Laurels of West Columbus, the

Inspectors wroteBased on staff interviews, policy review, and record review, the facility failed to ensure a resident who was dependent on staff assistance with showers received routine showers. This affected one (#64) of three residents reviewed for activities of daily living (ADL). The facility census was 88.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure bags of enteral nutrition product and water for tube feeding were labeled and dated appropriately for Residents #56 and #79. This affected two (#56 and #79) of two residents in the facility with active orders for tube feeding. The facility census was 79.

Inspectors wroteBased on observation, staff interviews, and review of facility policy regarding enhanced barrier precautions, the facility failed to ensure infection control protocols were followed during the use of a tube feeding device for Resident #56. This affected one (#56) of two residents reviewed for tube feeding infection control. The facility census was 79. Review of the medical record for Resident #56 revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, adult failure to thrive, mild protein-calorie malnutrition, and gastrostomy status (a gastrostomy is a surgical opening in the abdominal wall, often for the use of a feeding tube). Further review of the medical record for Resident #56 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. [...]

Inspectors wroteBased on medical record review, staff interview, resident family interview, and review of self-reported incidents, the facility failed to conduct an investigation and report an allegation of potential neglect related to a resident elopement to the State Survey Agency. This affected one (#94) of three residents reviewed for elopements. The census was 89.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide residents and representatives with discharge summaries to ensure a safe and orderly discharge from the facility. This affected one (#92) of three residents reviewed for discharge. The census was 89. Findings Include:Review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of Resident #92's progress notes dated 09/27/25 revealed her son came to the facility and stated he wanted to take his mother home. The note revealed the nurse told her son he would need to sign against medical advice (AMA) documents prior to taking Resident #92 home. Further review revealed there was nothing else listed in the progress note about Resident #92 leaving the facility to go home. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure treatments for care of spine incisions were completed as ordered. This affected one (#91) of three residents reviewed for treatments. The census was 89. Findings Include:Review of the medical record revealed Resident #91 was admitted to the facility on [DATE]. Diagnoses included infection and inflammatory reaction, fusion of the spine, chronic obstructive pulmonary disease, alcohol dependence, atherosclerotic heart disease, congestive heart failure, hypertensive heart disease, presence of coronary angioplasty implant and graft, hyperlipidemia, anemia, hypo-osmolality and hyponatremia, depression, cardiomyopathy, and other seizures. Review of Resident #91's Minimum Data Set (MDS) assessment, dated 09/19/25, revealed the resident was cognitively intact. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This effected one (#93) of three residents reviewed for medication administration. The facility census was 89.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff interview, Power of Attorney (POA) interview, closed medical record review, review of a facility submitted Self-Reported Incident (SRI), review of hospital records and review of the facility policy, the facility failed to ensure Resident #83, who had a diagnosis of dementia, had a previous elopement attempt from the facility, and had a Wanderguard (wearable bracelet that triggers alarms at the doors to alert when a resident attempts to exit) applied to his left ankle, did not elope from the facility without staff knowledge. [...]

Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to ensure residents received necessary care and services so they could attend outside medical appointments. This affected two (#14, #81) of three residents reviewed for appointments. The census was 79.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure tube feeding was provided as physician ordered. This affected one (#14) of two residents reviewed for tube feeding. The census was 79.

Inspectors wroteBased on medical record review, observations and staff and resident interviews, the facility failed to ensure medications were available from the pharmacy for administration. This affected one (#81) out of three residents reviewed for medication administration. The facility census was 79.

Inspectors wroteBased on medical record review and staff and resident interviews, the facility failed to ensure laboratory testing was completed as physician ordered. This affected one (#14) of three residents reviewed for laboratory testing. This census was 79.

Inspectors wroteBased 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.

Inspectors wrote2. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote2. 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. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote1b. 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. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, facility investigation review, staff interview, and facility policy review, the facility failed to complete a thorough investigation in regard to a resident's injury of unknown origin. This affected one (Resident #44) of three residents investigations reviewed. The census was 88. Findings Include: Resident #44 was admitted to the facility on [DATE]. Her diagnoses were displaced bicondylar fracture of left tibia, muscle weakness, need for assistance with personal care, Type II Diabetes, atrial fibrillation, ischemic cardiomyopathy, congestive heart failure, hypertensive heart disease, pulmonary hypertension, obstructive sleep apnea, anemia, insomnia, hypothyroidism, atherosclerotic heart disease, chronic kidney disease, and personal history of trans ischemic attack (TIA). [...]

Inspectors wroteBased on observations, staff and resident interviews, policy review, and record review, the facility failed to ensure medications were administered to the residents without significant medication errors. This affected one (Resident #15) of three residents reviewed for medication administration. The facility census was 89.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to properly evaluate and monitor a pressure ulcer. This resulted in actual harm when Resident #3's pressure ulcer to her coccyx, which was not open, was not monitored and/or assessed, was not assessed by the wound physician, and was found to have opened on 11/26/22. Additionally, the facility failed to properly monitor and evaluate a pressure ulcer and ensure pressure reducing interventions were implemented timely for Resident #84. This resulted in actual harm when Resident #84 was found to have coccyx redness on 12/10/22 which was not monitored or assessed until 01/04/23 when the coccyx wound was determined to be a stage three pressure ulcer. Furthermore, Resident #84 was not provided timely pressure relieving interventions. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to medications were not left unattended and unsecured. This had the ability to affect all 21 residents (#2, #10, #12, #15, #16, #20, #22, #23, #24, #25, #36, #41, #42, #46, #49, #58, #62, #66, #70, #73, #192) who resided on the 200 to 212 hall. The facility census was 89.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure walls were in good repair in resident rooms. This had the potential to affect all eight (#7, #10, #22, #31, #41, #44, #45, and #50) residents who resided in rooms #201, #203, #211, #215, #216, #220, #222, and #224. The facility census was 89.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and facility policy review, the facility failed to ensure indwelling urinary catheter collection bags were contained in a privacy bag to maintain dignity. This affected two (#5 and #75) of two residents reviewed for catheters. Additionally, the facility failed to ensure residents were dressed in a dignified manner. This affected one (#21) resident out of one resident reviewed for appropriate clothing. The census was 89.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure a resident advanced directives form was signed by the physician. This affected one (#21) out of two residents reviewed for advance directives. The census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident indwelling urinary catheter was discontinued/removed as ordered by the physician. This affected one (#5) out of two residents reviewed for urinary catheters. The census was 89.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to monitor resident pain levels and document the effectiveness of non-pharmacological interventions for pain. This affected one resident (#84) out of three residents reviewed for pain management. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, and review of Medscape, the facility failed to ensure resident medications had appopriate indications for use and were monitored appropriately. This affected two residents (#40 and #84) out of five residents reviewed for unnecessary medications. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, and review of prescribing information from the Food and Drug Administration (FDA), the facility failed to ensure an there was an appropriate diagnosis for the use of antipsychotic medications. This affected one (#84) out of five residents reviewed for unnecessary medications. The census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Resident #84's tube feeding and water flushes were documented accurately. This affected one resident (#84) out of one resident reviewed for tube feeding. The facility census was 89.