Health inspection·April 26, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of self-reported incidents, and facility policy review, the facility failed to report of alleged resident abuse in a timely manner to the State Survey Agency. This affected one (#43) of three residents reviewed for resident abuse. The census was 47. Findings Include: Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included other cerebrovascular disease, dysphagia, difficulty walking, muscle weakness, hyperparathyroidism, vitamin D deficiency, hypothyroidism, hypertension, hyperlipidemia, osteoporosis, major depressive disorder, and mild cognitive impairment. Review of Resident #43's Minimum Data Set (MDS) assessment, dated 03/06/24, revealed the resident was assessed with severe cognitive impairment. Interview with the Director of Nursing (DON) on 04/26/24 at 1:05 P.M. confirmed there were no allegations of abuse reported to her regarding Licensed Practical Nurse (LPN) #103 and Resident #43. Interview with Registered Nurse (RN) #101 on 04/26/24 at 1:15 P.M. confirmed she was told by LPN #102 that there were a couple nurse aides gossiping about an incident that happened between LPN #103 and Resident #43. RN #101 confirmed she approached both nurse aides and asked what they were talking about, but could not give specific information other than State Tested Nurse Aide (STNA) #105 told them there was an incident that happened between LPN #103 and Resident #43. At that point, RN #101 went to speak with STNA #105. RN #101 stated STNA #105 confirmed LPN #103 chest bumped Resident #43 out of another resident's room so that another resident would not get upset. RN #101 confirmed no allegation of abuse was made by STNA #105 or she would have reported it. Interview with the Administrator on 04/26/24 at 1:50 P.M. and 2:45 P.M. revealed she was not told about any abuse allegations regarding Resident #43 and LPN #103. The Administrator stated she was aware of the chest bumping allegation when she spoke with STNA #104 (who no longer works at the facility), but she stated he did not report any type of physical or verbal abuse allegation. The Administrator stated she was not aware of any allegation made that LPN #103 told Resident #43 she was going to hit her back if Resident #43 hit LPN #103. The Administrator confirmed had that been reported to her, she would have completed a self-reported incident (SRI). Interview with STNA #105 on 04/26/24 at 2:27 P.M. revealed she was present with STNA #104 and STNA #106 when LPN #103 chest bumped Resident #43 out of another resident's room. STNA #105 stated she (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: 365656 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 365656 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of New London The 204 W Main St New London, OH 44851 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)