Inspection·September 29, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on medical record review, staff and guardian interviews, and policy review, the facility failed to provide the correct location for discharge on a discharge notice. This affected one (Resident #204) of three residents reviewed for proper discharges. The facility census was 101. Findings include: Review of the medical record for Resident #204 revealed an admission date of 07/23/22 with medical diagnoses of paranoid schizophrenia, end stage renal disease, and anxiety. Resident #204 was discharged to an acute care hospital on [DATE] for increased behaviors and agitation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #204 was cognitively intact and required supervision at times with bed mobility, toileting, and transfers. Review of the nursing progress note dated 09/01/23, revealed the dialysis center would no longer provide dialysis to Resident #204 because of his increased behaviors and an episode where Resident #204 pulled out his dialysis tubing and experienced bleeding. Further review revealed a note dated 09/02/23, which stated Resident #204 had a change in condition with altered mental status and behavioral symptoms. Review of the progress note revealed Resident #204 pulled items off walls and was throwing them, went into other resident rooms and was throwing their clothes and exposed his penis to a female resident on the unit. Further review of the medical record revealed an immediate discharge from facility letter dated 09/06/23, showing Resident #204 would be discharged due to the facility not being able to meet the needs of the resident and the resident was a danger to himself and other residents. The location of discharge was documented as a behavioral hospital. The letter continued to state upon discharge from the behavioral hospital, the resident would return to the facility. Interview on 09/29/23 at 12:02 P.M. with Resident #204's guardian revealed Resident #204 was transferred to an acute hospital setting, not a behavioral unit, on 09/02/23. Resident #204's guardian stated the facility contacted her on 09/06/23 via phone to notify her Resident #204 was issued an immediate discharge from the facility because he was a harm to himself, and other residents and the facility was not able to meet his needs. Resident #204's guardian stated the facility informed her the immediate discharge notice would be sent to her via certified mail. Resident #204's guardian stated she never received the notice in the mail, so she went to the facility, and they provided her with a copy of the letter. Resident #204's guardian stated the discharge locations on the immediate discharge letter were incorrect and Resident #204 had not been discharged to a behavioral hospital but an (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 2 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 09/29/2023 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)