Skip to main content
Complaint Investigation

Laurels Of West Carrollton The

December 30, 2025 · West Carrollton, OH · 115 Elmwood Circle
Citations 2
CMS Rating 2/5
Beds 88
Provider ID 365598
Healthcare Facility
Laurels Of West Carrollton The
West Carrollton, OH  ·  View full profile →
Inspection Summary

LAURELS OF WEST CARROLLTON THE in WEST CARROLLTON, OH — inspection on December 30, 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.

Advertisement

Inspection Findings

FF0755
Pharmacy Service Deficiencies
Potential for More Than Minimal Harm

Based on observation, medical record review, staff interview, review of United States (U.S.) Food and Drug Administration (FDA) guidance, and facility policy review, the facility failed to ensure delayed-release and extended-release mediations were administered correctly to the residents.

This affected one (#32) of three residents reviewed for medication administration.

The facility census was 73.Findings include:

Review of the medical record for Resident #32 revealed an admission date of 11/10/23 with diagnoses including chronic diastolic congestive heart failure, type II diabetes mellitus, and aphasia following cerebral infarction.The physician's order dated 12/24/25 revealed may crush allowable medications.Observation on 12/30/25 at 8:37 A.M. revealed Registered Nurse (RN) #127 was observed to crush Potassium Chloride Extended Release (ER) (potassium salt for low potassium levels) 20 milliequivalents (mEq), and Omeprazole Delayed Release (DR) (treats acid reflux) 20 milligrams (mg). RN #127 took these two crushed medications and added it to a medicine cup containing pudding and mixed the medication with the pudding prior to administering it to Resident #32.Interview on 12/30/25 at 8:42 A.M. with RN #127 verified she crushed Potassium Chloride ER and Omeprazole DR.Review of U.S. FDA guidance on Omeprazole DR dated 11/27/15 revealed do not crush, break, or chew the tablet.

This decreases how well the medication works in the body.

The FDA guidance on Potassium Chloride ER dated 04/2018 stated to swallow pillow whole without crushing.

Review of the facility policy titled Medication Administration, last revised 10/17/23, revealed to follow safe preparation practices which included to check the Do Not Crush list before crushing medications.

Direct specific questions to the pharmacist. If necessary, contact the ordering physician for a change to different route of administration when the medication cannot be crushed.The facility's 'Medications Not To Be Crushed' list revealed Potassium Chloride and Omeprazole were on this list of medications not to crush.This deficiency represents non-compliance investigated under Complaint Number

  • 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

12/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of West Carrollton The

115 Elmwood Circle West Carrollton, OH 45449

SUMMARY STATEMENT OF DEFICIENCIES

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure staff wore personal protective equipment (PPE) in isolation rooms.

This had the potential to affect all 73 residents residing in the facility,Findings include:Medical record review for Resident #47 revealed an admission date of 04/30/24 with diagnoses including end stage renal disease, dependence on renal dialysis, and atrial fibrillation.The physician's order dated 12/25/25 revealed an order for contact and droplet isolation precautions related to Coronavirus (COVID-19) for 10 days.Observation and interview on 12/30/25 at 11:26 A.M. revealed Certified Nursing Assistant (CNA) #120 entered Resident #47's room to perform room cleaning. CNA #120 was observed entering and cleaning Resident #47's room without donning PPE.

CNA #120 confirmed there were signs posted outside of Resident #47's room indicating the resident was in isolation for droplet or contact precautions, with instructions to don PPE prior to entering the room.

During the interview, CNA #120 revealed she was unsure if PPE was required in the resident room because she was performing housekeeping duties.

Review of the facility policy titled Coronavirus (COVID-19), last revised 02/28/25, revealed residents with suspected or confirmed COVID-19 are to be place on Transmission-Based Precautions.

All staff entering the room of a resident on COVID-19 isolation are required to don appropriate PPE, including gown, gloves, eye protection, and respiratory protection, and the PPE use applies to all staff providing care or services in the resident room.This was an incidental finding discovered during the complaint investigation.

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 WEST CARROLLTON, 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 LAURELS OF WEST CARROLLTON THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement