Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Middletown during CMS and state inspections, most recent first.
A resident with impaired cognition and significant physical disabilities, who was care planned for two-person assistance during mobility and hygiene care, was being assisted by only one CNA during perineal care. As a result, the resident slid off the bed, hit his head on a chair, and complained of neck pain. The DON confirmed that the required two-person assistance was not provided at the time of the incident.
A significant medication error occurred when an LPN administered oxycodone to a resident with severe cognitive impairment and multiple diagnoses, despite the absence of an active physician order. The medication was recorded on the controlled drug log but not on the medication administration record, in violation of facility policy.
The facility failed to store, prepare, and distribute food in a sanitary manner, affecting all 97 residents. Observations revealed soiled areas, expired food, improper use of food thermometers, and mold in the ice machine. Staff interviews and policy reviews confirmed these deficiencies.
The facility failed to provide a clean, comfortable, and sanitary environment for its residents, affecting four individuals. Issues included broken and uncomfortable beds, visible drywall substances, and unpainted plaster on walls. Staff confirmed the residents' complaints and acknowledged the importance of addressing these issues, which had persisted for several months.
The facility failed to accurately code MDS assessments for six residents, leading to deficiencies in their comprehensive assessments. For example, one resident with severe cognitive impairment had an MDS assessment lacking functional status documentation, while another resident's dental issues were not accurately documented. The facility did not have a specific MDS completion policy but claimed to follow the RAI manual guidelines.
The facility failed to complete a PASRR upon admission for a resident with multiple mental health diagnoses, including anoxic brain injury, depression, bipolar disorder, schizoaffective disorder, functional quadriplegia, and convulsions. Despite a Review Results letter indicating a Pre-Admission Screen determination was not applicable and a level of care determination as Intermediate, there was no documentation of a PASRR in the resident's medical record. The Administrator confirmed the absence of PASRR documentation and was unable to verify its completion upon admission.
The facility failed to develop comprehensive dental care plans for two residents with significant dental issues, despite their expressed concerns and observed dental caries and broken teeth. This was confirmed by staff interviews and observations.
The facility failed to conduct regular care conferences for three residents, despite their medical conditions and cognitive status. The administrator confirmed the deficiency, citing the absence of a Social Service designee as the reason.
The facility failed to ensure proper hand hygiene and the application of a prescribed hand splint for a resident with functional quadriplegia. Despite physician orders and care plan interventions, the resident reported that the splint had not been applied for months, and his contracted hand had not been cleaned. Observations and interviews confirmed these deficiencies.
A resident with functional quadriplegia did not have his hand splint applied as ordered by the physician. Despite records indicating compliance, the resident reported and observations confirmed that the splint had not been applied for months, and his contracted hand was not cleaned, emitting a foul odor. Interviews revealed inconsistencies in care and failure to follow the facility's policy on braces and splints.
A resident with impaired cognition was found in possession of eight pills without an order or assessment permitting self-administration. The RN was unsure of the pills' origin despite having observed the resident take medication earlier. The facility's policy requires staff to observe residents swallow their medication, which was not followed.
The facility failed to ensure staff followed proper infection control procedures during IV medication administration. An LPN was observed dropping a PICC line on a resident's arm and preparing to administer a saline flush without recleaning the tip, contrary to the facility's aseptic technique policy.
The facility failed to provide timely care for a resident with a urinary tract infection, delaying the collection of a urine specimen and failing to document attempts or notify the physician of the delay. The resident had multiple medical diagnoses and required maximum staff assistance.
The facility failed to ensure timely completion of physician-ordered lab work for two residents. One resident had multiple lab tests ordered but not drawn despite recommendations, and another resident's urinalysis was delayed without proper documentation or physician notification.
The facility failed to complete weekly wound evaluations for a resident with a surgical wound following a left below the knee amputation (BKA). The resident's wound was not properly documented or measured for nearly a month, during which time the wound deteriorated. This deficiency was confirmed by an LPN and represents non-compliance with the facility's policy on Skin Management.
Failure to Provide Required Two-Person Assistance During Care Resulting in Resident Fall
Penalty
Summary
A resident with a history of nontraumatic intracerebral hemorrhage, traumatic compartment syndrome, paraplegia, and dysphagia was admitted to the facility and assessed as having impaired cognition with a BIMS score of six. The resident's care plan and comprehensive evaluation indicated a requirement for two-person assistance during self-care and mobility, specifically for toileting and hygiene care, due to the risk of falls and impaired ADL performance. Interventions included placing the bed against the wall and ensuring two staff members were present during care. On the date of the incident, the resident was receiving perineal care from a single CNA, despite the documented need for two-person assistance. While being turned to the left side, the resident slid off the bed, struck his head on a nearby chair, and landed on his back. The resident was alert and responsive but reported right-sided neck pain. The DON confirmed that only one staff member was present during the incident, which was not in accordance with the resident's care plan and facility expectations.
Medication Administered Without Active Physician Order
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered 5 mg of oxycodone to a resident who did not have an active physician order for the medication. The resident, who had diagnoses including encephalopathy, epilepsy, asthma, anxiety, dysphagia, and muscle weakness, was noted to have severely impaired cognition and required assistance with self-care. The administration of oxycodone was prompted by the resident exhibiting signs of agitation. The medication was documented on the Controlled Drug Record log but was not recorded on the medication administration record due to the absence of an active order. Review of facility policy confirmed that medications are to be administered only in accordance with written physician orders and all administrations should be recorded in the medication administration record. The incident was verified by the facility administrator, who confirmed the LPN's actions as described in the incident report.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store, prepare, and distribute food in a sanitary manner, potentially affecting all 97 residents. During an initial tour of the kitchen, a trash can under the hand washing sink was found soiled with splatter, and dirty dishtowels with live gnats were observed. The kitchen floor had debris, and the dishwasher had food debris. The walk-in refrigerator contained expired food items, and a large box was stored directly on the floor. The dietary manager confirmed that the facility received outdated frozen bread and allowed it to thaw on a rolling rack, following guidance from the corporate dietician based on a Google search. Pest control records could not confirm treatment for gnats despite the presence of pests in the kitchen area. During a lunch tray line observation, a dietary cook used a food thermometer without sanitizing it between uses, despite being advised not to use alcohol wipes. The dietary manager provided a dry paper towel for wiping the thermometer, which was used to check multiple food items. Additionally, the facility's ice machine had a brown substance on the front and an unknown black spotted substance inside, which was identified as mold by a dietary aide. The ice machine had not been cleaned since December 2023, contrary to the facility's policy of regular cleaning and disinfection. Further observations revealed that a dietary cook used gloved hands instead of tongs to place brats into buns during the lunch tray line. The dietary manager confirmed that tongs were available and should have been used. These deficiencies in food storage, preparation, and distribution practices were confirmed by staff interviews and policy reviews, indicating a failure to maintain sanitary conditions in the facility's kitchen, potentially impacting all residents receiving meals from the kitchen.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and sanitary environment for its residents, affecting four residents. Resident #46 reported that his bed was uncomfortable and appeared broken, with the mattress not lying correctly on the bed frame and a large white drywall substance on the wall beside his bed for several months. Resident #51 complained about feeling the bed rails through his mattress and pointed out uneven paint behind his bed. Both residents indicated that they had reported these issues to the staff, but no corrective actions had been taken. Observations confirmed the residents' complaints, with visible issues in the physical environment of their rooms. Further observations revealed that Resident #25's room had multiple black scratches on the walls, lightly covered with plaster but not painted. Resident #36's room had similar issues, with several areas of plaster but no paint. Interviews with staff, including a State Tested Nurse Aide (STNA) and the Housekeeping Manager, confirmed the residents' complaints and the poor condition of the rooms. The STNA and Housekeeping Manager acknowledged the importance of addressing these issues but noted that the problems had persisted for several months without resolution.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for six residents, leading to deficiencies in their comprehensive assessments. For instance, Resident #01, with severe cognitive impairment and multiple medical diagnoses, had an annual MDS assessment that lacked documentation to support the assessment of functional status, with section GG left blank. Similarly, Resident #24, who was cognitively intact, had a quarterly MDS assessment that also lacked documentation of functional status, with section GG left blank. The facility did not have a specific MDS completion policy but claimed to follow the RAI manual guidelines. Further deficiencies were noted for other residents. Resident #41, with multiple medical conditions including cognitive impairment, had an MDS assessment that failed to provide an assessment related to the level of care required. Resident #74, dependent on staff for medication administration, had an MDS assessment that did not assess his functioning level. Residents #92 and #82 had MDS assessments that inaccurately documented their dental status, despite observations and interviews confirming dental issues. The Regional MDS Nurse and RN confirmed the inaccuracies in the MDS assessments for these residents, indicating a failure to follow the RAI manual guidelines.
Failure to Complete PASRR Upon Admission
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) was completed upon admission for a resident with multiple mental health diagnoses, including anoxic brain injury, depression, bipolar disorder, schizoaffective disorder, functional quadriplegia, and convulsions. The medical record review revealed that the resident was admitted with these conditions and was cognitively intact but dependent on assistance for toilet hygiene, bed mobility, and transfers. Despite a Review Results letter indicating a Pre-Admission Screen determination was not applicable and a level of care determination as Intermediate, there was no documentation of a PASRR in the resident's medical record. The facility's policy required all individuals with serious mental illness or intellectual/developmental disabilities to be evaluated for appropriate placement in a nursing facility, starting with a Level 1 screening. The Administrator confirmed the absence of PASRR documentation and was unable to verify its completion upon admission.
Failure to Develop Comprehensive Dental Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the dental needs of two residents. Resident #92, who was admitted with diagnoses including osteomyelitis, anxiety, COPD, CHF, and psychoactive substance abuse, had a BIMS score of 15 indicating intact cognition and required supervision for activities of daily living. Despite these needs, there was no dental care plan in place. During an interview, Resident #92 expressed concerns about her broken lower teeth, which were observed to have several dental caries and broken teeth. This was confirmed by RN #245 and Clinical Coordinator RN #324, who verified the absence of a specific dental care plan for Resident #92's dental issues. Similarly, Resident #82, admitted with diagnoses including local skin infection, cellulitis, sepsis, and bipolar disorder, also had a BIMS score of 15 indicating intact cognition and required extensive assistance for bed mobility, transfers, toileting, and eating. Despite these needs, there was no dental care plan in place. Resident #82 expressed concerns about dental caries, and observations revealed multiple blackened and fragmented teeth. This was confirmed by RN #245 and the DON, who verified the absence of a specific dental care plan for Resident #82's dental issues.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to conduct resident care conferences as required, affecting three residents out of the five reviewed. Resident #24, who has medical diagnoses including atrial fibrillation and congestive heart failure, had only one care conference documented in the past 12 months despite being cognitively intact. Resident #54, with conditions such as chronic obstructive pulmonary disease and end-stage renal disease, also had only one care conference documented in the past year, despite requiring maximum staff assistance for various activities. Resident #79, who suffers from chronic respiratory failure and diabetes mellitus, had not attended a care conference for a very long time, with only one documented care conference in the past 12 months. Interviews with the residents confirmed the lack of regular care conferences, and the facility administrator acknowledged the deficiency, attributing it to the absence of a Social Service designee. The facility's policy mandates that care conferences be held within 72 hours of admission and quarterly thereafter, but this was not adhered to. The administrator confirmed that the medical records did not contain documentation to support that care conferences were conducted or offered as per the facility's policy.
Failure to Provide Hand Hygiene and Apply Hand Splint
Penalty
Summary
The facility failed to ensure that a resident was provided with proper hand hygiene and the application of a prescribed hand splint. Resident #49, who has a diagnosis of functional quadriplegia and other related conditions, was found to be dependent on staff for most activities of daily living. Despite physician orders and care plan interventions specifying the application of a hand splint twice a week and the necessity of hand hygiene, the resident reported that the splint had not been applied for months, and his contracted hand had not been cleaned. Observations confirmed that the hand splint was not applied on multiple occasions, and a sour odor was noted in the resident's room, which the resident attributed to his unclean hand. Interviews with the resident and staff further revealed inconsistencies in the care provided. The resident stated that staff had not placed the splint or cleaned his hand in months. A registered nurse claimed to have applied a washcloth to the resident's hand but was unable to demonstrate the task when asked. The facility's policy on braces and splints required a scheduled program for applying and removing the appliance and inspecting the skin for any issues, but this was not adhered to, leading to the deficiency in care for Resident #49.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to ensure that a resident's hand splint was applied as ordered by the physician. Resident #49, who has a diagnosis of functional quadriplegia and other related conditions, was supposed to have a hand splint applied to his right hand twice a week. Despite the Treatment Administration Record indicating that the splint was applied, the resident reported that staff had not placed the splint on his hand for months. Observations over two days confirmed that the hand splint was not applied, and the resident's contracted hand emitted a foul odor due to lack of hygiene care. Interviews with the resident and a registered nurse revealed inconsistencies in the application and care of the hand splint. The resident stated that staff had not cleaned his contracted hand or applied the splint for months. The registered nurse was unable to demonstrate how she applied a washcloth to the resident's hand, despite claiming to have done so. The facility's policy on braces and splints requires a scheduled program for applying and removing the appliance, as well as regular skin inspections, which were not adhered to in this case.
Failure to Observe Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was observed taking their medications at the time of administration. This deficiency was identified during a review of the medical record, observations, and interviews with both the resident and staff. Resident #74, who has diagnoses including alcohol dependence, epilepsy, dementia, anxiety, and metabolic encephalopathy, was found to have a Brief Interview Mental Status (BIMS) score of 10, indicating impaired cognition. Despite this, the resident was in possession of a medicine cup containing eight pills, which included Depakote, Keppra, Vitamin B, Vitamin D, and aspirin, without any order or assessment permitting self-administration of medications. During an observation and interview, the resident presented the medicine cup and stated it contained the pills he needed to take. A Registered Nurse (RN) verified the resident had eight pills in the cup and admitted to being unsure where the pills had come from, despite having observed the resident take the pills he administered that morning. The facility's policy on Medication Administration, last revised on 10/17/23, requires staff to observe residents swallow their medication, which was not adhered to in this instance.
Failure to Follow Infection Control Procedures During IV Medication Administration
Penalty
Summary
The facility failed to ensure staff followed proper infection control procedures during the administration of intravenous medication. Specifically, an LPN was observed administering medication via a PICC line to a resident with diagnoses including osteomyelitis, anxiety, and heart failure. The LPN cleansed the tip of the needleless connector with an alcohol swab but then intentionally dropped the line, causing it to land on the resident's arm. The LPN was prepared to administer the saline flush without recleaning the potentially contaminated tip until the surveyor intervened. The facility's policy on medication administration, last revised on 10/17/23, requires injections to be prepared using aseptic technique in a clean area.
Failure to Provide Timely Care for Urinary Tract Infection
Penalty
Summary
The facility failed to provide timely care and services to treat a urinary tract infection for a resident with multiple medical diagnoses, including neuromuscular dysfunction of the bladder. The resident, who had moderate cognitive impairment and required maximum staff assistance, was admitted with a physician order for a 16 French indwelling catheter and a subsequent order for a urinalysis with culture due to dysuria. Despite the resident's complaints of pain, dark-colored urine, and burning with urination, the facility delayed obtaining the urine specimen and failed to document attempts to collect it or notify the physician of the delay. The medical record revealed that the urine specimen was eventually obtained and placed in the refrigerator for lab pick-up, but there was no documentation of attempts to collect the specimen on the specified dates or any record of the resident refusing the collection. The Director of Nursing confirmed the lack of documentation and the failure to notify the physician about the delay. This deficiency was identified during an investigation under Complaint Number OH00153951.
Failure to Complete Physician-Ordered Lab Work in a Timely Manner
Penalty
Summary
The facility failed to ensure physician-ordered laboratory work was completed in a timely manner for two residents. Resident #52, who was admitted with multiple diagnoses including blindness, urine retention, and diabetes, had physician orders for various lab tests to be drawn every three months. Despite pharmacy recommendations on three separate occasions, the lab work had not been drawn as of the survey date. The Director of Nursing confirmed the oversight during an interview. Resident #298, admitted with diagnoses such as pneumonia and chronic obstructive pulmonary disease, had a physician order for a repeat urinalysis with culture due to dysuria. The medical record indicated that the resident complained of pain and dark-colored urine, and an order for a urinalysis was given. However, there was no documentation to support that the facility attempted to collect the urine specimen on the specified dates or that the resident refused the collection. Additionally, there was no documentation that the physician was notified of the delay. The Director of Nursing confirmed these findings during an interview.
Failure to Complete Weekly Wound Evaluations
Penalty
Summary
The facility failed to complete weekly wound evaluations for a resident with a surgical wound following a left below the knee amputation (BKA). The resident, who was admitted with multiple medical diagnoses including diabetes mellitus with neuropathy and depression, had a surgical wound with 20 staples that was not properly documented or measured from 02/20/24 until 03/19/24. The only wound evaluation during this period was on 03/19/24, which revealed the wound had deteriorated and measured 0.57 cm in length, 1.97 cm in width, and 1.6 cm in depth. The resident had injured the left BKA stump the day before, causing the incision to open, drain, and increase in pain, as noted by a Certified Nurse Practitioner (CNP) on 03/19/24. An interview with an LPN confirmed the lack of documentation for weekly wound evaluations for the resident's left BKA surgical site. The facility's policy on Skin Management, revised on 07/14/21, required weekly documentation of wound location, measurements, and characteristics until resolved. This deficiency was investigated under Complaint Number OH00152531 and represents non-compliance with the facility's own policy and standard care practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arlington Pointe Care Center | 2.1 mi | ★★★★★ | 5 | 0 |
| Willow Knoll Post-acute And Senior Living | 2.7 mi | ★★★★★ | 10 | 0 |
| Otterbein Middletown | 3.3 mi | ★★★★★ | 13 | 0 |
| Majestic Care Of Middletown Llc | 3.5 mi | ★★★★★ | 2 | 0 |
| Ohio Living Mount Pleasant | 3.8 mi | ★★★★★ | 3 | 0 |
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