Health inspection·September 26, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed provide appropriate assistance for a resident during care to prevent a fall. This effected one (#8) of three residents reviewed for falls. The census was 93.Findings include:Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, traumatic compartment syndrome of the right upper and lower extremities, paraplegia, and dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of six and was assessed to require self-care assistance and mobility assistance.Review of Resident #8's admission comprehensive evaluation dated 09/15/25 revealed for toileting the resident was determined to be a two-person assist.Review of the care plan for Resident #8 dated 09/19/25 revealed he was at risk for fall related injury and falls related to impaired activities of daily living (ADLs) performance and communication deficit. Interventions include placing the resident's bed against the wall and having two staff members present at time of mobility and hygiene care.Review of the medical record for Resident #8 revealed on 09/22/25 he was receiving perineal care by Certified Nurse Aide (CNA) #150. The resident was being turned to his left side when he slid off of his bed, hitting his head on a nearby chair before landing on his back. The resident was alert and responsive, with no visible injuries, but complained of right-sided neck pain. The resident's physician and the resident's family were subsequently notified.During an interview with the Director of Nursing (DON) on 09/26/25 at 5:15 P.M. she explained the expectation for a resident assessed as two-person assist would be provided care by two people. The DON confirmed only one staff member was present and providing care for Resident #8 at the time of the fall on 09/22/25 when there should have been two staff members assisting. This deficiency represents non-compliance investigated under Complaint Number 2575413. Page 1 of 2 365457 365457 09/26/2025 The Laurels of Middletown 751 Kensington Street Middletown, OH 45044

F 0760 Ensure that residents are free from significant medication errors. 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, review of an incident report, staff interview, and policy review, the facility failed to ensure residents had active orders for a medication prior to administration, resulting in a significant medication error. This effected one (#10) of three residents reviewed for medication administration. The census was 93.Findings include:Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included encephalopathy, epilepsy, asthma, anxiety, dysphagia, and muscle weakness. Resident #10 was discharged from the facility on 08/07/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of three and was assessed to require self-care assistance.Review of the facility's incident report dated 07/22/25 revealed, on 07/21/25, Licensed Practical Nurse (LPN) #200 confirmed she administered five (5) milligrams (mg) of oxycodone to Resident #10 earlier that date due to him exhibiting signs of agitation. Resident #10 did not have a current order for oxycodone at the time of the administration. The administration was recorded on the Controlled Drug Record log, but not on the medication administration record due to the inactive order. During an interview on 09/26/25 at 4:07 P.M. with the Administrator, she confirmed the events as detailed in the incident report verifying LPN #200 administered oxycodone to Resident #10 without the resident having an active order for the medication. The Administrator added LPN #200 had not worked in the facility since the incident occurred.Review of the facility policy titled, Medication Administration, revised 10/17/23, revealed medications are administered in accordance with the written orders of the physician. All medication administrations should be recorded in the medication administration record.This deficiency represents non-compliance investigated under Complaint Number 2575413. Residents Affected - Few 365457 Page 2 of 2