Health inspection·August 18, 2023

F 0921 room [ROOM NUMBER]: was dirty under the bed, the molding was off the wall and the wall needed painted by the sink. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: had damaged drywall to the left of bed B. There was trash under the bed. Residents Affected - Some room [ROOM NUMBER]: had a swarm of ants by the air conditioner. room [ROOM NUMBER]: both beds had dirt and debris under them. room [ROOM NUMBER]: had holes in the wall and drywall that needed patched and painted. room [ROOM NUMBER]: had trash on the floor in the corner of the room, three pillows were on the floor, a gait belt and brief. room [ROOM NUMBER]: the molding was off the wall and there was trash under the bed. room [ROOM NUMBER]: had a three foot by eight-inch hole behind the bed affecting. room [ROOM NUMBER]: the walls need painted. room [ROOM NUMBER]: the floor molding was off the wall by the sink. room [ROOM NUMBER]: there was a towel under the air conditioner to catch leaking water. room [ROOM NUMBER]: had a towel on the floor under the air conditioner to catch leaking water. The walls needed painted. room [ROOM NUMBER]: the wall by bed A needed painted. room [ROOM NUMBER]: the molding was coming off. The walls around the sink and hand towel rank needed painted because the paint was off. room [ROOM NUMBER]: had a one- and one-half foot by eight-inch hole in the wall by the air conditioner that needed patched and painted. room [ROOM NUMBER]: there was a one foot by three-inch hole in the wall that needed patched and painted. The overbed light pull string was broke off and the light did not come on affecting. room [ROOM NUMBER]: there was food on the floor and a brush under bed B. The wall walking in on the left was gouged and needed painted. The fall mat by bed A had pieces missing around the perimeter. room [ROOM NUMBER]: the wall to the right walking in was gouged up with exposed drywall and needed patched and painted. The floor was dirty by the air conditioner. room [ROOM NUMBER]: the molding was off the wall by the air conditioner. room [ROOM NUMBER]: the molding was off the wall by the sink pulling the drywall off behind. room [ROOM NUMBER]: the molding was hanging off by the sink. The paint was off and needed painted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 2 of 7 Printed: 05/15/2026 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 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 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 0921 by bed A and by the sink. Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: the air conditioner needed painted. room [ROOM NUMBER]: bed B had two holes behind the bed that needed patched, and the room needed. Residents Affected - Some room [ROOM NUMBER]: there were holes in the wall on the left side walking in the room that needed patched and painted. There was trash under bed B. room [ROOM NUMBER]: Resident #68 said his air conditioner was leaking. room [ROOM NUMBER]: the thermostat was hanging off the wall. room [ROOM NUMBER]: there was trash in the corner of bed A, gloves, and glasses. room [ROOM NUMBER]: had holes in the wall by the air conditioner that needed patched and painted. room [ROOM NUMBER]: had a one foot by three-inch hole in the wall by the air conditioner. There were unpainted white dry wall patches in the room. room [ROOM NUMBER]: the gouged wall needs painted walking the room on the left. room [ROOM NUMBER]: the air conditioner vents were partially occluded with dust. The Hall 2 double doors had gaps under them exposing daylight under the doors. Review of the facility map revealed there were 70 resident rooms in the facility. Forty of the seventy rooms had identified issues. All the resident rooms were not observed. Review of the undated closed Work Order request in the TELLS system between 05/01/23 and 08/18/23 included a request to repair the wall in 167 bed B and 216 bed B. Observations 08/18/23 of room [ROOM NUMBER] revealed continuing wall issues a two foot by one foot area on the wall to the left of the air conditioner exposing drywall that needed painted. The wall by bed B was gouged up next to the bed and chair and needed patched and painted. Observation of room [ROOM NUMBER] revealed continuing concerns room [ROOM NUMBER] bed B had two holes behind the bed that needed patched, and the room needed painted. Interview 08/18/23 at 6:18 P.M., with the Administrator verified he saw holes in the walls, leaking air conditioners, and unpainted walls, molding off or falling off walls, The Administrator said he has spoken to the Director of Housekeeping about the cleaning needed improved. He had plans of taking him to one of the sister facility's for him to see how they clean. He had a performance improvement plan to address maintaining the facility. The first area they are working on is stripping and cleaning the resident floors. They are able to do one room a day. So, it would take approximately 70 days for the first project. He found out his former maintenance man was signing off work orders as complete when they were not corrected. The facility was not maintained when there were issues the building. There is only one maintenance man who is busy with the new maintenance issues. The Administrator verified it would be difficult for one maintenance man to address current issues and go back and do the volume of work it would take to get the all the outstanding repairs addressed. The Administrator acknowledged the holes in the drywall, dirty floors, and leaking water would make it easier for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 3 of 7 Printed: 05/15/2026 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 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete mice to enter the facility. The Administrator verified 62 Residents (#1, #2, #3, #4, #5, #7, #11, #12, #15, #17, #18, #22, #24, #25, #26, #27, #30, #31, #32, #33, #35, #36, #38, #39, #40, #42, #45, #46, #47, #50, #53, #54, #56, #57, #59, #65, #68, #69, #71, #75, #76, #78, #79, #83, #84, #85, #86, #87, #88, #89, #94, #97, #100, #101, #102, #104, #105, #109, #110, #113, #115, and #116) resided in the affected rooms. This deficiency represents the noncompliance under Master Complaint Number OH00145492 and Compliant Number OH00145368. Event ID: Facility ID: 365222 If continuation sheet Page 4 of 7 Printed: 05/15/2026 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 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of exterminator reports, resident and staff interviews, the facility failed to act upon exterminator recommendations and maintain the facility to control mice and ants. This affected 12 (#3, #18, #26, #27, #34, #42, #48, #60, #64, #83, #89, and #90) and had the potential to affect all the individuals in the home. The census was 112. Residents Affected - Many Findings include: Interview on 08/18/23 at 4:05 P.M., with Resident #83 revealed he thought he saw a mouse in his room about a month ago. Interview on 08/18/23 at 4:08 P.M., with Resident #64 revealed he saw a mouse in his room around 3:00 A.M. about a month and a half ago. Interview on 08/18/23 at 4:10 P.M., with Resident #89 revealed he saw a mouse outside. Interview on 08/18/23 at 4:12 P.M., with Resident #3 revealed she saw mice in her room a few days ago around the trash can. She told the nurse and two were caught. Interview on 08/18/23 at 4:14 P.M., with Resident #90 revealed she saw some mice in her room about a week ago. They caught two on a sticky pad. Interview on 08/18/23 at 4:16 P.M., with Resident #60 revealed she started to see mice in her room a couple weeks ago. They caught two on sticky traps. Interview on 08/18/23 at 4:22 P.M., with Resident #26 revealed they caught five mice in her room. Interview on 08/18/23 at 4:24 P.M., with Resident #34 revealed they caught four mice on one tacky strip in her room. They were under her bed and by the window last week. Interview on 08/18/23 at 4:26 P.M., with Resident #48 included she saw mice by her window. Interview on 08/18/23 at 4:30 P.M., with Resident #18 included she saw mice in her room, and they caught four in her room. Observation 08/18/23 between 5:00 P.M. and 6:00 P.M., revealed Resident #27 and #42's room had a swarm of ants by the air conditioner. Investigation of a complaint related to mice in the facility revealed numerous mice had been caught in resident rooms. Review of exterminator reports starting 05/04/24 included on a routine monthly visit two mice were found on the main floor in the kitchen on a tincat glue board. They had five exterior [NAME] stations placed, nine rodent trap mouse glue boards, one insect light traps glueboard and an aerosol foam was added to the drains kitchen door. Three additional bait station /traps were skipped due to not being able to access areas. Pending recommendations included on 10/10/22 there was a gap noted on the front door. The recommendation included to add weather stripping. As of a 08/15/23 exterminator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 5 of 7 Printed: 05/15/2026 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 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 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 0925 reported the gap had not been closed. Level of Harm - Minimal harm or potential for actual harm The 06/08/23 monthly inspection included three spiders were found in the kitchen and one rodent. A rodent trap was added to the kitchen under the hand sink. Open actions from previous service included on 10/10/22 there was a gap noted on the front door. The recommendation included to add weather stripping. The entry was still pending. On 01/21/20, debris was present in the kitchen. The recommendation was to clean and sanitize. The entry was still pending. On 01/17/19, debris was present in the kitchen station 3 with a recommendation to clean it. The entry was still pending. On 01/17/19, debris was present in the kitchen station 5 with a recommendation to clean it. The entry was still pending. On 09/26/18, a recommendation was logged moisture was present in the kitchen station four area. The recommendation was to search out source. The entry was still pending. An entry 04/16/18, included dead activity noted at station 5 with a recommendation to treat per scope. The entry was still pending. Residents Affected - Many Review of the 07/06/23 monthly exterminator report included one dead mouse was found in the kitchen. Mouse glue boards were added for cock roaches. Open actions from previous service included on 10/10/22 there was a gap noted on the front door. The recommendation included to add weather stripping. The entry was still pending. On 01/21/20 debris was present in the kitchen. The recommendation was to clean and sanitize. The entry was still pending. On 01/17/19, debris was present in the kitchen station 3 with a recommendation to clean it. The entry was still pending. On 01/17/19, debris was present in the kitchen station 5 with a recommendation to clean it. The entry was still pending. On 09/26/18, a recommendation was logged moisture was present in the kitchen station four area. The recommendation was to search out source. The entry was still pending. An entry 04/16/18, included dead activity noted at station 5 with a recommendation to treat per scope. The entry was still pending. The exterminator was called to perform extra treatment due to mice on 08/02/23 and 08/15/23. Interview on 08/18/23 at 3:12 P.M., with the Director of Nursing revealed they get mice from a field behind the facility. There are traps set outside and some inside. Interview on 08/18/23 at 3:19 P.M., with Maintenance #188 revealed last week when he was off the Administrator contacted the exterminator and they put sticky traps in a couple units due to complaints of mice. They were out the week of July 31 st for an extra visit due to mice. This neighborhood is a battle with mice. The exterminator put sticky pads inside to catch them and I put pellets outside that the mice can eat. Staff has complained and some residents also. Unit 3 rooms 161-177 had the most complaints. The bait stations are always out. We usually have about 15 in the building in the kitchen stock room, common areas, and under sinks. We normally do not put traps in the resident room. Last week we put sticky traps in resident rooms. We focused on Unit 3 but there are others throughout. There is one in every room on Unit 3. If there isn't a sticky trap that means, we have caught mice on the pad. Housekeeping is checking the traps. One housekeeper has called several times he caught mice. Maintenance #188 stated the paperwork from the exterminator is all electronic. He does not print it out. Interview on 08/18/23 at 7:24 P.M., with the Administrator revealed they have caught some mice in resident rooms. He stated he never saw exterminator reports. He looked at them and acknowledged the reports had an Open Actions from Previous Services section with a list of recommendations that had not been addressed dating back to 2018. This deficiency represents the noncompliance under Master Complaint Number OH00145492 and Compliant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 6 of 7 Printed: 05/15/2026 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 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 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 0925 Number OH00145368. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 7 of 7