Health inspection·August 22, 2019

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 08/21/19 at 12:18 P.M. with the DON confirmed Resident #23's plan of care documented the resident as above the knee amputation. He confirmed the care plan had not been corrected to reflect the resident's current status. 4. Resident # 30 was admitted to the facility on [DATE] with diagnoses including post traumatic seizures, dysphasia, anxiety disorder, schizoaffective disorder and Alzheimer's disease. A care plan updated on 10/18/2018 revealed Resident #30 was unable to verbally communicate, cannot make needs known, occasionally makes eye contact and has hearing and vision impairment. An MDS assessment dated [DATE] revealed Resident #30 was severely cognitively impaired and required two persons to extensive physical assist with activities of daily living. Review of Resident #30's care plan, updated on 08/20/19 by the Social Service Designee (SSD) #400, revealed Resident #30 exhibits the following behaviors: yelling, screaming, cursing and not choosing to follow established treatment regimens. A review of interventions care planned for such behavior revealed staff is to acknowledge the guest's right to not follow the prescribed or recommended treatment regimens and to allow Resident #30 an opportunity to discuss mood, feelings, and concerns. On 08/19/19 from 11:30 A.M. to 11:50 A.M. during observation Resident #30 was yelling while in her bed. At 11:50 A.M. interview with Resident #30's guardian revealed he had gone into her room around 11:15 A.M. and most likely startled her because he is a man and had a business suit on. He explained, Resident #30 has a terrible past of physical abuse from a young age to an adult and suffers from post-traumatic stress syndrome from the abuse. Her yelling is a result of her being afraid. She cannot express her feelings verbally due to her medical diagnosis, therefore she can only scream. On 08/22/19 at 10:20 A.M. interview with the SSD #400 confirmed Resident #30 cannot speak and express her feelings which inconsistent with as it is indicated in her care plan. The plan of care should have been updated to reflect appropriate interventions given Resident #30's limitations as a result of her diagnoses. Review of the facility policy titled Interdisciplinary Care Plan Policy and Procedure, dated June 2017, revealed it is the policy of the facility to develop an interdisciplinary care plan for each guest that includes measurable goals and time frames directed toward achieving and maintaining each guest's optimal medical, physical, mental and psychological needs. Care plans are to be revised as dictated by change(s) in the guest's condition. 3. Medical record review for Resident #34 revealed an admission date of 05/05/14. Medical diagnoses included Parkinson's Disease, seizure disorder, and traumatic brain injury. Review of quarterly MDS assessment dated [DATE] revealed Resident #34 was rarely or never understood. Her functional status was extensive assistance for bed mobility, transfers, toilet use and eating was total dependence. Review of care plan dated 10/25/17 for Resident #34 revealed she was a potential for social isolation related to resident's traumatic brain injury. Interventions were to invite and encourage to appropriate group activities of choice weekly. Activity staff will continue to engage guest in social interaction though daily group activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 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 365256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Worthington, The 1030 High St 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of quarterly activity assessment progress note dated 06/17/19 by Director of Recreation #54 (DOR) revealed guest does not do well in a group setting due to getting easily agitated and yelling out. As stated by the family, guest does not like being around others and preferred to be in room watching television or listening to music. Interview with DOR #54 on 08/21/19 at 12:59 P.M. revealed in a care conference meeting a few weeks ago it was expressed by the family Resident #34 didn't like people and hated group activities. She verified the care plan wasn't changed and should have been. Event ID: Facility ID: 365256 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 365256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Worthington, The 1030 High St 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to ensure accurate documentation related to an indwelling urinary catheter. This affected one (Resident #38) of one resident reviewed for indwelling urinary catheters. The facility census was 92. Findings include: Record review revealed Resident 338 was admitted on [DATE]. Diagnoses included cervical-four spinal injury, tetraplegia, urinary tract infections, acute cystitis, anxiety, neurogenic bladder, hyponatremia, insomnia and muscle spasms. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had a slight cognitive deficit. He was also assessed to required extensive to total assistance from staff for his daily care. He was assessed to have an indwelling urinary catheter and his continence could not be rated due to the indwelling catheter. Review of the current physician's orders identified an order for a 16 French urinary indwelling catheter, dated 07/03/19. No orders were noted for catheter care. Review of Resident #38's plan of care dated 07/11/19, revealed he was at risk for urinary tract infection related to having an indwelling urinary catheter. Intervention included among others, the resident was to receive catheter care as per facility policy. Review of the nursing progress notes dated 07/02/19 through 08/21/19, revealed he received an indwelling Foley catheter on 07/03/19, for neurogenic bladder. Review of the nursing notes revealed the only documentation of catheter care having been administered was dated 07/06/19. Review of the treatment administration record (TAR) for Resident #38 dated August 2019, revealed no catheter care on the TAR. Review of the State Tested Nurse's Aide (STNA)'s daily task log, each shift, dated 07/23/19 through 08/21/19, revealed Resident #38 was documented as being continent of urine on 07/24/19, 08/07/19, -8/08/19, 08/15/19, 08/20/19 and 08/21/19. He was documented as being incontinent of urine 27 times during the reviewed time period. He was documented as continence not rated due to an indwelling catheter 37 times. Ten time Resident #38 was documented as continence not rated due to having a condom catheter and two times documented as not applicable. Interviews with STNA's #68 and #79 on 08/21/19 at 11:17 A.M. revealed they documented resident care in the computer. STNA #79 stated she documented under the care area that automatically came up for the particular resident. If the care was indicated she didn't chart it. Observation of Resident #38 on 08/21/19 at 11:32 A.M. revealed the resident to have an indwelling urinary catheter. Interview on 08/21/19 at 11:33 A.M. with Resident #38, revealed he thought he received catheter care daily but wasn't sure. He stated he had already received his morning care for the day, and he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 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 365256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Worthington, The 1030 High St 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 0690 received a bed bath. He stated he believed they cleaned his genital area. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 08/21/19 at 12:13 P.M. confirmed no physician's orders for catheter care, no treatment for catheter care had been documented on the TAR and confirmed the STNA documentation of Resident #38's indwelling urinary catheter was not consistent or correct. Residents Affected - Few On 08/21/19 at 5:00 P.M. in an interview with the DON, he confirmed he had requested orders for catheter care every shift for Resident #38. Review of the facility's policy titled Indwelling Urinary Catheter (Foley) Care and Management undated, taken from Lippincott procedures, revealed the maintenance of urinary catheter care, assessments of and any teaching to the resident on catheter care should be documented. Further review of the policy revealed no specific time line for administering catheter care. The policy stated care should be given on a routine basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 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 365256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Worthington, The 1030 High St 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and policy review, the facility failed to ensure medication carts were free of expired medications. This affected two medication storage carts and one medication storage room. The facility census was 92. Findings include: On 08/22/19 at 8:48 A.M. one unopened bottle of Fer-in-Sol liquid iron supplement, located in the East One medication cart, was observed to have an expiration date of 09/01/18. A bottle of Pro-Stat sugar free liquid protein was observed with an expiration date of 03/13/19 and one bottle of Uti-Stat urinary tract protection complex with an expiration date of July 2019. Interview on 08/22/19 at 8:58 A.M. with Licensed Practical Nurse (LPN) #144, confirmed the three mediations were expired. She also confirmed Resident #50 received the pro-stat and Resident #80 received the Uti-Stat complex. Observation on 08/22/19 at 9:00 A.M. of the South medication cart revealed one bottle of Uti-Stat urinary tract protection complex with an expiration date of July 2019. Interview on 08/22/19 at 9:10 A.M. with LPN #101 confirmed the medication was expired and confirmed Resident #53 was the only resident to have received that medication from her cart. Review of the facility's policy titled Storage and Expiration of Medications Biologicals Syringes and Needles dated 12/01/07, revealed all medication will have an expiration date on the label and be retained no longer than the recommended manufacturer expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 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 365256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Worthington, The 1030 High St 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure an occupational therapy recommendation for restorative care was provided for a resident. This affected one (Resident #34) of two residents reviewed for range of motion. The facility identified 30 residents receiving rehabilitative services. Residents Affected - Few Record review for Resident #34 revealed an admission date of 05/05/14. Medical diagnoses included Parkinson's Disease, seizure disorder, and traumatic brain injury. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was rarely or never understood. Her functional status was extensive assistance for bed mobility, transfers, toilet use and eating was total dependence. Review of discharge records from Occupational Therapy (OT) dated 06/16/19 revealed recommendations were for splints to bilateral upper extremities (arms) and passive range of motion to protect joint integrity. PROM to BUE was to be completed 15 repetitions one time a day and the splint was to be worn four hours a day and to provide skin checks for the resident as well. Review of progress note, physician orders, restorative documentation and care plan from 06/16/19 to 08/21/19 revealed no documentation the recommendation by the OT department or the task had been done. Observation of Resident #34 and interview with family on 08/21/19 at 11:23 A.M. revealed the resident's arms were contractured and the splints were lying in the resident's room. The family revealed she was supposed to be wearing them, but hadn't been for quite sometime now. Interview with Occupational Therapy Assistant (OTA) #72 on 08/21/19 at 12:46 P.M. revealed the process was to write it out and educate the Director of Nursing (DON) on the recommendation and from that point it would be up to nursing staff to implement the recommendation. She verified the resident was supposed to wear the splints four hours a day with passive range of motion to both arms for 15 repetitions to maintain joint integrity. Interview with the Restorative State Tested Nursing Aide #68 (RSTNA) on 08/21/19 at 1:38 P.M. revealed Resident #34 went out to the hospital sometime in June 2019 and came back and since then there wasn't any orders to place the splint or perform the passive range of motion to the arms. She verified during the interview this had not been implemented for the resident. Interview with the Assistant Director of Nursing (ADON) on 08/21/19 at 1:42 P.M. revealed she knew about the recommendation for Resident #34 but had not implemented it yet since she was still trying to learn the process. The Administrator stated during interview on 08/22/19 at 10:00 A.M. the facility did not have a policy regarding restorative care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365256 If continuation sheet Page 7 of 7