Laurels Of West Carrollton The

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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

1. 2671171. 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

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Laurels of West Carrollton The

115 Elmwood Circle West Carrollton, OH 45449

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 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.

Residents Affected - Many

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

Event ID:

Facility ID:

If continuation sheet