Health inspection·May 23, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and resident and staff interviews, the facility failed to provide a clean, comfortable, and sanitary environment for the residents. This affected four (#25, #36, #46 and #51) out of four residents reviewed for the physical environment. The facility census was 97. Findings include: Interview on 05/20/24 at 2:48 P.M. with Resident #46 revealed he was upset that his bed was not comfortable and felt as though it was broken. Resident #46 confirmed his mattress was not lying on the bed correctly. Resident #46 stated his bed does not face the television in his room and he must turn his head to the left to watch television. Resident #46 stated the brown wall beside his bed had a large white drywall substance on it for several months. Interview on 05/21/24 at 8:33 A.M. with Resident #51 revealed he can feel the bed rails on the frame pushing through his mattress. Resident #51 pointed to a large, rounded area on his mattress and the bed rails underneath it. Resident #51 stated he was told by staff he will have a replacement mattress; however, he was never given one. Resident #51 stated he was the paint would be corrected pointing toward several colors of uneven paint behind the head of his bed, however nothing has been done. Observation with interview on 05/21/24 at 9:02 A.M. revealed three walls with multiple black scratches on the walls lightly covered with plaster. The observation revealed the areas had not been painted. Interview with Resident #25 stated her room had looked that way for quite a while. Observation with interview on 05/21/23 at 9:39 A.M. revealed three walls in Resident #36's room to have several areas with plaster but no paint. Interview with Resident #36 stated his room looked that way when he arrived on 04/18/24. Interview on 05/21/24 at 1:45 P.M. with State Tested Nurse Aide (STNA) #254 confirmed the large white patched drywall area on the wall next to Resident #46's bed. STNA #254 attempted to fix the footboard of Resident #46 and confirmed the mattress was lying on the bed uneven. STNA #254 confirmed the mattress was curled up into the air on the left side at the top corner and the bottom corner. STNA #254 confirmed the large gap approximately eleven inches wide at the head of the bed between the headboard and mattress because the mattress did not fit on the bed frame appropriately. STNA #254 confirmed Resident #254's bed was placed against the wall and his head must be turned to the left to watch his television in bed. STNA #254 confirmed the importance of television to Resident #46's quality of life. Interview on 05/21/24 at 2:10 P.M. with the Housekeeping Manager (HM) #291 confirmed Resident #51 Page 1 of 20 365457 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had a large, rounded area in his mattress that stood up over the bed frame rails. HM #291 confirmed the facility has mattresses downstairs and it could easily be replaced. HM #291 verified the two different colors on the wall in no paint pattern behind Resident #51's bed. On 05/22/24 at 2:31 P.M. interview with Housekeeper #227 confirmed the walls in Resident #25 and #36 rooms had many scratches on the walls which were lightly covered with plaster and had not been painted. Housekeeper #227 stated the walls for both rooms had been that way for several months. 365457 Page 2 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

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** 3. Record review for Resident #41 revealed he was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, bradycardia, orthostatic hypertension, hyperlipidemia, anemia, Parkinson's Disease, insomnia, cognitive impairment, and abdominal aortic aneurysm. Residents Affected - Some Review of the most recent MDS assessment for Resident #41, dated 03/23/24, revealed he had impaired cognition. The facility failed provide an assessment related to the level of care he required. 4. Record review for Resident #74 revealed he was admitted to the facility on [DATE]. His diagnoses included, alcohol, epilepsy, seizures, hyperlipidemia, heart failure, anxiety disorder, alcohol abuse, and metabolic encephalopathy. Review of the most recent MDS assessment dated , 04/15/24, revealed he had impaired cognition. Further review of the MDS assessment revealed he was dependent on staff for medication administration. The facility failed to assess his functioning level according to the assessment. On 05/22/24 at 11:38 AM interview Regional MDS Nurse #320 confirmed the activity of daily living (ADL's) sections were not assessed for Resident #74's MDS dated [DATE], and for Resident #41's MDS dated [DATE]. 5. Review of medical record for Resident #92 revealed admission date of 04/26/24. The resident was admitted with diagnoses including osteomyelitis, anxiety, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and psychoactive substance abuse. The resident remained in the facility. The admission MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required supervision for her activities of daily living. Section L (oral) revealed the obvious or likely cavity or broken teeth was marked no. Interview on 05/20/24 at 10:32 A.M. with Resident #92 revealed she had a concern for care of her broken lower teeth. Observation at the time of interview revealed she was edentulous on top with several dental carries at the gum level on her lower teeth and broken teeth on her left lower left. Interview and observation with Registered Nurse (RN) #245 on 05/22/24 at 11:38 A.M. verified Resident #92 had several dental carries on her lower teeth and a broken tooth on her lower left. 6. Review of medical record for Resident #82 revealed admission date of 3/23/24. The resident was admitted with diagnoses including local skin infection, cellulitis of the right and left upper arm, sepsis and bipolar disorder. The resident remained in the facility. The admission MDS dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required extensive one person assistance for bed mobility, transfers, toileting and eating. Section L of the MDS revealed no documentation of broken or loose teeth, and no obvious cavities or broken natural teeth. Interview on 05/20/20 at 10:10 A.M. with Resident #82 revealed he had concerns for dental carries. Observation revealed multiple blackened, and fragmented teeth on both the upper and lower teeth. 365457 Page 3 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0641 Level of Harm - Minimal harm or potential for actual harm On 05/22/24 at 11:38 A.M. interview with Regional MDS Nurse #320 confirmed the MDS assessment for Residents #01, #24, #41, #74, #82, and #92 were not coded accurately as per the RAI manual guidelines. Interview and observation with RN #245 on 05/22/24 at 11:52 A.M. verified Resident #82 had multiple broken/fragmented and blackened teeth. Residents Affected - Some Review of the RAI 3.0 manual, Version 1.18.11 dated October 2023 revealed the MDS assessments are a core set of screening, clinical and functional status data elements which form the foundation of the comprehensive assessment for all residents. The RAI manual stated the MDS assessments should accurately reflect the resident's status. Based on record review, observations, resident and staff interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to accurately code Minimum Data Set (MDS) assessments. This affected six (#01, #24, #41, #74, #82, and #92) residents out of the 25 residents reviewed for MDS accuracy. The facility census was 97. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 07/25/04 with medical diagnoses of traumatic brain injury, paranoid schizophrenia, psychotic disorder with delusions and seizures. Review of the medical record for Resident #01 revealed an annual MDS assessment, dated 03/28/24, revealed Resident #01 had severe cognitive impairment. The MDS did not have any documentation to support Resident #01's functional status was assessed. Review of section GG of Resident #01's MDS was dashed, and all areas were blank. 2. Review of the medical record Resident #24 revealed an admission date of 08/02/19 with medical diagnoses of atrial fibrillation, anxiety, right sided hemiparesis related to cerebral infarction, hypertensive heart disease, and congestive heart failure. Review of the medical record for Resident #24 revealed a quarterly MDS assessment, dated 03/20/24, which indicated Resident #24 was cognitively intact. The MDS did not have any documentation to support Resident #24's functional status was assessed. Review of section GG of Resident #24's MDS was dashed, and all areas were blank. On 05/23/24 at 10:52 A.M. interview with Administrator confirmed the facility did not have a MDS completion policy but stated the facility followed the procedures and guidelines in the RAI manual to ensure accurate completion of MDS assessments. 365457 Page 4 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure a Pre-admission Screening and Resident Review (PASRR) was completed upon admission. This affected one (#25) out of the two residents reviewed for PASRR completion. The facility census was 97. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 08/05/22 with medical diagnoses of anoxic brain injury, depression, bipolar disorder, schizoaffective disorder, functional quadriplegia, and convulsions. Review of the medical record for Resident #25 revealed an annual Minimum Data Set (MDS) dated [DATE] which indicated Resident #25 was cognitively intact and was dependent for toilet hygiene, bed mobility, and transfers. Review of the medical record for Resident #25 revealed a Review Results letter, dated 07/22/16, which stated the Pre-admission Screen determination was not applicable and level of care determination was Intermediate. Further review of the medical record revealed no documentation of a PASRR for the Review Results letter dated 07/22/16. Interview on 05/23/24 at 10:03 A.M. with Administrator confirmed the medical record for Resident #25 did not contain documentation to support the PASRR for the 07/22/16 Review Results letter. Administrator stated she was unable to confirmed Resident #25's PASRR was completed accurately upon admission. Review of the policy titled Review of Pre-admission Screening and Guest/Resident Review, revised 12/15/22, stated all persons seeing admission to a nursing facility, who are seriously mentally ill and/or have an intellectual/developmental disability, are required to be evaluated to determine if a nursing facility is the appropriate place to receive services. The policy stated the process begins with the completion of the screening, Level 1. 365457 Page 5 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on record review, observations, resident and staff interviews, the facility failed to develop a comprehensive care plan to address resident's dental status. This affected two (#82 and #92) of 25 resident care plans reviewed. The facility census was 97. Findings include: 1. Review of medical record for Resident #92 revealed admission date of 04/26/24. The resident was admitted with diagnoses including osteomyelitis, anxiety, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) and psychoactive substance abuse. The resident remained in the facility. Review of Resident #92's admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required supervision for her activities of daily living. Record review of the care plan of Resident #92 revealed no dental plan of care. Interview on 05/20/24 at 10:32 A. M. with Resident #92 revealed she had a concern for care of her broken lower teeth. Observation at the time of interview revealed several dental carries at the gum level on her lower teeth and broken teeth on her left lower left. Interview and observation with Registered Nurse (RN) #245 on 05/22/24 at 11:38 A.M. verified Resident #92 had several dental carries on her lower teeth. Interview on 05/23/24 at 2:05 P.M. with Clinical Coordinator RN #324 verified there was no specific dental care plan and no care plan which contained interventions for dental carries. 2. Review of medical record for Resident #82 revealed admission date of 3/23/24. The resident was admitted with diagnoses including local skin infection, cellulitis of the right and left upper arm, sepsis and bipolar disorder. The resident remained in the facility. Review of Resident #82's admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required extensive one person assistance for bed mobility, transfers, toileting and eating. Review of Resident #82's care plan revealed there was no dental plan of care. Interview on 05/20/20 at 10:10 A.M. with Resident #82 revealed he had concerns for dental carries. Observation revealed multiple blackened, and fragmented teeth. Interview and observation with RN #245 on 05/22/24 at 11:52 A.M. verified Resident #82 had multiple broken/fragmented and blackened teeth. Interview on 05/23/24 at 2:07 P.M. with the Director of Nursing (DON) verified there was no specific dental care plan and/or no care plan which contained interventions for Resident #82's dental 365457 Page 6 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0656 carries. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365457 Page 7 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record reviews, resident and staff interviews, and policy review, the facility failed to conduct resident care conferences. This affected three (#24, #54 and #79) residents out of the five residents reviewed for care conferences. The facility census was 97. Findings include: 1. Review of the medical record Resident #24 revealed an admission date of 08/02/19 with medical diagnoses of atrial fibrillation, anxiety, right sided hemiparesis related to cerebral infarction, hypertensive heart disease, and congestive heart failure. Review of the medical record for Resident #24 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/20/24, which indicated Resident #24 was cognitively intact. Review of the medical record for Resident #24 revealed the facility conducted a quarterly care conference on 03/25/24. Review of the medical record revealed no documentation to support the facility conducted any other care conferences in the past 12 months. Interview on 05/21/24 at 9:28 A.M. with Resident #24 stated he recently had a care conference but that was the first care conference in over a year. 2. Review of the medical record for Resident #54 revealed an admission date of 04/19/23 with medical diagnoses of chronic obstructive pulmonary disease, left above the knee amputation, diabetes mellitus, and end stage renal disease. Review of the medical record for Resident #54 revealed an annual MDS assessment, dated 03/18/24, which indicated Resident #54 was cognitively intact and required maximum staff assistance for bathing and was dependent on staff for toilet hygiene, transfers, and bed mobility. Review of the medical record for Resident #54 revealed the facility conducted a quarterly care conference on 03/12/24. Review of the medical record revealed no documentation to support the facility conducted any other care conferences in the past 12 months. Interview on 05/20/24 at 2:51 P.M. with Resident #54 stated the facility does not offer care conferences to her quarterly. 3. Review of the medical record for Resident #79 revealed an admission date of 02/17/23 with medical diagnoses of chronic respiratory failure, cerebral infarction, left hemiparesis, heart failure and diabetes mellitus. Review of the medical record for Resident #79 revealed a quarterly MDS assessment, dated 04/25/24, which indicated Resident #79 was cognitively intact and was dependent upon staff for bed mobility, transfers, and toilet hygiene. Review of the medical record for Resident #79 revealed the facility conducted a quarterly care conference on 10/30/23. Review of the medical record revealed no documentation to support the facility conducted any other care conferences in the past 12 months. 365457 Page 8 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/20/24 at 10:45 A.M. with Resident #79 stated he had not attended a care conference for a very long time. Interview on 05/22/24 at 3:30 P.M. with Administrator confirmed the medical records for Residents #24, #54, and #79 did not contain documentation to support the facility conducted care conferences or offered to hold care conferences. Administrator stated the facility did not have a Social Service designee for a while and care conferences were not done as per policy. Review of the policy titled, 72 Hour admission Conference, revised 04/19/22, stated the care conference is to be with the resident, family, and members of Interdisciplinary Team (IDT). The policy stated the purpose was to align expectations of service and care and include the resident and family in the care planning process. The process allows the IDT to communicate nursing and therapy goals, and expectations for discharge as indicated. The policy continued to state the first meeting, upon admission, would occur within 72 hours of admission for all residents. The policy stated ongoing meetings would be individually scheduled with residents and family based on their needs, and for the residents that were long term they would have a care conference to coincide with the admission and quarterly assessments. 365457 Page 9 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, observations, resident and staff interviews and policy review, the facility failed to ensure a resident was provided with hand hygiene. This affected one (#49) out of four residents reviewed for personal hygiene. The facility census was 97. Residents Affected - Few Findings include: Resident #49 was admitted to the facility on [DATE] with a diagnosis of functional quadriplegia, injury of unspecified level of cervical spinal cord, muscle spasms, muscle weakness, anxiety, and depressive disorders. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #49 is cognitively intact. His functional status is listed as set up to dependent on staff for all activities of daily living. For showering the resident is dependent but for toileting he is substantial/maximal assistance. For eating and hygiene he is just set up only. Review of the care plan revealed Resident #49 has a functional ability deficit and requires assistance with self-care/mobility related to impaired mobility, muscle weakness, pain, bowel and bladder incontinence, psychoactive medication usage, right hand splint, Hoyer lift for transfers. Interventions included half side rails for bed mobility, Hoyer lift for transfers, right hand splint as ordered. Keep fingernails trimmed and clean. Provide assistance as needed for each activity until the resident performs skill competently and is safe with level of care; re-evaluate regularly to be certain that the skill level is maintained, and the resident remains safe in the environment. Hand splint to be used Tuesday and Thursday only. Review of the physician orders dated 09/19/23 revealed apply hand splint to right hand twice a week as tolerated. May remove for hand hygiene. Guest may wear hand splint as tolerated and needed. One time a day, every Tuesday and Thursday, for contracture's to right hand. Review of the Treatment Administration Record (TAR) for 03/2024, 04/2024, and 05/2024, revealed Resident #49's hand splint was signed off as completed. Interview on 05/21/24 at 8:30 A.M. with Resident #49 revealed the staff never place his hand splint on his contracture right hand. Resident #49 revealed the last time staff applied the hand splint was months ago. Resident #49 also revealed they never try to wash the contracted hand or fingers. Observation on 05/21/24 at 8:30 A.M., 1:00 P.M., revealed Resident #49 did not have the hand splint applied. On 05/21/24 at 4:40 P.M. observation of Resident #49 revealed the hand splint was still not applied. Observation on 05/22/24 at 10:50 A.M. revealed the hand splint was still not applied. Observation on 05/21/24 and 05/22/24 revealed a sour odor in Resident #49's room that the resident stated was caused by his unattended/foul smelling contracted hand. Observation and interview on 05/22/24 at 10:50 A.M. with Resident #49 revealed the staff did not place the splint on his right contracted hand on 05/21/24 as physician ordered. Resident #49 revealed staff have not placed his splint or washcloth in his hand in months. Resident #49 also revealed the staff had not cleaned his contracted hand in months. 365457 Page 10 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Registered Nurse (RN) #316 at 10:50 A.M. revealed she applied a washcloth to the contracted hand of the Resident on 05/21/24. When asked how she did this she was not able to demonstrate this task. Review of the facility policy titled, Braces and Splints dated 04/05/24 revealed staff will a scheduled program of applying and removing the appliance. Schedule hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations, rashes, etc. and will be reported to charge nurse and attending physician. 365457 Page 11 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interviews and policy review, the facility failed to ensure a resident's hand splint was applied as physician ordered. This affected one (#49) out of four residents reviewed for range of motion. The facility census was 97. Findings include: Resident #49 was admitted to the facility on [DATE] with a diagnosis of functional quadriplegia, injury of unspecified level of cervical spinal cord, muscle spasms, muscle weakness, anxiety, and depressive disorders. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #49 is cognitively intact. His functional status is listed as set up to dependent on staff for all activities of daily living. For showering the resident is dependent but for toileting he is substantial/maximal assistance. For eating and hygiene he is just set up only. Review of the care plan revealed Resident #49 has a functional ability deficit and requires assistance with self-care/mobility related to impaired mobility, muscle weakness, pain, bowel and bladder incontinence, psychoactive medication usage, right hand splint, Hoyer lift for transfers. Interventions included half side rails for bed mobility, Hoyer lift for transfers, right hand splint as ordered. Keep fingernails trimmed and clean. Provide assistance as needed for each activity until the resident performs skill competently and is safe with level of care; re-evaluate regularly to be certain that the skill level is maintained, and the resident remains safe in the environment. Hand splint to be used Tuesday and Thursday only. Review of the physician orders dated 09/19/23 revealed apply hand splint to right hand twice a week as tolerated. May remove for hand hygiene. Guest may wear hand splint as tolerated and needed. One time a day, every Tuesday and Thursday, for contracture's to right hand. Review of the Treatment Administration Record (TAR) for 03/2024, 04/2024, and 05/2024, revealed Resident #49's hand splint was signed off as completed. Interview on 05/21/24 at 8:30 A.M. with Resident #49 revealed the staff never place his hand splint on his contracture right hand. Resident #49 revealed the last time staff applied the hand splint was months ago. Resident #49 also revealed they never try to wash the contracted hand or fingers. Observation on 05/21/24 at 8:30 A.M., 1:00 P.M., revealed Resident #49 did not have the hand splint applied. On 05/21/24 at 4:40 P.M. observation of Resident #49 revealed the hand splint was still not applied. Observation on 05/22/24 at 10:50 A.M. revealed the hand splint was still not applied. Observation on 05/21/24 and 05/22/24 revealed a sour odor in Resident #49's room that the resident stated was caused by his unattended/foul smelling contracted hand. Observation and interview on 05/22/24 at 10:50 A.M. with Resident #49 revealed the staff did not place the splint on his right contracted hand on 05/21/24 as physician ordered. Resident #49 revealed staff have not placed his splint or washcloth in his hand in months. Resident #49 also revealed the staff had not cleaned his contracted hand in months. 365457 Page 12 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Registered Nurse (RN) #316 at 10:50 A.M. revealed she applied a washcloth to the contracted hand of the Resident on 05/21/24. When asked how she did this she was not able to demonstrate this task. Review of the facility policy titled, Braces and Splints dated 04/05/24 revealed staff will a scheduled program of applying and removing the appliance. Schedule hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations, rashes, etc. and will be reported to charge nurse and attending physician. 365457 Page 13 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility policy, the facility failed to provide timely care and services to treat a urinary tract infection. This affected one (#298) out of three residents reviewed for change of condition. The facility census was 97. Findings include: Review of the medical record for Resident #298 revealed an admission date of [DATE] with medical diagnoses of pneumonia, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and neuromuscular dysfunction of the bladder. Further review of the medical record revealed Resident #298 was discharged to the hospital on [DATE] and expired at the hospital. Review of the medical record for Resident #298 revealed an admission Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #298 had moderate cognitive impairment and required maximum staff assistance for bed mobility and transfers and was dependent for toilet hygiene and bathing. Review of the medical record for Resident #298 revealed physician orders dated [DATE] for 16 French indwelling catheter for neuromuscular dysfunction of bladder and an order dated [DATE] for repeat urinalysis with culture for dysuria one time only. Review of the medical record for Resident #298 revealed a nurse progress note, dated [DATE] at 5:15 P.M. which stated resident complained of pain with urination, dark colored urine, dysuria, and burning with urination. The note stated the nurse notified the physician and an order to obtain a urinalysis with culture was given. Further review of the medical record revealed a nurse's progress note dated [DATE] at 7:13 A.M. which stated the resident refused any attempt to collect urine specimen as ordered. A nurse's progress note dated [DATE] at 12:16 P.M. stated the urine specimen was obtained as ordered and placed in refrigerator for lab pick up. Review of the medical record revealed no documentation to support the facility attempted to collect the urine specimen on [DATE] or [DATE] or that the resident refused to allow staff to obtain the urine specimen on [DATE] or [DATE]. Further review of the medical record revealed no documentation to support the facility notified the physician of the delay in obtaining the urine specimen. Interview on [DATE] at 10:16 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #298 did not contain documentation to support the facility attempted to obtain the urinalysis with culture from Resident #298 on [DATE] or [DATE]. DON also confirmed the medical record did not contain documentation to support the facility notified the physician of the delay in the order being carried out. Review of the facility policy titled, Physician Order, revised [DATE], stated the physician orders are obtained to provide a clear direction in the care of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00153951. 365457 Page 14 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews and policy review, the facility failed to ensure a resident was observed to take their medications at the time of administration. This affected one (#74) of five residents reviewed medication administration. The facility census was 97. Findings include: Review of medical record for Resident #74 revealed admission date of 04/09/24. The resident was admitted with diagnoses including alcohol dependence, epilepsy, dementia without behavior, anxiety and metabolic encephalopathy. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 had a Brief Interview Mental Status (BIMS) score of 10 indicating impaired cognition. The activities of daily living were not assessed. Review of Resident #74's medical record revealed a physician orders for 500 micrograms of Vitamin B daily, 50000 of Vitamin D daily, 125 milligrams of Depakote twice daily, 81 milligrams aspirin daily and 500 milligrams Keppra twice daily. Review for Resident #74's medical record revealed there was no order or assessment that permitted the resident to self-administer medications. Observation and interview on 05/20/24 at approximately 9:49 A.M. with Resident #74 revealed he presented a medicine cup which he said contained the pills he needed to take. Interview and observation on 05/20/24 at 9:54 A.M. with Registered Nurse (RN) #268 verified Resident #74 was in possession of eight pills in a medicine cup. RN #268 stated he observed Resident #74 take the pills he administered that morning and was unsure where the pills had come from. RN #268 verified there were eight pills in the medicine cup. RN #268 stated the pills were two Depakote (anti-seizure), two Keppra (anti-convulsant), two vitamin B (supplement), one vitamin D (supplement) and one aspirin (non-steroidal anti-inflammatory drug). Review of the facility policy, Medication Administration last revised 10/17/23 revealed to observe the resident swallow the medication. 365457 Page 15 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #298 revealed an admission date of [DATE] with medical diagnoses of pneumonia, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and neuromuscular dysfunction of the bladder. Further review of the medical record revealed Resident #298 was discharged to the hospital on [DATE] and expired at the hospital. Residents Affected - Few Review of the medical record for Resident #298 revealed an admission Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #298 had moderate cognitive impairment and required maximum staff assistance for bed mobility and transfers and was dependent for toilet hygiene and bathing. Review of the medical record for Resident #298 revealed physician orders dated [DATE] for 16 French indwelling catheter for neuromuscular dysfunction of bladder and an order dated [DATE] for repeat urinalysis with culture for dysuria one time only. Review of the medical record for Resident #298 revealed a nurse progress note, dated [DATE] at 5:15 P.M. which stated resident complained of pain with urination, dark colored urine, dysuria, and burning with urination. The note stated the nurse notified the physician and an order to obtain a urinalysis with culture was given. Further review of the medical record revealed a nurse's progress note dated [DATE] at 7:13 A.M. which stated the resident refused any attempt to collect urine specimen as ordered. A nurse's progress note dated [DATE] at 12:16 P.M. stated the urine specimen was obtained as ordered and placed in refrigerator for lab pick up. Review of the medical record revealed no documentation to support the facility attempted to collect the urine specimen on [DATE] or [DATE] or that the resident refused to allow staff to obtain the urine specimen on [DATE] or [DATE]. Further review of the medical record revealed no documentation to support the facility notified the physician of the delay in obtaining the urine specimen. Interview on [DATE] at 10:16 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #298 did not contain documentation to support the facility attempted to obtain the urinalysis with culture from Resident #298 on [DATE] or [DATE]. DON also confirmed the medical record did not contain documentation to support the facility notified the physician of the delay in the order being carried out. Review of the facility policy titled, Physician Order, revised [DATE], stated the physician orders are obtained to provide a clear direction in the care of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00153951. Based on medical record review, staff interview and policy review, the facility failed to ensure physician ordered laboratory (lab) work was completed/drawn in a timely manner. This affected two (#52 and #298) out of six residents reviewed for lab services. The facility census was 97. Findings include: 1. Review of Resident #52's medical record revealed he was admitted to the facility on [DATE] with a diagnosis of blindness, urine retention, hemiplegia following cerebrovascular accident, obstructive and reflux uropathy, seizures, diabetes type II, bipolar disorder, depression, and anxiety 365457 Page 16 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0770 disorders. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was cognitively intact. His functional status is listed as partial to moderate assistance for all activities of daily living. Residents Affected - Few Review of the physician orders dated [DATE] revealed renal, magnesium, complete blood count (CBC), Thyroid-stimulating hormone (TSH), liver function test (LFT), lipid panel, hemoglobin A1,C iron, vitamin b12, vitamin D, level Depakote, to be drawn every three months. Review of the pharmacy recommendations dated [DATE], [DATE], and [DATE] revealed Resident #52's lab work was recommended. Further review of Resident #52's medical record revealed the labs had not been drawn as of [DATE]. Interview with the Director of Nursing on [DATE] at 10:00 A.M. confirmed the lab work had been missed for Resident #52. 365457 Page 17 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

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 interviews and policy review, the facility failed to store, prepare, and distribute food in a sanitary manner. This had the potential to affect all 97 residents residing at the facility who receive their meals from the facility kitchen. The facility census was 97. Findings include: 1. During the initial tour of the facility kitchen with the Administration Aide (AA) #266 on 05/20/24 at 7:44 A.M., a trash can located underneath the kitchen hand washing sink which was soiled with splatter running down the sides. Observations revealed a pile of soiled and dirty dishtowels with multiple live gnats flying on and around the dishtowels. The kitchen floor appeared dirty with debris throughout. The dishwasher had food debris all over the top and along the bottom of the dishwasher. Further review of the kitchen revealed a walk-in refrigerator and AA #266 confirmed a large plastic container of sweet potatoes marked 05/16/24 -05/18/24. AA #266 confirmed a large metal container with boiled eggs and water dated 05/11/24. A large metal container of precooked scrambled eggs was dated 05/08/24. AA #266 confirmed the large brown box located directly on the floor of the dry storage area. AA #266 confirmed the large rolling rack of bread with multiple loaves of white bread with an expiration date of 04/17/24. The multiple bags of white bread buns were dated 03/17/24. AA #266 confirmed the identified concerns. Interview on 05/22/24 at 7:51 A.M. with the Dietary Manager (DM) #294 confirmed the large rolling rack of bread and buns arrived from the supplier outdated but frozen. DM #294 stated she spoke with her supplier and the supplier told her to place a sign over the bread that it is edible for seven days passed the thaw date. DM #294 stated she removes the bread from the boxes and placed on the rolling rack and allows it to thaw while on the rack. Interview on 05/22/24 at 8:45 A.M. interview with the Administrator revealed the facility utilizes bread from a vender that is frozen. The Administrator stated the information provided about the bread to be used within seven days of thaw was given to the facility team by the corporate dietician not the vendor. Interview on 05/22/24 at 10:13 A.M. with DM #294 confirmed the facility receives the frozen outdated bread on Tuesday and Thursday. DM #294 stated the staff place the frozen bread and buns on the rolling rack in the dry storage area and allow it to thaw. DM #294 stated the facility updated their policy to show they receive this frozen bread out of date. DM #294 stated the corporate dietician told her the frozen bread was good for seven days after it thaws. DM #294 stated the corporate dietitian obtained this information by a Google search. Review of the facility policy titled, Pest Control, dated 08/27/21, stated the facility pest control program will have an emphasis on the kitchens and areas prone to infestation. The purpose of the policy was to provide an environment free of pests. Review of the facility pest control visits revealed the kitchen was treated on 02/26/24 and 05/07/24, however, could not confirm the treatment was for gnats. 2. Observation and interview with DM #294 and Dietary [NAME] (DC) #230 on 05/22/24 at 11:38 P.M. during the lunch time tray line revealed the DC #230 picked up the food thermometer and placed it into 365457 Page 18 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the pureed brats without cleansing/sanitizing the thermometer to obtain a temperature. Observations revealed DC #230 took the food thermometer and placed it directly into the mechanical soft brats and failed to sanitize the food thermometer. DC #230 was interviewed before he continued to obtain more food temperatures and he stated he did not have to sanitize the food thermometer because he was told not to use alcohol wipes on the food thermometer. DM #294 was standing next to DC #230 and confirmed the facility was advised to no longer sanitize the food thermometers and handed DC #230 a dry paper towel. DC #230 wiped the food thermometer and placed it in the brat sausage to obtain a temperature. DC #230 removed the food thermometer from the brat and wiped with a dry paper towel and obtained a macaroni salad temperature. Once more, DC #230 wiped the thermometer with the dry paper towel and obtained a food temperature from the cucumber and tomato salad. 3. Observation and interview of the facility ice machine on 05/22/24 at 11:53 A.M. with Dietary Aide (DA) #218 confirmed the facility ice machine had a brown substance splattered all along the front of the machine. DA #218 lifted the door to the ice machine and revealed a white plastic cover over the ice. DA #218 confirmed the white plastic cover over the ice had an unknown black spotted substance all along the white plastic tray. DA #218 stated the unknown black substance appeared to be mold. Observation and interview on 05/22/24 at 12:17 P.M. with the DM #294 confirmed the ice machine had brown splatter across the front of the machine. DM #294 pointed to the sticker on the ice machine and stated this ice machine was cleaned in December 2023 and is due to be cleaned in June 2024. DM #294 confirmed inside the ice machine an unknown black substance was spotted all along the top of the white plastic tray. Review of the facility policy titled, Ice Chest and Ice Machine, dated 08/17/21, revealed the facility will clean, disinfect, and maintain ice-storage chests on a regular basis. 4. Observation of the facility lunch tray line on 05/22/24 from 11:50 A.M. to 12:27 P.M. with DM #230 revealed DC #230 donned plastic clear gloves and used his hands to place the brats in the buns instead of tongs. Interview on 05/22/24 at 12:17 P.M. with the DM #294 confirmed DC #230 had used his gloved hands to place the brats into the buns instead of tongs. DM #294 confirmed DC #230 should have used tongs instead of DC #230's gloved hand and also confirmed tongs were available for use. The facility confirmed all 97 residents receive their meals from the kitchen. 365457 Page 19 of 20 365457 05/23/2024 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview and policy review, the facility failed to ensure staff followed proper infection control procedure when administering intravenous medication. This affected one (#50) out of five residents observed for medication administration. Facility census was 97. Residents Affected - Few Findings include: Review of medical record for Resident #20 revealed admission date of 04/22/24. Diagnoses include osteomyelitis, anxiety, and heart failure. Review of Resident #20's admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She was independent with activities of daily living. Observation on 05/21/24 at 9:23 A.M. with Licensed Practical Nurse (LPN) #309 of the Peripherally Inserted Central Catheter (PICC) line medication administration for Resident #20 revealed LPN #309 cleansed the tip of the needleless connector of the PICC line with an alcohol swab and then intentionally dropped the line and it landed on the Resident #20's arm. LPN #309 was prepared to administer the saline flush without recleaning the potentially contaminated tip until the surveyor interviewed LPN #309. LPN #309 verified the tip was no longer sterile after intentionally dropping the line down. Review of the facility policy, Medication Administration last revised 10/17/23 revealed injections should be prepared using aseptic technique in a clean area. 365457 Page 20 of 20