Health inspection·October 18, 2023

F 0689 A.M. to 12:00 P.M. Level of Harm - Actual harm Review of the police report dated 08/27/23 revealed at 9:45 A.M., the caller (a Good Samaritan) reported a person (Resident #113) was found down at Bank #500 (which was 0.4 miles from the facility). The caller reported blood was everywhere, the person's eye was black, and the person was scared. Police and emergency services arrived on scene at 9:47 A.M. and subsequently transferred Resident #113 to the hospital. Residents Affected - Few Review of the hospital notes dated 08/27/23 revealed Resident #113 was found down outside a bank that day (08/27/23) and arrived at the ER at 10:21 A.M. for evaluation and treatment. Resident #113 was a made a level two trauma given her age and obvious head injury and confusion. Resident #113 had no recollection of what happened. Resident #113 received seven stitches to the left hand, a hematoma and three stitches to the left eye, and a bruise and scabs on her left knee. On 08/28/23, Resident #113 was discharged from the hospital to the facility. Review of the progress note dated 08/28/23 at 1:00 P.M. revealed Resident #113 returned from the hospital at 12:35 P.M. Resident #113 had a bruise and stitch wound on the left eye measuring 2.5 centimeter (cm) by 0.2 cm with three stitches, a bruise and stitch wound on the left hand measuring 5.5 cm by 2.1 cm with seven stitches, and a bruise and scabs on the left knee. On 08/29/23 and 08/30/23, the progress notes mentioned status post fall monitoring. On 08/31/23, Resident #113 went to the ER due to status post fall on 08/27/23. She returned to the to the facility with injuries. A wander guard was placed for the resident's safety. Review of the facilities SRI control number 238548 revealed the facility submitted on SRI on 08/27/23 at 3:04 P.M. regarding an injury of unknown source origin. Resident #113 reported that she sustained these injuries after falling off the sidewalk. The Administrator and Director of Nursing (DON) interviewed all staff on day shift and all employees stated they did not witness the incident. Resident #113 had severe cognitive impairment and a diagnosis of severe dementia without behavioral disturbance. The facility unsubstantiated the allegation of injury of unknown origin. The injuries to the resident appeared consistent with a fall from standing onto her left side. Review of the facilities elopement investigation dated 08/27/23 revealed all day shift staff were interviewed and no staff had seen Resident #113 during their shift, which started at 7:00 A.M. Registered Nurse (RN) #289 noticed Resident #113's breakfast tray was not touched. RN #243 did not see her but realized Resident #113 did not come down to ask for her breakfast like she usually did around 10:30 to 11:00 A.M. State Tested Nursing Assistant (STNA) #365 did not see Resident #113 at 7:00 A.M. and didn't realize she was missing until her breakfast tray was uneaten. STNA #360 did not recall seeing her at all in the morning. STNA #281 did not see Resident #113 walking the halls. The facility's investigation did not reveal what time the initial search for Resident #113 began inside the facility. The day shift staff reported they started to look for Resident #113 within the facility then notified the DON. The DON was notified by Licensed Practical Nurse (LPN) #240 on 08/27/23 at 12:02 P.M. that Resident #113 was missing. The DON initiated the search for Resident #113 following the facility's Elopement policy. Review of the facility's Incident and Accident Investigation Form dated 08/27/23 revealed Resident #113 was located at the address of Bank #500 on 08/27/23 at 9:47 A.M. Resident #113 walked out of the facility without an assistive device and was found down on the sidewalk bleeding from the left hand and left eye. Licensed Practical Nurse (LPN) #240 notified the Director of Nursing (DON) on 08/27/23 at 12:02 P.M. when Resident #113 was unable to be located in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 2 of 4 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 10/18/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few Interview with Administrator on 10/17/23 at 12:47 P.M. revealed he had placed the call to the police department on 08/27/23 sometime after 12:00 P.M. to find out if they had any information on the whereabouts of Resident #113. The police reported Resident # 113 was found at Bank #500 with injuries and was transported to the ER. With the knowledge of Resident #113's location, he updated staff, who were searching for Resident #113, and proceeded to go to the hospital to verify the status of Resident #113. A telephone interview with LPN #240 on 10/17/23 at 9:20 A.M. revealed LPN #240 was unable to locate Resident #113 for morning medication administration on 08/27/23 but could not recall the time she was unable to locate Resident #113. LPN #240 verified she did not see Resident #113 at the start of her shift at 7:00 A.M. A search was started for Resident #113, and she was unable to state the time, and was unable to be located. LPN #240 notified the DON to inform her Resident #113 was missing but was not able to recall the time she notified the DON. A telephone interview with STNA #228 on 10/17/23 at 9:54 A.M. revealed the staff began to be concerned for Resident #113's location on 08/27/23 when her breakfast was not eaten when clearing trays from breakfast. STNA #228 could not recall the time they identified Resident #113's location could not be determined. STNA #228 stated she did not see Resident #113 at the beginning of her shift, and confirmed she helped search for the missing resident, but again she was unsure of the time. Interview with the DON on 10/17/23 at 11:52 A.M, stated on 08/27/23, the DON began providing immediate education to all staff on shift after the search and subsequent location of Resident #113. An immediate investigation was started. The DON verified the facility failed to identify the length of time that Resident #113 was missing from the facility. Interview on 10/17/23 at 1:26 P.M. with Physician #417 verified Resident #113 always required supervision, required long-term care for severe cognitive deficits, and the inability to understand safety concerns of surrounding because of the progressive dementia diagnosis. Review of the facility's policy on Elopement, last revised on 04/26/22, revealed it is the policy of the facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility. The definition of elopement was defined when a guest/resident who needs supervision leaves a safe area without authorization and/or necessary supervision to do so. Rounds of all guests/residents are made at the beginning of the shift, at mealtimes, and at the end of the shift at a minimum by direct care staff and licensed nurses. Certified nursing assistant (CNA)/STNA or nurse can achieve this through the medication administration pass, mealtime passes, and during care rounds. The deficient practice was corrected on 08/29/23 when the facility implemented the following corrective actions: • On 08/27/23, the DON and Administrator initiated an investigation of Resident #113's elopement from the facility. • On 08/28/23, Resident #113 returned from the hospital. Resident #113 was assessed to be at risk for elopement and a wander guard was placed on Resident #113's right ankle for her safety. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 3 of 4 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 10/18/2023 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 0689 #113's care plan was updated to reflect the resident's risk for elopement and a wander guard was implemented. Level of Harm - Actual harm • Residents Affected - Few On 08/28/23, all current resident's elopement evaluation scores were reviewed to identify any resident at risk for elopement. All residents who were identified at risk for elopement were audited to ensure the completion of the following items: the residents had the appropriate interventions for the risk of elopement, care plans were updated, a physician order for intervention(s), and had current information in elopement risk binders. This was completed by the DON/designee. • On 08/28/23, all licensed nurses checked the residents who have a wander guard bracelet for placement and function. • On 08/28/28, the DON/designee completed an in-service of the facility's elopement policy and procedures for all staff. All staff were educated on the frequency of visual checks of the residents. • On 08/28/23, all alarmed doors were verified for functioning, alarm signaling with wander guard bracelets, and subsequently daily checks performed. • On 08/29/23 at 2:15 P.M. and 9:00 P.M., the maintenance department completed elopement drills. No concerns were identified. • On 08/29/23, the DON/designee will audit all new admissions and residents due for quarterly elopement evaluation completion and implementation of intervention applicable weekly for four weeks and report finding to the facility's Quality Assurance (QA) committee. This was an incidental finding discovered during the course of the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365222 If continuation sheet Page 4 of 4