Health inspection·December 16, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on staff interview, medical record review, review of hospital documentation, review of the Certification and Licensure System (CALS) and review of facility policy, the facility failed to report an allegation of sexual abuse to the state agency. This affected one (#10) of three residents reviewed for abuse. The facility census was 75. Findings include: Review of the medical record for Resident #10 revealed admission date of 11/04/24. Diagnoses included acute respiratory failure. Resident #10 discharged from the facility on 11/30/24 against medical advice (AMA). Review of the admission Minimum Data Set (MDS) assessment, dated 11/11/24, revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of two, indicating severely impaired cognition. Resident #10 required extensive two-person assistance for bed mobility, transfers, toileting and she was dependent for eating. Review of hospital documentation dated 12/03/24 revealed an allegation of sexual abuse was made. A Sexual Assault Nurse Examiner (SANE) evaluation was completed and the police and Ombudsman were notified. Review of CALS revealed no evidence the facility filed a self-reported incident (SRI) related to the allegation of sexual abuse involving Resident #10. Interview on 12/16/24 at 4:27 P.M. with the Administrator revealed she became aware of the sexual abuse allegation on 12/11/24, after reviewing the hospital documentation. The Administrator denied prior knowledge of the allegation. The Administrator acknowledged it was facility policy to report allegations of abuse to the state agency by filing an SRI and further verified the facility did not report the allegation. Review of the facility policy titled, Abuse Prohibition Policy, last revised 09/09/22, revealed the Administrator would notify state agencies within two hours of an abuse allegation or serious injury, but not later than 24 hours for all other allegations. This deficiency represents non-compliance investigated under Complaint Number OH00160670. 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 12/16/2024 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)