Health inspection·August 2, 2023

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify resident and/or resident representatives of a room change. This affected two (#80 and #82) of four residents reviewed for room changes. The facility census was 78. Findings include: 1. Review of the medical record for Resident #80 revealed an admission date of [DATE] with medical diagnoses of metabolic encephalopathy, hypertension, dementia, and dysphagia. The medical record revealed Resident #80 expired on [DATE]. Review of the medical record for Resident #80 revealed an admission Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #80 had severely impaired cognition and required limited staff assistance with bed mobility, transfers, ambulation, and toileting. Review of the medical record for Resident #80 revealed Resident #80 changed rooms on [DATE] from room [ROOM NUMBER]-A to room [ROOM NUMBER]-P. Review of the medical record did not not contain documentation to support the facility notified the resident or resident representative of the room change. Interview on [DATE] at 11:10 A.M. with Social Service Director (SSD) #205 confirmed the resident and/or resident representative are to be notified prior to any room change occurring. SSD #205 confirmed the medical record for Resident #80 did not contain documentation to support the facility notified the resident and/or representative of the room change on [DATE]. 2. Review of the medical record for Resident #82 revealed an admission date of [DATE] with medical diagnoses of metabolic encephalopathy, hypertension, and dementia. The medical record revealed Resident #82 discharged from the facility on [DATE]. Review of the medical record for Resident #82 revealed a significant change MDS assessment, dated [DATE], which indicated Resident #82 had moderate cognitive impairment and required extensive staff assistance for bed mobility, transfers, and dressing, and was dependent for bathing. Review of the medical record for Resident #82 revealed Resident #82 changed rooms on [DATE] from room [ROOM NUMBER]-A to room [ROOM NUMBER]-B. Review of the medical record did not contain documentation to support the facility notified the resident and/or resident representative of the room change. Interview on [DATE] at 4:00 P.M. with the Director of Nursing (DON) confirmed the medical record (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365598 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 365598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449 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)