Inspection visit
Health inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
(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 20
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
05/23/2024
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
365457
If continuation sheet
Page 2 of 20
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
05/23/2024
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)
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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 3 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 4 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 5 of 20
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
05/23/2024
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)
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 6 of 20
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
05/23/2024
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)
F 0656
carries.
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 7 of 20
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
05/23/2024
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)
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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 8 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 9 of 20
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
05/23/2024
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)
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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 10 of 20
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
05/23/2024
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)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
365457
If continuation sheet
Page 11 of 20
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
05/23/2024
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)
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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 12 of 20
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
05/23/2024
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
365457
If continuation sheet
Page 13 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 14 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 15 of 20
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
05/23/2024
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)
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 16 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 17 of 20
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
05/23/2024
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)
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 18 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 19 of 20
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
05/23/2024
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365457
If continuation sheet
Page 20 of 20
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
12 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.
F584 - Safe Environment
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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
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.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F688 - Mobility
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.
FAQ · About this visit
Common questions about this visit
What happened during the May 23, 2024 survey of THE LAURELS OF MIDDLETOWN?
This was a inspection survey of THE LAURELS OF MIDDLETOWN on May 23, 2024. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE LAURELS OF MIDDLETOWN on May 23, 2024?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
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.