Health inspection·October 21, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interview, record review, review of facility self-reported incident and investigation, and policy review, the facility failed to prevent misappropriation of the resident's controlled substances. This affected two (Residents #67 and #83) of 12 residents reviewed for misappropriation. The facility identified 45 residents who had orders for controlled substances. The facility census was 85. Residents Affected - Few Findings include: 1. Review of Resident #83's medical record revealed an admission date of 08/23/24. Diagnoses included Huntington's disease, chorea (a type of dyskinesia characterized by rapid, jerky, and involuntary body movements) and anxiety. Resident #83 has received hospice care since admission to the facility. Review of Resident #83's admission Minimum Data Set (MDS) assessment, dated 08/30/24, revealed Resident #83 was cognitively intact. Resident #83 had no reported behaviors or rejection of care. Review of Resident #83's physician orders revealed an order dated 08/30/24 for Lorazepam (used to decrease anxiety and a controlled substance) oral solution two milligrams (mg) per milliliter (ml), give 0.75 ml (1.5 mg) by mouth four times daily for anxiety. Resident #80 also had an order dated 08/23/24 for Morphine Sulfate (treats severe pain and a controlled substance) oral solution 100 mg/5.0 ml, give 0.25 ml (5.0 mg) by mouth once daily at bedtime. Review of Resident #83's Medication Administration Record (MAR) dated September 2024 revealed she was not recorded as having received any of her scheduled medications on 09/23/24 at 9:00 P.M., which included Lorazepam 0.75 ml (1.5 mg) oral concentrate and Morphine Sulfate 0.25 ml (5.0 mg) oral concentrate. Review of Resident #83's Controlled Substance Records for Lorazepam administrations from 08/23/24 to 10/12/24 revealed one bottle was exhausted following the 09/22/24 at 9:00 P.M. dose. A new bottle and the next chronological entry was dated 09/24/24 at 7:00 A.M. There were no recorded Lorazepam removals on 09/23/24. Review of a handwritten Controlled Substance Record, with Resident #83's name at the top, listed one medication, Morphine Sulfate 100 mg/5.0 ml. There was no corresponding listed dose, nor was there a prescription number listed on the form. The first dose was recorded as administered on 09/19/24, at 1:29 A.M. at which time 0.25 ml of medication was administered. Seven subsequent doses of Morphine Sulfate were administered, with the last one recorded at 09/23/24 at 9:00 A.M. and leaving an amount of 14 ml of Morphine Sulfate remaining in the container. Following that entry, on 09/24/24 at Page 1 of 25 366481 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12:12 A.M. the Director of Nursing (DON) and Registered Nurse (RN) #322 logged a corrected count indicating 12 ml of Morphine Sulfate remained in the container, indicating 2.0 ml was unaccounted for. 2. Review of Resident #67's medical record revealed an admission date of 07/31/24. Diagnoses included insomnia, obstructive sleep apnea, and anxiety. Review of Resident #67's admission MDS assessment, dated 08/07/24, revealed Resident #67 was cognitively intact. Review of Resident #67's physician orders revealed an order dated 09/01/24 for Zolpidem Tartrate (also known as Ambien, a sedative/hypnotic medication used to treat insomnia and a controlled substance) 10 mg one tablet nightly at bedtime. Resident #67 also had an order for alprazolam (also known as Xanax and a controlled substance) 0.5 mg tablet, give one tablet by mouth every eight hours as needed (PRN) for anxiety. Review of Resident #67's MAR dated September 2024 revealed the resident's ordered nightly Zolpidem Tartrate tablet was recorded as administered. Resident #67 was recorded as receiving a PRN dose of alprazolam on 09/23/24 at 9:18 P.M. Review of a facility self-reported incident (SRI) tracking number 252230, initiated 09/24/24, revealed on 09/23/24, the Director of Nursing (DON) returned to the facility due to the behavior of a floor nurse, RN #399. A urine screen was completed on-site with the nurse's verbal consent and was positive for cocaine, benzodiazepines, and opioids. Following RN #399's removal from the building, a narcotic count was completed on the nurse's assigned medication cart and it was determined multiple controlled medications were missing for Resident #83 and #67. An investigation was initiated. The local police department was notified, the pharmacy was notified, and RN #399 was reported to the Ohio Board of Nursing. The report indicated interviews with interviewable residents were completed without incident. Audits were to be completed three times weekly for four weeks. The facility substantiated the SRI, indicating misappropriation had occurred. Review of the facility's investigation for SRI #252230 revealed on 09/23/24 at approximately 11:30 P.M., RN #399 was on duty working at the facility and was observed by another nurse to be acting erratic, very confused, fidgety, taking off shoes and socks, and had fallen several times, one of which included hitting her head with a visible quarter-sized raised dark area to her approximately 11:50 P.M., and observed RN #399's behavior and other staff reports, and completed a urine drug screen on RN #399. A review of DON's handwritten statement, dated 09/24/24, revealed the DON received a phone call from Licensed Practical Nurse (LPN) #458, stating RN #399 was acting very strange, she was talking to herself, having difficulty walking, and even had fallen several times, hitting her head at one point. LPN #458 communicated that she did not know what to do, she could not send RN #399 home because she was not safe to drive. The statement indicated DON arrived at the facility at 11:50 P.M. and observed RN #399 seated at the nurse's station with an aide holding her up. RN #399's shoes and socks were off, RN #399 was having abnormal movements and appeared confused. An unnamed aide helped her get her shoes on, and the DON helped guide and steady her into the DON's office. The DON asked how RN #399 was feeling and RN #399 stated she was feeling dizzy. The DON asked if she could have any medical conditions that would explain the feeling to which RN #399 stated no. The DON explained she needed RN #399 to do a urine drug test due to erratic behavior that had been observed to which RN #399 agreed. The DON helped RN #399 up, assisted her with sitting on the commode due to unsteadiness of gait and balance. After obtaining the urine the DON assisted RN #399 up off the commode and guided her to 366481 Page 2 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the desk to wash her hands, and back into the DON's office. The DON set the timer for the drug screen for five minutes and asked RN #399 if she had taken anything or had any medical conditions again. RN #399 stated no. The DON asked if she had anyone she could contact for her and RN #399 stated no. The DON informed RN #399 she would be calling 911 for her to be transported to a local emergency department for further evaluation to which RN #399 agreed. The drug screen result indicated a positive result for opiates, benzodiazepines, and cocaine. RN #399 was informed by the DON she was being suspended pending the outcome of the investigation. After RN #399 left the building, the DON and RN #322 counted the medication cart. RN #399 had been previously responsible for, and it was determined controlled medications were missing for Residents #83 and #67. The DON made copies of the controlled drug records and containers and noted a corrected count with a second nurse. Review of LPN #458's statement, dated 09/24/24, revealed around midnight, she observed RN #399 stumbling and leaning forward while at the nurse's station. When approached, she appeared disoriented and was unable to respond coherently. RN #399 began packing and moving down the hallway. Concerned about her condition, LPN #458 contacted the DON to report the situation. LPN #458 reported her and another unnamed staff member managed to get RN #399 to sit at the nurse's station where she removed her shoes and socks and continued to exhibit erratic movements, leaning forward and jerking to the side. At this point, the DON arrived and took RN #399 to a private area for further assessment. Subsequently, the DON requested 911 be called for further evaluation. The DON secured the keys to the medication cart and conducted an inventory with RN #322. RN #399 was escorted out of the facility by two paramedics. Review of LPN #456's statement, dated 09/24/24, revealed one of the staff nurses reported to him that a nurse was talking to herself and was unable to stand still. LPN #456 assisted her onto a chair but was still behaving abnormally until paramedics arrived. Review of Resident #83's statement, dated 09/24/24, revealed the resident stated she had received her nighttime medication, however, did not receive her morphine, nor had she requested any. Resident #83 denied any pain or anxiety at the time of the interview and denied feelings of being unsafe at the facility. Review of Resident #67's statement, dated 09/24/24, revealed the resident stated he received his night medication, but does not know if he had gotten his Ambien or not, nor his Xanax. Resident #67 stated he did not ask for Xanax. Resident #67 also stated he felt safe at the facility and denied any pain or anxiety at the time of the interview. The investigative file revealed undated education on the facility's controlled substances policy. The policy was attached to a sign-in sheet. Only 12 nurses were recorded as signing the in-service sheet out of 35 nurses listed as employed by the facility, excluding the DON. The ongoing audits performed by nursing leadership failed to identify additional concerns with the accounting for the controlled substances following the incident on 09/23/24 with RN #399. Review of RN #399's Employee Disciplinary Record dated 09/24/24 revealed RN #399 was terminated from the facility on 09/25/24. The listed rule violation was Rule #45 - Staff may not steal or attempt to steal or be in unauthorized possession of property and Rule #53 - Staff may not report to work in an unfit condition including under the influence of alcohol, over the counter, or controlled substances that would impact member to perform job duties. The listed supervisor remarks included on 09/23/24 there were two guests (residents) with missing narcotics. RN #399 was acting erratic and confused and were unable to walk without assistance. RN #399 failed a drug test on said day. RN #399 was 366481 Page 3 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few terminated via telephone and informed she was not welcome on campus. The form was signed by the DON and Administrator. An interview on 10/15/24 at 12:23 P.M. with the DON revealed she was the one who responded to the building on 09/23/24 for RN #399's erratic and concerning behavior, and she identified the missing narcotics. The DON summarized the investigation she completed, which was consistent with the written information contained in the SRI facility investigative file. The DON stated prior to leaving the facility after addressing the situation with RN #399, she had completed a narcotic count with all the nurses in the facility and there were no other controlled substance discrepancies. When she came back into work on 09/24/24 at approximately 8:00 A.M., she spoke with a few other residents and identified them as Residents #76 and #78. The DON stated they had no concerns. When asked if she had identified like residents who had orders for controlled substances, the DON stated she had not. Following the incident, the two Unit Managers have been auditing their designated units three times weekly. When asked to see evidence of the audits that were completed, the DON retrieved multiple pages of resident census/bed boards dated 09/25/24, 09/26/24, 09/30/24, 10/01/24, 10/04/24, 10/07/24, 10/09/24 and 10/11/24 from the facility SRI investigative file and stated these were the audits. The census/bed board did not identify the form as an audit. The sheets did not identify which residents had received or had orders for controlled substances. There were no other markings or highlights on the form, and there was no mention of exactly what was being audited. When asked, the DON stated the facility's audits only consisted of making sure the physical number or amount of medication left in the controlled substance medication package matched the amount on the controlled drug record form. The DON confirmed she, nor the Unit Managers, had reviewed the controlled drug record forms to be sure the appropriate amount of medication was recorded as administered, nor had any of the auditors matched the controlled drug record forms up with each residents Medication Administration Record (MAR) to ensure the removed doses of controlled substances were recorded as administered to the appropriate resident. An interview on 10/17/24 at 4:20 P.M. with the Administrator, DON, and Regional Clinical Coordinator (RCC) #530 discussed the facility's investigation following the 09/23/24 incident of RN #399 misappropriating Resident #83 and Resident #67's controlled medications. The Administrator and DON confirmed the misappropriation occurred. Concerns were identified with the facility's audits post-incident, as it was unclear per the audits which residents and exactly what was being audited. The Administrator stated she was unaware of any additional controlled medication missing for any resident and was informed of Resident #83's missing medication (unsure whether Morphine or Lorazepam as she controlled drug record sheet is unclear). The DON confirmed the audits and education completed with the staff nurses following the 09/23/24 event were ineffective. Review of the policy titled Abuse Prohibition Policy, dated 10/14/24, revealed each guest/resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatment on an ongoing basis. It is the responsibility of all staff to provide a safe environment for the guests/residents. This deficiency represents noncompliance investigated under Control Number OH00158415. 366481 Page 4 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, resident interview, record review, review of facility self-reported incidents and investigation, and policy review, the facility failed to ensure a thorough investigation was completed following a substantiated instance of staff to resident misappropriation of controlled substances. This affected two (Residents #67 and #83) of 12 resident records reviewed for medication administration. The facility census was 85. Residents Affected - Few Findings include: Review of a facility self-reported incident (SRI) tracking number 252230, initiated 09/24/24, revealed on 09/23/24 the Director of Nursing (DON) returned to the facility due to the behavior of a floor nurse, Registered Nurse (RN) #399. A urine screen was completed on-site with the nurse's verbal consent and was positive for cocaine, benzodiazepines, and opioids. Following RN #399's removal from the building, a narcotic count was completed on RN #399's assigned medication cart and it was determined multiple controlled medications were missing for Residents #83 and #67. An investigation was initiated. The local police department was notified, the pharmacy was notified, and RN #399 was reported to the Ohio Board of Nursing. The report indicated interviews with interviewable residents were completed without incident. Audits were to be completed three times weekly for four weeks. The facility substantiated the SRI, indicating misappropriation had occurred. Review of the facility's investigative file for SRI #252230 revealed on 09/23/24 at approximately 11:30 P.M., RN #399 was on duty working at the facility and was observed by another nurse (Licensed Practical Nurse (LPN) #458)to be acting erratic, very confused, fidgety, taking off shoes and socks, and had fallen several times, one of which included hitting her head with a visible quarter-sized raised dark area to her approximately 11:50 P.M., and observed RN #399's behavior and other staff reports, and completed a urine drug screen on RN #399. The drug screen result indicated a positive result for opiates, benzodiazepines, and cocaine. The facility obtained statements from the DON, LPN #458, and LPN #456. The facility obtained detailed statements from Residents #83 and #67. There were only two other residents listed as interviewed, Residents #76 and #78. The form listed a statement on the investigation form which stated, like guests on C-hall were interviewed to determine if they were affected as well, stated no. There were no listed questions that were asked. There was no evidence to suggest residents who were not interviewed had been assessed for any pain, distress, or injuries. The facility did not have RN #399's scheduled assignments prior to the incident on 09/23/24 and did not investigate if RN #399 may have misappropriated the resident's medications prior to 09/23/24 to identify it this was a single incident or not. There was no statement from RN #399. There were no statements from any of the State Tested Nursing Assistants (STNA) on duty at the time of the incident. The file contained no list of residents who had orders for controlled substances on RN #399's assignment. An interview on 10/15/24 at 12:23 P.M. with the DON stated prior to leaving the facility after addressing the situation with RN #399, she had completed a narcotic count with all the nurses in the facility and there were no other controlled substance discrepancies. When she came back into work on 09/24/24 at approximately 8:00 A.M., she spoke with a few other residents and identified them as Residents #76 and #78. The DON verified she had not identified like residents who had orders for controlled substances on RN #399's assignment. The DON verified there were no STNAs interviewed/statements obtained. The DON verified not all residents were assessed 366481 Page 5 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Following the incident, the two Unit Managers have been auditing their designated units three times weekly. When asked to see evidence of the audits that were completed, the DON retrieved multiple pages of resident census/bed boards dated 09/25/24, 09/26/24, 09/30/24, 10/01/24, 10/04/24, 10/07/24, 10/09/24 and 10/11/24 from the facility SRI investigative file and stated these were the audits. The census/bed board did not identify the form as an audit. The sheets did not identify which residents had received or had orders for controlled substances. There were no other markings or highlights on the form, and there was no mention of exactly what was being audited. When asked, the DON stated the facility's audits only consisted of making sure the physical number or amount of medication left in the controlled substance medication package matched the amount on the controlled drug record form. The DON confirmed she, nor the Unit Managers, had reviewed the controlled drug record forms to be sure the appropriate amount of medication was recorded as administered, nor had any of the auditors matched the controlled drug record forms up with each residents Medication Administration Record (MAR) to ensure the removed doses of controlled substances were recorded as administered to the appropriate resident. Review of the policy titled Abuse Prohibition Policy, dated 10/14/24, revealed each guest/resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatment on an ongoing basis. It is the responsibility of all staff to provide a safe environment for the guests/residents. Allegations shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physicians, families, and/or representatives. This deficiency represents noncompliance investigated under Complaint Number OH00158415. 366481 Page 6 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and family interview, record review, and facility procedure review, the facility failed to implement post-operative drain care for one (Resident #89) of three residents reviewed for drain care. The facility identified two residents with post-operative drains. The facility census was 85. Residents Affected - Few Findings include: Review of the closed medical record for Resident #89 revealed an admission date of 08/28/24. Medical diagnoses included cholangiocarcinoma (cancer of the bile ducts), surgical aftercare following surgery on the digestive system, intrahepatic bile duct carcinoma, and bacteremia. Resident #89 was hospitalized from [DATE] to 09/12/24. Resident #89 discharged from the facility on 09/26/24. Review of Resident #89's five-day Minimum Data Set (MDS) assessment, dated 09/19/24, revealed the resident had intact cognition. Resident #89 was recorded as receiving surgical wound care. Review of Resident #89's hospital After Visit Summary (AVS), dated 08/28/24, revealed the resident admitted to the facility with a midline abdominal incision requiring a wound vac, intravenous antibiotic therapy, and a post-operative surgical drain. The AVS listed detailed instructions on how to care for the drain. Instructions included a section titled How to clean the skin around your drain tubing and listed the skin around the drain tubing should be cleaned once daily. The skin should be cleansed with soap and water unless otherwise directed by the doctor. Clean the skin around the tubing, start at the center where the tube comes out of the skin. Use a circular motion to clean the skin around the tube, slowly move out and away from the tube three to four inches. Do not clean back towards the tube. A section titled How to change the dressing listed instructions to first cleanse the site and allow to dry. Open a four inch by four inch split gauze package, touch only the edges of the gauze pad, place the gauze around the tubing. Tape the dressing in place and secure with tape. The instructions noted to change the dressing once daily, or if the dressing became wet or dirty. Review of Resident #89's care plan, dated 08/28/24, revealed the resident had an actual impairment to skin integrity related to sutures to his right chest, incision to his abdomen, and a drain tube to his abdomen. Listed interventions included to apply an air mattress to the bed, encourage good nutrition and hydration, follow facility protocols for treatment, and observe for signs and symptoms of infection and report to the physician as needed. Review of Resident #89's physician's orders, from 08/28/24 to 09/26/24, revealed the resident had no order transcribed into the facility's electronic health record for any post-operative drain site care. Resident #89 had an order dated 08/28/24 to drain the JP drain every shift and record the drainage amount. Resident #89 also had an order dated 09/12/24 to monitor the JP drain site every shift for signs or symptoms of infection. Review of Resident #89's Treatment Administration Record (TAR) for August 2024 and September 2024 revealed no entries of any site care or dressing changes recorded as provided to Resident #89. Review of Resident #89's interdisciplinary progress notes from 08/28/24 to 09/26/24 revealed no evidence that any post-operative drain site care had been performed or that a dressing to the site had been applied. An interview by telephone on 10/17/24 at 12:27 P.M. with a family member of Resident #89 revealed 366481 Page 7 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0684 Level of Harm - Minimal harm or potential for actual harm the resident had admitted to the facility for rehabilitation and post-operative care after a lengthy hospitalization. The family member reported the resident had gone to a follow up provider for an appointment who was concerned the facility was not adequately monitoring and/or caring for the post-operative drain. The family member of Resident #89 stated he was unsure if or how often Resident #89's drain site care was being performed while a resident. Residents Affected - Few An interview by telephone on 10/18/24 at 10:34 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #218 revealed she had been familiar with Resident #89's care. Resident #89 had one drain while a resident, it was a gravity drain with a collection bag, draining bile-like liquid. LPN UM #218 stated she believed the facility staff was cleansing the drain site with wound cleanser and applying a split gauze dry dressing once daily. LPN UM #218 stated this would be considered a treatment per nursing and recalled it being described in Resident #89's admission orders from the hospital. LPN UM #218 stated if this treatment was not listed as completed on the Treatment Administration Record (TAR), then technically it was not completed. LPN UM #218 confirmed orders such as post-operative drain site care orders should all be transcribed at the time of admission, listed on the TAR, as that is what prompts the nursing staff to complete the treatment. An interview on 10/18/24 at 11:40 A.M. with the Director of Nursing (DON) reviewed Resident #89's hospital AVS dated 08/28/24 and his August 2024 and September 2024 TARs. The DON confirmed there was no evidence Resident #89 received post-operative drain site care while a resident. The DON stated the facility did not have a policy for drain care or management, but there was a procedure the facility followed. Review of the procedure Surgical Wound with a Drain Dressing Application, dated 05/20/24, revealed adhering to certain procedures when caring for a patient with a surgical wound can help prevent infection by preventing pathogens from entering the wound. In addition to promoting patient comfort, performing such procedures protects the skin surface from maceration and excoriation caused by contact with irritating drainage and also enables measurement of wound drainage to monitor fluid balance. The procedure stated to verify and follow the practitioner's order for specific wound care instructions. This deficiency represents non-compliance investigated under Complaint Number OH00158542. 366481 Page 8 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

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 resident and staff interviews, review of facility policy, and record review, the facility failed to ensure residents were safely transferred, falls were documented in the facility's incident and accident log and resident medical record, and the facility completed thorough fall investigations to determine the root cause analysis. This affected two (Resident #47 and #72) of three residents reviewed for falls. The facility census was 85. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 04/20/24. Diagnoses included hemiplegia and hemiparesis, respiratory failure with hypoxia, vascular disease, muscle weakness, and contracture of the left hand. Review of the progress note dated 08/12/24 revealed a stated tested nursing assistant (STNA) notified the nurse that Resident #47 was lowered to the floor by staff. The STNA stated the resident was being transferred from bed to wheelchair when the resident started to shuffle feet and was lowered to the floor. The progress note dated 08/14/24 revealed the nurse and STNA heard loud noises and went to the resident's room and found the resident lying on his side. Resident #47 stated he slipped out of bed during his meal while reaching for his silverware. The resident's left forearm was bleeding and stated his hip was sore from his previous fall. The new intervention was to be up in wheelchair for meals and use weighted silverware. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact and had impaired mobility on bilateral lower extremities and one side upper extremities. Resident #47 was dependent on staff for transfers. The progress noted dated 08/23/24 revealed Resident #47 had a decline with transfers with new order for mechanical lift for all transfers. Review of the plan of care dated 09/03/24 revealed Resident #47 had a functional ability deficit and required assistance with self-care and mobility with interventions including mechanical lift for all transfers. Two staff for mechanical lift transfers. Resident #47 was at risk for falls and revealed interventions to anticipate needs, follow facility fall protocol and use mechanical lift for transfers. The fall investigation dated 09/15/24 revealed Resident #47 was in his room and an STNA was assisting the resident to get dressed for the day when Resident #47 slipped out of his wheelchair because the brake broke. The investigation revealed Resident #47 was assisted by staff (transfer) when the fall occurred, and a gait assist device was in use at the time of the fall. The new intervention was to have dycem and wheelchair repaired along with neurological checks being completed. The investigation did not include staff statements. The fall report in the resident's medical record was left blank with no description of the fall and only included new interventions for dycem to wheelchair and maintenance to evaluate and repair wheelchair. 366481 Page 9 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The physician note dated 09/16/24 revealed Resident #47 was seen for a fall yesterday morning (09/15/24). The physician discussed the fall that occurred with staff and was informed an STNA did not know how to secure the resident and (the wheelchair) brakes were not working. The note stated the wheelchair was being sent for repair this date (09/16/24). The progress notes dated 09/17/24 revealed Resident #47 was status post fall day two with delayed hematoma noted to distal left ankle. The nurse informed the physician of the new bruise on Resident #47's distal ankle. New order for two view x-rays of left ankle ordered. The progress note dated 09/18/24 at 6:33 A.M. revealed the x-ray came back stating no fracture, swelling noted, injury was likely strain or sprain. Review of the facilities incident accident log revealed Resident #47 had only one documented fall from 08/01/24 to 10/12/24. This fall documented occurred on 08/14/24. There was no mention of Resident #47's falls on 08/12/24, 08/14/24, or 09/15/24 on the incident accident log. Interview on 10/16/24 at 10:58 A.M. with Director of Nursing (DON) and Corporate Nurse #530 stated all falls should be documented on the fall incident/accident log. Interview on 1016/24 at 3:28 P.M. with the Administrator acknowledged Resident #47's fell from a wheelchair after it rolled away during a transfer. The Administrator acknowledged staff should have been responsible for locking the brakes prior to the transfer and if brakes were broken, or had any issues, the transfer should have been into a different chair or location. Interview on 10/17/24 at 8:21 A.M. with the DON confirmed Resident #47's fall on 09/15/24 did not have staff statements and the fall was not described in Resident #47's medical record. Interview on 10/18/24 at 8:30 A.M. with Resident #47 stated he had several falls where staff dropped me. 2. Review of the medical record for Resident #72 revealed an admission date of 05/13/24. Diagnoses included atrial fibrillation, hemiplegia and hemiparesis, epilepsy, heart disease, contracture of the left hand, and cognitive communication deficit. Review of the fall investigation dated 09/13/24 revealed Resident #72 fell during a staff assisted transfer from bed to chair. The investigation revealed the resident was lowered to the floor after resident slipped. Intervention of use of proper footwear, therapy follow up and use sit-to-stand lift. The investigation report revealed Resident #72 was being assisted by two state tested nursing aides (STNA) when the resident began to slip. She was assisted to the floor by staff and no injuries were noted. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact and had an impairment on one side of upper extremities and impairment on both sides for lower extremities. Resident #72 required substantial to maximum assistance from staff for transfers and toileting. Review of the progress notes dated 10/05/24 revealed Resident #72 was being transferred from the commode to wheelchair and slid off the front of the wheelchair landing on her buttocks. Staff were present during the fall and confirmed Resident #72 had no injuries noted. 366481 Page 10 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse practitioner note dated 10/05/24 revealed Resident #72 was seen after a fall where the resident slid from the edge of her wheelchair after being assisted with a transfer. Resident #72 slipped because she was not positioned all the back in the wheelchair which was confirmed by staff. The fall investigation dated 10/05/24 revealed staff witnessed the fall from wheelchair to floor during transfer from commode. Resident #72 landed on her buttocks with no apparent injury. It was documented that the fall occurred during a staff assisted transfer with no gait assistance device in use at the time of the transfer. Intervention of the use of two staff for sit-to-stand transfers. The fall investigation did not identify that staff did not follow previous interventions (sit-to-stand lift) which led to another fall during a staff transfer. The investigation did not include a proper root cause analysis of the cause of the fall. Review of the plan of care dated 10/14/24 revealed Resident #72 had a risk for falls with interventions including anti-rollback to wheelchair, dycem to wheelchair, educate to use call light, use of sit-to-stand lift, and resident to use manual wheelchair until power chair use can be assessed. Resident #72 had a functional mobility deficit with interventions to allow time for tasks, use of sit-to-stand for transfers with two person assist. Provide substantial/maximum assistance for toileting, hygiene, upper body dressing and dependent care with showering, footwear, lower body dressing and personal hygiene Interview on 10/17/24 at 5:26 P.M. with STNA #222 verified Resident #72 had a fall during a transfer from the toilet to the wheelchair. STNA #222 verified Resident #72 was supposed to use the sit-to-stand lift but stated it was not working properly. STNA #222 just tried to complete the transfer with one staff hand on assist to place Resident #72 in the wheelchair. He revealed during the transfer, Resident #72 was placed on the edge of the wheelchair seat and then slipped off as she was not sitting back far enough. STNA #222 stated he was educated on proper use of the sit-to-stand lift and realized he did not have the lift straps properly hooked up which made the machine not work properly. Interview on 10/17/24 at 10:03 A.M. with the Director of Nursing (DON) and Corporate Nurse #530 confirmed the facility had falls from staff transfers due to lack of knowledge and improper use of equipment. They confirmed Resident #72 had a fall from staff transfer due to not following proper fall protocols in using equipment of unhooking resident from the sit-to-stand lift before being properly placed in the wheelchair. Review of the facility policy titled Fall Management, dated 09/22/23, revealed the facility shall identify resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each resident would be provided with adequate supervision, assistive devices and functional programs to minimize risk of falls. If a fall occurred, the interdisciplinary team would conduct an evaluation to ensure appropriate interventions measures were in place to minimize risk of future falls. The DON was responsible for coordination of an interdisciplinary approach for evaluation and monitoring. Review of practice guidelines dated 2024 revealed the resident shall have a fall care plan related to risk factors and incorporate resident choice to minimize the risk of fall. When a fall occurs, the licensed nurse would evaluate the resident for injury and huddle would be done to determine the root cause of the fall. The nurse shall complete the incident accident report in PCC (electronic medical record), review or revise the care plan, document in the medical record and on the 24-hour dashboard, initiate a post fall evaluation and document progress notes for 72 hours following the fall. If 366481 Page 11 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0689 a potential head injury occurred, neurological checks shall be completed. Level of Harm - Minimal harm or potential for actual harm This deficiency represents noncompliance investigated under Complaint Number OH00158243. Residents Affected - Few 366481 Page 12 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, record review, and policy review, the facility failed to provide suprapubic catheter site care as ordered for Resident #46. This affected one (Resident #46) of three residents reviewed for indwelling urinary catheters. The facility identified 12 residents who had indwelling urinary catheters. The facility census was 85. Findings include: Review of Resident #46's medical record revealed an admission date of 11/29/23. Medical diagnoses included short bowel syndrome without colon, ileostomy status, and neuromuscular dysfunction of the bladder. Resident #46 was hospitalized from [DATE] to 10/10/24 at a local hospital for a urinary tract infection and diarrhea in the presence of an ileostomy. Resident #46 re-admitted to the facility on [DATE]. Review of Resident #46's care plan, dated 06/16/23, revealed the resident was at risk for urinary tract infections and catheter-related trauma, and had an indwelling suprapubic catheter. Listed interventions included to position catheter and tubing below the level of the bladder, check tubing for kinks each shift, and to provide catheter care per policy. Review of Resident #46's Minimum Data Set (MDS) annual assessment, dated 08/22/24, revealed Resident #46 had intact cognition. Resident #46 had no recorded behaviors or rejection of care. Resident #46 was recorded as having an indwelling urinary catheter. Review of Resident #46's physician's orders revealed an order dated 02/08/24 to provide suprapubic catheter care every shift and as needed. Listed instructions included to cleanse the resident's suprapubic site with normal saline, apply split sponge and change every night shift and as needed. Review of Resident #46's Treatment Administration Record (TAR) for August 2024 and September 2024 revealed the suprapubic catheter care and suprapubic dressing were recorded as administered daily while the resident was in the facility, except for the night shift entry on 10/16/24, which was blank. An observation and interview on 10/17/24 at 8:15 A.M. revealed Resident #46 she was in her lying in bed. The resident was awake and alert. Her urinary catheter drainage bag was lying on the floor. Resident #46 stated she had a rough night, she had been awake multiple times and had to change her colostomy drainage bag multiple times to get a good seal. Resident #46 lifted up her gown, gestured to her right abdominal ileostomy pouch and stated she finally got a good seal and the bag was no longer leaking. Upon lifting up her gown, Resident #46's left lower abdominal suprapubic site was visible with no dressing applied. The suprapubic insertion site appeared reddened, and had visible dried red/brown residue underneath and surrounding then indwelling catheter tubing. Resident #46 had a stat lock catheter securement device secured to her right leg, and the catheter tubing was folded and bent just below the securement device, kinking off the tubing. Resident #46 stated she occasionally has discomfort at her suprapubic site, she stated sometimes it hurt, but more so burned. When asked if she had received suprapubic catheter care last evening or night, Resident #46 stated yeah right that never happens. Resident #46 clarified she only received catheter care if she put her call light on and specifically asked. Resident #46 stated the nurses very rarely apply a gauze dressing around the suprapubic insertion site like they were supposed to. 366481 Page 13 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation and interview on 10/17/24 at 8:25 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #374 at Resident #46's bedside revealed the resident was still lying in bed. LPN UM #374 visualized Resident #46's suprapubic catheter site. LPN UM #374 confirmed it did not appear Resident #46 had received suprapubic catheter care last night and verified the presence of the red/brown dried drainage on the catheter tubing and around the suprapubic insertion site. LPN UM #374 confirmed Resident #46's skin appeared reddened around the insertion site and it did not appear comfortable. LPN UM #374 confirmed Resident #46 was supposed to have a dry split-gauze dressing applied to the suprapubic insertion site daily, night shift was to apply, and the dressing was not in place. A follow up interview on 10/17/24 at 8:33 A.M. with LPN UM #374 checked Resident #46's TAR for October 2024 and confirmed a blank (missing) entry for night shift on 10/16/24. LPN UM #374 stated the night shift nurse did not provide catheter care as ordered by the physician. LPN UM #374 stated treatments, including catheter care and corresponding site care, should be completed as ordered. Review of the procedure titled Indwelling Urinary Catheter Care and Management dated 12/19/23, revealed inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter-associated urinary tract infection (CAUTI). The procedure listed to apply personal protective equipment and to provide routine hygiene using soap and water. Keep the catheter and drainage tubing free from kinks and avoid dependent loops to allow free flow of urine. Do not place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI. This deficiency represents noncompliance investigated under Master Complaint Number OH00158907 and Complaint Numbers OH00158542, OH00158333, and OH00158251. 366481 Page 14 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, record review, and facility procedure review, the facility failed to transcribe physician's orders for and provide intravenous site care for Resident #46's central venous access upon her hospital return. This affected one (Resident #46) of three resident records reviewed for intravenous access devices. The facility only identified one resident with intravenous access. The facility census was 85. Residents Affected - Few Findings include: Review of Resident #46's medical record revealed an admission date of 11/29/23. Medical diagnoses included short bowel syndrome without colon, ileostomy status, and neuromuscular dysfunction of the bladder. Resident #46 was hospitalized from [DATE] to 10/10/24 at a local hospital for a urinary tract infection and diarrhea in the presence of an ileostomy. Resident #46 re-admitted ot the facility on 10/10/24. Review of Resident #46's Minimum Data Set (MDS) annual assessment, dated 08/22/24, revealed Resident #46 had intact cognition. Resident #46 had no recorded behaviors or rejection of care. Review of Resident #46's hospital Discharge summary, dated [DATE], revealed Resident #46 was treated in the hospital for a urinary tract infection with an identified bacteria. Listed action items noted Resident #46 will complete ertapenem (an antibiotic medication) at the skilled nursing facility on 10/14/24, after which time her port could be de-accessed. Review of Resident #46's hospital after visit summary, dated 10/10/24, revealed Resident #46 had an accessed subcutaneous port, and provided vascular access catheter care instructions. Listed instructions included when the port is in use, the Huber needle (a special type of needle used to access ports to administer medications and is secured in place with an occlusive bandage while the port is accessed) was to be changed every seven days. The sterile transparent dressing covering the port access needed to be changed every seven days or whenever the dressing gets wet, soiled, loose, or is open to air. An observation and interview on 10/16/24 at 3:04 P.M. with Resident #46 revealed she was seated in her wheelchair in her room. Resident #46 stated she had recently been in the hospital, and she has frequent hospital visits due to various medical complexities. Resident #46 reported she had last been in the hospital for a UTI, and had returned less than one week ago. Resident #46 stated she had just finished antibiotic shots to clear her UTI. Resident #46 stated she was unsure why she had to get the shots as she still had intravenous access, as she tapped her left chest. Resident #46 pulled the neck of her sweater down to reveal an accessed, implanted port in her left chest, dated 10/07/24. Resident #46 stated the nurses were not using the port, and she had asked a few different times why she could not have her antibiotic administered through her port. A subsequent observation and interview on 10/17/24 at 8:15 A.M. revealed the resident lying in bed. Resident #46's left chest port remained access with the dressing in place dated 10/07/24, unchanged from the previous observation. Resident #46 stated no staff members had done anything with her intravenous chest port and questioned why she still had it. An observation and interview on 10/17/24 at 8:20 A.M. with Licensed Practical Nurse (LPN) Unit 366481 Page 15 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Manager (UM) #374 in Resident #46's room confirmed Resident #46 still had her left chest port accessed and confirmed the date was listed on the dressing as 10/07/24. LPN UM #374 stated the resident must have had her port accessed at the hospital but confirmed the resident had not received any medication by intravenous route since she returned from the hospital on [DATE]. LPN UM #374 stated the standard of care for the chest port is for the access and dressing to be changed every seven days. LPN UM #374 stated she would take care of it. An observation and interview on 10/17/24 at 11:45 A.M. with the Director of Nursing (DON) and MDS Coordinator #252 in Resident #46's revealed Resident #46's left chest port remained access. The date on the dressing remained 10/07/24, unchanged from prior observation. The DON and MDS Coordinator #252 agreed the resident's chest port was accessed and the DON stated dressings for central venous access should be changed on a weekly basis. A subsequent observation and interview on 10/18/24 at 10:45 A.M. revealed Resident #46 up in her wheelchair. Resident #46 stated she still had her port accessed and thought a nurse was going to take care of it. Resident #46 stated no one had offered to remove it or change the dressing. Resident #46 stated she was unsure why she had her chest port accessed if no one intended to use it. An interview on 10/18/24 at 11:43 A.M. with the Director of Nursing revealed she would ensure Resident #46's chest port was de-accessed later that day. The DON confirmed the chest port access and the dressings covering the accessed chest port should have been changed after a maximum of seven days. Review of the procedure IV Dressing Change, dated 2024, revealed transparent semipermeable dressings should be changed at least every seven days. Change it immediately if the dressing becomes visibly soiled, loosened, or dislodged. This deficiency represents noncompliance investigated under Master Complaint Number OH00158907, Complaint Number OH00158251, Complaint Number OH00158333, and Complaint Number OH00158542. 366481 Page 16 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on staff interview, record review, and policy review, the facility failed to ensure records of controlled medications were properly maintained. This affected two (Resident #83 and #88) of 12 residents whose records were reviewed for medication administration. The facility identified 45 residents with orders for controlled medications. The facility census was 85. Findings include: 1. Review of Resident #83's medical record revealed an admission date of 08/23/24. Medical diagnoses included Huntington's Disease, chorea (a type of dyskinesia characterized by rapid, jerky, and involuntary body movements), epilepsy, and anxiety. Resident #83 has received hospice care since admission to the facility. Review of Resident #83's physician's orders revealed an order dated 08/30/24 for Lorazepam (a benzodiazepine used to decrease anxiety, controlled substance) oral solution 2 milligrams (mg) per milliliter (ml), give 0.75 ml (1.5 mg) by mouth four times daily for anxiety. Resident #80 also had an order dated 08/23/24 for Morphine Sulfate (opioid analgesic, controlled substance) oral solution 100 mg/5 ml, give 0.25 ml (5 mg) by mouth once daily at bedtime. Review of a handwritten Controlled Substance Record, with Resident #83's name at the top, listed one medication, Morphine Sulfate 100 mg/5 ml. There was no corresponding listed dose, nor was there a prescription number listed on the form. The first dose was recorded as administered on 09/19/24 at 1:29 A.M. at which time 0.25 ml of medication was administered. Seven subsequent doses of Morphine Sulfate were administered, with the last one recorded at 09/23/24 at 9:00 A.M. and leaving an amount of 14 ml of Morphine Sulfate remaining in the container. Following that entry, on 09/24/24 at 12:12 A.M., the Director of Nursing (DON) and Registered Nurse (RN) #322 logged a corrected count indicating 12 ml of Morphine Sulfate remained in the container, indicating two ml was unaccounted for. A subsequent review of Resident #83's handwritten controlled substance record, revealed this appeared to have been the same form which a copy was contained in Resident #83's record. Morphine Sulfate 100 mg/5 ml was written, with a single line drawn through the medication name and strength. Above the crossed-out Morphine Sulfate, a second medication, Ativan (brand name for Lorazepam) two mg/ml, take 0.5 ml sublingually four times daily was written. Licensed Practical Nurse (LPN) #454 signed her name below the crossed out Morphine entry. The form revealed entries on both the front and the back of the sheet, with columns including date, time, amount given, amount remaining, and signature (of person removing). Following the corrected count recorded by the DON and RN #322 on 09/24/24 at 12:12 A.M., eight subsequent doses of 0.25 ml of medication was recorded as being removed from the controlled medication supply. The back of the paper noted the following doses (listed in order): 09/30/24 at 2:25 P.M. 0.75 ml was removed, leaving an amount remaining of 9.25 ml. 09/30/24 at 7:20 P.M., 0.75 ml of medication was removed, with an amount remaining of 8.5 ml. 366481 Page 17 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0755 - Level of Harm - Minimal harm or potential for actual harm 09/30/24 at 9:00 P.M., 0.25 ml of medication was removed, 8.25 ml. - Residents Affected - Few 10/03/24 at 9:00 A.M., 0.25 ml of medication was removed, but the total amount subtracted from the total reflected 0.75 ml removed, with the remaining amount listed at 7.5 ml. 10/01/24 at 9:00 P.M., 0.25 ml was removed, with a remaining amount of 7.25 ml. 10/01/24 at 8:30 A.M., 0.75 ml was removed, with a remaining amount of 6.5 ml. 10/01/24 at 1:00 P.M., 076 ml was written down as removed, but the total amount remaining was crossed off. LPN #454 and LPN #464 co-signed the form and noted the actual count of the medication remaining was less than one cubic centimeter (equivalent to one ml). An interview on 10/17/24 at 1:01 P.M. with the DON and Regional Clinical Coordinator (RCC) #530 revealed a concern regarding Resident #83's handwritten controlled drug record form related to entries dated after 09/24/24. The DON stated the form looked suspicious and confirmed the medication name and strength being crossed out, entries out of chronological order, and amounts removed not aligning with the amount remaining in the vial were concerning. The DON stated she had no idea Resident #83's medication, unsure whether Morphine or Lorazepam as she controlled drug record sheet was unclear, contained evidence that at least 5.5 ml of medication was unaccounted for. The DON confirmed both LPN #454 and LPN #464 were both present in the facility and working that day (10/17/24). The DON and RCC #530 acknowledged issues with the controlled drug record sheet not being accurate with potentially missing amounts of liquid morphine and/or lorazepam. 2. Review of the medical record for Resident #88 revealed an admission date of 03/28/24 and discharge date of 09/13/24 (death). Diagnoses included heart failure. Review of the physician orders dated 06/06/24 to 09/13/24 revealed an order for Morphine Sulfate Solution (narcotic, controlled substance) 20 milligrams (mg) per one milliliter (ml) with instructions to give 0.25 ml by mouth every two hours as needed (PRN) for pain. Review of the narcotic sheet for Morphine PRN revealed on 09/10/24, it was documented a dose at 2218 (10:18 P.M.) of 0.25 ml given then a second dose at 3:00 P.M. of 0.25 ml given but 1.0 ml deducted from the medication cart. A third entry dated 09/13/24 was documented at 1:00 P.M. It revealed one dose of 0.25 ml was given but 0.5 ml was deducted from the count in the medication cart. Interview on 10/17/24 around 4:00 P.M. with the Administrator, Director of Nursing (DON) and Corporate Nurse #530 acknowledged discrepancies in Resident #88's medications. The narcotic sheet had discrepancies in the times of medication dosing and the counts completed after each dose was given. They 366481 Page 18 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acknowledged issues with the narcotic sheet not being accurate with potentially missing amounts of liquid morphine. Review of the pharmacy policy Inventory Control of Controlled Substances, revised 08/01/24, revealed the facility should maintain separate individual controlled substance records on all schedule II (controlled) medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record. These records should include the resident name, prescription number, medication name, strength, dosage form, and dosage, the total quantity received by the facility, date and time of administration, quantity remaining, and name and signature of person administering the medication. Facility staff should not enter more than one prescription for a controlled substance medication on each page of a declining inventory. Facility should ensure that staff IMMEDIATELY report suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up in accordance with facility policy and applicable law. A facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile: current and discontinued inventory of controlled substances to the log used in the facility's controlled medication inventory system, current inventory to the controlled medication declining inventory record and to the residents MAR, and unused controlled substances held in storage awaiting destruction with the declining inventory record. This deficiency represents noncompliance identified while investigating Complaint Number OH00158415. 366481 Page 19 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

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 observation, staff and resident interview, record review, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #46) of 12 residents' records reviewed for medication administration. The facility census was 85. Residents Affected - Few Findings include: Review of Resident #46's medical record revealed an admission date of 11/29/23. Medical diagnoses included short bowel syndrome without colon, ileostomy status, and neuromuscular dysfunction of the bladder. Resident #46 was hospitalized from [DATE] to 10/10/24 at a local hospital for a urinary tract infection and diarrhea in the presence of an ileostomy. Resident #46 re-admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) annual assessment, dated 08/22/24, revealed Resident #46 had intact cognition. Resident #46 had no recorded behaviors or rejection of care. Review of Resident #46's hospital Discharge summary, dated [DATE], revealed Resident #46 was treated in the hospital for a urinary tract infection (UTI) with an identified bacteria. Listed action items noted Resident #46 will complete ertapenem (an antibiotic medication) at the skilled nursing facility on 10/14/24, after which time her implanted port (accessed intermittently to provide central intravenous access for intravenous medication administration) could be de-accessed. Review of Resident #46's continuity of care document, dated 10/10/24, revealed a notation from an infectious disease provider indicating Resident #46 required a total duration of seven days of her intravenous ertapenem, listing the stop date as 10/14/24. The document indicated that Resident #46's central access could be removed at the end of therapy. Review of Resident #46's hospital after visit summary, dated 10/10/24, revealed Resident #46 had orders for Ertapenem. There was two listed entries. One listed Ertapenem one gram intramuscularly to be injected every 24 hours for five days. This entry had an X drawn overtop of it. An additional entry listed Ertapenem one gm every 24 hours as an intermittent infusion (indicating by intravenous route), with the diluent and final concentration at the discretion of the receiving pharmacy. The first dose (post-hospital discharge) was listed to be administered on the evening of 10/10/24. Review of Resident #46's physician's orders revealed an order dated 10/11/24 for Ertapenem one gm, inject one gm by intramuscular route every 24 hours for UTI for five days. The listed start date was 10/11/24, and the stop date was listed as 10/15/24. Review of Resident #46's Medication Administration Record (MAR) revealed the resident's Ertapenem one gm was recorded as administered by intramuscular route once daily from 10/11/24 to 10/15/24. There was no recorded sites listed on the MAR to reflect in which muscle Resident #46 received her injection. An observation and interview on 10/16/24 at 3:04 P.M. with Resident #46 stated she had recently been in the hospital, and she has frequent hospital visits due to various medical complexities. Resident #46 reported she had last been in the hospital for a UTI, and had returned less than one week ago. Resident #46 stated she had just finished antibiotic shots to clear her UTI. Resident #46 stated 366481 Page 20 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was unsure why she had to get the shots as she still had intravenous access, as she tapped her left chest. Resident #46 pulled the neck of her sweater down to reveal an accessed, implanted port in her left chest, dated 10/07/24. Resident #46 stated the nurses were not using the port, and she had asked a few different times why she could not have her antibiotic administered through her port. Resident #46 stated she hated the shots and confirmed the shots were given by the nurse, via syringe and a needle inserted into one of her arms and were painful during and for a short time following each injection. Resident #46 stated the shots made her arms sore and she was happy to be done with them. An interview on 10/17/24 at 7:20 A.M. with Unit Manager (UM) #374 revealed she completed chart checks on residents' records upon admission and re-admission. UM #374 stated during the chart checks, she ensured orders were transcribed accurately, and as part of the check she also assessed the residents. A subsequent interview with UM #374 at 8:44 A.M. reviewed Resident #46's hospital discharge orders compared with orders which were transcribed into the facility's electronic health record. UM #374 confirmed the resident's ertapenem order should have been entered to be administered by intravenous route, and she had erroneously entered intramuscular route which she confirmed was crossed out on the hospital after visit summary. UM # 374 confirmed there was no other documented evidence in the resident's progress notes or assessments indicating any physician or provider had ordered a change in route after returning to the facility. An interview on 10/18/24 at 11:43 A.M. with the Director of Nursing confirmed the facility does not have a specific policy for medication errors. Review of the policy Medication Administration, dated 10/17/24, revealed medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the 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 noncompliance investigated under Complaint Number OH00158542 and Complaint Number OH00158333. 366481 Page 21 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure the medical record was maintained as an accurate depiction of resident care. This affected one (Resident #88) of 12 residents reviewed for medical record accuracy. The facility census was 85. Findings include Review of the medical record for Resident #88 revealed an admission date of [DATE] and discharge date of [DATE] (death). Review of the physician orders dated [DATE] revealed an order for Morphine Sulfate Solution 10 milligram (mg) per 6.0 milliliter (ml) with instructions to give 0.25 ml by mouth every two hours as needed (PRN) for pain. Resident #88 was receiving hospice services. The Medication Administration Record (MAR) dated 09/2024 revealed on the day of his death ([DATE]), Resident #88 received Morphine PRN dose one time at 11:22 A.M. Review of the narcotic sheet for Morphine PRN revealed the only entry from the date of death ([DATE]) was documented at 1:00 P.M. Review of the progress notes dated [DATE] at 2:37 A.M. revealed a nursing note from Licensed Practical Nurse (LPN) #376 from [DATE] night shift. The note stated, Resident had low oxygen saturations 40% through four liters of oxygen during shift change, continue to monitor, ensure head of bed was elevated, guest pulse was thready and fainting saturations kept dropping. At 7:50 P.M., Resident #88 was deceased and hospice was notified. Interview on [DATE] at 4:10 P.M. with Licensed Practical Nurse (LPN) #376 stated she started work on [DATE] (day of death) at 7:00 P.M. and stated when she entered the room, Resident #88 was found deceased and had no vital signs or respirations identified and was cold to touch. She did not remember documentation of the event, but confirmed the note in the medical record was not accurate to the events that occurred. LPN #376 confirmed Resident #88 did not have any respirations or saturations and she did not sit up the bed or provide any care prior to his death. Interview on [DATE] at 7:15 A.M. with LPN #212 stated she had seen the resident around 3:00 P.M. to 4:00 P.M. and then changed the reported last seen time to 4:00 P.M. to 5:00 P.M. She stated she had passed a pain pill (morphine) during the last visit of her shift. Interview on [DATE] at 10:03 A.M. with Director of Nursing and Corporate Nurse #530 acknowledged Resident #88 died and LPN #376's note provided details of care being provided that was not actually provided. They verified the medical record should only contain accurate details of what occurred. Review of the facility policy titled Documentation Expectations, dated [DATE] revealed documentation of the medical record should be credible, complete and accurate. Knowingly documenting untrue statements, making false entries and omitting information shall be willful acts of falsification resulting in disciplinary action. This deficiency represents noncompliance investigated under Complaint Number OH00158542 and Complaint Number OH00158243. 366481 Page 22 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure proper personal protective equipment (PPE) was utilized for residents who required enhanced-barrier precautions (EBP) for open wounds. This affected two (Residents #39 and #41) of three residents reviewed for wound care. The facility identified 23 residents with open wounds. The facility census was 85. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 03/11/22. Medical diagnoses included chronic kidney disease and vascular dementia. Review of Resident #39's Minimum Data Set (MDS) quarterly assessment, dated 07/02/24, revealed the resident had moderately impaired cognition. Resident #39 was at risk for skin breakdown but was noted upon assessment to have no unhealed pressure ulcers. Review of Resident #39's care plan, dated 10/16/24, revealed the resident has an actual impairment to skin integrity related to pressure injury. Resident #39 was listed as having a stage II pressure injury (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to his coccyx which was resolved on 10/16/24. Resident #39 also had a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle) to his left heel. Review of Resident #39's physician's orders revealed an order dated 10/09/24 to cleanse the left heel with normal saline and pat dry, apply calcium alginate, cover with border gauze and change daily on night shift. A second order dated 10/16/24 stated to cleanse a stage II coccyx wound with soap and water and pat dry, apply barrier cream every shift and as needed. Resident #39 had an order dated 04/15/24 for enhanced carrier precautions related to catheter/wound. An observation on 10/16/24 at 6:47 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #374, Certified Nursing Assistant (CNA) #314, and Wound Physician #475 revealed the three approaching Resident #39's room. A PPE cart was located directly outside of Resident #39's private room and contained gloves, gowns, and masks. A sign was hanging on the door to Resident #39's room indicating EBP were required for high-contact resident activities, including wound care. LPN UM #374 parked the treatment cart outside of Resident #39's room, obtained necessary supplies, and entered the room with CNA #314. Once in the room, LPN UM #374 and CNA #314 applied gloves, informed the resident they were there to perform wound care, and began repositioning the resident. LPN UM #374 and CNA #314 did not don a gown. CNA #314 assisted Resident #39 to reposition onto his left side, LPN UM #374 cleansed the resident's bilateral buttocks and coccyx area, allowed Wound Physician #475 to visualize and assess the resident's coccyx area, and identified the coccyx area as resolved. LPN UM #374 applied barrier cream as a preventative measure, positioned the resident onto his back, and then removed her gloves and washed her hands. LPN UM #374 applied a new pair of gloves, and removed the dressing to Resident #39's left heel. Neither LPN UM #374 nor CNA #314 were wearing a gown. CNA #314 elevated Resident #39's left leg to allow Wound Physician #475 to visualize and measure the resident's left heel wound. LPN UM #374 cleansed the left heel wound with normal saline, applied a new dressing of calcium alginate and a border gauze, and re-applied Resident #39's bilateral offloading heel boots. A follow up interview on 10/16/24 at 2:15 P.M. with LPN UM #374 revealed residents who have invasive things, such as wounds, catheters, colostomy, intravenous access, or any other abnormal openings 366481 Page 23 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would require EBP to be in place. When asked to describe what EBP consisted of, LPN UM #374 stated personal care type tasks would require at least glove and gown use. LPN UM #374 confirmed she did not wear a gown when performing wound rounds earlier this date for Resident #39 nor any other resident she saw that day. LPN UM #374 stated it was not her usual practice to wear a gown during wound rounds with each resident. LPN UM #374 confirmed EBP called for gown use during high contact activities, including wound care, and CNA #314 and herself should have been wearing gowns. 2. Review of the medical record for Resident #41 revealed an admission date of 02/08/21. Medical diagnoses included spina bifida, epilepsy, colostomy status, and paraplegia. Review of Resident #41's MDS quarterly assessment, dated 07/13/24, revealed the resident had intact cognition. Resident #41 was identified to have one unhealed pressure ulcer that was not present upon admission. Review of Resident #41's care plan, dated 09/11/24, revealed the resident had an actual impairment to skin integrity related to a stage IV pressure ulcer to the left ischium. Listed interventions included to observe for signs of infection and apply treatment as ordered. Review of Resident #41's physician's orders revealed an order dated 04/24/24 to cleanse the left ischium with normal saline, pat dry, apply calcium alginate and cover with border gauze and change daily on night shift. Resident #41 also had an order dated 04/15/24 for enhanced carrier precautions related to catheter/wound. An observation on 10/16/24 at 7:08 A.M. revealed LPN UM #374 and CNA #314 approach Resident #41's room with the treatment cart. LPN UM #374 stated they were going to evaluate Resident #41's left ischium wound. A PPE cart was available outside the resident's room in which were gown, gloves, and masks. A sign was hanging on the door to Resident #41's room indicating EBP were required for high-contact resident activities, including wound care. LPN UM #374 gathered necessary treatment supplies and her and CNA #314 entered the resident's room. Both applied gloves but neither applied a gown. Resident #41 assisted in repositioning herself onto her right side to expose her left ischium. LPN UM #374 removed the old dressing, Wound Physician #475 measured and assessed the area. LPN UM #374 cleansed and dressed the wound. At no time during the observation did LPN UM #374, CNA #314, or Wound Physician #475 apply or wear a gown. A follow up interview on 10/16/24 at 2:15 P.M. with LPN UM #374 revealed residents who have invasive things, such as wounds, catheters, colostomy, intravenous access, or any other abnormal openings would require EBP to be in place. When asked to describe what EBP consisted of, LPN UM #374 stated personal care type tasks would require at least glove and gown use. LPN UM #374 confirmed she did not wear a gown when performing wound rounds earlier this date for Resident #41, nor any other resident she saw that day. LPN UM #374 stated it was not her usual practice to wear a gown during wound rounds with each resident. LPN UM #374 confirmed EBP called for gown use during high contact activities, including wound care, and CNA #314 and herself should have been wearing gowns. Review of the policy Enhanced Barrier Precautions dated 04/01/24 revealed EBP are indicated for residents with an infection, colonization with a multi-drug resistant organism (MDRO), and a wound or an indwelling medical device. EBP should remain in place for the duration of a resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at higher risk. Health care personnel caring for residents on enhanced precautions should wear gloves and gowns during high-contact resident care. Examples of high contact resident care activities 366481 Page 24 of 25 366481 10/21/2024 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0880 requiring gown and glove use included wound care. Level of Harm - Minimal harm or potential for actual harm Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multi-drug resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24, revealed key points included MDRO transmission in skilled nursing facilities,contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following which included wounds. Residents Affected - Few This deficiency represents noncompliance investigated under Master Complaint Number OH00158907 and Complaint Numbers OH00158542, OH00158333, and OH00158251. 366481 Page 25 of 25