Laurels Of Hillsboro

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

at 10:12 A.M. with the Administrator and DON confirmed the Executive Director of Homeless Shelter #500 had posted a list on Facebook of all the services the shelter offered. They confirmed they did not assist with setting up transportation to the follow-up appointment for Resident #79 as the Executive Director of Homeless Shelter #500 had stated he would assist in doing so. They confirmed there was no documentation of self-administration of insulin or other medications in the resident's medical record since 12/04/24. They confirmed there was no additional documentation of discharge planning or diabetic teaching

in the resident's medical record since 07/2025. Telephone interview on 12/16/25 at 10:40 A.M. with Executive Director #360 (Homeless Shelter #500 employee) confirmed he had told staff at the facility this would not be a good program for Resident #79 as the resident did not have any recent work skills or references, had no income, and had no life skills. Executive Director #360 confirmed he told the facility as a last resort they would be happy to help. Executive Director #360 confirmed after 90 days the resident would be discharged out of the homeless shelter and there were no good housing options for him. Executive Director #360 confirmed medical care and treatment were not provided by himself or House Manager #305 and they were the only two employees of the shelter. Executive Director #360 confirmed Resident #79 seemed to have the mentality of a child and appeared to be agoraphobic (fearing or avoiding places or situations which might cause panic) as he almost always remained in his dorm on his bed. Interview on 12/16/25 at 11:51 A.M. with Ombudsman #250 during her visit to the facility revealed a complaint regarding

an inappropriate discharge had been called into the Ombudsman's office for Resident #79. Ombudsman #250 confirmed she had visited Resident #79 at Homeless Shelter #500 and he had stated he was unaware of discharge plans prior to 12/08/25 and wanted to return to the facility. Ombudsman #250 confirmed she had not been notified by the facility of the plan to discharge the resident before or after his discharge. Ombudsman #250 confirmed she was filing an appeal regarding the resident's inappropriate discharge. Interview with LPN #179 on 12/16/25 at 2:31 P.M. confirmed Resident #79 was able to draw up his own insulin but had problems with his eyesight and did not do well with insulin vials and insulin syringes.

Telephone interview on 12/16/25 at 3:52 P.M. with Insurance Employee #472 confirmed neurocognitive testing had been completed for Resident #79 prior to his discharge which showed the resident had developed learned helplessness while residing in the facility. Insurance Employee [TRUNCATED]

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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

12/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of Hillsboro

175 Chillicothe Avenue Hillsboro, OH 45133

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Based on closed record review and staff interviews, the facility failed to provide notice of discharge timely and appropriately. This affected one resident (#79) out of the four residents reviewed for discharge. The facility census was 74.Findings include:Closed record review for Resident #79 revealed the resident was admitted to the facility in 05/2003 and had diagnoses which included type one diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term use of insulin.Review of

the quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, revealed the resident was cognitively intact.Further record review for Resident #79 revealed no discharge notice had been provided to the resident or Ombudsman prior to the resident being discharged from the facility on 12/08/25.Interview on 12/11/25 at 1:59 P.M. with the Administrator and Social Service Director #180 confirmed no discharge notice had been provided to Resident #79 as he was agreeable to go. They confirmed no discharge notice had been made to the Ombudsman as of the present date and time.This deficiency represents non-compliance identified during the investigation of Complaint 2690578 and 2688635.

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