a
readmission on [DATE]. Diagnosis included sepsis, muscle weakness, dysphagia, cognitive communication
deficit, vascular dementia with behavioral disturbances, sepsis with shock, hypertensive and diabetes.
Review of most recent quarterly MDS assessment dated [DATE] revealed Resident #21 had severe
cognitive impairment. The resident required extensive assist for bed mobility, eating, toileting and personal
hygiene.
Review of the progress note dated 11/28/18 revealed the resident was transferred to the hospital and
admitted for critical lab values. Further review revealed a transfer form was given to the emergency medical
technician (EMT) at the time of transfer to the hospital.
Review of the facility documentation titled Transfer Notice-Ohio dated 11/28/18 revealed Resident #21 was
given a transfer notice on 11/28/18 at the time of discharge to the hospital, but the document was silent for
the reason of the transfer.
Review of progress notes for dated 11/28/18 thru 12/07/18 were silent for documentation of written transfer
notice provided to the resident representative.
Interview with CRCC #300 on 01/16/19 at 3:19 P.M. verified a written transfer notice was given to the
Resident #21, who was cognitively impaired, and not the resident representative CRCC #300 further
verified the transfer notice did not include the reason for the transfer.
Based on record review, interview, and policy review the facility failed to provide a copy of the transfer and
discharge notification to the Ombudsman. The facility also failed to provide residents with notifications that
included the reasons for their discharges. This affected four (#6, #19, #21 and #38) of eight residents
reviewed for discharge notification. The facility census was 101.
Findings include:
1. Record review revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses;
muscle wasting and atrophy, unspecified injury at unspecified level of cervical spinal cord, hypotension,
concussion without loss of consciousness, vitamin D deficiency, other psychotic disorder, insomnia,
gangrene, acquired absence of left leg above knee, type two diabetes and muscle weakness.
Review of Resident #6's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the
resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and
personal hygiene. Resident #6 also required supervision with eating and total dependence with transfers.
Further review of Resident #6's record revealed the resident discharged to the hospital on [DATE] with
urosepsis and returned to the facility on [DATE]. Resident #6 was also discharged to the hospital on [DATE]
with respiratory failure and returned to the facility on [DATE]. Resident #6 was discharged to the hospital on
[DATE] with increased confusion, an increased temperature and no urine output. Resident #6 returned to
the facility from the hospital on [DATE]. Further review of Resident #6's chart revealed no Ombudsman
notification or notifications to the resident of the reason for his discharges for the hospitalizations on
01/05/18, 07/09/18 and/or 08/31/18.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 2 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview with Corporate Regional Clinical Coordinator (CRCC) #300 on 01/15/19 at 3:13 P.M. revealed
Resident #6 did not receive a bed hold notice or notification of the reason for his discharge when the
resident was discharged to the hospital on [DATE], 07/09/18 and 08/31/18.
Follow up interview with CRCC #300 on 01/16/19 at 10:11 A.M. revealed the Ombudsman was not notified
that Resident #6 was discharged to the hospital on [DATE], 07/09/18 and 08/31/18.
Follow up interview with CRCC #300 on 01/16/19 at 4:22 P.M. verified the facility did not have a policy on
notifying the Ombudsman of transfers and discharges from the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 3 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident
#38 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction, retention of urine,
paraplegia, dysphagia oropharyngeal phase, major depressive disorder, paranoid schizophrenia, anxiety
disorder, neuromuscular dysfunction of bladder, diabetes type II, heart failure, hypertension and chronic
obstructive pulmonary disease.
Review of the MDS dated [DATE] revealed the resident had moderate cognitive impairment. Her functional
status was listed as extensive two-person assist to totally dependent on staff for all activities of daily living.
Further review of the medical record revealed Resident #38 was sent out to the local hospital on two
occasions (07/11/18 and 11/06/18). There was no evidence of a bed hold notice was given to the resident
or to their representative.
Interview with CRCC #300 on 01/15/19 at 6:30 P.M. confirmed the facility did not give Resident #38 or their
representative a bed hold notice.
Review of the facility Bed Hold and Return to Facility policy dated December 2016 revealed the facility will
provide written information of the bed hold policy to the resident or resident's representative upon leaving
for hospitalization.
2. Medical record review for Resident #19 revealed admission date of 09/22/17. Medical diagnoses included
atrial fibrillation, heart failure, and deaf nonspeaking.
Review of the annual MDS dated [DATE] revealed Resident #19 was cognitively intact. Functional status
was independent for bed mobility, transfers, eating and toilet use. She was always continent for bowel and
bladder.
Review of progress notes dated 10/01/18 revealed Resident #19 went to a physician's appointment and
was sent to the hospital for admission related to edema from her congestive heart failure. The resident
returned to the facility on [DATE].
Further review of the record revealed no evidence of bed hold notice was given.
Interview with CRCC #300 on 01/16/19 at 3:45 P.M. revealed there was no notification of bed hold given to
the resident
3. Review of the medical record for Resident #21 revealed an admission date of 10/24/18 and a
readmission on [DATE]. Diagnosis included sepsis, muscle weakness, dysphagia, cognitive communication
deficit, vascular dementia with behavioral disturbances, sepsis with shock, hypertensive and diabetes.
Review of most recent quarterly MDS assessment dated [DATE] revealed Resident #21 had severe
cognitive impairment. The resident required extensive assist for bed mobility, eating, toileting and personal
hygiene.
Review of the progress note dated 11/28/18 revealed the resident was transferred to the hospital
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 4 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
and admitted for critical lab values. Further review revealed no evidence of a bed hold notice was given to
the resident or to the resident's representative.
Interview with CRCC #300 on 01/16/19 at 3:19 P.M. verified that the bed hold policy was given to the
resident on admission, but was not given to Resident #21 on 11/28/18 when a transfer to the hospital
occurred.
Based on record review, interview, and policy review the facility failed to ensure residents received bed hold
notification. This affected four (#6, #19, #21 and #38) of eight residents reviewed for discharge notification.
The facility census was 101.
Findings include:
1. Record review revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses;
muscle wasting and atrophy, unspecified injury at unspecified level of cervical spinal cord, hypotension,
concussion without loss of consciousness, vitamin D deficiency, other psychotic disorder, insomnia,
gangrene, acquired absence of left leg above knee, type two diabetes and muscle weakness.
Review of Resident #6's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the
resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and
personal hygiene. Resident #6 also required supervision with eating and total dependence with transfers.
Further review of Resident #6's record revealed the resident discharged to the hospital on [DATE] with
urosepsis and returned to the facility on [DATE]. Resident #6 was also discharged to the hospital on [DATE]
with respiratory failure and returned to the facility on [DATE]. Resident #6 was discharged to the hospital on
[DATE] with increased confusion, an increased temperature and no urine output. Resident #6 returned to
the facility from the hospital on [DATE]. Further review of Resident #6's chart revealed no bed hold notice
was provided for the hospitalizations on 01/05/18, 07/09/18 and/or 08/31/18.
Interview with Corporate Regional Clinical Coordinator (CRCC) #300 on 01/15/19 at 3:13 P.M. revealed
Resident #6 did not receive a bed hold notice when resident was discharged to the hospital on [DATE],
07/09/18 and 08/31/18.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 5 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical
record review for Resident #5 revealed an admission date of 12/28/15. Medical diagnoses included benign
prostatic hyperplasia, urinary tract infection, and chronic lung disease.
Review of the annual MDS dated [DATE] revealed the resident was was cognitively intact. Functional status
was extensive assistance for bed mobility, transfers, toilet use and he was independent for eating. Further
review of the MDS revealed pain was not assessed.
Interview with MDS Coordinator #84 on 01/16/19 at 2:36 P.M. verified the resident had pain frequently. She
indicated she locked the MDS on 10/04/18 and had to dash out the rest of the assessment for Section J
(pain management section) which caused the pain to not show as being assessed. She further verified the
assessment was not completed in a timely manner.
Based on record review, and interview the facility failed to ensure resident's Minimum Data Sets (MDS)
assessments assessed the resident's cognition, mood and pain. This affected four Resident's (#5, #84,
#105 and #303) of 27 reviewed for MDS. The facility census was 101.
Findings include:
1. Record review revealed Resident #84 was admitted to the facility on [DATE] with the following diagnoses;
acute kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain,
generalized anxiety disorder and cocaine abuse.
Review of Resident #84's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the
resident's cognition and mood were marked as not assessed. Resident #84 was reported as independent
with toileting and required supervision with bed mobility, transfer, dressing, eating and personal hygiene.
Review of Resident #84's Brief Interview for Mental Statues (BIMS) dated 01/15/19 revealed the resident
was cognitively intact.
Interview with MDS Coordinator #84 on 01/15/19 at 4:35 P.M. verified Resident #84's mood and cognition
were not assessed for the MDS assessment dated [DATE].
2. Record review revealed Resident #105 was admitted to the facility on [DATE] with the following
diagnoses; cellulitis of the right finger, chronic viral hepatitis C, osteomyelitis, muscle weakness, cognitive
communication deficit and opioid abuse. Further review of Resident #105's record revealed the resident
discharged from the facility on 12/20/18.
Review of Resident #105's discharge MDS assessment dated [DATE] revealed resident's cognition and
mood were marked as not assessed. Resident #105 was independent with bed mobility, transfers, dressing,
toileting and personal hygiene and required supervision with eating.
Review of Resident #105's BIMS dated 12/10/18 revealed the resident was cognitively intact.
Interview with MDS Coordinator #84 on 01/15/19 at 4:35 P.M. verified Resident #105's mood and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 6 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0636
cognition were not assessed during the resident's MDS assessment dated [DATE].
Level of Harm - Minimal harm
or potential for actual harm
3. Record review revealed Resident #303 was admitted to the facility on [DATE] with the following
diagnoses; type two diabetes mellitus without complications, hyperlipidemia, obesity, unspecified atrial
fibrillation, chronic obstructive pulmonary disease, heart failure, other abnormalities of gait and mobility,
repeated falls and muscle wasting and atrophy. Further review of Resident #303's record revealed the
resident was discharged to another skilled nursing facility on 11/19/18.
Residents Affected - Some
Review of Resident #303's discharge MDS assessment dated [DATE] revealed the resident's cognition and
mood were marked as not assessed. Resident #303 was reported to require supervision with transfers,
dressing and eating and was independent with bed mobility, toileting and personal hygiene. Further review
of Resident #303's record revealed the resident did not to have any additional MDS assessments that
assessed her activities of daily living or cognition prior to her discharge MDS on 11/09/18.
Interview with MDS Coordinator #84 on 01/15/19 at 4:35 P.M. verified Resident #303's mood and cognition
were not assessed during the resident's MDS assessment dated [DATE].
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 7 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0637
Assess the resident when there is a significant change in condition
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and review of the Resident Assessment Instrument (RAI) the facility failed to
identify and complete a significant change assessment. This affected two Residents (#21 and #25) of 27
reviewed for resident assessments. The facility census was 101.
Residents Affected - Few
Findings include:
1. Record review for Resident #25 revealed an original admission date of 01/11/18. The resident was sent
to the hospital on [DATE] due to a fractured hip from a fall. The resident was readmitted on [DATE].
Diagnosis included fracture of right hip, pain in left knee, contracture of left hip, diabetes mellitus, muscle
weakness, heart disease, major depressive disorder, psychosis, Alzheimer's disease, and anxiety.
Review of significant change assessment Minimum Data Set (MDS) dated [DATE] revealed Resident #25
had moderately impaired cognition. The MDS did not indicate a fall with major injury even thought the
resident had a fall on 08/08/18 that resulted in a fractured hip. The resident had a weight of 148 pounds.
Further review of the MDS revealed the resident had no pressure or vascular ulcers.
Review of plan of care for Resident #25 for actual impaired skin integrity with an initiation date of 08/07/18
and a revision date of 10/02/18 revealed a stage 2 pressure ulcer was added to the problem list.
Review of nutritional plan of care for Resident #25 revealed an initiation date of 08/07/18 and a revision
date of 10/09/18 indicated a significant weight loss at the 30 day, 90 day and 180 day look back period.
Review of the nurses note on 08/08/18 at 11:46 A.M. indicated Resident #25's sister was advised of
incident (no details present in medical record) from last night and fall today, facility reaching out to
psychiatric facility for possible evaluation. A progress note of 08/08/18 at 3:22 P.M. indicated Resident #25
complained of right hip pain, declined medications, and accepted ice cream. Then a progress note at 4:29
P.M. indicated a x-ray revealed right hip fracture and resident was sent to the hospital for evaluation.
Review of physician orders (PO) dated 10/04/18 revealed to cleanse the left ankle with normal saline and
pat dry. Apply hydrocolloid (type of dressing to absorb drainage from a wound) dressing to cover and
change every other day and PRN (as needed) for prevention. Review of PO dated 01/09/19 revealed to
cleanse the right heel with betadine (disinfectant), allow to air dry, apply a betadine soaked 4 x 4 (gauze
dressing), cover with abdominal (ABD) pad (thick absorbent dressing), wrap with kerlix daily and as needed
(PRN).
Review of the Certified Nurse Practitioner progress notes dated 10/23/18 revealed Resident #25 was being
treated for venous wound to the right heel, a stage two (measurement of depth) located on the left lateral
ankle, and a stage three located on the left medial knee.
Review of quarterly MDS assessment dated [DATE] revealed the fall from 08/08/18 was not documented.
The resident had a weight of 129, a decline of 14.73 percent. The resident had developed one stage two
pressure ulcer, one stage 3 pressure ulcer and one venous ulcer during the look back period.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 8 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0637
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the Long Term Care Facility Care Resident Assessment Instrument (RAI) 3.0 version 1.16
(instruction to complete the MDS) revealed a significant change should be completed when a major decline
or improvement in a resident's status that: will not normally resolve itself without intervention by staff or by
implementing standard disease-related clinical interventions, impacts more than one area (sections of the
MDS) of the resident's health status; and requires interdisciplinary review and/or revision of the care plan.
Additionally the RAI manual instructs the coordinator to complete a significant change assessment when
there is an emergence of a new pressure ulcer at a Stage two or higher.
Interview with MDS Coordinator #84 on 01/15/19 at 2:30 P.M. verified a significant assessment was not
completed as required. MDS Coordinator #84 verified the resident had a fall with a major injury, had
developed venous and pressure ulcers and had a significant weight loss.
2. Review of the medical record for Resident #21 revealed an original admission date of 10/24/18. Resident
was discharged on 11/27/18 to the hospital for G-tube placement and abnormal labs. He was readmitted on
[DATE]. Diagnosis included sepsis, muscle weakness, dysphagia, cognitive communication deficit, vascular
dementia with behavioral disturbances, sepsis with shock, hypertensive, diabetes and G-tube (tube place
thru the skin into the stomach for nutritional administration) placement
Review of the admission MDS dated [DATE] revealed the resident had severe cognitive impairment. The
resident required supervision with eating and extensive assist for dressing, toileting and personal hygiene.
The resident had a weight recorded as 166 pounds.
Review of most recent quarterly MDS dated [DATE] revealed Resident #21 had severe cognitive
impairment. The resident required extensive assist for eating, dressing, toileting and personal hygiene. The
resident had a decline in eating ability. The resident had a weight recorded as 151.2.
Review of Resident #21 recorded weights revealed on 11/26/18 the resident weighed 184 pounds. On
12/07/18 the resident's weight was 150, a loss of 18.48 percent.
Review of nursing progress notes on 12/07/18 at 3:44 P.M. revealed new orders to discontinue continuous
G-tube feeding and start bolus of Glucerna 1.5 carb steady 300 ml every six hours, flush with 240 ml of
water every six hour.
Review of the dietary progress notes dated 12/11/18 at 3:35 P.M. for Resident #21 revealed the resident
had a significant weight loss and the physician was notified. Dietary recommendation for new bolus
feedings of 375 milliliters (ml) of Glucerna 1.2 every six hours with 240 ml flush every six hours.
Review of the Plan of Care for Resident #21 for the focus area of altered nutritional hydration status
revealed an initiation date of 12/12/18 with interventions including obtain weekly weights, obtain and
monitor labs as ordered, observe and report weight changes of three percent in one week, greater than five
percent in one month and greater than seven point five percent in three months, offer an alternate when
fifty percent or less of the meal is consumed, provide supplement as ordered, assist resident with meals,
administer tube feedings as ordered, and registered dietitian to evaluate monthly and PRN.
Interview with MDS Coordinator #84 on 01/16/19 at 03:52 P.M., verified she did not complete a significant
change assessment when the resident returned from the hospital. The resident had a newly
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 9 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0637
placed G-tube, weight loss and a decline in eating ability.
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:
365457
If continuation sheet
Page 10 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to accurately code an injectable medication on the Minimum
Data Set (MDS). This affected one Resident (#72) of five reviewed for unnecessary medications. The facility
census was 101.
Residents Affected - Few
Findings include:
Record review for Resident #72 revealed an admission date of 12/19/18 with diagnosis including fracture of
left hip, muscle weakness, communication deficit, chronic obstructive pulmonary disease, stroke,
hypertension and seizures.
Review of the MDS dated [DATE] revealed the residents cognition was not assessed. The resident required
extensive assist for bed mobility, dressing, toileting and personal hygiene with staff support. The number of
medications the resident received as injections in the last seven days was coded as zero.
Review of physician orders for the month of December 2018 revealed an order for Enoxaparin injectable
(brand name anti clotting medication) 30 milligrams (mg)/0.3 milliliters (ml) administer 0.3 ml (30 mg)
subcutaneously (injection) two times a day with no stop date.
Interview with MDS Coordinator #84 on 01/15/19 at 1:19 P.M. revealed the MDS was coded inaccurately in
regards to the number of medications the resident received as injections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 11 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to accurately complete a baseline plan of care within 48 hours
of admission. This affected two Residents (#21 and #72) of 27 reviewed for baseline plan of care. The
facility census was 101.
Findings include:
1. Record review for Resident #72 revealed an admission date of 12/19/18 with diagnosis including fracture
of left hip, muscle weakness, communication deficit, chronic obstructive pulmonary disease, stroke,
hypertension and seizures.
Review of Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was was not assessed.
The resident required extensive assist for bed mobility, dressing, toileting and personal hygiene with staff
support.
Review of baseline plan of care revealed the medical record was silent for this document.
Interview with Registered Nurse (RN) #27 on 01/15/19 at 12:19 P.M. revealed she was unable to locate the
baseline plan of care.
Interview with the Corporate RN #300 on 01/16/19 at 1:30 P.M., revealed the base line plan of care for
Resident #72 was not completed and not given to the resident or resident representative.
2. Medical record review for Resident #21 revealed an admission date of 10/24/18 and a readmission on
[DATE]. Diagnosis included sepsis, muscle weakness, dysphagia, cognitive communication deficit,
dementia with behavioral disturbances, sepsis with shock, hypertensive, diabetes and G-tube placement
(tube placed into the stomach for nutritional support).
Review of the most recent quarterly MDS dated [DATE] revealed Resident #21 had impaired cognition. He
required extensive assist for bed mobility, dressing, eating, tolieting and personal hygiene.
Review of baseline plan of care for Resident #21 dated 10/24/18 revealed the recently placed feeding tube
was not addressed.
Interview with the Director of Nursing (DON) on 01/16/19 at 4:40 P.M., revealed the baseline plan of care
was not complete and that the feeding tube section should have been included.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 12 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of
the record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses of [NAME] disease,
seizures, neuromuscular dysfunction of bladder, transient cerebral ischemic attacks, pressure ulcer of
sacral region stage IV, bipolar disorder, aphasia, dysphasic, diabetes type II, hypertension, and
quadriplegia.
Review of the MDS revealed Resident #58 had significant cognitive impairment. Her functional status was
listed as totally dependent on staff for all ADL. Resident #58 had an indwelling Foley catheter.
Review of the care plan dated 12/29/18 revealed Resident #58 had the potential for alteration in activities.
Resident #58 received one to one social visits from activity staff due to low participation. She enjoyed doing
exercises, listening to music, and having people talk to her. Resident #58's family was in daily to visit with
her and she enjoyed spending time with them.
Interview with the Staff #57 on 01/15/19 at 4:00 P.M. confirmed the activity staff did not implement one to
one activities as stated on Resident #58's plan of care.
3. Medical record review for Resident #55 revealed an admission date of 11/16/18. Medical diagnoses
included traumatic brain injury.
Review of the quarterly MDS dated [DATE] revealed he was rarely or never understood. He was totally
dependent for bed mobility, transfers, eating and toileting.
Review of care plans for Resident #55 revealed there was no care plan developed for activities or range of
motion.
Interview with Activities Director #57 on 01/15/19 at 12:15 P.M. verified there was no care plan developed
for activities.
Interview with Corporate Regional Clinical Coordinator (CRCC) #300 on 01/16/19 at 4:00 P.M. verified there
wasn not a care plan developed for range of motion.
Review of policy entitled Interdisciplinary Care Plan revised April 2015 revealed it was the policy of the
facility to develop an care plan for each guest that included measurable goals and time frames directed
toward achieving and maintaining each resident's optimal medical, physical, mental and psychosocial
needs.
4. Review of the record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of
dementia with behavioral disturbance, metabolic encephalopathy, back pain, hypokalemia, hypertension,
major depressive disorder and recurrent insomnia.
Review of the MDS dated [DATE] revealed the resident had moderate cognitive impairment. Her functional
status was listed as supervision to extensive assistance with grooming and hygiene. The MDS also listed
Resident #43 as being frequently incontinent of urine and bowel.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 13 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Further review of Resident #43's medical record revealed she was being administered the antipsychotic
medication, Risperdal for dementia with behavioral disturbances. The resident was also prescribed
Memantine for dementia with behavioral disturbances, Donpezil for memory loss, Zoloft for depression, and
Depakote tablet for behaviors.
Interview with the DON on 01/16/19 at 4:30 P.M. confirmed Resident #43 did not have a plan of care for
psychotropic medications.
Based on record review, observation, interview and policy review the facility failed to ensure residents had
care plans developed and implemented for smoking, falls, activities, psychotropic medications, and range of
motion. This affected five Resident's (#13, #43, #55, #58 and #84) of 27 residents reviewed for care
planning. The facility census was 101.
Findings include:
1. Record review revealed Resident #84 was admitted to the facility on [DATE] with the following diagnoses;
acute kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain,
generalized anxiety disorder and cocaine abuse.
Review of Resident #84's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the
resident's cognition was not assessed. Resident #84 was reported to be independent with toileting and
required supervision with bed mobility, transfer, dressing, eating and personal hygiene.
Review of Resident #84's record revealed the resident signed the smoking policy upon admission to the
facility on [DATE].
Review of Resident #84's care plan dated 01/12/19 revealed the resident should be supervised while
smoking and all smoking materials should be kept by staff members.
Review of Resident #84's smoking assessment dated [DATE] revealed resident to require supervision while
smoking. Resident #84's chart did not contain any additional smoking assessments.
Observation of Resident #84 on 01/14/19 at 7:45 A.M. revealed resident was smoking unsupervised in the
back of the facility by the ash trays.
Interview with Licensed Practical Nurse (LPN) #74 at the time of the observation verified Resident #84 was
smoking without supervision in the back of the building. LPN #74 reported residents were not permitted to
smoke without supervision.
Review of Resident #84's progress notes dated 1/14/2019 at 9:58 A.M. revealed the resident was noted
smoking out in the back of the facility towards the parking lot.
Observation of Resident #84 on 01/14/18 at 6:00 P.M. revealed the resident was smoking outside in front of
the building.
Review of Resident #84's Brief Interview for Mental Statues (BIMS) dated 01/15/19 revealed the resident
was cognitively intact.
Review of the facility's undated Guest Smoking policy revealed residents should be supervised while
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 14 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0656
smoking and all smoking materials should be kept at the nurse's station.
Level of Harm - Minimal harm
or potential for actual harm
2. Record review revealed Resident #13 was admitted to the facility on [DATE] with the following diagnoses;
vascular dementia with behavioral disturbance, hemiplegia affecting right dominant side, muscle wasting
and atrophy, stiffness of unspecified joint, cognitive communication deficit, restlessness and agitation,
restlessness and agitation, psychotic disorder with delusions, hyperlipidemia, alcohol abuse and major
depressive disorder.
Residents Affected - Some
Review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident was severely
cognitively impaired. The resident required extensive assistance with bed mobility, dressing, eating and
personal hygiene. Resident #13 also required total dependence with transfers and toileting.
Review of Resident #13's care plan dated revealed interventions included fall mat to the side of the bed and
a personal alarm to the bed as ordered. Further review of Resident #13's care plan revealed the fall mat
and the personal alarm were added to the care plan on 10/03/18.
Review of Resident #13's physicians orders (PO) dated 08/17/17 revealed an order for fall mat to the side
of her bed. Review of PO dated 11/10/18 revealed an order for clip alarm while in bed. The clip alarm was
to be checked for placement and functioning every shift.
Observation on 01/15/19 at 8:35 A.M. revealed Resident #13 was laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
Observation on 01/15/19 at 9:44 A.M. revealed Resident #13 to be laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
Observation on 01/15/19 at 10:47 A.M. revealed Resident #13 was laying in bed with a family member and
staff member in her room. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at
the time of the observation.
Observation on 01/15/19 at 5:39 P.M. revealed Resident #13 was laying in bed with a family member sitting
at her bedside. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of
the observation.
Observation on 01/16/19 at 9:08 A.M. revealed Resident #13 was laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
Observation on 01/16/19 at 9:51 A.M. revealed Resident #13 was laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
Interview with the Director of Nursing (DON) on 01/16/19 at 9:52 A.M. verified Resident #13 was laying in
bed without a clip alarm or fall mat to the side of her bed. The DON confirmed Resident #13 had a order
and was care planned for a clip alarm while in bed and a fall mat to the side of the bed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 15 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical
record review for Resident #5 revealed an admission date of 12/28/15. Medical diagnoses included benign
prostatic hyperplasia, urinary tract infection, and chronic lung disease.
Review of annual MDS dated [DATE] revealed he was cognitively intact. Functional status was extensive
assistance for bed mobility, transfers, toilet use and he was independent for eating.
Review of care conferences from 06/01/18 through 01/15/19 revealed the most recent care conference was
conducted 01/15/19.
Interview with Resident #5 on 01/13/19 at 2:33 P.M. revealed he never had a care conference.
Interview with CRCC #300 on 01/15/19 at 4:00 P.M. verified there wasn't any care conferences that could
be found.
4. Medical record review for Resident #19 revealed admission date of 09/22/17. Medical diagnoses included
atrial fibrillation, heart failure, and deaf nonspeaking.
Review of the annual MDS dated [DATE] revealed Resident #19 was cognitively intact. Functional status
was independent for bed mobility, transfers, eating and toilet use. she was always continent for bowel and
bladder.
Review of care conferences for Resident #19 from 06/01/18 through 01/15/19 revealed there was no care
conferences in the record.
Interview with Resident #19 on 01/14/19 at 8:51 A.M. revealed she couldn't remember if she had a care
conference.
Interview with CRCC #300 on 01/15/19 at 4:00 P.M. verified there wasn't any care conferences that could
be found.
5. Medical record review for Resident #76 revealed he was admitted on [DATE]. Medical diagnoses included
diabetes and chronic kidney disease.
Review of the quarterly MDS dated [DATE] revealed the resident was cognitively intact. Functional status
was limited assistance for bed mobility and transfer. He was supervision for eating and independent for
toilet use.
Review of care conferences from 06/01/18 through 01/15/19 revealed Resident #76's only care conference
was dated 12/20/18.
Interview with Resident #76 on 01/15/19 at 2:00 P.M. revealed he has only had three care conferences
since admission and stated the staff who are supposed attend are not in the meeting.
Interview with CRCC #300 on 01/15/19 at 4:00 P.M. verified the only documented care conference was on
12/20/18.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 16 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the Care Conference Minutes policy dated April 2015 revealed care conferences will be held
initially, annually, upon a significant change and quarterly.
Based on record review, and interview the facility failed to ensure a resident's care plan was revised. The
facility also failed to provide residents with the ability to participate in the implementation and development
of their care plans. This affected five (#5, #6, #19, #67 and #76) of 27 residents reviewed for care planning.
The facility census was 101.
Findings include:
1. Record review revealed Resident #67 was admitted to the facility on [DATE] with the following diagnoses;
other symbolic dysfunctions, unspecified abnormalities of gait and mobility, muscle weakness, type two
diabetes mellitus without complications, polyarthritis, mood disorder, anxiety disorder, major depressive
disorder, hypertension, and intracranial injury without loss of consciousness.
Review of Resident #67's annual Minimum Data Sets (MDS) assessment dated [DATE] revealed the
resident was cognitively intact and required supervision with bed mobility, transfers, dressing, eating,
personal hygiene. Resident #67 was independent with toileting.
Further review of Resident #67's record revealed no care conferences were noted in the record since
06/01/18.
Review of Resident #67's care plan dated 09/14/8 revealed the resident was fitted for dentures.
Review of Resident #67's dental visit dated 10/06/18 revealed the resident was not a good candidate for
dentures.
Interview with Resident #67 on 01/14/19 at 9:51 A.M. revealed he had not been invited to any care
conferences. Resident #67 also reported he wanted dentures but had not received them.
Interview with Corporate Regional Clinical Coordinator (CRCC) #300 on 01/15/19 at 3:03 P.M. revealed
Resident #67 had not had any care conferences since 06/01/18.
Interview with MDS Coordinator #84 on 01/15/19 at 4:35 P.M. verified Resident #67 had reported he had
been fitted for dentures and that is why it was added to the care plan. MDS Coordinator #84 reported she
was not aware of the dental visit on 10/06/18 that indicated Resident #67 was not a good candidate for
dentures.
2. Record review revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses;
muscle wasting and atrophy, unspecified injury at unspecified level of cervical spinal cord, hypotension,
concussion without loss of consciousness, vitamin D deficiency, other psychotic disorder, insomnia,
gangrene, acquired absence of left leg above knee, type two diabetes and muscle weakness.
Review of Resident #6's quarterly MDS assessment dated [DATE] revealed the resident was cognitively
intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene.
Resident #6 also required supervision with eating and total dependence with transfers.
Further review of Resident #6's record revealed no care conferences noted in the chart since
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 17 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0657
06/01/18.
Level of Harm - Minimal harm
or potential for actual harm
Interview with Resident #6 on 01/13/19 at 11:46 A.M. revealed the resident had not been invited to any care
conferences.
Residents Affected - Some
Interview with CRCC #300 on 01/15/19 at 3:03 P.M. revealed Resident #6 had not had any care
conferences since 06/01/18.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 18 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, family and staff interview and policy review the facility failed to ensure restorative
therapy was provided to residents. This affected one (#55) of one resident reviewed for rehabilitation and
restorative care. The facility identified 23 residents who received rehabilitative services. The census was
101.
Residents Affected - Few
Findings include:
Medical record review for Resident #55 revealed an admission date of 11/16/18. Medical diagnoses
included traumatic brain injury.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was rarely or never
understood. He was totally dependent for bed mobility, transfers, eating and toileting. Further review of the
MDS revealed there were functional limitations in range of motion (ROM) for the upper and lower
extremities impairment for both sides.
Review of Physical Therapy (PT) discharge notes dated 12/17/18 for Resident #55 revealed to provide
bilateral extremities ROM while in bed. Review of Occupational Therapy (OT) discharge notes dated
01/01/19 revealed for the restorative aide to perform ROM for resident before applying splints and brace to
upper extremities.
Review of documentation for restorative care under tasks from 12/17/18 through 01/15/19 revealed the
record was silent for ROM services.
Interview with Resident #55's family on 01/13/19 at 12:19 P.M. revealed the resident had previously
received ROM therapy for his hands and legs, but it stopped. The family member indicated she didn't know
why. She stated Restorative Aide (RA) #70 was working as an aide on the floor and the facility was
supposed to be hiring someone else to do the therapy.
Interview with RA #70 on 01/16/19 at 2:26 P.M. revealed Resident #55 was supposed to receive ROM,
three times a week, for 15 minutes for both upper and lower extremities. RA #70 indicated she had been
trained to perform the ROM. She verified she had only been doing the ROM, once a week, because she
gets pulled to the floor to work as an aide.
Review of policy entitled Passive Range of Motion revised 05/18/18 revealed ROM exercises refer to
movement of a joint through partial or complete range of activity with the assistance of a health care
provider. The staff is to document the joints that were exercised.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 19 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident
#58 was admitted to the facility on [DATE] with diagnoses of [NAME] disease, seizures, neuromuscular
dysfunction of bladder, transient cerebral ischemic attacks, pressure ulcer of sacral region stage IV, bipolar
disorder, aphasia, dysphasic, diabetes type II, hypertension, and quadriplegia.
Residents Affected - Some
Review of the MDS revealed Resident #58 had significant cognitive impairment. Her functional status is
listed as totally dependent on staff for all activities of daily living. Resident #58 had an indwelling Foley
catheter.
Review of the care plan dated 12/29/18 revealed Resident #58 had the potential for alteration in activities.
Resident #58 was to receives one to one social visits from activity staff due to low participation. She
enjoyed doing exercises, listening to music, and having people talk to her. Resident #58's family was in
daily to visit with her and she enjoyed spending time with them.
Interview with the Staff #57 on 01/15/19 at 4:00 P.M. confirmed the activity staff did not implement the one
to one activities as indicated on Resident #58's plan of care.
Review of policy entitled Recreation Service Objectives revised November 2016 revealed Recreation
Services will provide an ongoing recreation program based on the comprehensive assessment, care plan,
and preferences of the resident. The recreation program is to support guests in their choice of activities to
include group, individual, and independent captivities that empowers, maintains, and supports all residents
in the facility through utilization of treatment approaches, leisure education and opportunities for guest
participation.
Based on medical record review, observation, and resident and staff interview, the facility failed to ensure
activities were provided for a resident who was deaf , failed to ensure residents were assessed and that the
activities met the residents interests. This affected four (#5, #19, #55 and #58) of seven reviewed for
activities. The census was 101.
Findings include:
1. Medical record review for Resident #19 revealed admission date of 09/22/17. Medical diagnoses included
atrial fibrillation, heart failure, and deaf nonspeaking.
Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact.
Functional status was independent for bed mobility, transfers, eating and toilet use. she was always
continent for bowel and bladder.
Interview with Resident #19 on 01/14/19 at 8:47 A.M. revealed she was able to communicate by reading
lips. She indicated she doesn't participate in activities because she does not know what everyone was
saying. She stated she very rarely received an interpreter.
Observations on 01/15/19 at 7:52 A.M. revealed the residents door was closed. At 8:58 A.M., the residents
door remained closed. At 10:30 A.M. the resident was out of her room and in her wheelchair.
Interview with Activities Director (AD) #57 on 01/15/19 at 12:20 P.M. revealed on 01/02/19, she added
Resident #19 to the list to be seen daily. She stated she had visited the resident before and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 20 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Resident #19 told her she didn't like to go to activities because she couldn't hear what everyone was
saying. She stated she didn't have any documentation she was visiting the room or that her assistants had
seen the resident. A subsequent interview on 01/15/19 at 4:00 P.M., AD #57 stated the resident refused to
socialize in her room.
2. Medical record review for Resident #55 revealed an admission date of 11/16/18. Medical diagnoses
included traumatic brain injury.
Review of the quarterly MDS dated [DATE] revealed he was rarely or never understood. He was totally
dependent for bed mobility, transfers, eating and toileting.
Interview with family of Resident #55 on 01/13/19 at 12:05 P.M. revealed she would like the facility to read
to the resident. At the time of the family interview, the resident was lying in bed.
Observation on 01/15/19 at 7:53 A.M. the resident was seated in a wheelchair in his room. At 8:58 A.M., he
was in his room with family. Staff was observed in his room providing care.
Interview with AD #57 on 01/15/19 at 12:14 P.M. verified she had not approached Resident #55 as the
facility was always in the room. She also verified she had not discussed activities with the family.
3. Medical record review for Resident #5 revealed an admission date of 12/28/15. Medical diagnoses
included benign prostatic hyperplasia, urinary tract infection, and chronic lung disease.
Review of the annual MDS dated [DATE] revealed he was cognitively intact. Functional status was
extensive assistance for bed mobility, transfers, toilet use and he was independent for eating.
Review of Resident #5's care plan revealed the resident received one on one social visits from activity staff.
Review of activity participation log from 12/01/18 through 12/31/18 revealed there was independent
socialization and independent television and movies which were checked everyday. There was no evidence
of one to one social visits.
Interview with Resident #5 on 01/13/19 at 2:26 P.M. revealed he didn't participate in activities because he
didn't like anything that was offered. He indicated he would if there was things he liked to do but staff would
have to transport him in his wheelchair. He stated he didn't think the staff had time to take him to activities.
Observations on 01/15/19 at 7:50 A.M. revealed the door to the residents room was closed. On 01/15/19 at
7:50 A.M., the nurse was administering a breathing treatment and assessing blood pressure. On 01/15/19
at 11:20 A.M. the resident was sitting in his room in a chair.
Interview with AD #57 on 01/15/19 at 12:18 P.M. revealed the activities staff did not do one on ones with the
resident anymore because he refused. AD #57 stated there was no documentation of the refusals. She
stated she had not seen him out of his room or met him. She stated activities went into his room monthly to
get a list for shopping. She verified there were no other activities provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 21 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review observation, and interview and the facility failed to ensure a pressure reducing device was
monitored and had the correct settings. his affected one Resident (#25) of six reviewed for pressure. The
facility identified two residents who utilized alternating pressure mattress. The facility census was 101.
Residents Affected - Few
Findings include:
Record review revealed Resident #25 was admitted on [DATE]. The resident was sent to the hospital on
[DATE] due to a fractured hip. The resident was readmitted on [DATE]. Diagnoses included fracture of the
right hip, pain in the left knee, contracture of the left hip, diabetes mellitus, muscle weakness, heart
disease, major depressive disorder, psychosis, Alzheimer's disease, and anxiety.
Review of physician orders for the month of January 2019 revealed an order for an air mattress with
concave side to the bed at all times to help define bed boundaries. This order had a start date of 10/04/18.
Review of the plan of care for actual impaired skin integrity with an initiation date of 08/07/18 and a revision
date of 10/02/18 revealed an intervention for air mattress to bed at all times.
Review of the Certified Nurse Practitioner progress notes dated 01/09/2019 revealed Resident #25 was
being treated for venous wound to right heel
Review of nutrition at risk monitoring record Resident #25 dated 01/11/19 revealed a weight of 131 pounds.
Observation of Resident #25 on 01/15/19 at 3:51 P.M., revealed the resident was in bed with the air
mattress control unit set at a weight of 450 pounds.
On 01/15/19 at 3:58 P.M., Licensed Practical Nurse (LPN) #63 was interviewed and revealed she did know
who was responsible for setting the control unit for the bed operations and would have to ask the nurse
manager.
Interview with Nurse Manager #66 on 01/15/19 at 4:09 P.M. revealed the facility rented some of the
alternating air mattresses and the mattresses came preset with the setting. She indicated she was not sure
if Resident #25's mattress was a rental. She also stated she was unsure if the lights on the control unit
indicated a correct weight of 450 pounds.
Review of the Treatment Administration Record (TAR) for the months of 10/2018, 11/2018. 12/2018 and
01/2019 had no evidence the settings for the air mattress were monitored for the correct weight settings.
Follow up interview with LPN #63 on 01/15/19 at 4:10 P.M. revealed the nurses documented on the TAR
that the speciality bed was in place but that did not include monitoring the settings of the control unit.
Interview with Nurse Manager #66 on 01/15/19 at 4:29 P.M. revealed she changed the digital control
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 22 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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
unit to Resident #25's air mattress to the correct setting of 150 pounds. Nurse Manager #66 verified the bed
was not setting correctly when it was set at 450 pounds. She revealed she did not know how long the bed
had been incorrectly set.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 23 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, interview, review of Self Reported Incident (SRI) and review of facility policy the
facility failed to ensure residents received adequate supervision. This resulted in actual harm to Resident
#25 when the resident entered another residents room, the other resident shoved Resident #25 and caused
her to fall. Resident #25 sustained a fractured hip and was admitted to the hospital. The facility also failed to
ensure fall devices were in place and residents received adequate supervision with smoking. This affected
three Residents (#13, #25, and #84) of four reviewed for supervison to prevent accidents and hazards. The
facility census was 101.
Findings include:
1. Record review revealed Resident #25 was originally admitted on [DATE]. The resident was sent to the
hospital on [DATE] related to a fractured hip. The resident was readmitted on [DATE]. Diagnosis included
fracture of the right hip, pain in the left knee, contracture of the left hip, diabetes mellitus, muscle weakness,
heart disease, major depressive disorder, psychosis, Alzheimer's disease, and anxiety.
Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was
readmitted to the facility on [DATE] after repair of her hip fracture. The resident was cognitively impaired
and totally dependent on one to two staff for all activities of daily living except for eating which she required
extensive assist of one.
Review of Resident #25's care plans revealed the resident resided on a locked secure unit due to poor
safety awareness, sexually inappropriateness, physical and verbal aggression.
The care plan addressed hypersexuality as evidenced by writing inappropriate comments on items, sexual
ideations of inappropriate contact with staff, frequent verbalizations sexual in nature, and aggressively
patting staff on the cheek.
Review of progress note dated 07/11/18 revealed Resident #25 was transferred to a psychiatric facility on
07/02/18 and returned to the facility 07/11/18. Review of progress note dated 07/18/18 at 12:43 P.M. by
social service staff indicated Resident #25 was unable to have a roommate due to behaviors and history of
throwing hot liquids at others. A subsequent progress note on 07/18/18 indicated the resident was
transferred to a psychiatric facility. Review of a progress notes dated 07/31/18 revealed the resident
returned to the facility and was placed on the secure unit for safety or herself and others.
Review of progress note dated 08/08/18 at 11:46 A.M. indicated Resident #25's sister was advised of an
incident (no details were documented in the medical record) from last night and of a fall that occurred.
Review of progress note dated 08/08/18 at 3:22 P.M. indicated Resident #25 complained of right hip pain.
The resident declined pain medications, but accepted ice cream. Review of progress note dated 08/08/18 at
4:29 P.M. indicated x-ray results revealed right hip fracture and the resident was sent to the hospital for an
evaluation.
Review of a SRI dated 08/08/18 revealed Resident #308 complained of Resident #25 touching her
inappropriately the night before, specifically touching her breast and between her legs. The other
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 24 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 - Actual harm
resident was dressed and the touching occurred over top of her clothing. Further review of the SRI revealed
staff had observed Resident #25 sitting with Resident #308. Resident #25 did have her hand on Resident
#308's leg, directly above her knee. Resident #308 requested for staff to remove Resident #25 as she did
not want anyone to think she was gay and she did not want anyone rubbing on her.
Residents Affected - Few
Interview with Regional Corporate Compliance (RCC) #300 on 01/17/19 at 9:20 A.M. revealed Resident
#25 had a severe decline in her abilities since the hip fracture. RCC #300 indicated the resident was
nonambulatory after the incident on 08/08/18. RCC #300 revealed Resident #25 touched Resident #308
inappropriately, so Resident #308 shoved Resident #25 and caused her to fall,. Resident #25 sustained a
fractured hip and was admitted to the hospital. RCC #300 stated she did not feel Resident #308
intentionally hurt Resident #25 and Resident #308 had voiced remorse after the incident.
Interview on 01/17/19 at 10:05 A.M. with the Administrator and RCC #300 revealed the SRI was completed
by the previous Director of Nursing (DON) and they were unaware of what was submitted. RCC #300
verified the SRI should have been submitted as a resident to resident abuse. The SRI should have
contained information about Resident #25 being shoved and sustaining a fractured hip.
Review of former Resident #308's medical record revealed an admit date of 09/22/17 and discharge of
09/05/18. Resident #308's diagnosis included chronic pain, cognitive communication deficit, alcoholic
cirrhosis, anxiety disorder, major depressive disorder, atrial fibrillation, chronic obstructive pulmonary
disease and seizures.
Review of a MDS assessment dated [DATE] indicated supervision only was required for activities of daily
living.
Review of Resident #308's care plan dated 10/04/17 indicated alteration in mood and behaviors with history
of instigating altercations. Interventions included attempts to determine what may trigger behaviors.
2. Record review revealed Resident #84 was admitted to the facility on [DATE] with the following diagnoses;
acute kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain,
generalized anxiety disorder and cocaine abuse.
Review of Resident #84's quarterly MDS assessment dated [DATE] revealed the resident's cognition was
not assessed. Resident #84 was reported to be independent with toileting and required supervision with
bed mobility, transfer, dressing, eating and personal hygiene.
Further review of Resident #84's record revealed the resident signed the smoking policy on 12/21/18.
Review of Resident #84's smoking assessment dated [DATE] revealed the resident required supervision
while smoking. Review of Resident #84's care plan dated 01/12/19 revealed the resident should be
supervised while smoking and all smoking materials should be kept by staff members.
Observation of Resident #84 on 01/14/19 at 7:45 A.M. revealed the resident was smoking unsupervised in
the back of the facility by the ash trays.
At the time of the observation, Licensed Practical Nurse (LPN) #74 was interviewed and verified Resident
#84 was smoking without supervision in the back of the building. LPN #74 reported residents
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 25 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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
were not permitted to smoke without supervision.
Level of Harm - Actual harm
Review of Resident #84's progress note dated 1/14/19 at 9:58 A.M. revealed the resident was note smoking
out in the back of the facility towards the parking lot.
Residents Affected - Few
Observation of Resident #84 on 01/14/19 at 6:00 P.M. revealed the resident was smoking outside in front of
the building.
Review of Resident #84's Brief Interview for Mental Statues (BIMS) dated 01/15/19 revealed the resident
was cognitively intact.
Review of the facility's undated Guest Smoking policy revealed residents should be supervised while
smoking and all smoking materials should be kept at the nurse's station.
3. Record review revealed Resident #13 was admitted to the facility on [DATE] with the following diagnoses;
vascular dementia with behavioral disturbance, hemiplegia affecting right dominant side, muscle wasting
and atrophy, stiffness of unspecified joint, cognitive communication deficit, restlessness and agitation,
restlessness and agitation, psychotic disorder with delusions, hyperlipidemia, alcohol abuse and major
depressive disorder.
Review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident was severely
cognitively impaired. The resident required extensive assistance with bed mobility, dressing, eating and
personal hygiene. Resident #13 also required total dependence with transfers and toileting.
Review of Resident #13's care plan dated revealed interventions included fall mat to the side of the bed and
a personal alarm to the bed as ordered. Further review of Resident #13's care plan revealed the fall mat
and the personal alarm were added to the care plan on 10/03/18.
Review of Resident #13's physicians orders (PO) dated 08/17/17 revealed an order for fall mat to the side
of her bed. Review of PO dated 11/10/18 revealed an order for clip alarm while in bed. The clip alarm was
to be checked for placement and functioning every shift.
Observation on 01/15/19 at 8:35 A.M. revealed Resident #13 was laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
Observation on 01/15/19 at 9:44 A.M. revealed Resident #13 to be laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
Observation on 01/15/19 at 10:47 A.M. revealed Resident #13 was laying in bed with a family member and
staff member in her room. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at
the time of the observation.
Observation on 01/15/19 at 5:39 P.M. revealed Resident #13 was laying in bed with a family member sitting
at her bedside. Resident #13 did not have a fall mat to the side of her bed or a clip alarm on at the time of
the observation.
Observation on 01/16/19 at 9:08 A.M. revealed Resident #13 was laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 26 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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
Observation on 01/16/19 at 9:51 A.M. revealed Resident #13 was laying in bed. Resident #13 did not have
a fall mat to the side of her bed or a clip alarm on at the time of the observation.
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview with the DON on 01/16/19 at 9:52 A.M. verified Resident #13 was laying in bed without a clip
alarm or fall mat to the side of her bed. The DON confirmed Resident #13 had a order and was care
planned for a clip alarm while in bed and a fall mat to the side of the bed.
Event ID:
Facility ID:
365457
If continuation sheet
Page 27 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and interview the facility failed to ensure a resident with a history of weight loss
and who was pocketing food received a speech evaluation. This affected one Resident (#27) of one
reviewed for nutritional status. The facility census was 101.
Residents Affected - Few
Findings include:
Medical record review for Resident #27 revealed an admission date of 05/07/15 with diagnosis of mood
disorders, hearing loss, dementia without behaviors, abnormal heart beats with pacemaker placement,
arthritis, muscle weakness, mental disorder, depressive disorder, anemia, hypertension, and chronic kidney
disease.
Review of the most recent quarterly assessment dated [DATE] revealed the resident was not assessed for
cognition. The resident required extensive assist with eating and had weight loss in the last month or six
month. The resident had no identified dental or chewing problems.
Review of the plan of care with an initiation date of 08/10/18 and revision on 09/25/18, 10/02/18, and
01/04/19 revealed an identified problem of nutritional and/or dehydration risk related to dementia,
depression, chronic kidney disease stage three, hypertension, and iron deficiency anemia. Interventions
included administering medication as ordered (Remeron, appetite stimulant), monitor for ineffectiveness
and side effects, labs as ordered, monthly weights, food in individual bowls, assistance with eating or
drinking as needed and refer to occupational and speech therapy as needed.
Review of progress notes dated 11/12/18 at 4:44 P.M. documented that the resident was pocketing some
food and diet was downgraded to puree. Will consult speech therapy.
Review of physician orders dated 11/13/18 revealed a dietary order for a regular diet, pureed texture,
regular consistency finger foods and food to be placed in individual bowls. Nutritional juice drink two times a
day at breakfast and lunch for supplemental nutrition related to weight loss.
Review of progress notes dated 12/04/18 at 11:24 P.M. documenting significant weight loss in the past 180
days. The medical doctor was notified of the weight loss.
Review of progress notes dated 01/04/19 at 12:16 P.M. documenting significant weight loss in the past 180
days. The medical doctor was notified of the weight loss.
Review of the weight recorded in the electronic health record revealed on 01/04/19 the resident #27 had a
weight of 103.3 pounds. Further review revealed the weights were recorded as 10/29/18 at 107.0 pounds,
on 11/26/18 at 104.3 pounds, and on 12/24/18 as 104.0.
Observation of Resident #27 on 01/15/19 12:39 P.M. revealed the resident was being cued to come to the
dining room for the lunch meal. The food was being served in individual bowls and staff was assisting the
resident with meal consumption. The food was pureed, and a supplement juice was present on tray.
Interview with Licensed Practical Nurse (LPN) #63 on 01/16/19 at 10:03 A.M. revealed Resident #27
required total assist with meals. LPN #63 further revealed the resident at times will refuse to eat ,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 28 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
but staff can encourage her to eat something else. Staff will also offer her a supplement if she refuses to
eat. LPN #63 revealed the resident had lost weight in the past but her weight had stabilized with the diet
change and therapy.
Interview with Therapy Director #305 on 01/16/19 at 10:38 A.M., revealed quarterly screening was
completed on all residents to monitor for changes. Therapy Director #305 indicated being unsure why a
screening was not completed on Resident #27 for speech therapy.
Interview with Corporate Regional Clinical Coordinator (CRCC) #300 on 01/16/19 at 12:01 P.M., verified
speech therapy was not contacted regarding the pocketing of food or the diet downgrade.
Observation of Resident #27 on 01/16/19 at 12:37 P.M., revealed the resident ambulated to the dining
room.
Interview with State Tested Nursing Assistant (STNA) #10 on 01/16/19 at 12:46 P.M., reported the resident
continues to pocket food in her mouth when she eats. STNA #10 indicated she will stroke the resident's
chin and remind her to swallow. STNA #10 further indicate the resident always has someone with her when
she was eating because she was choking with regular food. The resident did better with the pureed food
and just needed needs reminders for swallowing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 29 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff and resident interviews and policy review the facility failed to ensure residents
pain was properly managed and failed to ensure a speciality appointment for pain was scheduled in a
timely manner. This resulted in actual harm to Resident #5 who had uncontrolled pain and difficulty
sleeping. This affected one (#5)of one resident reviewed for pain management. The facility identified 53
residents on a pain management program. The facility census was 101.
Residents Affected - Few
Findings include:
Medical record review for Resident #5 revealed an admission date of 12/28/15. Diagnoses included benign
prostatic hyperplasia, urinary tract infection, and chronic lung disease.
Review of the annual Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact.
The functional status was extensive assistance for bed mobility, transfers, toilet use and he was
independent for eating. Further review of the MDS revealed Resident #5 was on a scheduled pain
medication regimen.
Review of the physician orders (PO) dated 08/04/17 revealed routine Percocet 5-325 milligrams (mg) one
tablet every 12 hours for pain. Review of PO dated 10/03/17 revealed routine Hydorxcholorquine Sulfate
200 mg one tablet routine twice a day and routine Aspercreme with Lidocaine 4%, apply to neck and back
every 12 hours for pain. Review of PO dated 11/30/17 revealed routine Neurotin 600 mg three times a day
for multiple tender points. Review of PO dated 11/24/18 revealed Prednisone one mg daily for pain. Review
of PO dated 11/27/18 revealed routine Naprosyn 500 mg one tablet every 12 hours for rheumatoid arthritis.
Review of physician history and physical dated 11/27/18 revealed the resident was seen for increase in
pain to lower back and knees and for inability to sleep at night. Resident was started on Naprosyn 500 mg
twice a day and explained to resident once the pain was under control it should help with him sleeping.
Resident voiced understanding.
Review of the nurses progress notes dated 11/27/18 at 6:16 P.M. written by Licensed Practical Nurse (LPN)
#74, revealed the physician assessed the resident. The physician ordered Naposyn 500 mg every 12 hours
routine and to follow up with the rheumatoid arthritis physician.
Review of the Medication Administration Record (MAR) from 01/01/19 through 01/16/19 revealed the
resident rated his pain at 9:00 A.M. as a eight three times, as a seven 10 times and as a five two times.
Further review of the MAR revealed at 9:00 P.M. the resident rated his pain as a eight, three times, as a
seven, 10 times, as a six and five once.
Review of the care plan dated 01/10/19, revealed the resident was at risk for pain related to rheumatoid
arthritis. Interventions included routine pain medications, which offered a good short term relief, monitor for
effectiveness of the interventions, monitor for increased level of pain and notify the physician.
Interview with Resident #5 on 01/13/19 at 2:39 P.M., revealed his pain was not under control. He stated he
had rheumatoid arthritis and none of his medications helped
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 30 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0697
Level of Harm - Actual harm
Residents Affected - Few
Interview with LPN #74 on 01/16/19 at 3:46 P.M., revealed she placed the referral for the rheumatoid
arthritis physician on this day. When asked why she didn't make the referral on 11/27/18, she stated she
tried to call the office, but did not have time to sit around on hold or wait for a return phone call from the
physician's office. She stated there was no evidence in the record to indicate she had attempted to call and
make the referral.
Review of facility policy titled, Pain Management Program dated March 2005, revealed the pain
management program will be used by nursing staff to evaluate, provide appropriate interventions, and
monitor the effectiveness of the pain regimen for residents experiencing chronic pain in order to promote
comfort and the ability to reach the residents highest functional level.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 31 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews and staff interviews, the facility failed to ensure residents who were receiving psychotropic
medications were assessed for non pharmaceutical interventions prior to receiving the medications and
also failed to ensure gradual dose reductions were attempted for the use of psychotropic medications. This
affected three (#30, #33, and #88) of three residents reviewed for unnecessary medications. The facility
census was 101.
Finds include:
1. Review of Resident #88's medical record revealed an admission date of 10/14/15. Diagnosis included
hypertension, diabetes, schizophrenia, coronary artery disease anxiety disorder, chronic gout, major
depressive disorder, insomnia, renal impairment, diverticulitis, acquired coagulation factor deficiency, and
heart failure.
Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #88 was cognitively
intact and was supervision only for all activities of daily living. The MDS indicated no symptoms of
depression.
Review of a care plan dated 10/29/13, revealed problems of mood, behaviors, non-compliance, and
psychotropic medication use.
Review of physician orders revealed Fluoxetine 20 milligram (mg) daily, Ativan 1 mg at bedtime, Quetiapine
50 mg twice a day, and Bupropion 300 mg daily.
Review of pharmacy recommendations dated 02/01/18, recommended consideration of a Trazadone
reduction, a Quetiapine reduction, and a Bupropion reduction. All recommendations were declined by the
physician. No recommendations were found for Fluoxetine or Ativan.
Interview on 01/16/19 at 3:08 P.M. with the Director of Nursing reported no other pharmacy
recommendations were available, verifying Ativan and Fluoxetine medications, had not been addressed for
greater than one year.
2. Resident #30 was admitted to the facility on [DATE]. Diagnosis included chronic obstructive pulmonary
disease, muscle wasting and atrophy, major depressive disorder, combined systolic and diastolic
congestive heart failure, encephalopathy, psychosis, diabetes Type II, anxiety and Alzheimer's disease.
Review of the Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS)
score of 10, indicating moderate cognitive impairment. His functional status was listed as extensive one to
two person assist to totally dependent on staff for activities of daily living. The MDS also revealed Resident
#30 was frequently incontinent of urine and bowel.
Review of the care plan dated 11/12/18, revealed Resident #30 received antipsychotic medications related
to unspecified psychosis and depression. Resident #30 was at risk for adverse effects of medication use.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 32 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the physician orders on 01/2019, revealed Resident #30 was ordered and being administered
Oxycodone-Acetaminophen 5-325 milligrams (MG) every six hours as needed for pain. The resident was
also ordered Cloanzepam 0.5 mg every 12 hours as needed for anxiety.
Further review of the medical record revealed the physician had not addressed the as needed medication
every 14 days as required. The review of the medical records also revealed the nursing staff had not
implemented non-pharmacological interventions before administering the medication.
Interview with Corporate Regional Clinical Coordinator (CRCC) #300 on 01/15/19 at 4:30 P.M. confirmed
the physician had not been addressing the as needed medication as required. She also confirmed the
facility nursing staff had not been doing non-pharmacological interventions prior to administering the
medication.
3. Record review for Resident #33 revealed an admission date of 10/31/10. Diagnosis included stroke,
hemiplegia, muscle wasting, difficulty with speaking, anemia, dementia with behaviors, high cholesterol,
insomnia, muscle weakness, overactive bladder, allergies, hearing loss, anxiety and major depressive
disorder.
Review of most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 had
impaired cognition. She required extensive assist with bed mobility, transfer, dressing, toileting and personal
hygiene. Resident #33 had no hallucinations or delusions recorded for the look back period. No behaviors
were coded in Section F for Resident #33. Review Section N (monitors drug types) revealed the resident
received antianxiety, antipsychotic and antidepressants medication daily during the look back period.
Review of the physician orders for the month of January 2018 for Resident #33, revealed an order date of
02/13/18 for Clonazepam (name brand) tablet 0.5 milligrams (mg), give 1 tablet by mouth every 12 hours for
anxiety; Trazodone (name brand) tablet 75 mg, give 1.5 tablet by mouth one time a day for insomnia with a
start date of 01/29/18; Risperidone (antipsychotic) 2 mg by mouth daily for dementia with a start date of
01/27/18; and Sertraline (antidepressant) 25 mg one tablet daily for major depressive disorder with a start
date of 02/12/16.
Review of Psychiatric Progress notes dated 12/28/18 for Resident #33, revealed a diagnosis of anxiety and
depression.
Review of the progress notes for Resident #33 from 01/16/19 through 03/16/18, revealed there was no
documentation that gradual dose reductions were attempted for the Trazadone, Risperidone and
Clonazepam medications.
Review of the consultant pharmacist recommendation document dated 03/16/18 for Resident #33, revealed
the resident has been receiving the antipsychotic medication Risperidone and the antidepressant Sertraline
for greater than six months without a gradual dose reduction.
Interview with Corporate Nurse #300 on 01/16/19 at 3:30 P.M., verified gradual dose reductions had not
been attempted for the above medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 33 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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.
Based on observations and staff interview, the facility failed to ensure expired medications and laboratory
supplies were discarded appropriately and medications were secure and inaccessible to unauthorized staff.
This affected two of two medication carts and an undetermined number of residents who utilize the
medications and supplies from the storage rooms. The facility census was 101.
Findings include:
1. Observations of the nurses station storage area on the South unit on 01/15/19 at 10:49 A.M., revealed
five intravenous solution bags labeled 0.45% Normal Saline with an expiration date of 12/13/18 an two
select silicone cure catheter for suction with expiration dates of 08/08/18 were being stored in this area
during the survey. All other injectable medications and medical supplies being stored was not expired.
Interview with Regional Support Registered Nurse #310, immediately following the observation on 01/15/19
at 10:49 A.M., verified there were expired injectable's, food items and medical supplies stored in the nurses
stations supply areas. She further stated the drugs should be returned to pharmacy for a credit or stored in
a secured cabinet until destruction.
2. Observation of the nurses station refrigerator on the East unit on 01/15/19 at 11:09 A.M., revealed five
insulin pens that were sealed in a clear bag with a pharmacy label dated 01/14/19, was found in the
refrigerator that was used to store food and drinks for the residents and staff. All other medications being
stored in the locked medication refrigerator was not expired.
Interview with Regional Support Registered Nurse #310, immediately following observation on 01/15/19 at
11:09 A.M., verified there were medications being stored in a refrigerator that was unlocked and accessible
to unlicensed staff.
Interview with Licensed Practical Nurse #74 on 01/15/19 at 11:12 A.M., revealed the insulin was delivered
last night and was not correctly stored in the locked refrigerator used for medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 34 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0773
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the
results.
Based on record review and staff interview, the facility failed to ensure laboratory tests were completed as
ordered by the physician. This affected one (#33) of five residents reviewed for laboratory services. The
facility census was 101.
Findings include:
Record review for Resident #33 revealed an admission date of 10/31/10. Diagnoses included stroke,
hemiplegia, muscle wasting, difficulty with speaking, anemia, dementia with behaviors, high cholesterol,
insomnia, muscle weakness, overactive bladder, allergies, hearing loss, anxiety and major depressive
disorder.
Review of the physician orders for Resident #33, revealed laboratory orders with a start date of 09/28/16,
for a Basic Metabolic Profile (BMP) every three months; a Complete Blood Count (broad screening to test
for anemia and infections), Magnesium ( test for abnormal levels) and Renal Panel (kidney function) every
four months with a start date of 01/25/17; a Hepatic Panel (liver functions) every six months with a start
date of 10/11/16; a HgBA1C ( average sugar levels in blood over two to three months) every six months
with a start date of 01/26/17; and a Lipid Panel (cholesterol level) every six months with a start date of
09/28/16.
Review of the progress notes for Resident #33 from 01/16/19 through 03/16/18, revealed there was no
evidence the laboratory tests were completed.
Interview with the Director of Nursing on 01/16/19 at 2:13 P.M., verified the laboratory tests were not
completed as ordered by the physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 35 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interview and review of the facility policy, the facility failed to ensure the
dishwasher and food items were being properly maintained to prevent contamination and spoilage. This
affected 99 of 99 residents who receive meals from the facility kitchen. The facility identified for two (#55
and #58) residents who receive nothing by mouth (NPO). The facility census was 101.
Findings include:
Observations of the facility's kitchen on 01/13/19 at 9:25 A.M., revealed Dietary Aide #99 and Dietary Aide
#112, to be actively washing dishes from breakfast. Observation of the dishwasher temperature revealed
the dishwasher to be running at 100 degrees Fahrenheit during the wash and 110 degrees Fahrenheit
during the rinse. The metal plate on the side of the dishwasher revealed the dishwasher to require a
minimum temperature of 120 degrees Fahrenheit during the wash and rinse. Observation of Dietary Aide
#99 testing the chemicals in the dishwasher, revealed the chemical to be at 0 parts per million (ppm).
Interview with Dietary Aide #99 on 01/13/19 at 9:25 A.M., verified the dishwasher was not up to
temperature and the chemical in the dishwasher was not at the appropriate ppm.
Observations of the walk-in refrigerator on 01/13/19 at 9:30 A.M., revealed there to be an undated and
unlabeled lunch meat sandwich in a bag and an undated and unlabeled salad. Further observation of the
kitchen on 01/13/19 at 9:30 A.M., revealed Dietary Aide #99 and Dietary Aide #112 continued to run
breakfast dishes through the dishwasher, despite the dishwasher not being at the appropriate temperature
or have the appropriate ppm of chemical.
Interview with [NAME] #75 on 01/13/19 at 9:30 A.M., verified there to be undated and unlabeled lunch meat
sandwich in a bag and an undated and unlabeled salad in the walk-in refrigerator. [NAME] #75 also
confirmed Dietary Aide #99 and Dietary Aide #112, were continuing to run breakfast dishes through the
dishwasher despite the dishwasher not being at the appropriate temperature or have the appropriate ppm
of chemical.
Review of the facility policy titled, Dish Machine Temperature and Sanitizer Records, dated April 2010,
revealed staff were responsible for checking dish machine temperatures. The policy also revealed
dishwashers that use chemical sanitization should have a wash of at least 120 degrees Fahrenheit and a
final rinse of 50 ppm. The policy also indicated, The flow of the fresh water sanitizing rinse shall be within
the range on the manufactures data plate.
Review of the facility policy titled, Date Marking, dated April 2011, revealed an established procedure for
date marking shall be used by the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 36 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record review, staff interview and review of facility policy, the facility failed to ensure medical
records were complete, accurate and protected. This affected three (#5, #35 and #20) 27 of residents
reviewed during the investigation portion of the survey. The facility census was 101.
Findings include:
1. Review of Resident #20's medical record revealed an admission date of 04/09/15. Diagnosis included
kidney failure anxiety disorder, major depressive disorder, bipolar disorder, paranoid schizophrenia, and
hypertension.
Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #20 was cognitively
intact and required extensive assist of one for activities of daily living.
Review of the skin risk assessment dated [DATE], indicated the resident was at risk for skin disturbance.
Review of a care plan with a revised date of 01/03/19, revealed an intervention of treatments as ordered.
Review of a Certified Nurse Practitioner (CNP) note dated 01/02/19, revealed a diagnosis of abrasion to the
left upper buttock that had just reopened. The area measured 0.5 centimeters (cm) x 6 cm without a depth,
linear in appearance without warmth, odor, or drainage. An order was written by the CNP on 01/02/19, to
apply wound gel and a foam dressing daily with a referral to a wound center.
Review of the wound physician orders dated 01/07/19, indicated the buttock abrasion was to be cleansed
with soap and water, Bactroban ointment applied, then a dry dressing twice a day, and return visit in one
week.
Review of the physician orders for January 2019, failed to reveal any orders for cleansing or applying a
dressing for the left buttock. The January orders included an order for Mupirocin ointment (Bactroban),
apply to wound left buttock topically two times per day dated 01/07/19.
Interview on 01/15/19 at 4:41 P.M. with Resident #20, revealed she reported she had visited the wound
physician earlier in the day. Resident #20 complained the facility nurses had stopped washing her buttock
wound a week prior and was not putting a dressing on the wound. She reported the wound physician had
updated the wound orders today.
Interview on 01/15/19 at 5:23 P.M. with Licensed Practical Nurse (LPN) #74, reported Resident #20 had a
wound center visit earlier in the day and indicated wound care orders received indicated a dressing was to
be applied. LPN #74 stated previous orders were for ointment only, that a dressing had not been applied
since wound center visit on 01/17/19.
Interview on 01/15/19 at 7:08 P.M. with the Director of Nursing (DON), verified the wound center had
ordered on 01/07/19, cleansing Resident #20's buttock wound, then applying ointment and a dressing. The
DON verified the 01/07/19 orders, were not present on the Medication and Treatment
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 37 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0842
Administration record, and Resident #20 had not received the ordered treatments.
Level of Harm - Minimal harm
or potential for actual harm
2. Observations on 01/16/19 at 9:57 A.M., revealed a computer sitting on top of the medication cart,
opened and turned on to the Point of Care software in the memory care unit. The screen was exposing
Resident #35's medication administration record with current medications and a photo of the resident .
Observation of a clip board with work assignment document was attached to the clip board and exposed
with a listing of Rooms #100 through #109's and included vital signs, appointments and bowel movements
that was left uncovered on the top of the medication cart. Observation of two nurses were behind a locked
door across the hallway from the medication cart.
Residents Affected - Few
Interview on 01/16/19 at 10:00 A.M. with Licensed Practical Nurse #62, verified the computer was open and
turned on, exposing confidential information of the Resident #35. She further verified the clip board
contained vital signs, appointments, and bowel movements of the resident's located in the memory care
unit.
Review of the facility policy titled, Medication Administration, dated 07/09, revealed the medication
administration record (MAR) was to be closed on top of the medication cart between administering
medications to each resident.
3. Medical record review for Resident #5 revealed an admission date of 12/28/15. Diagnoses included
benign prostatic hyperplasia, urinary tract infection, and chronic lung disease.
Review of the annual Minimum Data Set (MDS) dated [DATE], revealed he was cognitively intact. The
functional status was extensive assistance for bed mobility, transfers, toilet use and was independent for
eating.
Review of the physician orders for laxative medications included Dulcolax Suppository 10 milligram (mg)
dated 11/14/16, to insert 10 mg rectally every 24 hours as needed for constipation; Milk of Magnesia 400
mg/ml oral suspension dated 10/18/16, give 30 ml orally every 24 hours as needed for constipation; and
Senexon-S 8.6 mg-50 mg tablet dated 10/26/16, give one tablet orally every 12 hours as needed for
constipation.
Review of the bowel records for Resident #5, revealed from 01/06/19 at 8:13 P.M. to 01/12/19 at 6:43 P.M.,
there was no documentation of a bowel movement.
Review of the progress notes dated 01/06/19 through 01/12/19, revealed there was no mention of
constipation or the resident refused laxative medications.
Review of the Medication Administration Record from 01/06/19 through 01/12/19, revealed laxative
medication mentioned above were not given or refused.
Interview with Resident #5 on 01/13/19 at 2:42 P.M., revealed he was constipated and said he didn't know if
it was his medication that was causing him to become constipated.
Interview on 01/16/19 at 11:46 A.M. with Corporate Regional Clinical Coordinator #300, revealed the
resident stated for a long time he didn't want laxative medications. She verified there wasn't any
documentation in the record of refusals by the resident for a laxative.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 38 of 39
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
365457
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Laurels of Middletown
751 Kensington Street
Middletown, OH 45044
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 0926
Have policies on smoking.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff interview, record review and review of the facility policy, the facility failed to implement
their smoking policy in regards to supervising residents with smoking and smoking materials. This affected
one (#84) of one resident reviewed for smoking. The facility census was 101.
Residents Affected - Few
Findings include:
1. Record review revealed Resident #84 was admitted to the facility on [DATE]. Diagnoses included acute
kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain, generalized
anxiety disorder and cocaine abuse.
Review of Resident #84's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the
resident's cognition was not assessed. Resident #84 was reported to be independent with toileting and
required supervision with bed mobility, transfer, dressing, eating and personal hygiene.
Further review of Resident #84's record revealed the resident signed the smoking policy on 12/21/18.
Review of Resident #84's smoking assessment dated [DATE], revealed the resident required supervision
while smoking. Review of Resident #84's care plan dated 01/12/19, revealed the resident should be
supervised while smoking and all smoking materials should be kept by staff members.
Review of Resident #84's progress note dated 1/14/19 at 9:58 A.M., revealed the resident was noted
smoking out in the back of the facility towards the parking lot.
Review of Resident #84's Brief Interview for Mental Status (BIMS) dated 01/15/19, revealed the resident
was cognitively intact.
Observation of Resident #84 on 01/14/19 at 7:45 A.M., revealed the resident was smoking unsupervised in
the back of the facility by the ash trays.
At the time of the observation, Licensed Practical Nurse (LPN) #74 was interviewed and verified Resident
#84 was smoking without supervision in the back of the building. LPN #74 reported residents were not
permitted to smoke without supervision and verified the policy was not followed.
Observation of Resident #84 on 01/14/19 at 6:00 P.M., revealed the resident was smoking outside in front
of the building.
Review of the undated facility policy titled, Guest Smoking, revealed residents should be supervised while
smoking and all smoking materials should be kept at the nurse's station.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 39 of 39
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
28 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F679 - Activities
Provide activities to meet all resident's needs.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
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.
F773 - The facility must—
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0347GeneralS&S Fpotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F913 - Have direct access to an exit corridor;
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
FAQ · About this visit
Common questions about this visit
What happened during the January 16, 2019 survey of THE LAURELS OF MIDDLETOWN?
This was a inspection survey of THE LAURELS OF MIDDLETOWN on January 16, 2019. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE LAURELS OF MIDDLETOWN on January 16, 2019?
Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.