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Complaint Investigation

The Laurels Of Middletown

September 26, 2025 · Middletown, OH · 751 Kensington Street
Citations 2
CMS Rating 4/5
Beds 109
Provider ID 365457
Healthcare Facility
The Laurels Of Middletown
Middletown, OH  ·  View full profile →
Inspection Summary

THE LAURELS OF MIDDLETOWN in MIDDLETOWN, OH — inspection on September 26, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of six and was assessed to require self-care assistance and mobility assistance.Review of Resident #8's admission comprehensive evaluation dated 09/15/25 revealed for toileting the resident was determined to be a two-person assist.

Review of the care plan for Resident #8 dated 09/19/25 revealed he was at risk for fall related injury and falls related to impaired activities of daily living (ADLs) performance and communication deficit.

Interventions include placing the resident's bed against the wall and having two staff members present at time of mobility and hygiene care.

Review of the medical record for Resident #8 revealed on 09/22/25 he was receiving perineal care by Certified Nurse Aide (CNA) #150.

The resident was being turned to his left side when he slid off of his bed, hitting his head on a nearby chair before landing on his back.

The resident was alert and responsive, with no visible injuries, but complained of right-sided neck pain.

The resident's physician and the resident's family were subsequently notified.

During an interview with the Director of Nursing (DON) on 09/26/25 at 5:15 P.M. she explained the expectation for a resident assessed as two-person assist would be provided care by two people.

The DON confirmed only one staff member was present and providing care for Resident #8 at the time of the fall on 09/22/25 when there should have been two staff members assisting.

This deficiency represents non-compliance investigated under Complaint Number 2575413.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Laurels of Middletown

751 Kensington Street Middletown, OH 45044

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/26/25 at 4:07 P.M. with the Administrator, she confirmed the events as detailed in the incident report verifying LPN #200 administered oxycodone to Resident #10 without the resident having an active order for the medication.

The Administrator added LPN #200 had not worked in the facility since the incident occurred.

Review of the facility policy titled, Medication Administration, revised 10/17/23, revealed medications are administered in accordance with the written orders of the physician.

All medication administrations should be recorded in the medication administration record.This deficiency represents non-compliance investigated under Complaint Number 2575413.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MIDDLETOWN, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE LAURELS OF MIDDLETOWN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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