Health inspection·June 9, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #12 revealed an admission date of 12/20/23. Diagnoses included type two diabetes mellitus, anxiety disorder, depression, osteoarthritis and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Resident #12 had limited functional range of motion noted on both sides for both upper and lower extremities and was staff dependent for personal hygiene needs. Review of Certified Nursing Assistant (CNA) documentation in the task section of the medical record from 05/01/25 to 05/31/25 revealed Resident #12 was documented to have shower/bath/bed baths on 05/06/25, 05/14/25. 05/17/25, 05/20/25, and 05/24/25. It was documented no shower/bath/ bed bath was provided on 05/10/25 and 05/28/25 and refused on 05/31/25. Interview on 06/03/25 at 10:56 A.M. with Resident #12 stated she has never refused her shower; the aides tell her there were no Hoyer lift pads available to get her up onto the shower bed so they will just give her a bed bath. Resident #12 stated the aides did not wash her hair and only washed her privates and armpits during a bed bath. Interview on 06/03/25 and 1:03 P.M. with Unit Manager (UM) #206 revealed UM #206 was unable to confirm whether Resident #12 had a shower or a bed bath, stating only the task documentation only indicated a shower/bath/bed bath was provided Resident #12 and did not differentiate what was actually provided to Resident #12. UM #206 was unable to provide any documentation or evidence confirming if Resident #12 received a shower or bed bath. When requested to see the Hoyer pad used for transferring the resident to the shower, LPN #206 was unable to locate the resident's specific bariatric Hoyer pad. When LPN #206 went to the laundry area to look for the Hoyer pads, she was unable to locate any and stated they must be somewhere, but could not identify their location. Interview on 06/03/25 at 2:25 P.M. with Certified Nursing Assistant (CNA) #200 confirmed an issue with the number of Hoyer Lift Pads were available. CNA #200 stated there seems to be a miscalculation of how many Hoyer pads they have vs how many they need. CNA #200 explained they have several residents who get up and down a couple of times a day, so the pad remains with them all day. Resident #12 liked to get up and shower but the facility does not have enough Hoyer pads to go around recently to get her up on the shower bed. Interview on 06/04/25 at 6:02 A.M. with CNA #133 stated the CNAs feel there was no trouble with showers at night, but there were issues not enough Hoyer pads and slings for the Hoyer lift with residents who were larger. CNA #133 stated the residents who were larger do receive with bed baths. Page 1 of 34 366481 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/04/25 at 9:00 A.M. with Resident #12 confirmed she did not receive a shower last night on her scheduled shower day. Resident #12 stated she received a bed bath but her hair was not washed, Resident #12 emphasized she wants a shower not a bed bath to feel clean and have her hair washed. Based on record review, observations, and resident and staff interviews, the facility failed to ensure two residents (Residents #12 and #23) out of three residents reviewed for bathing received their preferred method of bathing or showering. The facility census was 88. Findings include: 1. Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, morbid obesity with alveolar hypoventilation, hemiplegia following cerebral infarction, contractures of the left upper extremity, depression, and bipolar disorder. The resident was non-ambulatory and was dependent on staff for all transfers and most activities of daily living. She used a specialty wheelchair and required two-person physical assistance with a mechanical lift for transfers. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact, required total dependence for all transfers and hygiene tasks, had bilateral upper and lower extremity impairments, and was always incontinent of bowel and bladder. Review of the care plan, revised on 05/23/25, revealed Resident #23 preferred to receive showers on Wednesdays and Saturdays at 3:00 P.M. and identified shower as her preferred bathing method. Review of the physician's order dated 05/23/25 revealed a weekly skin assessment with shower every Saturday night shift. Review of the Activities of Daily Living (ADL) documentation from 05/01/25 to 06/01/25 revealed Resident #23 did not receive showers per her preference. There were no showers documented on 05/08/25 and 05/17/25, and there were no progress notes indicating refusals on those dates. Showers were documented only on 05/10/25, 05/14/25, 05/22/25, 05/25/25, 05/29/25, and 06/01/25. Review of the bathing task documentation from 04/01/25 to 06/01/25 revealed Resident #23 did not receive a bed bath on 04/17/25, 04/24/25, 05/01/25, 05/08/25, and 05/17/25, with no documentation of refusals in the progress notes. Additionally, the task entries did not specify whether the resident received a bed bath or a shower, and there was no evidence elsewhere in the medical record to confirm which method of bathing, if any, had been provided. Interview on 06/02/25 at 10:06 A.M. with Resident #23 stated she was not receiving showers and could not recall the last time she had one. She stated her hair had not been washed in a while and reported wanting to get up for lunch, but staff would not assist her out of bed. Interview on 06/03/25 at 11:14 A.M. with Licensed Practical Nurse (LPN) #143 stated Resident #23 was scheduled to receive two showers per week, but often refused one. LPN #143 stated the refusals were supposed to be documented in progress notes and the resident had received a shower earlier that week. Interview on 06/03/25 at 11:34 A.M. with Clinical Coordinator #305 stated only completed showers 366481 Page 2 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were documented in task records, and refusals were not consistently recorded. She acknowledged the absence of reliable documentation showing whether a shower had been offered or refused. Interview on 06/03/25 at 11:41 A.M. with Resident #23 stated she had not received an actual shower in months and reported the staff did not offer her the opportunity to shower. She stated she was typically only provided with bed baths and reiterated her preference for showers. Interview on 06/03/25 at 11:44 A.M. with Certified Nursing Assistant (CNA) #111 stated the last time he recalled Resident #23 receiving a shower was in January. He stated all documentation regarding showers or refusals should have been found in the progress notes but was unable to confirm any such entries. Interview on 06/03/25 at 11:47 A.M. with Unit Manager #206 stated Resident #23 was scheduled to receive showers on Wednesday and Saturday nights. She confirmed documentation of showers should have been included in progress notes, but she was unable to provide records confirming whether the resident had received a shower or a bed bath. Observation on 06/03/25 at 12:44 P.M. revealed Resident #23 was lying in bed. When she lifted her head, her hair appeared stiff and matted from oil buildup and did not move naturally, suggesting that it had not been washed recently. Interview on 06/03/25 at 1:03 P.M. with Resident #23 and Unit Manager #206 together revealed the resident again reported she had not received a shower and expressed that she preferred showers over bed baths. The Unit Manager stated the only documentation available was under a general task labeled Shower/Bath/Bed Bath, and she could not confirm what type of bathing had been provided. She was unable to produce documentation confirming a completed shower or bed bath. When asked to locate the bariatric Hoyer pad needed to transfer the resident to the shower, the Unit Manager was unable to find it. She searched the laundry area and stated the pads must be somewhere, but could not identify their location. Observation on 06/03/25 at 1:59 P.M. revealed Unit Manager #206 later produced two Hoyer pads with the resident's name written on them but stated they had been missing for about a week. 366481 Page 3 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, review of Self-Reported Incident (SRI), and review of facility policy, the facility failed to prevent Resident #76's controlled substances from being misappropriated. This affected one (#76) of two residents reviewed for misappropriation. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #76 revealed an admission date of 04/28/25 and a discharge date of 05/16/25. Diagnoses included malignant neoplasm of anus, depression, neoplasm related pain, depression, insomnia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition. Review of the facilities SRI dated 04/24/25 revealed on 04/24/25, a nurse reported the narcotics were missing for Resident #76. The nurse went to dispense the medications, and they were unavailable. The nurse reported the concern to the Director of Nursing (DON). The pharmacy was asked to provide proof of delivery, and they sent the documentation, the medication delivery was signed for by an agency nurse working on the prior shift. The agency was contacted and was asked to drug screen and provide statement from agency nurse. The agency reported the drug screen was negative. Other nurses working on the unit were drug screened and the results were negative. Other nurses interviewed stated they were given other medications from the delivery but did not receive the narcotics. The resident's medication was pulled from Omnicell and given according to the order. The facility reordered the medication and paid for the replacement. Medication Administration Records (MAR) were reviewed for all residents on the med care unit and no missed doses were noted. Out of an abundance of caution, the facility filed a police report and reported agency nurse to the Ohio Board of Nursing and educated licensed nurses on the controlled substances policy. Review of the incident and accident form dated 04/23/25 revealed the resident involved was Resident #76, the alleged perpetrator was Agency Nurse #318, and employees involved were Registered Nurse (RN) #120 and Licensed Practical Nurse (LPN) #330. Agency Nurse #318 was assigned to the skilled unit, he accepted a pharmacy shipment at 3:05 P.M. and signed for narcotics. The narcotics in question were not available to dispense by the night nurse LPN #159. She called the pharmacy and stated they had been delivered. The pharmacy was asked to provide proof of delivery and they sent documentation signed by Agency Nurse #318. The DON examined the medication carts and medication room and reviewed the resident's file. RN #120 and LPN #330 were interviewed as well as Agency Nurse #318's agency. Employees were drug tested and were negative. The investigation was inconclusive. Agency Nurse #318 signed for medications and handed non-narcotic medications to RN #120 who gave them to LPN #300. The paperwork that accompanied the narcotics were not found either. Review of Omnicare's Proof of Delivery dated 04/24/25 revealed Oxycodone (narcotic pain medication) 10 milligrams (mg) six pills and Diazepam (controlled substance) five mg 30 pills were sent on 04/23/25. Agency Nurse #318's initials were written on the page. Review of the witness statement dated 04/24/25 revealed on 04/23/25, LPN #330 received from the agency nurse at 3:05 P.M. the non-controlled prescriptions for Resident #76. He indicated he did not receive any controlled prescriptions. 366481 Page 4 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0602 Level of Harm - Minimal harm or potential for actual harm Review of the witness statement dated 04/24/25 by RN #120 revealed Agency Nurse #318 handed her the medications to give to LPN #330. There were no opioids or narcotic sheets with the cards she received, just regular medications. Review of the drug tests for LPN #330, RN #120, and Agency Nurse #318 revealed they were negative. Residents Affected - Few Interview on 06/05/25 at 10:00 A.M. with the DON and Administrator verified Resident #76's medications were missing and Agency Nurse #318 was suspected of taking the controlled substances. Review of the facilities Abuse Prohibition Policy dated 10/14/22 revealed each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. This deficiency represents non-compliance investigated under Complaint Number OH00165729. 366481 Page 5 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the use of antipsychotic medication was based on a clinically supported diagnosis. This affected one (Resident #81) of five residents reviewed for antipsychotics. The facility census was 88. Findings include: Record review for Resident #81 revealed an admission date of 04/25/25. Diagnoses included bipolar disorder, psychoactive substance abuse, and nicotine dependence. Review of the physician orders dated 04/26/25 revealed Venlafaxine HCL extended release 150 milligrams (mg) to be administered once daily for depression. The physician order dated 04/30/25 revealed Quetiapine Fumarate 200 mg at bedtime for depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was cognitively intact and had no symptoms of depression. Interview with the Director of Nursing on 06/05/25 at 1:40 P.M. confirmed Resident #81 does not have a current diagnosis of depression in the medical record and there was no care plan related to depression in place. Review of the facility's Psychoactive Medication Management policy dated 04/28/25 revealed staff must verify orders for psychoactive medications are supported by appropriate clinical diagnoses and/or behavioral symptoms. When pharmacological interventions are indicated, the licensed staff will verify the physician order includes the appropriate clinically supported diagnosis and/or behavior symptoms. 366481 Page 6 of 34 366481 06/09/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, policy review, and review of Self-Reported Incident (SRI), the facility failed to thoroughly investigate Resident #76's missing controlled substances. This affected one (#76) of two residents reviewed for misappropriation. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #76 revealed an admission date of 04/28/25 and a discharge date of 05/16/25. Diagnoses included malignant neoplasm of anus, depression, neoplasm related pain, depression, insomnia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition. Review of the facilities SRI dated 04/24/25 revealed on 04/24/25, a nurse reported the narcotics were missing for Resident #76. The nurse went to dispense the medications, and they were unavailable. The nurse reported the concern to the Director of Nursing (DON). The pharmacy was asked to provide proof of delivery, and they sent the documentation, the medication delivery was signed for by an agency nurse working on the prior shift. The agency was contacted and was asked to drug screen and provide statement from agency nurse. The agency reported the drug screen was negative. Other nurses working on the unit were drug screened and the results were negative. Other nurses interviewed stated they were given other medications from the delivery but did not receive the narcotics. The resident's medication was pulled from Omnicell and given according to the order. The facility reordered the medication and paid for the replacement. Medication Administration Records (MAR) were reviewed for all residents on the med care unit and no missed doses were noted. Out of an abundance of caution, the facility filed a police report and reported agency nurse to the Ohio Board of Nursing and educated licensed nurses on the controlled substances policy. Review of the incident and accident form dated 04/23/25 revealed the resident involved was Resident #76, the alleged perpetrator was Agency Nurse #318, and employees involved were Registered Nurse (RN) #120 and Licensed Practical Nurse (LPN) #330. Agency Nurse #318 was assigned to the skilled unit, he accepted a pharmacy shipment at 3:05 P.M. and signed for narcotics. The narcotics in question were not available to dispense by the night nurse LPN #159. She called the pharmacy and stated they had been delivered. The pharmacy was asked to provide proof of delivery and they sent documentation signed by Agency Nurse #318. The DON examined the medication carts and medication room and reviewed the resident's file. RN #120 and LPN #330 were interviewed as well as Agency Nurse #318's agency. Employees were drug tested and were negative. The investigation was inconclusive. Agency Nurse #318 signed for medications and handed non-narcotic medications to RN #120 who gave them to LPN #300. The paperwork that accompanied the narcotics were not found either. Review of Omnicare's Proof of Delivery dated 04/24/25 revealed Oxycodone (narcotic pain medication) 10 milligrams (mg) six pills and Diazepam (controlled substance) five mg 30 pills were sent on 04/23/25. Agency Nurse #318's initials were written on the page. Review of the witness statements reviewed only two staff were interviewed, LPN #330 and RN #120. Review of the drug tests revealed only LPN #330, RN #120, and Agency Nurse #318 were tested. 366481 Page 7 of 34 366481 06/09/2025 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 Review of the schedule for 04/23/25 revealed there were seven aides and six nurses scheduled for day shift. Interview on 06/05/25 at 10:00 A.M., 11:11 A.M., and 11:30 A.M. with the DON verified she only interviewed the three involved nurses, she did not feel that the nurse aides would have been aware of any issues. She interviewed LPN #159 but did not obtain a witness statement. She reported she interviewed and assessed Resident #76 but verified there was no evidence of this. The DON additionally verified they only drug tested the two nurses. Review of the facilities Abuse Prohibition Policy dated 10/14/22 revealed allegations of abuse, which included misappropriation, shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. Allegations by anyone who becomes aware of abuse, mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must immediately report it to his/her Administrator. The DON or designee will complete an assessment of guest(s)/resident(s) and document the findings in the medical record. 366481 Page 8 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of medical record reviews, and review of the facility policy, the facility failed to notify the the Office of the State Long-Term Care Ombudsman of the resident's discharges from the facility. This affected two (#84 and #85) of two residents reviewed for discharge. The facility census was 88. Findings include: 1. Review of Resident #84's medical record revealed an admission date of 03/05/25 with discharge date of 03/14/25. Diagnoses included acute and chronic respiratory failure with hypercapnia and chronic obstructive pulmonary disease. Review of Resident #84's progress notes revealed she went to the hospital on [DATE] and did not return to the facility. There was no evidence in the medical record the Long-Term Care Ombudsman was notified for Resident #84's discharge to the hospital. Interview on 06/04/25 at 10:45 A.M. with the Administrator verified the Long-Term Care Ombudsman was not notified of Resident #84's discharge. 2. Review of Resident #85's medical record revealed an admission date of 04/04/25 and a discharge date of 04/14/25 her diagnoses including hepatic encephalopathy, low back pain, alcoholic cirrhosis, and chronic viral hepatitis C. Review of Resident #85's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was independent for cognitive skills. Review of Resident #85's progress notes revealed on 04/14/25 the resident left against medical advice. There was no evidence in the medical record the Long-Term Care Ombudsman was notified for Resident #85's discharge to the hospital. Interview on 06/04/25 at 10:45 A.M. with the Administrator verified the Long-Term Care Ombudsman was not notified of Resident #85's discharge. Review of the policy titled Transfer and Discharge dated 04/28/25 revealed notice must be provided as soon as practicable to the ombudsman. A list of residents could be sent to the ombudsman monthly. 366481 Page 9 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #28 had a care plan for a diuretic and Resident #81 had a care plan for smoking. This affected one resident (#28) of five residents reviewed for unnecessary medications and one resident (#81) of one resident reviewed for smoking. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included chronic obstructive pulmonary disease. Review of Resident #28's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #28's physician order dated 04/23/25 revealed an order for Furosemide (a diuretic) 20 milligrams, one tablet by mouth twice a day. Review of Resident #28's plan of care revealed it did not address his diuretic use. Interview on 06/04/25 at 3:20 P.M. with the Director of Nursing (DON) verified the care plan did not address his diuretic use. 2. Review of the medical record for Resident #81 revealed an admission date of 04/25/25. Diagnoses including nicotine dependence and psychoactive substance abuse. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 had intact cognition. Review of the progress note note dated 05/14/25 revealed Resident #81 was encouraged to quit smoking but expressed no interest and continued smoking approximately half a pack of cigarettes daily. The nursing staff had notified the physician that Resident #81 had been observed smoking in front of the building. Review of Resident #81's care plan revealed Resident #81's smoking was not addressed in his care plan. Interview on 06/02/25 at 2:30 P.M. with Licensed Practical Nurse (LPN) #113 confirmed Resident #81 was non-compliant with the facility's no-smoking rule but consistently exits the building to smoke outside. LPN #113 also stated this behavior had been discussed with facility management and was unsure if it was included in the plan of care. Interview on 06/05/25 at 1:37 P.M. with the Director of Nursing confirmed Resident #81's non-compliance with the facility smoking policy was not currently addressed in the resident's care plan and acknowledged the care plan should have been updated to reflect this behavior. 366481 Page 10 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received timely and adequate staff assistance with showers and personal hygiene. This affected one (Resident #53) of four residents reviewed for ADL care. The facility identified 24 residents who were dependent on staff for bathing. Residents Affected - Few Findings include: Review of the medical record for Resident #53 revealed an admission date of 04/24/25. Diagnoses included left knee effusion, depression, anxiety disorder, and chronic kidney disease. Review of the care plan dated 04/24/25 revealed Resident #53 has a functional ability deficit and required assistance with self-care and mobility related to altered mobility. Interventions revealed the resident prefers baths at 10:30 A.M., was dependent on staff for bathing, and required partial to moderate assistance with personal hygiene, including shaving. Review of the facility's hygiene guest preferences form dated 04/25/25 revealed Resident #53's scheduled bed baths were on Mondays and Thursdays during the day shift. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was cognitively intact. Resident #53 was dependent on staff for bathing and required partial to moderate assistance with personal hygiene including shaving. Review of the shower/bath task from 05/06/25 through 06/05/25 revealed there was no documentation showing Resident #53 received a bath or shaving during this period. Observation on 06/02/25 at 10:47 A.M. revealed Resident #53 had mustache and chin hairs approximately half an inch in length. Subsequent observations on 06/04/25 at 11:57 A.M. and 06/05/25 at 8:09 A.M. revealed Resident #82's facial hair remained present. Interview on 06/05/25 at 11:06 A.M. with Certified Nursing Assistant (CNA) #177 revealed Monday and Thursday were the scheduled bathing days for Resident #53. CNA #177 stated if a resident refuses shaving during bathing, the refusal was documented and nursing staff were promptly notified. Interview on 06/05/25 at 11:11 A.M. with Licensed Practical Nurses (LPN) #113 and #18 revealed Resident #53's medical record contained no documentation of a shower or bath in the past 30 days. LPN #113 confirmed CNAs were expected to offer shaving services during scheduled bathing days. Observation on 06/05/25 at 11:23 A.M. with LPN #113 revealed Resident #82 had mustache and chin hair present. When asked about preference for removal, Resident #82 gave an inappropriate response. Interview on 06/05/25 at 1:52 P.M. with the Director of Nursing (DON) revealed residents requiring shaving were expected to receive this service on their scheduled bathing days. The DON also confirmed baths and showers were documented electronically only in the shower/bath task. This deficiency represents non-compliance investigated under Complaint Number OH00166265. 366481 Page 11 of 34 366481 06/09/2025 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** 2. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included non-chronic pressure ulcer of the left heel, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, and depressive disorder. Residents Affected - Few Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Review of the Wound Care Clinic visit note dated 04/28/25 revealed Resident #26 was to have a follow up appointment with the clinic in one week. There was no evidence in Resident #26's medical record that Resident #26 attended an appointment at the Wound Care Clinic one week after his appointment on 04/28/25. Interview with Resident #26 on 06/05/25 at 11:02 A.M. confirmed they attended appointments at the Wound Care Clinic on Mondays and had missed an appointment on 05/05/25 due to the facility not scheduling transportation to the appointment. Interview with the Director of Nursing (DON) on 06/05/25 at 2:41 P.M. confirmed Resident #29 missed a scheduled appointment at the Wound Care Clinic on 05/05/25. 3. Review of the medical record for Resident #12 revealed an admission date of 12/20/23. Diagnoses included peripheral vascular disease, anxiety disorder, a history of thrombus/embolism, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition and received a antiplatelet medication. Review of Resident #12's physician orders revealed on 07/05/24, Clopidogrel Bisulfate (an antiplatelet medication) oral tablet 75 milligrams (mg) was ordered to be administered by mouth one time a day for blood thinner. On 07/05/24, there was an order to monitor for signs and symptoms of bleeding and notify the provider of any changes. Review of Resident #12's treatment administration record (TAR) for May and June 2025 revealed documentation of no bleeding or bruising was indicated for all of May and June 2025. Observation and interview with Resident #12 on 06/02/25 at 10:47 A.M. revealed bruises on the back of both hands. Bruises on the right hand took up most of the back of the hand while there were two quarter size bruises on the back of her left hand near the wrist. Resident #12 stated has had several bruises on her arms and hands. Resident #12 does not know how she got the bruises and stated she bruises easily. Resident #12 stated no one follows or monitors her bruising. Interview and observation on 06/03/25 at 2:11 P.M. with Licensed Practical Nurse (LPN) #208 confirmed bruises appeared to Resident #12's back of her hands LPN #208 confirmed they were not previously noted and she was unaware of where they came from. Interview and observation on 06/04/25 at 9:00 A.M. with Unit Manager (UM) #206 and the Director of 366481 Page 12 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing (DON) confirmed Resident #12 had discolored areas on the back of her right hand and smaller area on left hand and confirmed they were bruises. The DON instructed UM #206 to be sure there was an order to monitor for signs and symptoms of bleeding or bruising and the order was being followed. Interview on 06/04/25 at 11:00 A.M. with the DON and the Administrator confirmed Resident #12 shared with them that Resident #12's family noted the bruising on her hands last Saturday (05/31/25). The Administrator and DON confirmed that every shift monitoring for bleeding and bruising in Resident #12's TAR reflected no signs or symptoms of bleeding or bruising noted as being present on the resident's hands. This deficiency represents non-compliance identified during the investigation of Complaint OH00165422. Based on resident and staff interviews, observations and record review, the facility failed to ensure timely coordination with the physician for the removal of staples and did not ensure the residents attended their scheduled appointments. Additionally, the facility failed to timely identify and monitor a resident's bruising. This affected three (Residents #12, #26 and #252) reviewed for care and coordination and bruising. The facility census was 88. Findings include: 1. Review of the medical record for Resident #252 revealed an admission date of 05/15/25. Diagnoses included surgical after following surgery on the digestive system. Review of the discharge hospital records revealed on 04/29/25, Resident #252 underwent a exploratory laparotomy with midline abdominal incision, including staples and island dressing. The after visit summary revealed there was guidance to schedule an appointment with primary care provider as soon as possible and establish patient visit with nephrology on 06/23/25. Review of the nursing comprehensive evaluation dated 05/15/25 revealed Resident #252 had current skin condition, with 18 staples located on the abdomen and gastrostomy tube. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #252 had intact cognition. Skin conditions were present upon admission which included a surgical wound. Review of the skin assessment dated [DATE] revealed surgical wound present with 18 staples, incision approximated, present on admission measuring 7.1 centimeters (cm) in length by 11.9 cm wide by 0.9 cm depth. The wound was described as no drainage or odor with attached edges. Interview on 06/02/25 at 10:47 A.M. with Resident #252 stated they had concerns for staples located in his abdomen. The resident stated licensed nursing staff were aware of staples which have been present for over four weeks, however they have not heard when the staples will be removed. The skin assessment dated [DATE] revealed the surgical wound was present with 18 staples, incision approximated as 6.7 cm in length by 11.2 cm wide by 1.0 cm in depth. The wound was described as no drainage or odor with attached edges. Interview on 06/04/25 at 1:09 P.M. with the Director of Nursing (DON) confirmed Resident #252 has had midline staples present since admission, which were initially placed on 04/29/25 during an 366481 Page 13 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0684 exploratory surgery. The DON confirmed the staples would be removed per physician order. Level of Harm - Minimal harm or potential for actual harm Interview on 06/04/25 at 1:17 P.M. with Nurse Practitioner (NP) #342 confirmed Resident #252 currently has staples in which were from a surgery completed on 04/29/25. NP #342 confirmed staples were to be removed seven to 10 days after surgery. NP #342 confirmed the staples were in place longer than intended and she thought the resident was following up with gastrointestinal (GI) for removal. NP #342 was unsure if he has any appointments with GI scheduled in the future. Residents Affected - Few There were no physician orders to remove Resident #252's staples until 06/04/25. The physician order dated 06/04/25 revealed the abdominal staples were to be removed. 366481 Page 14 of 34 366481 06/09/2025 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 record review, observation, staff interviews, and facility policy review, the facility failed ensure fall interventions were in place for Resident #28 who had a history of falls and failed to document, communicate and follow up on Resident #252's fall. This affected two (Residents #28 and #252) of three residents reviewed for falls. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21 with diagnoses including cerebral palsy and epilepsy. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition. Review of the plan of care dated 06/09/21 revealed Resident #28 was at risk for fall related injury and falls related to cerebral palsy, decreased mobility, opioid pain medication use, and psychotropic medication use. Interventions included perimeter mattress to bed, encourage resident to ask for assistance with transfers, visual cue to ask for help with transfers in bathroom and positioning when going to sleep. Review of Resident #28's physician order dated 09/07/23 revealed an order for bilateral enabler bars, placement to be checked every shift. The physician order dated 01/07/25 revealed an order for a perimeter mattress to the bed, placement to be checked every shift. Review of Resident #28's fall investigation dated 05/18/25 revealed the resident had a fall self-transferring from the bed to the wheelchair. The intervention was to get a smaller mattress to enhance space so he could use his walker for support. Review of Resident #28's Treatment Administration Record (TAR) from 05/19/25 to 05/23/25 revealed enabler bars were marked as being in place. From 05/19/25 to 06/04/25, Resident #28's perimeter mattress was marked as being in place. Review of Resident #28 progress note dated 05/23/25 revealed the resident was observed sliding from the bed to the floor. The resident reported he had been sleeping and did not have a side rail on the bed to lean on as usual. Interview on 06/04/25 at 8:35 A.M. with the Director of Nursing (DON) verified his intervention of perimeter mattress and enabler bars were not in his fall care plan. The DON reported that on 05/18/25, Resident #28's bed was switched out. Observation on 06/04/25 at 8:40 A.M. with the DON revealed Resident #28 was in his bed, and no perimeter mattress was in place. The DON verified this and reported it had likely not been in place since his mattress was changed on 05/18/25. Interview on 06/04/25 at 10:45 A.M. with the Administrator and DON verified enabler bars were not in place when Resident #28 fell on [DATE] and stated the enabler bars should have been on Resident 366481 Page 15 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0689 Level of Harm - Minimal harm or potential for actual harm #28's bed. They initially verified the nurses had been marking enabler bars and perimeter mattress were in place in the TAR when it was not in place. 2. Review of the medical record for Resident #252 revealed an admission date of 05/15/25. Diagnoses included acute respiratory failure with hypoxia, seizure disorder, and chronic diastolic heart failure. Residents Affected - Few Review of the admission evaluation dated 05/15/25 revealed Resident #252 was identified as being at risk for falls. Review of the care plan dated 05/15/25 revealed Resident #252 was assessed as being at risk for falls related to the need for assistance with activities of daily living, a seizure disorder, and incontinence. Interventions included wearing appropriate footwear, keeping the environment clean, providing activities, and placing the call light within reach. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #252 had intact cognition. Resident #252 did not exhibit wandering behaviors, had an impairment of one upper extremity and both lower extremities, and was dependent on staff for all activities of daily living and ambulation. Review of the physician progress note dated 05/28/25 revealed an unwitnessed fall occurred earlier that morning. The family declared this fall directly to the physician who reported finding the resident on the floor on their left side. Post-fall assessment was documented as normal, with no injuries noted. A new plan of care included frequent rounding every two hours and as needed, along with continuation of all current fall interventions. Review of the fall assessment dated [DATE] revealed a fall event form had been completed six days after the event; however, no comprehensive evaluation of the fall was documented. Interview on 06/04/25 at 1:09 P.M. with the Director of Nursing (DON) stated she had no prior knowledge of the fall involving Resident #252. The DON confirmed the physician was informed directly by the family and nursing staff had not been notified. The intervention to monitor the resident every two hours was not implemented, as staff were unaware of the fall. The DON stated progress notes were not routinely reviewed by nursing and this concern was not discussed during daily morning rounds with nursing and the physician. The DON confirmed nursing staff have full access to physician progress notes within the electronic medical record system. Interview on 06/04/25 at 1:17 P.M. with Nurse Practitioner (NP) #342 confirmed learning of the fall from the resident's family, who reported it occurred around 6:30 A.M. on 05/28/25. NP #342 stated residents with unwitnessed falls should receive neurological checks and that rounding should have been increased to every two hours. NP #342 was unsure whether the event was communicated to nursing staff but indicated it should have been addressed during the care team's morning meeting. Subsequent interview on 06/05/25 at 1:49 P.M. with the DON confirmed licensed nursing staff and the NP failed to communicate effectively to ensure falls were identified, addressed, and followed up appropriately. Review of the facilities Incident and Accidents for Residents policy dated 05/01/22 revealed for resident-related incidents, pertinent clinical information and observations must be documented in the 366481 Page 16 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0689 medical record. All facts surrounding the event are to be collected, and incident reports must be submitted to the Director of Nursing and administration within 24 hours for review. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366481 Page 17 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interviews, and policy review, the facility failed to ensure weekly weights were obtained for new admissions and as ordered by the physician for residents identified as nutritionally at risk. This affected one (Resident #81) of three residents reviewed for nutrition. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #81 revealed an admission date of 04/25/25. Diagnoses included spinal fusion, malignant neoplasm of the cervix, lung, vertebrae, and bone, bacteremia, and acute kidney failure. Review of the initial nutritional evaluation dated 04/29/25 revealed a diet order for a regular diet with oral intake between 75-100%, and no reported chewing or swallowing concerns. No acute nutritional diagnoses were documented at that time. The evaluation recommended monitoring weights. Review of the care plan dated 04/29/25 revealed Resident #81 was at nutritional and/or dehydration risk due to cancer, corticosteriod use, and an obese body mass index. Interventions included encouraging choices within the ordered diet, offering substitutes, and referring to the dietitian as needed. Review of the weight summary revealed Resident #81 weighed the following: 186.9 pounds on 04/27/25 and 212 pounds on 05/26/25. This reflected a 25.1 pound weight gain and 13.4% severe weight gain in one month. There were no other weights record in the medical record. Interview on 06/05/25 at 1:34 P.M. with Registered Dietitian (RD) #341 stated Resident #81 should have received a minimum of four weeks of weekly weights upon admission per facility policy. RD #341 confirmed Resident #81 exhibited a significant weight gain on 05/26/25, after which the RD placed orders for weekly weights. Interview on 06/05/25 at 1:41 P.M. with the Director of Nursing (DON) confirmed Resident #81 was missing an order for weekly weights upon admission. The DON stated certified nursing assistants were responsible for obtaining weekly weights as ordered. Review of the facility's weight management policy dated 09/22/23 revealed residents will be weighed upon admission/readmission, weekly for four weeks, then monthly or as indicated by the physician. 366481 Page 18 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 record review, the facility failed to ensure the residents received the treatment in accordance with physician orders and professional standards for pain management. This affected three (Residents #23, #28, and #137) of five residents reviewed for unnecessary medications. The facility census was 88. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included cerebral palsy, chronic obstructive pulmonary disease, type two diabetes mellitus, and epilepsy. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition. Review of Resident #28's physician order dated 12/19/24 revealed an order for Acetaminophen 325 milligrams (mg) three tablets by mouth every six hours as needed for pain. Non-pharmacological interventions were listed. Review of the plan of care dated 04/03/25 revealed Resident #28 was at risk for pain and/or had acute/chronic pain related to chronic pain, decreased mobility, and depression. Interventions included anticipating residents need for pain relief as needed, notifying physician if interventions were unsuccessful, observing and reporting changes in resident, and observing for side effects of pain medication. The physician order dated 04/11/25 revealed Resident #28 had an order for Morphine Sulfate (opioid pain medication to treat moderate to severe pain) 15 mg one tablet by mouth every eight hours as needed for moderate to severe pain. Four non-pharmacological interventions were listed. Review of Resident #28's Medication Administration Record (MAR) for May 2025 and June 2025 revealed Acetaminophen was only given once on 05/04/25 for a pain of nine (pain scale ranging zero to no pain and 10 being the most severe pain). Morphine was given on 05/01/25 for a pain of five, on 05/03/25 for a pain of eight and one, on 05/05/25 for a pain of five, on 05/06/25 for a pain of one, on 05/09/25, for a pain of eight, on 05/11/25 for a pain of one and seven, on 05/12/25 for a pain of two and five, on 05/13/25 for a pain of five, on 05/14/25 for a pain of one, on 05/15/25 for a pain of five, on 05/16/25 for a pain of six and eight, on 05/17/25 for a pain of four and none, on 05/18/25 for a pain of eight, on 05/19/25 for a pain of eight and eight, on 05/20/25 for a pain of eight and one, on 05/21/25 for a pain of eight, on 05/22/25 for a pain of seven and two, on 05/23/25 for a pain of seven, on 05/24/25 for a pain of four and eight, on 05/25/25 for a pain of eight and one, on 05/26/25 for a pain of seven, on 05/27/25 for a pain of six, on 05/28/25 for a pain of eight, on 05/29/25 for a pain of seven and five, on 05/30/25 for a pain of six, on 05/31/25 for a pain of eight, and on 06/01/25 for a pain of three and eight. Review of Resident #28's progress note dated May 2025 and June 2025 revealed no description or location of pain was given for one morphine dose on 05/11/25, 05/16/25, 05/23/25, 05/30/25, and 06/01/25 and two morphine doses on 05/17/25 and 05/24/25. There was no description of pain or nonpharmacological interventions documented for one morphine dose on 05/11/25, 05/16/25, and 06/01/25 and two 366481 Page 19 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morphine doses on 05/01/25, 05/03/25, 05/05/25, 05/06/25, 05/12/25, 05/13/25, 05/14/25, 05/15/25, 05/18/25, 05/19/25, 05/20/25, 05/21/25, 05/22/25, 05/26/25, 05/27/25, 05/28/25 and 05/29/25. Interview on 06/04/25 at 3:20 P.M. with the Director of Nursing (DON) revealed moderate pain was five to eight, utilizing the pain scale of zero to 10. Staff should be documenting where the pain was at every time they were administering as needed medications. The DON verified Morphine was given for pain that was not considered moderate or severe. She additionally verified nursing had not documented sufficiently with Resident #28's pain medication administration. 2. Review of the medical record for Resident #82 revealed an admission date of 04/26/25. Diagnoses included pneumonia and generalized weakness. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 had intact cognition. Review of the care plan dated 04/26/25 revealed Resident #82 was identified as being at risk for pain related to cancer. Interventions included anticipating the resident's need for pain relief, responding immediately, and notifying the physician if interventions were ineffective or if the pain level significantly differed from the resident's usual pain experience. Review of Resident #82's physician orders revealed on 04/26/25, an order for Tylenol 325 milligrams (mg) orally every eight hours as needed for mild pain. On 04/28/25, an order for Oxycodone HCL (opioid pain medication to treat moderate to severe pain) five mg orally every four hours as needed for moderate to severe pain. Review of Resident #82's medication administration record (MAR) from 05/01/25 through 05/31/25 revealed Oxycodone was administered for pain scores of three (a pain range of zero to ten, zero was no pain and 10 was the most severe pain) on 05/20/25 and two on 05/28/25 and Tylenol was administered on 05/08/25 for pain score of six and on 05/25/25 for pain score of seven. The MAR from 06/01/25 through 06/05/25 revealed Oxycodone was administered for reported pain scores of zero on 06/01/25 and 06/04/25. Tylenol 325 mg was not administered during this period. Interview on 06/05/25 at 1:43 P.M. with the Director of Nursing (DON) confirmed nursing staff were expected to follow physician orders as written. The DON acknowledged Oxycodone was administered outside the physician ordered pain parameters on multiple occasions, including for scores of zero, two, and three. The DON stated Oxycodone administered outside the prescribed pain scale range of four to 10 was considered inappropriate. 3. Review of Resident #23's medical record revealed an admission to the facility on [DATE]. Diagnoses included multiple sclerosis, contractures of the left upper extremity, and chronic pain syndrome. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of the physician orders for Resident #23 revealed on 06/04/24, an order for Oxycodone HCL (opioid pain medication to treat moderate to severe pain) five milligrams (mg) two tablets by mouth every six hours as needed for pain. There were no parameters ordered for administration of Oxycodone HCL. On 10/06/23, an order for Acetaminophen tablet 500 mg every six hours as needed (PRN) for mild pain. Review of the Medication Administration Record (MAR) from 01/01/25 to 05/31/25 revealed Resident 366481 Page 20 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0697 Level of Harm - Minimal harm or potential for actual harm #23 received Oxycodone on 01/02/25 for a pain level of four (a pain range of zero to ten, zero was no pain and 10 was the most severe pain), on 01/05/25 for a pain level of two, on 01/06/25 and 01/09/25 for a level of four, on 01/12/25 for a pain level of two, on 01/18/25 for a pain level of zero, on 02/02/25 for a pain level of one, on 02/03/25, 02/04/25, 02/06/25, 02/12/25, 02/13/25, and 02/18/25 for pain levels of four, and on 02/21/25 for a level of one. Acetaminophen PRN was not administered in January and February 2025. Residents Affected - Few An interview on 06/05/25 at 8:17 A.M. with the Director of Nursing (DON) confirmed Resident #23 received Oxycodone for lower levels of pain despite Acetaminophen being prescribed for mild pain levels. The DON confirmed there were no established parameters in place to guide pain levels for the administration of Resident #23's Oxycodone. This deficiency represents non-compliance investigated under Complaint Number OH00166265. 366481 Page 21 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to timely respond to pharmacy recommendations, failed to provide rationale for declining pharmacy recommendations, and failed to follow through with the pharmacy recommendations and the physician accepting the pharmacy recommendation. This affected three (Residents #14, #23, and #28) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21 with diagnoses including cerebral palsy, type two diabetes mellitus, epilepsy, depression, and anxiety disorder. Review of Resident #28's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #28's pharmacy recommendation dated 06/25/24 revealed the resident received two or more antipsychotics and the pharmacist recommended considering a gradual dose reduction (GDR). There was no evidence the physician addressed the pharmacy recommendation. Review of Resident #28's physician order dated 06/28/24 revealed an order for Metocloprimide five milligrams (mg) three times a day for gastrointestinal upset. Resident #28's pharmacy recommendation dated 07/30/24 revealed a recommendation to taper Metocloprimide to five mg twice daily with an end goal of discontinuation. The physician accepted the recommendation. However, there was no physician order to to taper Metocloprimide to five mg. Resident #28's pharmacy recommendation dated 09/27/24 revealed the pharmacist recommended discontinuing sliding scale Insulin and increasing his Lantus. The physician declined the recommendation but did not give a rationale in the medical record or on the pharmacy recommendation form. Resident #28's pharmacy recommendation dated 12/30/24 revealed the resident was receiving potentially duplicate therapy with Triamcinolone 0.1% cream and Desonide 0.05% cream. The pharmacist wanted these reevaluated. The physician declined the recommendation but did not give a rationale in the medical record or on the pharmacy recommendation form. Review of the pharmacy recommendation dated 01/30/25 revealed it was recommended to decrease Pantoprazole from 40 mg twice a day to once a day. The physician accepted the recommendation. However, there was no physician order to decrease Pantoprazole to 40 mg daily. From 01/30/25 to 06/03/25, Resident #28 remained on Pantoprazole 40 mg twice a day. Interview on 06/04/25 at 10:45 A.M. and 2:00 P.M. with the Director of Nursing (DON) verified the physician did not respond to the pharmacist recommendation dated 06/25/24 to considering a GDR, there was no taper of Metocloprimide after the physician accepted the the pharmacy recommendation dated 07/30/24. The DON verified the physician did not provide a rationale when he declined to the pharmacy recommendation dated 09/27/24 to discontinue sliding scale Insulin and increasing his Lantus and did not provide a rationale to the pharmacy recommendation dated 12/30/24 to reevaluate the use of duplicate treatments. The DON also verified the Pantoprazole was never decreased to 40 mg daily after 366481 Page 22 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0756 the physician accepted the pharmacy recommendation dated 01/30/25. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #14's medical record revealed an admission date of 11/04/21 with diagnoses including dementia and depression. Review of Resident #14's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Residents Affected - Few Review of Resident #14's physician recommendation dated 07/31/24 revealed a gradual dose reduction (GDR) of Abilify was recommended. The physician declined the recommendation but did not give a rationale in the medical record or on the pharmacy recommendation form. Review of Resident #14's physician recommendation dated 10/31/24 revealed a GDR of Bupropion was recommended. There was no evidence the physician addressed this. Interview on 06/04/25 at 10:45 A.M. and 2:00 P.M. with the Director of Nursing (DON) verified the physician did not provide a rationale when he declined to Resident #14's pharmacy recommendation dated 07/31/24 to complete a GDR of Abilify. The DON verified there was no evidence the physician responded to the pharmacy recommendation dated 10/31/24 for a GDR of Buproprion. 3. Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, bipolar disorder, and chronic constipation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Review of the monthly pharmacy recommendations for Resident #23 revealed in August 2024, the pharmacist recommended a gradual dose reduction (GDR) for Aripiprazole (antipsychotic) to five milligrams, but the physician declined due to a prior GDR attempt. In March 2025, the pharmacist recommended discontinuing famotidine, but the physician declined the recommendation due to a previously failed gradual dose reduction (GDR). Resident #23's record did not have any documented evidence that the GDRs for Aripiprazole and famotidine had been previously attempted. An interview on 06/05/25 at 8:17 A.M. with the Director of Nursing (DON) revealed there was no evidence a GDR was attempted for Aripiprazole and famotidine. 366481 Page 23 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, facility policy review, Medscape guidance, and review of manufacturer guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had two medication errors out of 36 opportunities for an error rate of 5.56%. This affected one (Resident #28) of four residents reviewed for medication administration. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included type two diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition and received insulin medication. Review of the physician orders for Resident #28 revealed an order dated 12/29/24 for Insulin Lispro inject 30 units subcutaneously before meals and an order dated 12/17/24 for Admelog injection (Insulin Lispro) sliding scale coverage. Resident #28 had an additional order dated 02/07/25 for Basaglar Kwikpen to inject 35 units subcutaneously two times a day. Observation of medication administration on 06/04/25 at 6:28 A.M. revealed Licensed Practical Nurse (LPN) #155 prepared and administered Basaglar Kwikpen insulin 35 units subcutaneously and Admelog (Lispro) insulin 30 units plus 24 units for sliding scale coverage for a total of 54 units. LPN #155 did not the prime the insulin pens of Basaglar Kwikpen and Admelog prior to administering them to Resident #28. Interview on 06/04/25 at 6:30 A.M. with LPN #155 confirmed they did not prime the insulin pens Basaglar Kwikpen and Admelog prior to administering the insulin to Resident #28. LPN #155 confirmed she dialed the physician ordered doses of 35 units of Basaglar KwikPen and 30 units plus 24 units for sliding scale coverage for a total of 54 units and did not prime the pens prior to it. LPN #155 stated she did not prime them because none of the insulin pens need the needles to be primed. Interview on 06/04/25 at 10:00 A.M. with the Director of Nursing confirmed the expectation for nurses were to prime Insulin pens prior to administering the insulin dose. Review of the policy Medication Administration dated 10/17/23 revealed no specific instructions for priming the needle on insulin pens but did reference following manufacturers guidelines for medications in general. Review of the [NAME] Lilly and Company instructions for use of the Basaglar Kwikpen lists instructions to prime the pen before each injection. Instruction steps six, seven, and eight are the steps to prime the needle with two units of insulin. Sanofi-Aventis LLC instructions for the use of the Admelog SoloStar insulin pen lists instructions to prime the needle with two units of insulin and assure the needle in functioning properly in steps three A and three B. Review of Medscape guidance titled Intermittent Insulin Injections Insulin Overview dated 11/05/20 and located at https://emedicine.medscape.com/article/2049311-overview#a1 revealed to avoid air and 366481 Page 24 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0759 Level of Harm - Minimal harm or potential for actual harm to ensure proper dose, you will need to prime the syringe each time; to do this, dial two units; hold the pen with the needle pointing up and tap the cartridge gently a few times to get rid of any air bubble; press the push button all the way in until the dose selector returns to zero; a drop of insulin must appear at the needle tip; if not, change the needle and repeat the procedure. Residents Affected - Few 366481 Page 25 of 34 366481 06/09/2025 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** 1b. Review of Resident #28's physician reorder dated 03/27/25 revealed an order for Glipizide extended release 20 milligrams (mg) one time a day for diabetes mellitus. This was to be taken 30 minutes before meals. The physician order dated 05/13/25 revealed an order for Ziprasidone 80 mg one capsule by mouth twice a day for bipolar disorder. This was to be taken with meals. Residents Affected - Few Review of Resident #28's Medication Administration Record (MAR) for May and June 2025 revealed the resident's Ziprasidone was scheduled for 6:00 A.M. and 8:00 P.M. and Glipizide was scheduled for 9:00 A.M. Additionally, Resident #28 was not given Ziprasidone on multiple occasions including the evening dose on 05/02/25, 05/13/25, and 05/27/25. He missed the morning dose of 05/03/25 and 05/14/25. Interview on 06/04/25 at 8:25 A.M. and 06/04/25 at 2:54 P.M. with the Director of Nursing (DON) verified Resident #28's Glipizide and Ziprasidone were not scheduled at appropriate times. She reported Ziprasidone was in the facility and she was unsure why it was not administered. Interview on 06/04/25 at 3:40 P.M. with Consultant Pharmacist #316 revealed Glipizide was to be taken prior to meals to ensure maximum reduction in blood glucose with meals. If it were taken after meals, the resident would not be experiencing the maximum reduction. Ziprasidone was taken with meals to ensure adequate absorption. Missing doses of Ziprasidone would mean it would not be working as well. Review of the facilities meal times revealed on Resident #28's unit he resided on, breakfast was served at 7:30 A.M. and dinner was served at 4:45 P.M. Based on staff and pharmacist interview, review of Medscape guidance, review of manufacturer instructions, policy review, and record review, the facility failed to ensure Resident #28 was free from significant medication errors. This affected one (Resident #28) of eight residents reviewed for unnecessary medications and medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included type two diabetes mellitus, bipolar disorder and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition and received insulin medication. 1. Review of the physician orders for Resident #28 revealed an order dated 12/29/24 for Insulin Lispro inject 30 units subcutaneously before meals and an order dated 12/17/24 for Admelog injection (Insulin Lispro) sliding scale coverage. Resident #28 had an additional order dated 02/07/25 for Basaglar Kwikpen to inject 35 units subcutaneously two times a day. Observation of medication administration on 06/04/25 at 6:28 A.M. revealed Licensed Practical Nurse (LPN) #155 prepared and administered Basaglar Kwikpen insulin 35 units subcutaneously and Admelog (Lispro) insulin 30 units plus 24 units for sliding scale coverage for a total of 54 units. LPN #155 did not the prime the insulin pens of Basaglar Kwikpen and Admelog prior to administering them to Resident #28. 366481 Page 26 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0760 Level of Harm - Minimal harm or potential for actual harm Interview on 06/04/25 at 6:30 A.M. with LPN #155 confirmed they did not prime the insulin pens Basaglar Kwikpen and Admelog prior to administering the insulin to Resident #28. LPN #155 confirmed she dialed the physician ordered doses of 35 units of Basaglar KwikPen and 30 units plus 24 units for sliding scale coverage for a total of 54 units and did not prime the pens prior to it. LPN #155 stated she did not prime them because none of the insulin pens need the needles to be primed. Residents Affected - Few Interview on 06/04/25 at 10:00 A.M. with the Director of Nursing confirmed the expectation for nurses were to prime Insulin pens prior to administering the insulin dose. Review of the policy Medication Administration dated 10/17/23 revealed no specific instructions for priming the needle on insulin pens but did reference following manufacturers guidelines for medications in general. Review of the [NAME] Lilly and Company instructions for use of the Basaglar Kwikpen lists instructions to prime the pen before each injection. Instruction steps six, seven, and eight are the steps to prime the needle with two units of insulin. Sanofi-Aventis LLC instructions for the use of the Admelog SoloStar insulin pen lists instructions to prime the needle with two units of insulin and assure the needle in functioning properly in steps three A and three B. Review of Medscape guidance titled Intermittent Insulin Injections Insulin Overview dated 11/05/20 and located at https://emedicine.medscape.com/article/2049311-overview#a1 revealed to avoid air and to ensure proper dose, you will need to prime the syringe each time; to do this, dial two units; hold the pen with the needle pointing up and tap the cartridge gently a few times to get rid of any air bubble; press the push button all the way in until the dose selector returns to zero; a drop of insulin must appear at the needle tip; if not, change the needle and repeat the procedure. 366481 Page 27 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 record review, the facility failed to ensure physician orders for laboratory work were completed in a timely manner. This affected one (Resident #252) of two residents reviewed for laboratory work. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #252 revealed an admission date of 05/15/25. Diagnoses included cerebral infarction, moderate protein-calorie malnutrition, and encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #252 had intact cognition. Review of the physician progress note dated 05/30/25 revealed the physician was notified that Resident #252 made an attempt to bite nursing. The physician planned to obtain a complete blood count (CBC), comprehensive metabolic panel (CMP), Vitamin D level, Vitamin B12, and B-type natriuretic peptide (BNP). Review of the physician orders dated 05/30/25 revealed orders for CBC, CMP, Vitamin D level, Vitamin B12, BNP, and urinalysis with culture and sensitivity. Interview on 06/04/25 at 1:09 P.M. with the Director of Nursing (DON) verified Resident #252 received physician orders on 05/30/25 for several laboratory tests and a urinalysis after staff reported an attempt to bite staff. The DON confirmed the laboratory tests and urinalysis remain uncollected after four days, and the medical record does not contain evidence nursing staff attempted to obtain them and/or Resident #252 refused for the tests to be completed. The DON stated the physician orders remain active and unfulfilled from 05/30/25 through 06/03/25. The DON stated the expectations pertaining to laboratory work was that nursing staff should attempt collection the day the order was received and notify the physician of any refusals. Interview on 06/04/25 at 1:17 P.M. with Nurse Practitioner (NP) #342 verified she ordered a CBC, CMP, Vitamin D level, Vitamin B12, BNP, and urinalysis with culture and sensitivity due to Resident #252's attempt to bite staff. NP #342 expects labs to be completed promptly. She has not received updates or reports of Resident #252's refusal of the laboratory work and urinalysis. NP #342 expects nursing staff to notify her of any refusals and would consider discontinuing laboratory work after repeated unsuccessful attempts. 366481 Page 28 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure the residents received timely follow-up for missing dentures. This affected two (Residents #30 and #51) of three residents reviewed for dental concerns. The facility census was 88. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 05/02/22. Diagnoses included stroke, non-Alzheimer's dementia, malnutrition, anxiety, and depression. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was cognitively intact and did not exhibit behaviors during the review period. Resident #30 was able to feed self independently, required staff maximal assistance with oral hygiene. Resident #30 was on a mechanical soft diet and had no natural teeth or fragments. Review of Resident #30's plan of care revealed an intervention initiated on 08/16/24 to provide dental consults as needed and to provide diet as ordered. Review of the physician orders dated 08/14/24 revealed a mechanical soft diet with thin consistency and fortified foods at every meal. Review of a nursing progress note dated 10/01/24 revealed Resident #30's daughter requested the resident be seen by her own dentist. An appointment was scheduled for 10/09/24 at 11:00 A.M. regarding denture concerns. A social services note dated 11/26/24 documented Resident #30 was offered dental services that day, and follow-up would occur based on the dental report. A social services note dated 12/04/24 documented the dental office had been contacted, and a response was pending regarding the next steps to obtain dentures. A social services note dated 01/27/25 documented a dental appointment was made for 01/31/25 at 12:20 P.M. A nursing note dated 01/30/25 revealed a dental appointment was canceled due to uncertainty about payment. Transportation was also canceled. A social services note dated 02/19/25 revealed the dental provider had a cancellation and could see Resident #30 earlier. The Administrator signed authorization for private pay dentures for the bottom set only. A social services note dated 04/17/25 documented the bottom denture was completed and being mailed to the facility. A nursing note dated 05/02/25 (late entry) documented the dentures arrived on 04/24/25. The facility attempted to schedule an appointment but was unable to leave a message. 366481 Page 29 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A social services note dated 05/23/25 (late entry) stated Resident #30 was expected to receive the dentures at the 05/22/25 dental visit; however, no dentures were delivered. The Director of Nursing (DON) spoke with the dentist, who agreed to hand-deliver them. A nursing note dated 05/30/25 (late entry) confirmed the dentures arrived on 05/27/25. The facility again attempted to schedule an appointment, but no message could be left. Interview on 06/02/25 at 10:32 A.M. with Resident #30 stated she previously had bottom dentures that went missing but could not recall when. She stated the facility sent their contracted dentist after she requested her own. She confirmed she was currently on a mechanical soft diet due to her missing teeth, which she disliked. Interview on 06/04/25 at 11:25 A.M. with the Clinical Coordinator #305, DON, and Administrator revealed the facility was aware of Resident #30's missing dentures in August 2024, but the first outreach to the dental office did not occur until October 2024. The Administrator could not provide a reason for the delay. Interview on 06/04/25 at 1:45 P.M. with Unit Manager #206 confirmed Resident #30 was placed on a mechanical soft diet in August 2024 due to the loss of her bottom dentures. 2. Review of the medical record for Resident #51 revealed an admission date of 03/11/22. Diagnoses included hemiplegia following cerebral infarction, type II diabetes mellitus with diabetic chronic kidney disease, and vascular dementia. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was cognitively intact. The quarterly MDS assessment dated [DATE] revealed Resident #51 had no natural teeth or fragments and received a pureed diet. Resident #51's records showed prior authorization for denture adjustments was submitted on 12/02/24. A social services note dated 12/03/24 documented prior authorization for dental services was received and a signature would be obtained for submission. Resident #51's medical record did not have any follow up regarding Resident #51's dentures and did not indicate if/when Resident #51 received any denture adjustments from 12/03/24 to 06/01/25. Review of the physician orders revealed a new order on 12/31/24 for a pureed texture with thin consistency. Interview on 06/02/25 at 12:34 P.M. with Resident #51 stated he did not have his dentures, was eating mechanical soft food, and disliked the diet. He reported the dentures were stolen and stated he told administration, but he could not recall when. Observation and interview on 06/05/25 at 8:46 A.M. with Resident #51 stated the dentures went missing in January or February 2025. Interview at that time with the Administrator revealed she was not aware of the missing dentures. Interview on 06/05/25 at 8:56 A.M. with Licensed Practical Nurse #143 stated the resident had been without dentures for about a month. She had not reported the missing dentures and was unaware if they had been previously reported. 366481 Page 30 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0791 Level of Harm - Minimal harm or potential for actual harm Interview on 06/05/25 at 9:01 A.M. with Certified Nursing Assistant (CNA) #126 revealed she believed Resident #51 had dentures on the previous Sunday, but they were not located during a room search. Interview on 06/05/25 at 9:08 A.M. with Clinical Coordinator #215 revealed she was not aware of Resident #51's missing dentures and confirmed they could not be found in the room. Residents Affected - Few Interview on 06/05/25 at 9:24 A.M. with Clinical Coordinator #305 revealed she presented a set of dentures found in the laundry. Staff attempted to verify ownership with the resident. Clinical Coordinator #215 confirmed the resident's dentures had previously been labeled with his name on the top plate. The found set lacked identification. Clinical Coordinator #305 stated she would contact the dental provider for assistance. Interview on 06/05/25 at 10:33 A.M. with Dental Health Services Employee (DHSE) #400 revealed the last dental note was dated 11/26/24. Resident #51 had stated his dentures were thrown out and that he wanted replacements. The last documented use of dentures was on 11/01/22. DHSE #400 reported the dentures were noted as missing on 06/06/23, and Medicaid would not cover replacements within eight years. The office required the facility to initiate requests for prior authorizations. The employee stated the facility would be responsible for the cost of new dentures in this case. Review of the facility policy titled Dental Services dated 11/04/24 revealed the facility was responsible for the provision of routine and emergency dental services, including securing prior authorizations, tracking denture loss, initiating investigations, and ensuring follow-up within three days when dentures are lost or damaged. The facility was responsible for loss or damage caused by staff or improper care and required timely documentation and referral. This deficiency represents non-compliance investigated under Complaint Number OH00165729. 366481 Page 31 of 34 366481 06/09/2025 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 and resident and staff interview, the facility failed to ensure medications were documented in the medical record as administered to the resident and failed to ensure dressing changes and pressure-reducing interventions were documented in the medical record. This affected two (Residents #51 and #137) of 21 residents reviewed for medical record accuracy. The facility census was 88. Findings include: 1. Review of the medical record for Resident #137 revealed an admission date of 05/30/25. On 05/31/25, Resident #137 left the facility the against medical advice. Diagnoses including fifth metacarpal bone displaced fracture, chronic obstructive pulmonary disease, and acute respiratory failure. Review of the admission assessment dated [DATE] revealed Resident #137 had recently been admitted after an open heart surgery with a surgical incision to her sternum. Review of the physician orders dated 05/30/25 revealed an order for Acetaminophen extra strength oral tablet 500 milligrams (mg) every six hours as needed for pain. Review of the Medication Administration Record (MAR) revealed Acetaminophen was not administered to Resident #137 at the time she was at the facility on 05/30/25 and 05/31/25. Interview with Licensed Practical Nurse (LPN) #206 on 06/05/25 at 10:08 A.M. revealed she received a concern from Resident #137's daughter on the morning of 05/31/25 asking for Acetaminophen per physician orders. LPN #205 went to the medication cart and pulled the Acetaminophen and gave it to the nurse on the hall for administration. She verified she did not administer this medication to Resident #137 after she had obtained it from the medication cart. Subsequent interviews with LPN #206 on 06/05/25 at 11:04 A.M. verified Acetaminophen had not been signed off as administered to Resident #137 and no pain assessment was completed after it had been requested by the resident's daughter. On 06/05/25 at 11:25 A.M., LPN #205 verified she just spoke with the nurse that was working the floor and verified she did not document this administration on that day even though she remembered she had done so. LPN #205 stated the nurse will now document the administration as a late entry. 2. Review of the medical record for Resident #51 revealed an admission date of 03/11/22. Diagnoses included stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some of some parts of the wound bed) of the left heel, and vascular dementia without behavioral disturbance. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was cognitively intact had no behaviors and a stage IV pressure ulcer. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #51 revealed there were multiple missed treatments and a lack of documentation explaining the omissions. Off-loading boots were not applied as ordered on 02/28/25, 03/26/25, 03/27/25, 04/07/25, and 04/08/25. Wound care orders for the left heel were also missed on several dates, including: 366481 Page 32 of 34 366481 06/09/2025 Laurels of West Columbus, The 441 Norton Road Columbus, OH 43228

F 0842 Level of Harm - Minimal harm or potential for actual harm 02/28/25 for calcium alginate treatment (ordered from 01/08/25 through 03/06/25); 03/14/25, 03/26/25, and 03/27/25 for calcium alginate treatment (ordered from 03/10/25 through 04/02/25); and 04/07/25, 04/08/25, and 04/11/25 for silver alginate treatment (ordered from 04/02/25 through 04/23/25). There were no corresponding progress notes were found in the record to explain the missed treatments in February, March, or April 2025. Residents Affected - Few Interview on 06/02/25 at 12:36 P.M. with Resident #51 revealed he had concerns with facility staff not repositioning him every two hours while in bed. Resident #51 did not express any concerns related to treatments and/or off-loading boots. Interview on 06/04/25 at 10:00 A.M. with the Director of Nursing (DON) confirmed the off loading boots were not applied on 02/28/25, 03/26/25, 03/27/25, 04/07/25, and 04/08/25 and had missed treatment orders on 02/28/25 03/14/25, 03/26/25, 03/27/25, 04/07/25, 04/08/25, and 04/11/25. The DON stated she was looking into the progress notes to determine if any documentation existed explaining why the treatments were missed but did not provide any evidence as to why they were missed. 366481 Page 33 of 34 366481 06/09/2025 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 interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to appropriately clean and disinfect a glucometer between resident use. The affected one (Resident #28) of four residents observed for medication administration. The facility identified seven residents who received blood glucose monitoring utilizing the shared glucometer on A Hall. The facility census was 88. Residents Affected - Some Findings include: Observation on 06/04/25 at 6:28 A.M. revealed Licensed Practical Nurse (LPN) #155 checked a blood sugar for Resident #33 and proceeded to prepare medications for Resident #28. Resident #28 also needed a blood sugar test prior to administering insulin. There was no observation of cleaning the glucometer and the same glucometer was used for both residents. Interview on 06/04/25 at 6:34 A.M. with LPN #155 confirmed the glucometer was not cleaned between Residents #33 and #29. LPN #155 stated the standard practice was to clean the medication cart, glucometer, and blood pressure cuff when done with the medication round. LPN #155 also confirmed there were usually Sani wipes on the cart to clean equipment but not that day (06/04/25). Interview on 06/04/25 at 10:00 A.M. with the Director of Nursing (DON) confirmed the expectation was to clean and disinfect multiple patients use items, including glucometers, between each use. Review of the facility policy titled Cleaning and Disinfecting Multi-Use Resident Equipment dated 02/28/25 confirmed reusable resident care items should undergo cleaning and disinfection when they are visibly soiled and on a regular schedule that includes after each use, daily, or weekly as needed. Review of the CDC's guidance titled Considerations for Blood Glucose Monitoring and Insulin Administration dated 08/07/24 and found at https://www.cdc.gov/injection-safety/hcp/infection-control/index.html revealed one of the key points was to assign blood glucose meters to a person unless the device is assigned for use in professional settings and is cleaned and disinfected after every use. The summary of recommendations included to clean and disinfect blood glucose meters after every use, per the manufacturer's instructions. 366481 Page 34 of 34