Health inspection·April 12, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, staff interview, and policy review, the facility failed to complete weekly wound evaluations of a surgical wound. This affected one (#105) out of three residents reviewed for wound care. The facility census was 101. Residents Affected - Few Findings include: Review of the medical record for Resident #105 revealed an admission date of 02/20/24 with medical diagnoses of status post left below the knee amputation (BKA), diabetes mellitus with neuropathy, depression, bipolar disorder, anemia, and hypertension. Review of the medical record revealed Resident #105 discharged to the hospital on [DATE]. Review of the medical record for Resident #105 revealed an admission Minimum Data Set (MDS) assessment, dated 02/27/24, which indicated Resident #105 was cognitively intact and required supervision with bed mobility and moderate staff assistance with toilet hygiene, transfers, and bathing. The MDS indicated Resident #105 admitted with a surgical wound and treatment was in place. Review of the medical record for Resident #105 revealed a Nursing Comprehensive Evaluation, dated 02/21/24, which indicated Resident #105 admitted with a surgical wound to left lower extremity status post BKA. The evaluation stated the surgical wound had 20 staples but did not state a measurement or describe the wound characteristics. The evaluation also noted Resident #105 admitted with diabetic ulcers to right plantar foot and to the 3rd digit on right foot and both areas were noted to have measurements. Further review of the medical record revealed a wound evaluation completed 03/19/24 for the surgical wound to the left BKA. The surgical wound measured 0.57 centimeters (cm) in length by 1.97 cm in width and 1.6 cm in depth. The evaluation stated the surgical wound had deteriorated. Review of the medical record for Resident #105 revealed it did not contain documentation to support the facility completed wound evaluations, which included wound measurements and description for Resident #105's left BKA surgical site from 02/20/24 until 03/19/24. Review of the medical record for Resident #105 revealed a Certified Nurse Practitioner (CNP) wound note, dated 03/19/24, which stated Resident #105 had injured the left BKA stump in the bathroom the day before and the incision had opened, had drainage, and increased pain to the area. The note included measurements and a description of Resident #105's wound and the treatment plan. Interview on 04/12/24 at 2:45 P.M. with Licensed Practical Nurse (LPN) #221 confirmed the medical record for Resident #105 did not contain documentation to support the facility completed wound evaluation for the left BKA from 02/20/24 until 03/19/24. (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 04/12/2024 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)