Health inspection·June 21, 2023

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility did not give a NOMNC to Resident #90 because she chose to leave. The Administrator confirmed he was unable to verify Resident #90's decision to go home because it was not documented in Resident #90's medical record. The Administrator confirmed the facility had identified an opportunity for the facility to improve their discharge planning documentation. Review of the form titled, Form Instructions for Notice of Medicare Non-Coverage (NOMNC) CMS-10123-When to Deliver the NOMNC, stated a Medicare provider or health plan must deliver a completed copy of Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving skilled nursing. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to the last day of service. This deficiency represents non-compliance investigated under Complaint Number OH00143168. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 2 of 9 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the facility's fall investigation and policy review, the facility failed to provide adequate supervision to prevent accidents and ensure staff followed facility procedure with fall management. This resulted in Actual Harm when a staff member was providing care to Resident #73 and left the room leaving Resident #73 in an unsafe position in bed resulting in the resident falling from the bed. Resident #73 subsequently fractured her right femur requiring hospitalization and surgical repair. Additionally, the facility failed to ensure Resident #89 was provided adequate supervision during care resulting in an avoidable fall which placed the resident at risk for more than minimal harm that did not result in actual harm to the resident. This affected two (#73 and #89) out of four residents reviewed for falls. The census was 88. Findings include: 1. Review of the medical record for Resident #73 revealed an admission date of 10/27/22. Diagnoses included fracture of neck of right femur, depression, Parkinson's disease, and dysphagia. Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Resident #73 was assessed to require two-person extensive assistance with transfers, dressing, and toileting, independent with eating, and two-person total dependence with bathing. Review of the care plan dated 12/24/22 revealed Resident #73 was at risk for fall related injury and falls related to history of falls, weakness, and impaired mobility. Interventions included administer medications as ordered. Staff to anticipate and meet needs as needed. Staff to apply bilateral grab bars. Staff to assess the risk level for falls on admission and as needed. Staff to encourage to wear non-skid footwear when out of bed. Staff to ensure call light was within reach and encourage to use for assistance as needed. Review of the progress note dated 05/25/23 revealed nurse practitioner (NP) #70 assessed Resident #73 related to a fall. Resident #73 was seen and examined while resting in bed. Resident #73 was alert and oriented to person, place, and time on exam. Resident #73 stated she rolled out of bed overnight landing on her right hip and hitting her head. Resident #73 had a large bruise to right forehead. Upon exam, right hip had swelling and bruising noted. No notable deformities. Resident #73 reported pain to her right hip rating a six out of ten. NP #70 discussed with nursing staff and Resident #73's son to send to emergency room (ER) for further evaluation. Review of the progress note dated 05/25/23 at 10:26 A.M. revealed Resident #73 complained of pain to right hip with passive range of motion (PROM). NP #70 notified and ordered a stat x-ray. Review of the progress note dated 05/25/23 at 12:11 P.M. revealed Resident #73's son was in the facility requesting a computed tomography (CT) for Resident #73. NP #73 gave order for CT. Review of the progress note dated 05/25/23 at 12:58 P.M. revealed Resident #73 was picked up by Critical Care Transport and taken to Hospital #1 to be evaluated. Review of the progress note dated 05/30/23 at 4:12 P.M. revealed Resident #73 was readmitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 3 of 9 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0689 facility. Resident #73 had a right hip intramedullary nailing on 05/26/23. Incision site to right hip had 15 staples. Area to right hip revealed staples were intact and well-approximated with no drainage. Level of Harm - Actual harm Residents Affected - Few Review of Hospital #1's paperwork dated 05/25/23 revealed Resident #73 had a right femur fracture resulting in hospitalization and surgical repair. Review of the facility's timeline dated 05/25/23 revealed approximately between 5:00 A.M. and 5:30 A.M. State Tested Nurse's Aide (STNA) #15 entered Resident #73's room to provide incontinence care. STNA #15 turned Resident #73 on right side and then left the room to address a concern. Resident #73 was left on her side and reported she was slipping. Resident #73 fell onto floor and hit her right side of her face and body. STNA #15 returned to the room and found Resident #73 on the floor. STNA #15 left the room and returned with the Hoyer lift and put Resident #73 back into bed. At approximately 8:15 A.M. STNA #13 entered Resident #73's room and noticed swelling and bruising to the right side of Resident #73's face. STNA #13 asked what happened, and Resident #73 said she fell out of bed around 5:00 A.M. At approximately 8:20 A.M., STNA #13 notified Licensed Practical Nurse (LPN) #26 of what she was told. LPN #26 assessed Resident #73 and notified unit manager LPN #25. LPN #25 assessed Resident #73. During range of motion, Resident #73 complained of pain to right leg. Approximately between 8:30 A.M. and 12:00 P.M., staff were interviewed and Resident #73's son was notified. LPN #25 began calling night shift staff to understand what occurred and why the fall was not reported. LPN #25 notified Director of Nursing (DON). At approximately 12:11 P.M., Resident #73 was transported to Hospital #1 by ambulance for evaluation. At approximately 3:32 P.M., Resident #73's son reported Resident #73 was diagnosed with a hip fracture. At approximately 6:36 P.M., STNA #15 spoke with DON and denied Resident #73 had rolled out of bed the morning of 05/25/23. Review of the witness statement dated 05/25/23 from STNA #15 revealed she took care of Resident #73. STNA #15 denied Resident #73 rolled out of bed during her shift. STNA #15 denied using the Hoyer lift on Resident #73 during care on 05/24/23 and 05/25/23. Review of the witness statement dated 05/25/23 from STNA #13 revealed Resident #73 reported she fell on floor and hit head on wheel of bedside table. Resident #73 reported to be on the floor for a while and yelling. Review of the witness statement dated 05/25/23 from LPN #26 revealed STNA #13 came and got her to assess Resident #73. Resident #73 reported STNA #15 left to get supplies, and she rolled out of bed. STNA #15 came back, and Resident #73 was on the floor. LPN #25 attempted range of motion on right leg but Resident #73 yelled out in pain. Interview on 06/20/23 at 9:41 A.M. with STNA #13 revealed Resident #73 put her light on around 8:10 A.M. on 05/25/23. STNA #13 stated she went into Resident #73's room, and she was crying. STNA #13 reported Resident #73 had a purple bruise on the right side of her face. STNA #13 asked what happened, and Resident #73 said she fell. STNA #13 went to get LPN #26 to assess Resident #73. STNA #13 explained Resident #73 reported she fell out of bed when STNA #15 left the room. STNA #15 used the Hoyer lift to get Resident #73 back into bed by herself. STNA #13 revealed unit manager LPN #25 was notified and assessed Resident #73. Interview on 06/20/23 at 9:56 A.M. with unit manager LPN #25 revealed STNA #13 and LPN #26 came to her regarding the findings involving Resident #73. LPN #25 assessed Resident #73 and noted a bruise on the right side of her head into hairline. Resident #73 reported she fell out of bed when STNA #15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 4 of 9 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0689 Level of Harm - Actual harm Residents Affected - Few left the room, and she hit her head on the bedside table when she fell. LPN #25 voiced she completed range of motion on Resident #73 and reported pain to the right hip. LPN #25 notified son. LPN #25 stated Critical Care Transport transported Resident #73 to Hospital #1. Interview on 06/20/23 at 11:05 A.M. with the Administrator and DON revealed LPN #25 notified them regarding the incident with Resident #73. STNA #15 was providing care to Resident #73 and left the room. Resident #73 slipped out of bed and fell onto the floor. STNA #15 put Resident #73 back into bed via Hoyer lift without the help of other staff. Resident #73 had a fracture to the right hip. STNA #15 was suspended pending investigation. STNA #15 denied the fall occurring. STNA #15 refused to speak with the DON regarding the incident. About a week later, STNA #15 reached out to the DON. STNA #15 continued to deny the fall, and she was terminated. 2. Review of the medical record for Resident #89 revealed an admission date of 05/10/23, a readmission on [DATE] and a discharge date of 05/28/23. Diagnoses included malignant neoplasm of upper lobe, right bronchus, secondary malignant neoplasm of brain, emphysema, chronic obstructive pulmonary disease (COPD), and type two diabetes mellitus (DM II) with diabetic polyneuropathy. Review of the admission MDS assessment dated [DATE] revealed Resident #89 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. Resident #89 was assessed to require two-person limited assistance with transfers, one-person extensive assistance with dressing and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 05/10/23 revealed Resident #89 was at risk for fall related injury and falls related to general weakness and psychotropic medication use. Interventions included encourage to wear appropriate footwear as needed. Staff to keep environment as safe as possible with floors free from spills and/or clutter, adequate lighting, call light within reach, and commonly used items within reach. Staff to put call light within reach and encourage to use it for assistance. Physical therapy and occupational therapy to evaluate and treat as ordered and as needed. Review of the progress note dated 05/28/23 at 7:38 A.M. revealed STNA #10 was changing Resident #89 when STNA #10 turned to get depends from the table. When STNA #10 turned she saw Resident #89 rolling to the floor before STNA #10 could stop her. Resident #89 had rolled to the floor. The bed was lowered but not in lowest position. STNA #10 reported Resident #89 hit her head on the trash can but not very hard. LPN #23 came into room and found Resident #89 lying on right side beside her bed. LPN #23 assessed Resident #89 for injuries. Vital signs and range of motion were within normal limits. No injuries or complaint of pain noted upon assessment. LPN #23 educated STNA #10 on the importance of keeping bed in lowest position when leaving bedside. On-call provider, Director of Nursing notified, and Resident #89's daughter were notified of the incident. Review of the progress note dated 05/28/23 at 1:05 P.M. revealed neurological checks were completed on Resident #89 after fall and within normal limits. Blood sugar was 108 before breakfast, dropped to 67 after breakfast, and then orange juice and med pass were given. Blood sugar increased to 99. Resident #89 was more confused and lethargic with a raised area on right side of forehead. Physician was notified and gave orders to send to be evaluated at the emergency room. Resident #89's daughter requested to send Resident #89 to Hospital #2. Resident #89 was sent to Hospital #2's emergency room. Review of the fall investigation report dated 05/28/23 revealed STNA #10 called LPN #23 into Resident #89's room. LPN #23 found Resident #89 lying on right side on floor next to bed. LPN #23 assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 5 of 9 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0689 Level of Harm - Actual harm Residents Affected - Few Resident #89, which revealed no injuries, vital signs and range of motion were within normal limits, and no complaint of pain. Predisposing environmental factors revealed bed height was not appropriate. Physician and Resident #89's daughter were notified of the incident. Interview on 06/14/23 at 3:25 P.M. with DON revealed she attempted to reach STNA #10 to get a statement regarding the incident on 05/28/23 with Resident #89. The DON revealed STNA #10 would not return the DON's phone calls. The DON reported STNA #10 did not show up for her shifts after the incident on 05/28/23 with Resident #89. The DON explained due to STNA #10 never showing up to the facility again or returning any calls, STNA #10 was terminated. Attempted interview on 06/14/23 at 4:01 P.M. and 4:50 P.M. with STNA #10 was unsuccessful with no return call. Attempted interview on 06/14/23 at 4:03 P.M. and 4:55 P.M. with LPN #23 was unsuccessful with no return call. Review of the facility policy titled, Fall Management, dated 08/18/22 revealed the facility identified hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. When a fall occurred, the licensed nurse will evaluate the resident for injury. Do not move the individual until he/she had been examined by a nurse. The first responder will summon a nurse after ensuring the resident was safe. A fall huddle would be held to determine the root cause of the fall. The licensed nurse would notify the attending physician and the responsible party of the fall and document the notification in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00143261. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 6 of 9 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and review of the facility policy, the facility failed to timely and adequately address Resident #50 complaints of pain. This resulted in Actual Harm when Resident #50's pain become severe enough she expressed thoughts of self-harm. This affected one (#50) out of three residents reviewed for pain management. The facility census was 88. Residents Affected - Few Findings Include Review of the medical record for Resident #50 revealed readmission date to the facility on [DATE] following a hospital stay for acute chronic pancreatitis, acute urinary tract infection (UTI) and community-acquired pneumonia. Other diagnoses included cellulitis of right lower limb, hypokalemia, chronic obstructive pulmonary disease, asthma, heart failure, hypertensive heart disease, chronic pancreatitis, depression, anemia, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/23, revealed Resident #50 was cognitively intact. Further review of the MDS assessment revealed Resident #50 required extensive assistance from staff with bed mobility, bed transfers, dressing, and personal hygiene. Resident #50 required supervision with eating. Review of Resident #50's nursing progress notes, dated 03/12/23, resident started complaining at the beginning of the shift that her spleen was hurting, and she (Resident #50) was in pain. Resident #50's vitals revealed her blood pressure was documented at 133/65 millimeters of mercury (mm/Hg), pulse was 89 beats per minute, and her temperature was 97.6 degrees Fahrenheit. Further review of the nursing progress notes revealed Resident #50, came back again at the nurse's station and asked for her pain medication and it was given. Resident #50 voiced concern regarding her pancreas hurting and the nurse documented she contacted the nurse practitioner; however, the nursing notes stated, Resident #50 was determined to go to the emergency room to be evaluated by a physician. Further review of the progress notes for Resident #50 stated, the nurse advised Resident #50 to let the medication kick in and she was going to give her nitroglycerin. Resident #50 called the paramedics and was discharged to the hospital and admitted for pancreatitis and a UTI. Review of Resident #50's progress notes revealed Resident #50 returned to the facility on [DATE] at 3:58 P.M. with a diagnosis of acute pancreatitis and UTI. On 03/16/23, at 11:25 P.M. the nurse documented Resident #50 was given a dose of pregabalin (Lyrica) and Resident #50 requested her hydromorphone (Dilaudid). Further review of the nursing progress notes for Resident #50 revealed the nurse stated to Resident #50 she is unable to administer both medications at one time and Resident #50 was told she would have to wait at least two hours to have a dose of the hydromorphone. Resident #50 started complaining and the nurse documented the nurse left Resident #50's room. Further review of the nursing progress notes revealed Resident #50 went to the nurse's station at 1:00 A.M. threatening to call the authorities, the on-call manager or Director of Nursing (DON), and Resident #50 threatened to kill herself in order to get her pain medication (hydromorphone). The nurse documented Resident #50 was crying and stated the nurse was being unfair to her. The nurse stated it was her nursing judgement to have Resident #50 wait for two-hour window, prior to administering the hydromorphone. The nurse told Resident #50 unless the nurse obtained an order from the physician to give the Lyrica and Hydromorphone together the nurse could not proceed with administering the medications. Review of the nursing progress note for Resident #50, dated 03/17/23, revealed a physician's order, Hydromorphone HCI Oral liquid ONE MG /ML-give three ml every four hours for pain, may be given with other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 7 of 9 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0697 medications including, Lyrica. Level of Harm - Actual harm Review of Resident #50's Medication Administrator Report (MAR) revealed an order for Pregabalin Oral Capsule 75 milligram (mg), give one capsule by mouth two times a day for neuropathy start date 03/16/23 at 9:00 P.M. was signed off as given by the nurse. Hydromorphone HCI oral liquid one mg per milliliter (ml), give three ml by mouth every four hours as needed for pain was not signed off on the MAR for 03/16/23. Residents Affected - Few Review the controlled substance log for Resident #50 revealed Pregablin 75 mg was administered on 03/16/23 at 11:30 P.M. Further review of the controlled substance log for Resident # 50 revealed she Hydromorphone was administered on 03/16/23 at 4:00 P.M. Review of Resident #50's Medication Administration Record (MAR) revealed Resident #50 did not have any doses of Hydromorphone administered to her on 05/20/23. Review of the form titled, Controlled Substance Record, for the month of June 2023 for Resident #50 revealed she was administered Hydromorphone on 05/19/23 at 4:06 P.M. and her next dose was administered on 05/20/23 at 5:45 A.M. Review of the facility SRI, dated 05/22/23 revealed Resident #50 reported an allegation of neglect to the psychiatric nurse regarding the facility failing to provide her pain medication as ordered. Further review of the facility SRI revealed Resident #50 was interviewed by the Director of Nursing (DON) in regard to the concern reported by the psychiatric nurse about the alleged neglect regarding Resident #50's pain medication. The DON reported Resident #50 was informed by the floor nurse on 05/19/23 that Resident #50 was out of pain medication. Resident #50 stated she became tearful and stated Resident 50 stated the psychiatric nurse misrepresented what Resident #50 said. Further review of a Note regarding a Narrative Summary of Incident dated 05/22/23 revealed Resident #50 was interviewed by DON in regards to concerns reported by Pscyh services about alleged neglect with staff over the weekend in regards to pain medication and care. Resident #50 states she was informed Friday evening that her pain medication script ran out but that the nurse did contact on-call and that the e-script was sent to the pharmacy. Interview on 06/20/23 on 8:54 A.M. with the General Manager (GM) #601 of the pharmacy for the facility confirmed Resident #50's Hydromorphone was delivered to the facility and signed acceptance of delivery by License Practical Nurse (LPN) #31 on 05/20/23 at 5:47 A.M. Interview on 06/20/23 at 10:47 A.M. with the DON regarding Resident #50' nursing progress notes dated, 03/16/23, confirmed LPN #600 used her nursing judgement and decided not to administer pain medication with the pregabalin medication. The DON confirmed she would have contacted the physician and clarified the orders of administering the medications at the same time. The DON stated, that is why I called the physician the next day. The DON confirmed Resident #50 made statements of wanting to kill herself on 03/16/23 when she was unable to obtain her pain medication with the Lyrica. The DON stated Resident #50 stated she was suicidal because she did not get the pregabalin (Lyrica) and hydromorphone at the same time. Interview on 06/20/23 at 12:30 P.M. with Resident #50 revealed she had returned to the facility from the hospital on [DATE] and requested her pain medication at 11:30 P.M. when she was given her Pregablin. Resident #50 stated the nurse told her she could not receive the Pregablin and the hydromorphone together; however, this had not been an issue in the past. Resident #50 stated by 1:00 A.M. she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 8 of 9 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 366481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228 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 0697 Level of Harm - Actual harm Residents Affected - Few just lost it and stated she would kill herself if she did not get her medication. Resident #50 stated she was depressed over the pain she was in. Resident #50 further revealed she was upset by the incident that occurred in May 2023 regarding the facility had ran out of her pain medication. Resident #50 stated she did not understand how a facility could let someone run out of pain medication, why not just order when it was low. Resident #50 stated she contacted the psychiatric nurse and expected the conversation to be confidential. Resident #50 stated she did say that she was suicidal from the pain caused from not receiving her pain medication. Interview on 06/20/23 at 5:48 P.M. with LPN #600 confirmed she did not contact the physician on 03/16/23 at 1:00 A.M. regarding administering both medications (pregabalin and hydromorphone) at the same time. LPN #600 stated she waited until the next morning and discussed it with the DON and then the physician was contacted. Interview on 06/21/23 at 9:56 A.M. with the Administrator revealed a message was left on the facility phone from the psychiatric nurse on the weekend prior to 05/22/23 and it stated Resident #50 was suicidal because the facility neglected to administer her pain medication over the weekend. The Administrator stated the facility opened the SRI because the psychiatric nurse stated Resident #50 used the word neglect. The Administrator stated the facility did not substantiate the SRI because Resident #50 told the DON the psychiatric nurse did not report the message correctly. However, the Administrator confirmed Resident #50 did indicate she was suicidal for not having her pain medication on 05/20/23. Review of the facility policy titled, Medication Administration, dated 09/09/23, revealed Physician's Orders Medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the guest's/resident's age and condition or a medication order is inconsistent with the guest's/resident's current diagnosis or condition, contact the physician for clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00143730. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366481 If continuation sheet Page 9 of 9