The Laurels Of Walden Park

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Interview with Unit Manager #130 on [DATE REDACTED] at 8:12 A.M. confirmed there was a code status book located at each nurse's station. Unit Manager #130 confirmed there was not a copy of signed DNR paperwork in

the code status binder for Resident #129.

1. 4. Review of the medical record for Resident #198 revealed an admission date of [DATE REDACTED]. Diagnoses

included disorder of congestive heart failure and dementia. Review of the MDS 3.0 assessment dated [DATE REDACTED] revealed Resident #198 was cognitively intact.

Review of Resident #198’s physician orders revealed she had an advanced directive code status of DNRCC-A, which indicated Resident #198 did not wish for resuscitative measures to be initiated if they experienced cardiac or respiratory arrest; however, until such an arrest occurs, they would receive full medical treatment.

Observation of the code status book on Resident #198’s nursing unit revealed there was not a DNRCC-A signed form in the code status binder for Resident #198.

Interview with Registered Nurse (RN) #130 on [DATE REDACTED] at 9:01 A.M. confirmed there was no advanced directives sheet in the code status binder for Resident #198. RN #130 confirmed if a resident was to code,

they would need to be able to pull up the advanced directives in the binder to confirm the resident’s code status.

Review of the facility policy titled Ohio Advance Directive effective [DATE REDACTED] revealed the facility will determine whether the resident's physician issued a DNR Order in another setting and whether the resident would like

a DNR Order issued while in the facility. Copies of all advance directives will be obtained from the resident and/or family and placed in the medical record. If applicable, a DNR Order will be obtained from the residents physician and placed in the medical record.

This deficiency represents non-compliance investigated under Complaint Number OH00167220 (1260023).

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, observations, resident, guardian and staff interviews, and review of facility policy, the facility failed to maintain a safe, clean and homelike environment in resident rooms. This affected two (Resident #18 and #70) of seven residents reviewed for homelike environment. The facility census was 209 residents.Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE REDACTED].

Resident #18 had been appointed a guardian on 01/13/25. Interview with the guardian for Resident #18 on 08/04/25 at 1:54 P.M. stated the sink in Resident #18's room had been leaking and the faucet that been loose since March 2025. She stated she had notified the facility of this concern and it has never been fixed.

Observations on 08/04/25 at 2:48 P.M., 08/07/25 at 8:54 A.M. and 3:46 P.M., and on 08/11/25 at 8:26 A.M. revealed Resident #18's sink faucet was loose and dripping. The baseboard, approximately three feet in length, behind the toilet was separated from the wall, revealing a dark brown and black surface underneath.

An interview with the roommate of Resident #18, Resident #70, on 08/07/25 at 8:54 A.M. stated he used

the sink when he was up in his wheelchair. He stated the had told the facility about the loose, leaky sink faucet and it has never been fixed. An interview with Registered Nurse (RN) #330 on 08/11/25 at 8:23 A.M. stated he was aware of the loose leaking sink in Resident #18's room but not aware about the baseboard that was separated from the wall. An interview with Maintenance Workers #801 and #821on 08/11/25 at 8:26 A.M. confirmed Resident #18's sink faucet was loose, leaking and that the baseboard was separated from the wall revealing a dark surface area. They stated that they would fix the baseboard and sink. An

interview with Housekeeper #591 on 08/11/25 at 10:49 A.M. revealed she was aware of the separated baseboard and the loose and leaking sink faucet in Resident #18's room and she had reported it to her supervisor. Review of the undated facility policy titled Daily Cleaning of Guest Rooms revealed housekeeping is to report any items that need repaired to the maintenance department. Review of the facility policy titled Federal and State- Resident Rights and Facility Responsibilities dated 05/14/24 revealed

the resident has the right to a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will maintain a sanitary, orderly and comfortable interior.

Event ID:

Facility ID:

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Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

#72 calling her a 'fat expletive'. This nurse went to investigate the noise and Resident #183 called the nurse

an expletive as well. Resident #183 cursing kept going on even when this nurse intervened. Resident #183 made Resident #72 cry.

Review of the facility SRI control number 262200, dated 06/30/25, revealed Resident #183 was witnessed by staff screaming profanity words at Resident #72. This SRI was filed three days after the verbal abuse allegation occurred.

The nursing progress note dated 07/30/25 revealed Resident #183 was verbally abusive towards residents

in the dining area. Resident #183 used words like 'expletive you' and 'expletive' prompting immediate intervention from this nurse and the day shift nurse. Despite being asked to refrain from using such inappropriate language, Resident #183 got more angry and escalated his behavior using even more explicit language. Resident #183 eventually stopped and was escorted to his room to rest.

There was no SRI filed with the Stage Survey Agency (SA) by the facility for the allegation of verbal abuse by Resident #183 on 07/30/25.

Interview with the Administrator on 08/11/25 at 10:45 A.M. confirmed an SRI for the allegation of verbal abuse which occurred on 06/27/25 between Resident #183 and Resident #72 was not completed until 06/30/25, three days after the incident occurred. The Administrator additionally confirmed no SRI had been completed for the allegation of verbal abuse by Resident #183 on 07/30/25.

Review of the facility policy titled Abuse Prohibition, effective 10/14/22, revealed the Administrator or designee will notify any State or Federal agencies of allegations per state guidelines two hours if abuse allegation or serious injury; all other not later than 24 hours.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

The nursing progress notes dated 12/31/24 at 8:30 A.M. documented Resident #6 was found with bruising and skin tears to the face, blood on the face and bathroom floor, feces smeared on the body, and one gripper sock on foot with urine on the floor. The resident stated, I probably hit my head. Vital signs were stable.

The nursing notes dated 01/02/25 documented an IDT meeting was held to address the bruising and skin tears. The injury was consistent with contact with the bathroom door, and a night light was ordered for the resident’s room.

The facility was unable to provide any investigations into the physical aggression incident on 12/21/24 and any investigation into the injuries of unknown origin Resident #6 sustained.

An interview conducted on 08/07/25 at 11:15 A.M. with the Administrator confirmed although injuries and

an incident were documented, no formal investigation was initiated to determine the cause or to identify responsible parties. There was no evidence of staff interviews, injury assessments of other residents, or follow-up actions consistent with a proper abuse investigation. The Administrator acknowledged the facility failed to conduct a thorough investigation into the alleged abuse incidents involving Resident #6.

Review of the facility policy titled Abuse Prohibition effective 10/14/22 revealed allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must be immediately reported to his/her Administrator. A preliminary, on-site investigation will be initiated within twenty-four (24) hours of any report.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Review of the care plan, revised 04/16/25, revealed Resident #209 had a functional ability deficit and required assistance with self care/mobility. Interventions included keep fingernails clean and trimmed.

Observations on 08/04/25 at 10:40 A.M. and 2:05 P.M. and 08/0525 at 8:10 A.M., 10:15 A.M., and 1:40 P.M. revealed Resident #209 was lying in bed and the resident's left hand was contracted and the fingernails on

the left hand were long and dirty.

Observation and interview on 08/05/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #125 confirmed Resident #209 had a contracture of the left hand and the fingernails on the resident's left hand were long and dirty and in need of being cleaned and trimmed. CNA #125 obtained a damp washcloth and gently cleansed inside the resident's left hand. Upon removing the white washcloth from the resident's hand, brown debris was present. CNA #125 confirmed the residents hand had a yeast-like odor to it which should not be present.

Observation on 08/06/25 at 10:02 A.M. revealed Resident #209 was lying in bed. The resident's left hand was contracted and the fingernails to the left hand continued to be long and dirty.

Review of the facility policy titled Routine Resident Care effective 03/12/25 revealed daily personal hygiene minimally included assisting or encouraging residents with washing their face and hands, shaving, nail care, and brushing their teeth and/or providing denture care.

This represents noncompliance investigated under Complaint Number OH00167220 (1260023).

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Trainer #700 confirmed the splint had been given to Resident #37 in May. Athletic Trainer #700 stated if the splint had been removed twice a day and the skin assessed, no issues should have occurred. If the splint was too tight, it would cause pressure injuries. Interview on 08/07/25 at 2:08 P.M. with LPN #140 confirmed Resident #37's splint was not removed except during the twice-daily skin checks. LPN #140 also confirmed

the fax number provided above was correct. She confirmed an aide had accompanied Resident #37 to his appointment but could not recall the aide's name. Observation on 08/07/25 at 2:08 P.M. with Wound Nurse #870 revealed the wound on Resident #37's finger was moist with Betadine, with a scab covering the area and pink tissue visible at the center. After removing the gauze, staff noted the dorsal side of the finger showed scabbed tissue with surrounding pink skin. The wound nurse described the area as having superficial skin involvement. The left dorsal wound appeared to have some depth with a central scab, and

the wound nurse noted the depth could not be assessed until the scab detached. Review of the facility policy titled Skin Management dated 05/01/10 with a revision date of 09/19/24, revealed the policy aims to identify and implement interventions to prevent clinically unavoidable pressure injuries. It outlines an overview where residents with wounds, pressure injuries, or at risk for skin compromise are evaluated and treated to promote prevention and healing, with ongoing monitoring. Practice guidelines include a baseline total body skin evaluation upon admission, weekly Braden Scale assessments for four weeks, and appropriate preventive measures and interventions for at-risk residents. Residents with skin impairments receive physician-ordered treatment, with documentation of impairment details. The policy also addresses interdisciplinary team evaluations, weekly skin assessments, and the management of pressure injuries, vascular ulcers, skin tears, and bruises, including notification protocols and documentation requirements.

Management tools and cross-references to other guidelines are provided to support compliance. Review of

the NPIAP guidance titled 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide 2019 revealed to reduce the risk of medical device related pressure injuries, review and select medical devices with considerations to minimize issue damage, utilize the correct sizing/shape of the device for the individual and correctly secure the device. Assess the skin under and around medical devices for signs of pressure related injury as part of routine skin assessment. Remove medical device as soon as medically feasible. Use prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries. This deficiency represents non-compliance investigated under Complaint Number OH00167149 (1260022).

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Review of the active physician's order, dated 08/22/23, revealed to apply left c-roll splint for six hours between 7:00 A.M. and 3:30 P.M. Check skin upon removal.

Review of the care plan, revised 04/16/25, revealed Resident #209 had a functional ability deficit and required assistance with self care/mobility. Apply left c-roll splint for six hours between 7:00 A.M. and 3:30 P.M. as tolerated.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #209 had moderately impaired cognition and a functional limitation in range of motion to one upper extremity.

Observations on 08/04/25 at 10:40 A.M. and 2:05 P.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place.

Subsequent observations on 08/05/25 at 8:10 A.M., 10:15 A.M., and 1:40 P.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place.

Observation and interview on 08/05/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #125 confirmed Resident #209 had a contracture of the left hand and used to have a splint but did not anymore and had not had one in place on the day of the observation.

Observation on 08/06/25 at 10:02 A.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place.

Review of the facility policy titled Brace and Splint Program effective 05/01/24 revealed properly used, splints and braces can enhance mobility, correct alignment, and protect a specific extremity while maintaining skin integrity and circulation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm

re-admission, quarterly, annually, and with significant condition changes, developing an initial plan of care, evaluating for injury post-fall, completing incident reports, and conducting post-fall evaluations within 24 to 72 hours. The interdisciplinary team reviewed all falls, modified care plans, and conducted monthly reviews, while the Director of Nursing or designee documented changes and reported data to the Quality Assurance and Performance Improvement (QAPI) committee for trending and recommendations.

Residents Affected - Few

1. 3. Review of medical record for Resident #70 revealed an admission date of 11/08/24. Diagnoses included

peripheral vascular disease, right and left above knee amputations, and muscle wasting.

Review of the care plan dated 10/27/24 revealed Resident #70 wished to use smoking products and was assessed as being unsafe to smoke and needed supervision. The goal was listed to be safe while using smoking products and complying with the smoking policy. An intervention listed was that staff members were to maintain all smoking paraphernalia for all safe and unsafe smokers, including lighters.

Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed Resident #70 was cognitively intact, had rejection of care for one to three days during the assessment period, and utilized tobacco. Resident #70 required substantial to maximum assistance from staff for personal hygiene and partial to moderate assistance with oral hygiene.

Review of Resident #70’s smoking assessment dated [DATE REDACTED] revealed Resident #70 required supervision during smoke break related to his hands having contractures and weakness. Resident #70 was not safe to light smoking materials and did not utilize not oxygen. Resident #70 was not a safe smoker.

Review of Resident #70’s physician orders dated 06/24/25 revealed Resident #70 had an order for oxygen at six liters to maintain an oxygen level above 88 percent (%) every shift for shortness of breath as needed.

Observations of Resident #70 on 08/04/25 at 10:13 A.M., 12:26 P.M., and 2:50 P.M. revealed Resident #70 had two lighters with liquid visible in them at his bedside within reach on his bedside table.

Interview with Nursing Administration #130 on 08/04/25 at 2:53 P.M. confirmed the presence of two lighters within reach of Resident #70 at his bedside.

Interview with Activity Aide #211 on 08/05/25 at 4:25 P.M. and with Activity Aide #191 on 08/11/25 at 8:24 A.M. revealed even safe smokers were unable to keep lighters or other smoking paraphernalia on their person. All smoking materials were to be locked up in a smoking lock box.

Review of the facility policy titled “Smoking Policy” dated 06/17/25 revealed staff members will maintain all smoking paraphernalia for all safe and safe smokers, including lighters and lighter fluid.

This deficiency represents non-compliance investigated under Complaint Number OH00167527 (1260015).

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

eggs may hatch into their larval form in approximately 12 hours. He also verified that due to the findings on that day, the facility had installed florescent fly traps at the ends of each hall and prohibited entry or exiting from the outside doors located at the end of each hall. Prior to 06/30/25, staff frequently used the exit doors

on the tracheostomy for various reasons.

Attempts to interview Licensed Practical Nurse #680 and Respiratory Therapist #955, who worked on 06/30/25, during the survey were unsuccessful.

Review of the facility's undated policy titled Tracheostomy Suctioning revealed there was no relevant information on the care required for fly larvae infestation.

This deficiency represents non-compliance investigated under Complaint Number OH00167149 (1260022).

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697

Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, staff interview, and facility policy review, the facility failed to consistently evaluate the effectiveness of regularly scheduled opioid pain medication in accordance with the resident's comprehensive care plan. This affected one (#159) of five residents reviewed for unnecessary medications.

The facility census was 209. Findings include:Review of Resident #159's medical record revealed she was admitted to the facility on [DATE REDACTED]. Diagnoses included fibromyalgia (long-term condition that involves widespread body pain) and polyarthritis (a form of arthritis affecting five or more joints simultaneously, causing pain, swelling, warmth, and stiffness). Review of the physician order summary dated 03/04/25 revealed Resident #159 had an order for Tramadol (an opioid and treats moderate to severe pain) 50 milligrams (mg) give one tablet by mouth two times a day for polyarthritis. Review of the care plan dated 06/29/25 revealed Resident #159 was at risk for chronic pain and the interventions included evaluate the effectiveness of pain medication as given and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition as needed. Review of the medication administration record (MAR) from 07/01/25 to 08/11/25 for Resident #159 revealed an order for Tramadol HCL oral tablet 50 mg, give one tablet by mouth two times a day for polyarthritis, scheduled at 8:00 A.M. and 8:00 P.M. There was no pain scale and effectiveness of the medication in association with the administration of Tramadol in the MAR, treatment administration record (TAR), and progress notes. Review of Resident #159's Pain Level Summary from 05/11/25 to 08/11/25 revealed there were no records of a pain level during this time. An interview with Registered Nurse (RN) #660 on 08/11/25 at 9:19 A.M. verified there was no pain scale in Resident #159's MAR or medical record.

RN #660 stated that most of the residents have a pain scale and verified there was no documentation the staff were monitoring the effectiveness of Tramadol for Resident #159. An interview with Certified Nurse Practitioner (CNP) #51on 08/11/25 at 9:27 A.M. confirmed any resident receiving scheduled Tramadol should be assessed for pain every time it was given and then evaluated for effectiveness of the Tramadol.

Review of the facilities Pain Management policy last revised 3/05/25 revealed each resident identified with pain will have a pain management care plan. The care plan will have: a consistent pain scale to measure

the pain and frequency of re-evaluation, a desired level of pain reduction or acceptable level of pain, resident-centered functional outcomes (e.g., ability to participate in favorite activity, visiting with family, ambulating to the dining room, sleeping through the night), pain monitoring and who will monitor for the pain, nursing comfort measures to alleviate pain, and potential adverse effects of treatment.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699

trauma is identified, care plans to address the trauma, including triggers and interventions to mitigate or lessen re-traumatization will be authored.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance and review of facility policy, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) in designated resident rooms. This affected one (Resident #10) of four residents reviewed for EBP. The facility census was 209. Findings included:Review of the medical record for Resident #10 revealed an admission date of 07/15/21. Diagnoses included chronic obstructive pulmonary disease.

Residents Affected - Few

Review of Resident #10's physician orders for 08/01/25 to 08/11/25 revealed an active order for Resident #10 to be on EBP related to chronic wound.

Observation on 08/05/25 at 2:40 P.M. revealed Certified Nursing Assistant (CNA) #115 assisting Resident #10 at the bedside with gloves on. He went into the resident's bathroom and exited out of the room with gloved hands. CNA #115 was not wearing a gown during provision of care.

Interview on 08/05/25 at 2:42 P.M. with CNA #115 confirmed he performed incontinence care for Resident #10 with gloves only. CNA #115 confirmed he did not wear a gown as indicated by the EBP sign outside Resident #10's room.

Observation on 08/05/25 at 3:52 P.M. of Resident #10 who resided in bed B revealed outside of her room to

the right of her door were two signs for EBP for bed A and Resident #10 bed B. The sign indicated providers and staff must clean their hands, including before entering and when leaving the room, wear gloves and a gown for the following activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use central line, urinary catheter, feeding tube, tracheostomy and wound care (any opening requiring a dressing).

Review of the facility policy titled “Enhanced Barrier Precautions (EBP)” dated 03/05/25 revealed the facility is to use EBP in addition to standard precautions for preventing transmission of CDC targeted multidrug-resistant organisms (MDROs). EBP are indicated for residents with chronic wounds.

Health care personnel caring for residents on EBP should wear gloves and gowns during high-contact resident care such as dressing, bathing showering, transferring providing hygiene(focused on A.M. and P.M. care) changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: chronic wounds.

Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Walden Park

5700 Karl Road Columbus, OH 43229

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm

correction plan. The Administrator revealed licensed staff would perform skin assessments of vulnerable residents as a part of this correction plan starting immediately.

1. 2. Observation on 08/05/25 at 10:10 A.M. revealed multiple house flies and fruit flies were flying around the

tracheostomy unit. The flies were also landing on multiple surfaces during this observation.

Residents Affected - Many

Observation of Resident #47 on 08/06/25 at 9:45 A.M. revealed the resident's room was located next to an exit door that opens up to the outside.

Subsequent observations on 08/06/25 at 12:25 P.M., 08/07/25 at 2:10 P.M., and 08/11/25 at 9:55 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during these observations.

Interview with Respiratory Therapist #945 on 08/06/25 at 2:45 P.M. verified the tracheostomy and stoma of Resident #47 had been infested with fly larvae and the resident had been sent to the hospital due to the findings on 06/30/25.

Review of an undated facility policy titled Pest Control Policy revealed the facility would provide an environment free of pests.

This deficiency represents non-compliance investigated under Complaint Number OH00167149 (1260022) and Complaint Number OH00167441 (1260024).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet